Rule: Medicare: Hospital Inpatient Prospective Payment Systems and 2006 FY Rates

Friday,
August 12, 2005
Part II
Department of
Health and Human
Services
Centers for Medicare & Medicaid Services
42 CFR Parts 405, 412, 413, 415, et al.

Medicare Program; Changes to the
Hospital Inpatient Prospective Payment
Systems and Fiscal Year 2006 Rates; Final
Rule
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47278 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations
DEPARTMENT OF HEALTH AND of § 412.230(d)(2), are effective on AMI Acute myocardial infarction
HUMAN SERVICES October 1, 2005. The provisions of AOA American Osteopathic Association
§ 412.230(d)(2) are effective on August ASC Ambulatory Surgical Center
Centers for Medicare & Medicaid ASP Average sales price
12, 2005. This rule is a major rule as
AWP Average wholesale price
Services defined in 5 U.S.C. 804(2). Pursuant to BBA Balanced Budget Act of 1997, Pub. L.
5 U.S.C. 801(a)(1)(A), we are submitting 105–33
42 CFR Parts 405, 412, 413, 415, 419, a report to Congress on this rule on BES Business Expenses Survey
422, and 485 August 1, 2005. BIPA Medicare, Medicaid, and SCHIP [State
FOR FURTHER INFORMATION CONTACT: Children’s Health Insurance Program]
[CMS–1500–F]
Marc Hartstein, (410) 786–4548, Benefits Improvement and Protection Act
RIN 0938–AN57 of 2000, Pub. L. 106–554
Operating Prospective Payment, BLS Bureau of Labor Statistics
Medicare Program; Changes to the Diagnosis-Related Groups (DRGs), Wage CAH Critical access hospital
Hospital Inpatient Prospective Index, New Medical Services and CBSAs Core-Based Statistical Areas
Payment Systems and Fiscal Year 2006 Technology Add-On Payments, Hospital CC Complication or comorbidity
Rates Geographic Reclassifications, Postacute CIPI Capital Input Price Index
Care Transfers, and Disproportionate CMS Centers for Medicare & Medicaid
AGENCY: Centers for Medicare and Share Hospital Issues. Services
Medicaid Services (CMS), HHS. Tzvi Hefter, (410) 786–4487, Capital CMSA Consolidated Metropolitan
Statistical Area
ACTION: Final rule. Prospective Payment, Excluded
COBRA Consolidated Omnibus
Hospitals, Graduate Medical Education, Reconciliation Act of 1985, Pub. L. 99–272
SUMMARY: We are revising the Medicare Critical Access Hospitals, and Long- CoP Condition of Participation
hospital inpatient prospective payment Term Care (LTC)–DRGs, and Provider- CPI Consumer Price Index
systems (IPPS) for operating and capital- Based Facilities Issues. CRNA Certified registered nurse anesthetist
related costs to implement changes Steve Heffler, (410) 786–1211, CRT Cardiac Resynchronization Therapy
arising from our continuing experience Hospital Market Basket Revision and DRG Diagnosis-related group
with these systems. In addition, in the Rebasing. DSH Disproportionate share hospital
Addendum to this final rule, we Siddhartha Mazumdar, (410) 786– ECI Employment Cost Index
describe the changes to the amounts and 6673, Rural Hospital Community FDA Food and Drug Administration
FIPS Federal Information Processing
factors used to determine the rates for Demonstration Project Issues. Standards
Medicare hospital inpatient services for Mary Collins, (410) 786–3189, Critical FQHC Federally qualified health center
operating costs and capital-related costs. Access Hospitals (CAHs) Issues. FTE Full-time equivalent
We also are setting forth rate-of-increase Debbra Hattery, (410) 786–1855, FY Federal fiscal year
limits as well as policy changes for Quality Data for Annual Payment GAAP Generally accepted accounting
hospitals and hospital units excluded Update Issues. principles
from the IPPS that are paid in full or in Martha Kuespert, (410) 786–4605, GAF Geographic adjustment factor
part on a reasonable cost basis subject Specialty Hospitals Definition Issues. HIC Health Insurance Card
to these limits. These changes are HIS Health Information System
SUPPLEMENTARY INFORMATION:
GME Graduate medical education
applicable to discharges occurring on or
Electronic Access HCRIS Hospital Cost Report Information
after October 1, 2005, with one System
exception: The changes relating to This Federal Register document is HIPC Health Information Policy Council
submittal of hospital wage data by a also available from the Federal Register HIPAA Health Insurance Portability and
campus or campuses of a multicampus online database through GPO Access, a Accountability Act of 1996, Pub. L. 104–
hospital system (that is, the changes to service of the U.S. Government Printing 191
§ 412.230(d)(2) of the regulations) are Office. Free public access is available on HHA Home health agency
effective on August 12, 2005. a Wide Area Information Server (WAIS) HHS Department of Health and Human
Among the policy changes that we are through the Internet and via Services
HPSA Health Professions Shortage Area
making are changes relating to: The asynchronous dial-in. Internet users can HQA Hospital Quality Alliance
classification of cases to the diagnosis- access the database by using the World ICD–9–CM International Classification of
related groups (DRGs); the long-term Wide Web; the Superintendent of Diseases, Ninth Revision, Clinical
care (LTC)–DRGs and relative weights; Documents home page address is http:/ Modification
the wage data, including the /www.access.gpo.gov/nara_docs/, by ICD–10–PCS International Classification of
occupational mix data, used to compute using local WAIS client software, or by Diseases, Tenth Edition, Procedure Coding
the wage index; rebasing and revision of telnet to swais.access.gpo.gov, then System
the hospital market basket; applications login as guest (no password required). ICU Intensive Care Unit
for new technologies and medical Dial-in users should use IHS Indian Health Service
IME Indirect medical education
services add-on payments; policies communications software and modem IPPS Acute care hospital inpatient
governing postacute care transfers, to call (202) 512–1661; type swais, then prospective payment system
payments to hospitals for the direct and login as guest (no password required). IPF Inpatient psychiatric facility
indirect costs of graduate medical IRF Inpatient rehabilitation facility
education, submission of hospital Acronyms
IRP Initial residency period
quality data, payment adjustment for AAOS American Association of Orthopedic JCAHO Joint Commission on Accreditation
low-volume hospitals, changes in the Surgeons of Healthcare Organizations
requirements for provider-based ACGME Accreditation Council on Graduate LAMCs Large area metropolitan counties
facilities; and changes in the Medical Education LTC–DRG Long-term care diagnosis-related
AHIMA American Health Information group
requirements for critical access
Management Association LTCH Long-term care hospital
hospitals (CAHs). AHA American Hospital Association MCE Medicare Code Editor
DATES: Effective Dates: The provisions AICD Automatic implantable cardioverter MCO Managed care organization
of this final rule, except the provisions defibrillator MDC Major diagnostic category
Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47279
MDH Medicare-dependent small rural 2. Hospitals and Hospital Units Excluded b. Newborn Diagnoses Edit
hospital from the IPPS c. Diagnoses Allowed for ‘‘Males Only’’
MedPAC Medicare Payment Advisory a. IRFs Edit
Commission b. LTCH d. Tobacco Use Disorder Edit
MedPAR Medicare Provider Analysis and c. IPFs e. Noncovered Procedure Edit
Review File 3. Critical Access Hospitals (CAHs) 11. Surgical Hierarchies
MEI Medicare Economic Index 4. Payments for Graduate Medical 12. Refinement of Complications and
MGCRB Medicare Geographic Classification Education (GME) Comorbidities (CC) List
Review Board B. Summary of Provisions of the FY 2006 a. Background
MMA Medicare Prescription Drug, IPPS Proposed Rule b. Comprehensive Review of the CC List
Improvement, and Modernization Act of 1. Changes to the DRG Reclassifications c. CC Exclusion List for FY 2006
2003, Pub. L. 108–173 and Recalibrations of Relative Weights 13. Review of Procedure Codes in DRGs
MRHFP Medicare Rural Hospital Flexibility 2. Changes to the Hospital Wage Index 468, 476, and 477
Program 3. Revision and Rebasing of the Hospital a. Moving Procedure Codes from DRG 468
MSA Metropolitan Statistical Area Market Basket or DRG 477 to MDCs
NAICS North American Industrial 4. Other Decisions and Changes to the PPS b. Reassignment of Procedures among
Classification System for Inpatient Operating and GME Costs DRGs 468, 476, and 477
NCD National coverage determination 5. PPS for Capital-Related Costs c. Adding Diagnosis or Procedure Codes to
NCHS National Center for Health Statistics 6. Changes for Hospitals and Hospital MDCs
NCVHS National Committee on Vital and Units Excluded From the IPPS 14. Changes to the ICD–9–CM Coding
Health Statistics 7. Payment for Blood Clotting Factors for System
NECMA New England County Metropolitan Inpatients With Hemophilia 15. Other Issues
Areas 8. Determining Prospective Payment a. Acute Intermittent Porphyria
NICU Neonatal intensive care unit Operating and Capital Rates and Rate-of- b. Prosthetic Cardiac Support Device (Code
NQF National Quality Forum Increase Limits 37.41)
NTIS National Technical Information 9. Impact Analysis c. Coronary Intravascular Ultrasound
10. Recommendation of Update Factor for (IVUS) (Procedure Code 00.24)
Service
Hospital Inpatient Operating Costs d. Islet Cell Transplantation
NVHRI National Voluntary Hospital
11. Discussion of Medicare Payment C. Recalibration of DRG Weights
Reporting Initiative
Advisory Commission Recommendations D. LTC–DRG Reclassifications and Relative
OES Occupational Employment Statistics
C. Public Comments Received in Response Weights for LTCHs for FY 2006
OIG Office of the Inspector General 1. Background
OMB Executive Office of Management and to the FY 2006 IPPS Proposed Rule
2. Changes in the LTC–DRG Classifications
Budget II. Changes to DRG Classifications and
a. Background
O.R. Operating room Relative Weights
b. Patient Classifications into DRGs
OSCAR Online Survey Certification and A. Background
3. Development of the Proposed FY 2006
Reporting (System) B. DRG Reclassifications
LTC–DRG Relative Weights
PRM Provider Reimbursement Manual 1. General a. General Overview of Development of the
PPI Producer Price Index 2. Yearly Review for Making DRG Changes; LTC–DRG Relative Weights
PMS Performance Measurement System Request for Public Comment b. Data
PMSAs Primary Metropolitan Statistical 3. Pre-MDC: Intestinal Transplantation c. Hospital-Specific Relative Value
Areas 4. MDC 1 (Diseases and Disorders of the Methodology
PPS Prospective payment system Nervous System) d. Low-Volume LTC–DRGs
PRA Per resident amount a. Strokes 4. Steps for Determining the FY 2006 LTC–
ProPAC Prospective Payment Assessment b. Unruptured Cerebral Aneurysms DRG Relative Weights
Commission 5. MDC 5 (Diseases and Disorders of the 5. Other Public Comments Relating to the
PRRB Provider Reimbursement Review Circulatory System) LTCH PPS Payment Policies
Board a. Severity Adjusted Cardiovascular E. Add-On Payments for New Services and
PS&R Provider Statistical and Procedures Technologies
Reimbursement System b. Automatic Implantable Cardioverter/ 1. Background
QIA Quality Improvement Organizations Defibrillator 2. FY 2006 Status of Technology Approved
RHC Rural health clinic c. Coronary Artery Stents for FY 2005 Add-On Payments
RHQDAPU Reporting Hospital Quality Data d. Insertion of Left Atrial Appendage 3. Reevaluation of FY 2005 Applications
for Annual Payment Update Device That Were Not Approved
RNHCI Religious nonmedical health care e. External Heart Assist System Implant 4. FY 2006 Applicants for New Technology
institution f. Carotid Artery Stent Add-On Payments
RRC Rural referral center g. Extracorporeal Membrane Oxygenation III. Changes to the Hospital Wage Index
RUCAs Rural-Urban Commuting Area (ECMO) A. Background
Codes 6. MDC 6 (Diseases and Disorders of the B. Core-Based Statistical Areas for the
SCH Sole community hospital Digestive System): Artificial Anal Hospital Wage Index
SDP Single Drug Pricer Sphincter C. Occupational Mix Adjustment to FY
SIC Standard Industrial Codes 7. MDC 8 (Diseases and Disorders of the 2006 Index
SNF Skilled nursing facility Musculoskeletal System and Connective 1. Development of Data for the
SOCs Standard occupational classifications Tissue) Occupational Mix Adjustment
SOM State Operations Manual a. Hip and Knee Replacements 2. Calculation of the Occupational Mix
SSA Social Security Administration b. Kyphoplasty Adjustment Factor and the Occupational
SSI Supplemental Security Income c. Multiple Level Spinal Fusion Mix Adjusted Wage Index
TEFRA Tax Equity and Fiscal d. Charite(tm) Spinal Disc Replacement D. Worksheet S–3 Wage Data for the FY
Responsibility Act of 1982, Pub. L. 97–248 Device 2006 Wage Index Update
UHDDS Uniform Hospital Discharge Data 8. MDC 18 (Infectious and Parasitic E. Verification of Worksheet S–3 Wage
Set Diseases (Systemic or Unspecified Data
Sites)): Severe Sepsis F. Computation of the FY 2006 Unadjusted
Table of Contents 9. MDC 20 (Alcohol/Drug Use and Wage Index
I. Background Alcohol/Drug Induced Organic Mental G. Computation of the FY 2006 Blended
A. Summary Disorders): Drug-Induced Dementia Wage Index
1. Acute Care Hospital Inpatient 10. Medicare Code Editor (MCE) Changes H. Revisions to the Wage Index Based on
Prospective Payment System (IPPS) a. Newborn Age Edit Hospital Redesignation
1. General 1. Background Regulation Text

2. Effects of Reclassification 2. Multicampus Hospitals Addendum—Schedule of Standardized
3. Application of Hold Harmless Protection 3. Urban Group Hospital Reclassifications Amounts Effective with Discharges Occurring
for Certain Urban Hospitals Redesignated 4. Clarification of Goldsmith Modification On or After October 1, 2005 and Update
as Rural Criterion for Urban Hospitals Seeking Factors and Rate-of-Increase Percentages
4. FY 2006 MGCRB Reclassifications Reclassification as Rural Effective With Cost Reporting Periods
5. FY 2006 Redesignations under Section I. Payment for Direct Graduate Medical Beginning On or After October 1, 2005
1886(d)(8)(B) of the Act
Education I. Summary and Background
6. Reclassifications under Section 508 of
1. Background II. Changes to Prospective Payment Rates for
Pub. L. 108–173
I. FY 2006 Wage Index Adjustment Based 2. Direct GME Initial Residency Period Hospital Inpatient Operating Costs for
on Commuting Patterns of Hospital a. Background FY 2006
Employees b. Direct GME Initial Residency Period A. Calculation of the Adjusted
J. Requests for Wage Index Data Limitation: Simultaneous Match Standardized Amount
Corrections 3. New Teaching Hospitals’ Participation 1. Standardization of Base-Year Costs or
IV. Rebasing and Revision of the Hospital in Medicare GME Affiliated Groups Target Amounts
Market Baskets 4. GME FTE Cap Adjustments for Rural 2. Computing the Average Standardized
A. Background Amount
Hospitals
B. Rebasing and Revising the Hospital 3. Updating the Average Standardized
5. Technical Changes: Cross-References
Market Basket Amount
J. Provider-Based Status of Facilities under 4. Other Adjustments to the Average
1. Development of Cost Categories and Medicare
Weights Standardized Amount
1. Background a. Recalibration of DRG Weights and
2. PPS—Selection of Price Proxies 2. Limits on Scope of Provider-Based
3. Labor-Related Share Updated Wage Index—Budget Neutrality
Regulations—Facilities for Which Adjustment
C. Separate Market Basket for Hospitals
Provider-Based Determinations Will Not b. Reclassified Hospitals—Budget
and Hospital Units Excluded from the
IPPS Be Made Neutrality Adjustment
3. Location Requirement for Off-Campus c. Outliers
1. Hospitals Paid Based on Their
Facilities: Application to Certain d. Rural Community Hospital
Reasonable Costs
Neonatal Intensive Care Units Demonstration Program Adjustment
2. Excluded Hospitals Paid Under Blend
4. Technical and Clarifying Changes (Section 410A of Pub. L. 108–173)
Methodology
K. Rural Community Hospital 5. FY 2006 Standardized Amount
3. Development of Cost Categories and
Demonstration Program B. Adjustments for Area Wage Levels and
Weights for the 2002-Based Excluded
Cost-of-Living
Hospital Market Basket L. Definition of a Hospital in Connection
1. Adjustment for Area Wage Levels
D. Frequency of Updates of Weights in with Specialty Hospitals
2. Adjustment for Cost-of-Living in Alaska
IPPS Hospital Market Basket VI. PPS for Capital-Related Costs and Hawaii
E. Capital Input Price Index Section VII. Changes for Hospitals and Hospital Units C. DRG Relative Weights
V. Other Decisions and Changes to the IPPS Excluded From the IPPS D. Calculation of Prospective Payment
for Operating Costs and GME Costs A. Payments to Excluded Hospitals and Rates for FY 2006
A. Postacute Care Transfer Payment Policy Hospital Units 1. Federal Rate
1. Background 1. Payments to Existing Excluded Hospitals 2. Hospital-Specific Rate (Applicable Only
2. Changes to DRGs Subject to the and Hospital Units to SCHs and MDHs)
Postacute Care Transfer Policy a. Calculation of Hospital-Specific Rate
2. Updated Caps for New Excluded
B. Reporting of Hospital Quality Data for b. Updating the FY 1982, FY 1987, and FY
Hospitals and Units
Annual Hospital Payment Update 1996 Hospital-Specific Rates for FY 2006
1. Background 3. Implementation of a PPS for IRFs
4. Implementation of a PPS for LTCHs 3. General Formula for Calculation of
2. Requirements for Hospital Reporting of Prospective Payment Rates for Hospitals
Quality Data 5. Implementation of a PPS for IPFs
6. Report of Adjustment (Exception) Located in Puerto Rico Beginning On or
C. Sole Community Hospitals and After October 1, 2005 and Before October
Medicare Dependent Hospitals Payments
1, 2006
1. Background B. Critical Access Hospitals (CAHs)
a. Puerto Rico Rate
2. Budget Neutrality Adjustment to 1. Background b. National Rate
Hospital Payments Based on Hospital- 2. Policy Change Relating to Continued III. Changes to Payment Rates for Acute Care
Specific Rate Participation by CAHs in Lugar Counties Hospital Inpatient Capital-Related Costs
3. Technical Change 3. Policy Change Relating to Designation of for FY 2006
D. Rural Referral Centers CAHs as Necessary Providers A. Determination of Federal Hospital
1. Case-Mix Index a. Determination of the Relocation Status of Inpatient Capital-Related Prospective
2. Discharges a CAH Payment Rate Update
3. Technical Change b. Relocation of a CAH Using a Waiver To 1. Capital Standard Federal Rate Update
E. Payment Adjustment for Low-Volume Meet the CoP for Distance a. Description of the Update Framework
Hospitals VIII. Payment for Blood Clotting Factor b. Comparison of CMS and MedPAC
F. Indirect Medical Education (IME) Administered to Hemophilia Inpatients Update Recommendation
Adjustment 2. Outlier Payment Adjustment Factor
IX. MedPAC Recommendations
1. Background 3. Budget Neutrality Adjustment Factor for
A. Medicare Payment Policy
2. IME Adjustment for IPPS-Excluded Changes in DRG Classifications and
1. Update Factor
Hospitals Converting to IPPS Hospitals Weights and the Geographic Adjustment
3. Section 1886(d)(3)(E) Teaching Hospitals 2. Quality Incentive Payment Policy
Factor
That Withdraw Rural Reclassification 3. Refinement of DRGs Based on Severity
4. Exceptions Payment Adjustment Factor
G. Payment to Disproportionate Share of Illness 5. Capital Standard Federal Rate for FY
Hospitals (DSHs) 4. APR–DRGs 2006
1. Background 5. DRG Relative Weights 6. Special Capital Rate for Puerto Rico
2. Implementation of Section 951 of Pub. 6. High-Cost Outliers Hospitals
L. 108–173 B. Other MedPAC Recommendations B. Calculation of Inpatient Capital-Related
3. Calculation of the Medicare Fraction X. Other Required Information Prospective Payments for FY 2006
4. Calculation of the Medicaid Fraction A. Requests for Data From the Public C. Capital Input Price Index
H. Geographic Reclassifications B. Collection of Information Requirements 1. Background
2. Forecast of the CIPI for FY 2006 Table 8A—Statewide Average Operating increase in Medicare payments to
IV. Changes to Payment Rates for Excluded Cost-to-Charge Ratios-July 2005 hospitals that qualify under either of
Hospitals and Hospital Units: Rate-of- Table 8B—Statewide Average Capital Cost-to- two statutory formulas designed to
Increase Percentages Charge Ratios-July 2005
identify hospitals that serve a
A. Payments to Existing Excluded Table 9A—Hospital Reclassifications and
Hospitals and Units Redesignations by Individual Hospital disproportionate share of low-income
B. Updated Caps for New Excluded and CBSA—FY 2006 patient. For qualifying hospitals, the
Hospitals and Units Table 9B—Hospital Reclassifications and amount of this adjustment may vary
V. Payment for Blood Clotting Factor Redesignation by Individual Hospital based on the outcome of the statutory
Administered to Hemophilia Inpatients Under Section 508 of Pub. L. 108–173— calculations.
FY 2006 If the hospital is an approved teaching
Tables Table 9C—Hospitals Redesignated as Rural hospital, it receives a percentage add-on
Table 1A—National Adjusted Operating under Section 1886(d)(8)(E) of the Act— payment for each case paid under the
Standardized Amounts, Labor/Nonlabor FY 2006
Table 10—Geometric Mean Plus the Lesser of
IPPS (known as the indirect medical
(69.7 Percent Labor Share/30.3 Percent
Nonlabor Share If Wage Index Is Greater .75 of the National Adjusted Operating education (IME) adjustment). This
Than 1) Standardized Payment Amount percentage varies, depending on the
Table 1B—National Adjusted Operating (Increased to Reflect the Difference ratio of residents to beds.
Standardized Amounts, Labor/Nonlabor Between Costs and Charges) or .75 of Additional payments may be made for
(62 Percent Labor Share/38 Percent One Standard Deviation of Mean Charges cases that involve new technologies or
Nonlabor Share If Wage Index Is Less by Diagnosis-Related Groups (DRGs)— medical services that have been
Than or Equal to 1) July 2005 approved for special add-on payments.
Table 1C—Adjusted Operating Standardized Table 11—FY 2006 LTC-DRGs, Relative To qualify, a new technology or medical
Amounts for Puerto Rico, Labor/ Weights, Geometric Average Length of
service must demonstrate that it is a
Nonlabor Stay, and 5/6ths of the Geometric
Average Length of Stay substantial clinical improvement over
Table 1D—Capital Standard Federal Payment
Appendix A—Regulatory Impact Analysis technologies or services otherwise
Rate
Table 2—Hospital Case-Mix Indexes for Appendix B—Recommendation of Update available, and that, absent an add-on
Discharges Occurring in Federal Fiscal Factors for Operating Cost Rates of payment, it would be inadequately paid
Year 2004; Hospital Wage Indexes for Payment for Inpatient Hospital Services under the regular DRG payment.
Federal Fiscal Year 2006; Hospital The costs incurred by the hospital for
I. Background a case are evaluated to determine
Average Hourly Wage for Federal Fiscal
Years 2004 (2000 Wage Data), 2005 (2001 A. Summary whether the hospital is eligible for an
Wage Data), and 2006 (2002 Wage Data); additional payment as an outlier case.
Wage Indexes and 3-Year Average of 1. Acute Care Hospital Inpatient This additional payment is designed to
Hospital Average Hourly Wages Prospective Payment System (IPPS) protect the hospital from large financial
Table 3A—FY 2006 and 3-Year Average Section 1886(d) of the Social Security losses due to unusually expensive cases.
Hourly Wage for Urban Areas by CBSA Act (the Act) sets forth a system of Any outlier payment due is added to the
Table 3B—FY 2006 and 3-Year Average
Hourly Wage for Rural Areas by CBSA
payment for the operating costs of acute DRG-adjusted base payment rate, plus
Table 4A—Wage Index and Capital care hospital inpatient stays under any DSH, IME, and new technology or
Geographic Adjustment Factor (GAF) for Medicare Part A (Hospital Insurance) medical service add-on adjustments.
Urban Areas by CBSA based on prospectively set rates. Section Although payments to most hospitals
Table 4B—Wage Index and Capital 1886(g) of the Act requires the Secretary under the IPPS are made on the basis of
Geographic Adjustment Factor (GAF) for to pay for the capital-related costs of the standardized amounts, some
Rural Areas by CBSA hospital inpatient stays under a categories of hospitals are paid the
Table 4C—Wage Index and Capital prospective payment system (PPS). higher of a hospital-specific rate based
Geographic Adjustment Factor (GAF) for Under these PPSs, Medicare payment on their costs in a base year (the higher
Hospitals That Are Reclassified by CBSA of FY 1982, FY 1987, or FY 1996) or the
Table 4F—Puerto Rico Wage Index and
for hospital inpatient operating and
Capital Geographic Adjustment Factor capital-related costs is made at IPPS rate based on the standardized
(GAF) by CBSA predetermined, specific rates for each amount. For example, sole community
Table 4J—Out-Migration Wage Adjustment— hospital discharge. Discharges are hospitals (SCHs) are the sole source of
FY 2006 classified according to a list of care in their areas, and Medicare-
Table 5—List of Diagnosis-Related Groups diagnosis-related groups (DRGs). dependent, small rural hospitals
(DRGs), Relative Weighting Factors, and The base payment rate is comprised of (MDHs) are a major source of care for
Geometric and Arithmetic Mean Length a standardized amount that is divided Medicare beneficiaries in their areas.
of Stay (LOS) into a labor-related share and a Both of these categories of hospitals are
Table 6A—New Diagnosis Codes nonlabor-related share. The labor- afforded this special payment protection
Table 6B—New Procedure Codes
Table 6C—Invalid Diagnosis Codes
related share is adjusted by the wage in order to maintain access to services
Table 6D—Invalid Procedure Codes index applicable to the area where the for beneficiaries. (An MDH receives
Table 6E—Revised Diagnosis Code Titles hospital is located; and if the hospital is only 50 percent of the difference
Table 6F—Revised Procedure Code Titles located in Alaska or Hawaii, the between the IPPS rate and its hospital-
Table 6G—Additions to the CC Exclusions nonlabor-related share is adjusted by a specific rates if the hospital-specific rate
List cost-of-living adjustment factor. This is higher than the IPPS rate. In addition,
Table 6H—Deletions from the CC Exclusions base payment rate is multiplied by the an MDH does not have the option of
List DRG relative weight. using FY 1996 as the base year for its
Table 7A—Medicare Prospective Payment If the hospital treats a high percentage hospital-specific rate.)
System Selected Percentile Lengths of of low-income patients, it receives a Section 1886(g) of the Act requires the
Stay [FY 2004 MedPAR Update March
2005 GROUPER V22.0]
percentage add-on payment applied to Secretary to pay for the capital-related
Table 7B—Medicare Prospective Payment the DRG-adjusted base payment rate. costs of inpatient hospital services ‘‘in
System Selected Percentile Lengths of This add-on payment, known as the accordance with a prospective payment
Stay: [FY 2004 MedPAR Update March disproportionate share hospital (DSH) system established by the Secretary.’’
2005 GROUPER V23.0] adjustment, provides for a percentage The basic methodology for determining
capital prospective payments is set forth governing payments under the IRF PPS 4. Payments for Graduate Medical
in our regulations at 42 CFR 412.308 are located in 42 CFR part 412, subpart Education (GME)
and 412.312. Under the capital PPS, P. Under section 1886(a)(4) of the Act,
payments are adjusted by the same DRG costs of approved educational activities
for the case as they are under the b. LTCHs
are excluded from the operating costs of
operating IPPS. Similar adjustments are Under the authority of sections 123(a) inpatient hospital services. Hospitals
also made for IME and DSH as under the and (c) of Pub. L. 106–113 and section with approved graduate medical
operating IPPS. In addition, hospitals 307(b)(1) of Pub. L. 106–554, LTCHs are education (GME) programs are paid for
may receive an outlier payment for being transitioned from being paid for the direct costs of GME in accordance
those cases that have unusually high inpatient hospital services based on a with section 1886(h) of the Act; the
costs. amount of payment for direct GME costs
blend of reasonable cost-based
The existing regulations governing for a cost reporting period is based on
payments to hospitals under the IPPS reimbursement under section 1886(b) of
the Act to 100 percent of the Federal the hospital’s number of residents in
are located in 42 CFR Part 412, Subparts that period and the hospital’s costs per
A through M. rate during a 5-year period, beginning
with cost reporting periods that start on resident in a base year. The existing
2. Hospitals and Hospital Units or after October 1, 2002. For cost regulations governing payments to the
Excluded From the IPPS reporting periods beginning on or after various types of hospitals are located in
Under section 1886(d)(1)(B) of the October 1, 2006, LTCHs will be paid 100 42 CFR part 413.
Act, as amended, certain specialty percent of the Federal rate (LTCH PPS B. Summary of the Provisions of the FY
hospitals and hospital units are final rule (70 FR 24168)). LTCHs not 2006 IPPS Proposed Rule
excluded from the IPPS. These hospitals meeting the definition in § 412.23(e)(4)
In the FY 2006 IPPS proposed rule (70
and units are: Psychiatric hospitals and of the regulations may elect to be paid
FR 23306), we set forth proposed
units; rehabilitation hospitals and units; based on 100 percent of the Federal rate changes to the Medicare IPPS for
long-term care hospitals (LTCHs); instead of a blended payment in any operating costs and for capital-related
children’s hospitals; and cancer year during the 5-year transition period. costs in FY 2006. We also set forth
hospitals. Various sections of the LTCHs meeting the definition in proposed changes relating to payments
Balanced Budget Act of 1997 (Pub. L. § 412.23(e)(4) will be paid based on 100 for GME costs, payments to certain
105–33), the Medicare, Medicaid and percent of the standard Federal rate. The hospitals and units that continue to be
SCHIP [State Children’s Health existing regulations governing payment excluded from the IPPS and paid on a
Insurance Program] Balanced Budget under the LTCH PPS are located in 42 reasonable cost basis, payments for
Refinement Act of 1999 (Pub. L. 106– CFR part 412, subpart O. DSHs, and requirements and payments
113), and the Medicare, Medicaid, and for CAHs. The changes were proposed
SCHIP Benefits Improvement and c. IPFs
to be effective for discharges occurring
Protection Act of 2000 (Pub. L. 106–554) Under the authority of sections 124(a) on or after October 1, 2005, unless
provide for the implementation of PPSs and (c) of Pub. L. 106–113, inpatient otherwise noted.
for rehabilitation hospitals and units psychiatric facilities (IPFs) (formerly The following is a summary of the
(referred to as inpatient rehabilitation psychiatric hospitals and psychiatric major changes that we proposed and the
facilities (IRFs)), psychiatric hospitals units of acute care hospitals) are paid issues we addressed in the FY 2006
and units (referred to as inpatient under the new IPF PPS. Under the IPF IPPS proposed rule.
psychiatric facilities (IPFs)), and LTCHs, PPS, some IPFs are transitioning from
as discussed below. Children’s hospitals 1. Changes to the DRG Reclassifications
being paid for inpatient hospital and Recalibrations of Relative Weights
and cancer hospitals continue to be paid services based on a blend of reasonable
under reasonable cost-based cost-based payment and a Federal per As required by section 1886(d)(4)(C)
reimbursement. diem payment rate, effective for cost of the Act, we proposed annual
The existing regulations governing adjustments to the DRG classifications
reporting periods beginning on or after
payments to excluded hospitals and and relative weights. Based on analyses
January 1, 2005 (November 15, 2004 IPF
hospital units are located in 42 CFR of Medicare claims data, we proposed to
PPS final rule (69 FR 66921)). For cost
parts 412 and 413. establish a number of new DRGs and
a. IRFs January 1, 2008, IPFs will be paid 100 make changes to the designation of
percent of the Federal per diem diagnosis and procedure codes under
Under section 1886(j) of the Act, as other existing DRGs.
amended, rehabilitation hospitals and payment amount. The existing
regulations governing payment under We also presented analysis of FY 2006
units (IRFs) have been transitioned from applicants for add-on payments for
payment based on a blend of reasonable the IPF PPS are located in 42 CFR 412,
subpart N. high-cost new medical services and
cost reimbursement subject to a technologies (including public input, as
hospital-specific annual limit under 3. Critical Access Hospitals (CAHs) directed by Pub. L. 108–173, obtained in
section 1886(b) of the Act and the a town hall meeting).
adjusted facility Federal prospective Under sections 1814, 1820, and We proposed the annual update of the
payment rate for cost reporting periods 1834(g) of the Act, payments are made long-term care diagnosis-related group
beginning on or after January 1, 2002 to critical access hospitals (CAHs) (that (LTC–DRG) classifications and relative
through September 30, 2002, to payment is, rural hospitals or facilities that meet weights for use under the LTCH PPS for
at 100 percent of the Federal rate certain statutory requirements) for FY 2006.
effective for cost reporting periods inpatient and outpatient services based
beginning on or after October 1, 2002 on 101 percent of reasonable cost. 2. Changes to the Hospital Wage Index
(66 FR 41316, August 7, 2001; 67 FR Reasonable cost is determined under the We proposed revisions to the wage
49982, August 1, 2002; 68 FR 45674, provisions of section 1861(v)(1)(A) of index and the annual update of the
August 1, 2003, and 69 FR 45721, July the Act and existing regulations under wage data. Specific issues addressed
30, 2004). The existing regulations 42 CFR parts 413 and 415. included the following:
• The FY 2006 wage index update, • Changes relating to hospitals’ periods beginning in FY 2006 for
using wage data from cost reporting geographic classifications, including hospitals and hospital units excluded
periods that began during FY 2002. multicampus hospitals and urban group from the PPS.
• The occupational mix adjustment to hospital reclassifications.
the wage index that we began to apply • Changes and clarifications relating 9. Impact Analysis
effective October 1, 2004. to GME, including GME initial
• The revisions to the wage index In Appendix A of the proposed rule,
residency period limitation, new
based on hospital redesignations and we set forth an analysis of the impact
teaching hospitals’ participation in
reclassifications. that the proposed changes would have
Medicare GME affiliated groups, and the
• The adjustment to the wage index on affected hospitals.
GME FTE cap adjustment for rural
for FY 2006 based on commuting hospitals; 10. Recommendation of Update Factor
patterns of hospital employees who • Solicitation of public comments on for Hospital Inpatient Operating Costs
reside in a county and work in a possible changes in requirements for
different area with a higher wage index. provider-based entities relating to the In Appendix B of the proposed rule,
• The timetable for reviewing and location requirements for certain as required by sections 1886(e)(4) and
verifying the wage data that were in neonatal intensive care units as off- (e)(5) of the Act, we provided our
effect for the FY 2006 wage index. campus facilities; recommendations of the appropriate
3. Revision and Rebasing of the Hospital • Discussion of the second year of percentage changes for FY 2006 for the
Market Baskets implementation of the Rural following:
Community Hospital Demonstration
We proposed rebasing and revising • A single average standardized
Program; and
the hospital operating and capital amount for all areas for hospital
• Clarification of the definition of a
market baskets to be used in developing inpatient services paid under the IPPS
hospital as it relates to ‘‘specialty
the FY 2006 update factor for the for operating costs (and hospital-specific
hospitals’’ participating in the Medicare
operating prospective payment rates and rates applicable to SCHs and MDHs).
program.
the excluded hospital market basket to
be used in developing the FY 2006 • Target rate-of-increase limits to the
5. PPS for Capital-Related Costs
update factor for the excluded hospital allowable operating costs of hospital
In the proposed rule, we did not inpatient services furnished by hospitals
rate-of-increase limits. We also set forth propose any policy changes to the
the data sources used to determine the and hospital units excluded from the
capital-related prospective payment IPPS.
proposed revised market basket relative system. For the readers’ benefit, we
weights and choice of price proxies. discussed the payment policy 11. Discussion of Medicare Payment
4. Other Decisions and Changes to the requirements for capital-related costs Advisory Commission
PPS for Inpatient Operating and GME and capital payments to hospitals. Recommendations
Costs 6. Changes for Hospitals and Hospital Under section 1805(b) of the Act, the
In the proposed rule, we discussed a Units Excluded from the IPPS Medicare Payment Advisory
number of provisions of the regulations
In the proposed rule, we discussed Commission (MedPAC) is required to
in 42 CFR parts 412 and 413 and set
the proposed revisions and submit a report to Congress, no later
forth proposed changes concerning the
clarifications concerning excluded than March 1 of each year, in which
following:
• Solicitation of public comments on hospitals and hospital units, proposed MedPAC reviews and makes
two options for possible expansion of policy changes relating to continued recommendations on Medicare payment
the current postacute care transfer participation by CAHs located in policies. MedPAC’s March 2005
policy. counties redesignated under section recommendation concerning hospital
• The reporting of hospital quality 1886(d)(8)(B) of the Act (Lugar inpatient payment policies addressed
data as a condition for receiving the full counties), and proposed policy changes only the update factor for inpatient
annual payment update increase. relating to designation of CAHs as hospital operating costs and capital-
• Changes in the application of the necessary providers. related costs under the IPPS and for
budget neutrality adjustment to MDHs 7. Changes in Payment for Blood hospitals and distinct part hospital units
and SCHs for computing the hospital- Clotting Factor excluded from the IPPS. This
specific rate. recommendation is addressed in
• Updated national and regional case- In the proposed rule, we discussed
the proposed change in payment for Appendix B of the proposed rule.
mix values and discharges for purposes
blood clotting factor administered to MedPAC issued a second Report to
of determining rural referral center
status. inpatients with hemophilia for FY 2006. Congress: Physician-Owned Specialty
• The payment adjustment for low- Hospitals, March 2005, which addressed
8. Determining Prospective Payment other issues relating to Medicare
volume hospitals. Operating and Capital Rates and Rate-of-
• The IME adjustment for TEFRA payments to hospitals for inpatient
Increase Limits services. The recommendations on these
hospitals that are converting to IPPS
hospitals, and IME FTE resident caps for In the Addendum to the proposed issues from this second report were
urban hospitals that are granted rural rule, we set forth proposed changes to addressed in section IX. of the preamble
reclassification and then withdraw that the amounts and factors for determining of the proposed rule. For further
rural classification. the FY 2006 prospective payment rates information relating specifically to the
• Changes to implement section 951 for operating costs and capital-related MedPAC March 2005 reports or to
of Pub. L. 108–173 relating to the costs. We also established the proposed obtain a copy of the reports, contact
provision of patient stay days/SSI data threshold amounts for outlier cases. In MedPAC at (202) 220–3700 or visit
maintained by CMS to hospitals for the addition, we addressed the proposed MedPAC’s Web site at: http://
purpose of determining their DSH update factors for determining the rate- www.medpac.gov.
percentage. of-increase limits for cost reporting
C. Public Comments Received in resources used to treat cases in all Revision, Clinical Modification (ICD–9–
Response to the FY 2006 IPPS Proposed DRGs. CM).
Rule Congress recognized that it would be The process of forming the DRGs was
necessary to recalculate the DRG begun by dividing all possible principal
We received over 2,000 timely items
relative weights periodically to account diagnoses into mutually exclusive
of correspondence containing multiple
for changes in resource consumption. principal diagnosis areas referred to as
comments on the FY 2006 IPPS
Accordingly, section 1886(d)(4)(C) of Major Diagnostic Categories (MDCs).
proposed rule. Summaries of the public
the Act requires that the Secretary The MDCs were formed by physician
comments and our responses to those
panels as the first step toward ensuring
comments are set forth below under the adjust the DRG classifications and
that the DRGs would be clinically
appropriate heading. relative weights at least annually. These
coherent. The diagnoses in each MDC
adjustments are made to reflect changes
II. Changes to DRG Classifications and correspond to a single organ system or
in treatment patterns, technology, and
Relative Weights etiology and, in general, are associated
any other factors that may change the
with a particular medical specialty.
A. Background relative use of hospital resources. The
Thus, in order to maintain the
changes to the DRG classification
Section 1886(d) of the Act specifies requirement of clinical coherence, no
that the Secretary shall establish a system and the recalibration of the DRG final DRG could contain patients in
classification system (referred to as weights for discharges occurring on or different MDCs. Most MDCs are based
DRGs) for inpatient discharges and after October 1, 2005, are discussed on a particular organ system of the
adjust payments under the IPPS based below. body. For example, MDC 6 is Diseases
on appropriate weighting factors 1. General and Disorders of the Digestive System.
assigned to each DRG. Therefore, under This approach is used because clinical
the IPPS, we pay for inpatient hospital Cases are classified into DRGs for care is generally organized in
services on a rate per discharge basis payment under the IPPS based on the accordance with the organ system
that varies according to the DRG to principal diagnosis, up to eight affected. However, some MDCs are not
which a beneficiary’s stay is assigned. additional diagnoses, and up to six constructed on this basis because they
The formula used to calculate payment procedures performed during the stay. involve multiple organ systems (for
for a specific case multiplies an In a small number of DRGs, example, MDC 22 (Burns)). For FY 2005,
individual hospital’s payment rate per classification is also based on the age, cases are assigned to one of 520 DRGs
case by the weight of the DRG to which sex, and discharge status of the patient. in 25 MDCs. (We note that, in the FY
the case is assigned. Each DRG weight The diagnosis and procedure 2006 proposed rule (70 FR 23313), we
represents the average resources information is reported by the hospital inadvertently stated that there were 519
required to care for cases in that using codes from the International DRGs.) The table below lists the 25
particular DRG, relative to the average Classification of Diseases, Ninth MDCs.
MAJOR DIAGNOSTIC CATEGORIES (MDCS)

1 Diseases and Disorders of the Nervous System.
2 Diseases and Disorders of the Eye.
3 Diseases and Disorders of the Ear, Nose, Mouth, and Throat.
4 Diseases and Disorders of the Respiratory System.
5 Diseases and Disorders of the Circulatory System.
6 Diseases and Disorders of the Digestive System.
7 Diseases and Disorders of the Hepatobiliary System and Pancreas.
8 Diseases and Disorders of the Musculoskeletal System and Connective Tissue.
9 Diseases and Disorders of the Skin, Subcutaneous Tissue, and Breast.
10 Endocrine, Nutritional and Metabolic Diseases and Disorders.
11 Diseases and Disorders of the Kidney and Urinary Tract.
12 Diseases and Disorders of the Male Reproductive System.
13 Diseases and Disorders of the Female Reproductive System.
14 Pregnancy, Childbirth, and the Puerperium.
15 Newborns and Other Neonates with Conditions Originating in the Perinatal Period.
16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders.
17 Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms.
18 Infectious and Parasitic Diseases (Systemic or Unspecified Sites).
19 Mental Diseases and Disorders.
20 Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders.
21 Injuries, Poisonings, and Toxic Effects of Drugs.
22 Burns.
23 Factors Influencing Health Status and Other Contacts with Health Services.
24 Multiple Significant Trauma.
25 Human Immunodeficiency Virus Infections.
In general, cases are assigned to an procedure codes. These DRGs are for tracheostomies. Cases are assigned to
MDC based on the patient’s principal heart transplant or implant of heart these DRGs before they are classified to
diagnosis before assignment to a DRG. assist systems, liver and/or intestinal an MDC. The table below lists the
However, for FY 2005, there are nine transplants, bone marrow, lung, current nine pre-MDCs.
DRGs to which cases are directly simultaneous pancreas/kidney, and
assigned on the basis of ICD–9–CM pancreas transplants and for
PRE-MAJOR DIAGNOSTIC CATEGORIES (PRE-MDCS)

DRG 103 ................ Heart Transplant or Implant of Heart Assist System
DRG 480 ................ Liver Transplant and/or Intestinal Transplant
DRG 481 ................ Bone Marrow Transplant
DRG 482 ................ Tracheostomy for Face, Mouth, and Neck Diagnoses
DRG 495 ................ Lung Transplant
DRG 512 ................ Simultaneous Pancreas/Kidney Transplant
DRG 513 ................ Pancreas Transplant
DRG 541 ................ Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis
with Major Operating Room Procedures
DRG 542 ................ Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis
Without Major Operating Room Procedures
Once the MDCs were defined, each complications would consistently affect data should be submitted by mid-
MDC was evaluated to identify those the consumption of hospital resources. October for consideration in
additional patient characteristics that A patient’s diagnosis, procedure, conjunction with the next year’s
would have a consistent effect on the discharge status, and demographic proposed rule. This allows us time to
consumption of hospital resources. information is fed into the Medicare test the data and make a preliminary
Since the presence of a surgical claims processing systems and subjected assessment as to the feasibility of using
procedure that required the use of the to a series of automated screens called the data. Subsequently, a complete
operating room would have a significant the Medicare Code Editor (MCE). The database should be submitted by early
effect on the type of hospital resources MCE screens are designed to identify December for consideration in
used by a patient, most MDCs were cases that require further review before conjunction with the next year’s
initially divided into surgical DRGs and classification into a DRG. proposed rule.
medical DRGs. Surgical DRGs are based After patient information is screened In the FY 2006 IPPS proposed rule (70
on a hierarchy that orders operating through the MCE and any further FR 23312), we proposed numerous
room (O.R.) procedures or groups of development of the claim is conducted, changes to the DRG classification
O.R. procedures by resource intensity. the cases are classified into the system for FY 2006 and to the
Medical DRGs generally are appropriate DRG by the Medicare methodology used to recalibrate the
differentiated on the basis of diagnosis GROUPER software program. The DRG weights. The changes we proposed
and age (less than or greater than 17 GROUPER program was developed as a to the DRG classification system, the
years of age). Some surgical and medical means of classifying each case into a public comments we received
DRGs are further differentiated based on DRG on the basis of the diagnosis and concerning the proposed changes, the
the presence or absence of a procedure codes and, for a limited final DRG changes, and the
complication or a comorbidity (CC). number of DRGs, demographic methodology used to recalibrate the
information (that is, sex, age, and DRG weights are set forth below. The
Generally, nonsurgical procedures discharge status). changes we are implementing in this
and minor surgical procedures that are After cases are screened through the final rule will be reflected in the FY
not usually performed in an operating MCE and assigned to a DRG by the 2006 GROUPER, version 23.0, and are
room are not treated as O.R. procedures. GROUPER, the PRICER software effective for discharges occurring on or
However, there are a few non-O.R. calculates a base DRG payment. The after October 1, 2005. Unless otherwise
procedures that do affect DRG PRICER calculates the payments for noted in this final rule, our DRG
assignment for certain principal each case covered by the IPPS based on analysis is based on data from the
diagnoses, for example, extracorporeal the DRG relative weight and additional September 2004 update of the FY 2004
shock wave lithotripsy for patients with factors associated with each hospital, MedPAR file, which contains hospital
a principal diagnosis of urinary stones. such as IME and DSH adjustments. bills received through September 30,
Once the medical and surgical classes These additional factors increase the 2004 for discharges in FY 2004.
for an MDC were formed, each class of payment amount to hospitals above the
patients was evaluated to determine if base DRG payment. 2. Yearly Review for Making DRG
complications, comorbidities, or the The records for all Medicare hospital Changes; Request for Public Comment
patient’s age would consistently affect inpatient discharges are maintained in Many of the changes to the DRG
the consumption of hospital resources. the Medicare Provider Analysis and classifications are the result of specific
Physician panels classified each Review (MedPAR) file. The data in this issues brought to our attention by
diagnosis code based on whether the file are used to evaluate possible DRG interested parties. We encourage
diagnosis, when present as a secondary classification changes and to recalibrate individuals with concerns about DRG
condition, would be considered a the DRG weights. However, in the July classifications to bring those concerns to
substantial complication or 30, 1999 IPPS final rule (64 FR 41500), our attention in a timely manner so they
comorbidity. A substantial complication we discussed a process for considering can be carefully considered for possible
or comorbidity was defined as a non-MedPAR data in the recalibration inclusion in the next proposed rule and,
condition which, because of its presence process. In order for us to consider if included, may be subjected to public
with a specific principal diagnosis, using particular non-MedPAR data, we review and comment. Therefore, similar
would cause an increase in the length of must have sufficient time to evaluate to the timetable for interested parties to
stay by at least one day in at least 75 and test the data. The time necessary to submit non-MedPAR data for
percent of the patients. Each medical do so depends upon the nature and consideration in the DRG recalibration
and surgical class within an MDC was quality of the non-MedPAR data process, concerns about DRG
tested to determine if the presence of submitted. Generally, however, a classification issues should be brought
any substantial comorbidities or significant sample of the non-MedPAR to our attention no later than early
December in order to be considered and whether to establish such guidelines for intestinal transplantation, supported our
possibly included in the next annual making DRG reclassification decisions. decision to reassign intestinal
proposed rule updating the IPPS. We welcome public comments on this transplantation cases to DRG 480. One
The actual process of forming the issue. commenter commended CMS for its
DRGs was, and continues to be, highly progress, but urged us to continue to
iterative, involving a combination of 3. Pre-MDC: Intestinal Transplantation
evaluate a separate DRG for intestinal
statistical results from test data In the FY 2005 IPPS final rule (69 FR transplantation. While payment has
combined with clinical judgment. In 48976), we moved intestinal improved, the commenter stated that it
deciding whether to create a separate transplantation cases that were assigned is still inadequate, and insufficient
DRG, we consider whether the resource to ICD–9–CM procedure code 46.97 reimbursement could ultimately hinder
consumption and clinical characteristics (Transplant of intestine) out of DRG 148 beneficiary access to care.
of the patients with a given set of (Major Small and Large Bowel Response: As indicated in the FY
conditions are significantly different Procedures with CC) and DRG 149 2006 IPPS proposed rule (70 FR 23315),
than the remaining patients in the DRG. (Major Small and Large Bowel we found only three cases in the
We evaluate patient care costs using Procedures Without CC) and into DRG Medicare data that included an
average charges and lengths of stay as 480 (Liver Transplant). We also changed intestinal transplant. We found that the
proxies for costs and rely on the the title for DRG 480 to ‘‘Liver average charges were less for intestinal
judgment of our medical officers to Transplant and/or Intestinal transplant cases ($138,922) than liver
decide whether patients are distinct or Transplant.’’ We moved these cases out transplant cases ($165,314). Thus, even
clinically similar to other patients in the of DRGs 148 and 149 because our though we have a very low number of
DRG. In evaluating resource costs, we analysis demonstrated that the average cases to make these comparisons, the
consider both the absolute and charges for intestinal transplants are data do not suggest that intestinal
percentage differences in average significantly higher than the average transplants are underpaid in DRG 480.
charges between the cases we are charges for other cases in these DRGs. We remain committed to assigning
selecting for review and the remainder We stated at that time that we would procedures to the most appropriate DRG
of cases in the DRG. We also consider continue to monitor these cases. based on clinical coherence and
variation in charges within these Based on our review of the FY 2004 utilization of resources using the most
groups; that is, whether observed MedPAR data, we found 959 cases recently available data. As we stated in
average differences are consistent across assigned to DRG 480 with overall the FY 2005 IPPS final rule (69 FR
patients or attributable to cases that are average charges of approximately 48977), when we receive sufficient
extreme in terms of charges or length of $165,622. There were only three cases additional Medicare data on intestinal
stay, or both. Further, we also consider involving an intestinal transplant alone transplantation cases, we will again
the number of patients who will have a and one case in which both an intestinal consider the DRG assignment for
given set of characteristics and generally transplant and a liver transplant were intestinal transplants.
prefer not to create a new DRG unless performed. The average charges for the
it will include a substantial number of intestinal transplant cases ($138,922) Comment: One commenter concurred
cases. As we explain in more detail in were comparable to the average charges with the decision to assign intestinal
section IX. of this preamble, MedPAC for the liver transplant cases ($165,314), transplant cases to DRG 480 but
has made a number of recommendations while the remaining combination of an recommended that CMS create separate
regarding the DRG system. intestinal transplant and a liver DRGs for liver-intestinal and liver-
To date, we have not used specific transplant case had much higher kidney transplants. The commenter
statistical standards as part of our charges ($539,841), and would be paid requested that CMS report average
guidelines for determining when DRG as an outlier case. Therefore, we did not charges for these cases in the final rule.
changes are warranted. However, we propose any DRG modification for The commenter noted that DRGs have
could potentially establish objective intestinal transplantation cases for FY been created for double organ
guidelines that are used in the DRG 2006. transplants such as DRG 512
development process. For instance, such We note that an institution that (Simultaneous Pancreas/Kidney
standards could include a minimum performs intestinal transplantation, in Transplant).
percentage or absolute difference in correspondence to us written following Response: While the focus of our
average charges or length of stay and the publication of the FY 2005 IPPS review in the proposed rule was limited
number of cases in order for us to create final rule, agreed with our decision to to whether we should reassign intestinal
a DRG or change the DRG assignment of move cases assigned to code 46.97 to transplants to DRG 480, we reviewed all
a particular code or service. As part of DRG 480. cases in this DRG. Based on our review
our review and analysis of MedPAC’s Comment: Several commenters, of the FY 2004 MedPAR data, the
recommendations, we will consider including an institute that performs following table illustrates our findings:
Number of Average length Average

DRG cases of stay charges
DRG 480 .................................................................................................................................... 959 16.65 $165,622

Liver Transplantation ................................................................................................................. 876 16.5 165,314
Intestinal Transplantation ........................................................................................................... 3 26.0 138,922
Liver-Intestinal Transplantation .................................................................................................. 1 72.0 539,841
Liver-Kidney Transplantation ..................................................................................................... 79 21.3 237,759
As we stated in the proposed rule (70 the one liver-intestinal transplantation likely be paid as an outlier. One case is
FR 23315), while the average charges case, for which we had data, than the insufficient to create a new DRG.
and length of stay were much higher for other cases in DRG 480, the case would Similarly, we are reluctant to create a
new DRG for such a small number of patients who have a bleeding or requirements, increased diagnostic
liver-kidney transplant cases, even hemorrhagic stroke. Thrombolytic imaging costs, and increased laboratory
though average charges and length of therapy has been shown to be most and pharmacy costs. They also
stay are higher for liver-kidney effective when used within the first 3 demonstrated that these patients had
transplants than other cases in DRG 480. hours after the onset of a stroke, and it markedly better clinical outcomes. The
As discussed, in section IX.A. of this is contraindicated in hemorrhagic stroke representatives made two
final rule, we plan in the next year to stroke. The presence or absence of code suggestions concerning the stroke DRGs.
undertake a comprehensive review of 99.10 does not currently influence DRG The first proposal suggested
the existing Medicare DRG system and assignment. Since code 99.10 became modifying DRG 14 by renaming it
expect to make changes to the DRGs to effective, CMS has been monitoring the ‘‘Ischemic Stroke Treatment with a
better reflect the severity of illness. As DRGs and cases in which this code can Reperfusion Agent’’, and including only
we study this issue, we will further be found, particularly with respect to those cases containing code 99.10. The
analyze hospital costs for patients cardiac and stroke DRGs. remainder of stroke cases where the
needing multiple organ transplants. At Last year, CMS met with patient was not treated with a
this time, we are not making any further representatives from several hospital reperfusion agent would be included in
modifications to the DRGs for multiple stroke centers who recommended DRG 15, renamed ‘‘Hemorrhagic Stroke
transplants in FY 2006. modification of the existing stroke DRGs or Ischemic Stroke without a
14 (Intracranial Hemorrhage or Cerebral Reperfusion Agent’’. Hemorrhagic stroke
4. MDC 1 (Diseases and Disorders of the Infarction) and 15 (Nonspecific CVA
Nervous System) cases now found in DRG 14 that are not
and Precerebral Occlusion Without treated with a reperfusion agent would
a. Strokes Infarction) by using the administration
migrate to DRG 15.
of tPA as a proxy to identify patients
In 1996, the Food and Drug who have severe strokes. The The second suggestion was to leave
Administration (FDA) approved the use representatives stated that using tPA as DRGs 14 and 15 as they currently exist,
of tissue plasminogen activator (tPA), a proxy would help to identify patients and create a new DRG, with a
one type of thrombolytic agent that who have strokes that are more severely recommended title ‘‘Ischemic Stroke
dissolves blood clots. In 1998, the ICD– and costly and would recognize the Treatment with a Reperfusion Agent’’.
9–CM Coordination and Maintenance higher charges that these cases generate This suggested DRG would include only
Committee created code 99.10 (Injection because of their higher hospital resource cases where patients with strokes
or infusion of thrombolytic agent) in utilization. At that time, the presenters caused by arterial occlusion (or clot(s))
order to be able to uniquely identify the provided evidence that strokes where are also treated with tPA thrombolytic
administration of thrombolytic agents. tPA was used were both more severe therapy.
Studies have shown that tPA can be and more resource intensive. We have examined the MedPAR data
effective in reducing the amount of Specifically, they showed that patients for the cases in DRGs 14 and 15. We
damage the brain sustains during an who were given tPA for strokes had divided the cases based on the presence
ischemic stroke, which is caused by higher stroke severity scores at of a principal diagnosis of hemorrhage
blood clots that block blood flow to the presentation, and that they were more or occlusive ischemia and the presence
brain. tPA is approved for patients who expensive to care for because of of procedure code 99.10. The following
have blood clots in the brain, but not for increased intensive care unit monitoring table displays the results:
Average length Average

DRG Count of stay charges
14—All Cases ............................................................................................................................ 221,879 5.67 $18,997

14—Cases with intracranial hemorrhage .................................................................................. 41,506 5.40 19,193
14—Cases with intracranial hemorrhage with code 99.10 ....................................................... 61 7.4 37,045
14—Cases with intracranial hemorrhage without code 99.10 .................................................. 41,445 5.3 19,167
14—Cases without intracranial hemorrhage ............................................................................. 180,373 5.74 18,952
14—Cases without intracranial hemorrhage with code 99.10 .................................................. 2,085 7.20 35,128
14—Cases without intracranial hemorrhage without code 99.10 ............................................. 178,288 5.72 18,763
15—All cases ............................................................................................................................. 71,335 4.53 14,382
15—Cases with intracranial hemorrhage .................................................................................. 0 0 0
15—Cases without intracranial hemorrhage ............................................................................. 71,335 4.53 14,382
15—Cases without intracranial hemorrhage with code 99.10 .................................................. 302 5.10 24,876
15—Cases without intracranial hemorrhage without code 99.10 ............................................. 71,033 4.53 14,337
The above table shows that the reperfusion cases reported. However, we treated with a reperfusion agent as well
average standardized charges for cases stated that we believe it is possible that as the potential costs of these patients
treated with a reperfusion agent are more patients are being treated with a relative to others with strokes that are
more than $16,000 and $10,000 higher reperfusion agent than indicated by our also included in DRGs 14 and 15.
than all other cases in DRGs 14 and 15, data because the presence of code 99.10 Comment: Forty commenters
respectively. While these data suggest does not affect DRG assignment and supported the creation of a new DRG to
that patients treated with a reperfusion may be underreported. recognize the group of patients who
agent are more expensive than all other In the FY 2006 IPPS proposed rule, presented with stroke and who also
stroke patients, this conclusion is based we invited public comment on the received thrombolytic therapy. The
on a small number of cases. In the FY changes to DRGs 14 and 15 suggested by commenters cited the following reasons
2006 IPPS proposed rule, we did not the hospital representatives. In addition, for supporting this proposal: Increased
propose a change to the stroke DRGs we solicited public comment on the costs of caring for these patients,
because of the small number of number of patients currently being specifically in intensive care unit, more
diagnostic imaging studies, and have any Medicare charge information did not use it. Some hospitals in which
laboratory and pharmacy resources. In that supports creating separate DRGs for reperfusion therapy was commonplace
addition, the commenters noted that the hemorrhagic stroke patients treated with never used this code.
proposal is also supported by evidence hemostatic agents as we do for ischemic Response: We would like to take this
that patients receiving thrombolytic stroke patients treated with opportunity to reiterate that all cases
therapy have strokes of increased thrombolytic therapy. When hemostatic should be accurately and completely
severity. The commenters also stated agents are available on the market, we coded, irrespective of the DRG
that the proposal demonstrates the need will reevaluate this issue. implications of a specific code or codes.
for hospitals to have an incentive to Comment: One commenter believed By coding accurately and completely,
establish the infrastructure necessary to that the two potential changes to the we will have more information on
provide stroke patients with aggressive stroke DRGs as set forth in the proposed patient care costs for different services
evaluation and management services, rule are too limited as written. The and treatments that better enable us to
such as thrombolytic therapy, which commenter believed that the descriptor, research further changes to the DRG
have become the standard of care. ‘‘reperfusion agent’’, is not broad system.
Response: We appreciate the enough to encompass other promising Comment: One commenter noted that,
commenters’ responses in reply to our pharmacotherapies for stroke that are in because only a single type of
solicitation for public comment on the late stages of clinical development. The reperfusion agent is presently approved
changes to DRGs 14 and 15 as suggested commenter pointed out that these for stroke treatment, the proposed
in the proposed rule. The level of detail therapies include treatment for both change would create a DRG that is, de
provide in the responses helped us to ischemic stroke and hemorrhagic stroke. facto, product specific. In addition, the
formulate a change to the medical stroke The commenter further noted that it is commenter stated that the DRG change
DRGs. We agree with the commenters unlikely that any of the potential on which CMS requested comment
that there is an increased cost in caring therapies will be approved for use would improve access to therapy for
for these patients including increased during FY 2006. The commenter only a small fraction of all stroke
use of the intensive care unit, more recommended that CMS broaden the patients. The commenter added that
diagnostic imaging studies, and title for the proposed new DRG to implementation of a narrowly-defined
laboratory and pharmacy resources. We include a wider range of any newly change [by creating a specific stroke-
also agree that—(1) the data indicate approved therapies. plus-tPA DRG] may necessitate further
that patients receiving thrombolytic Response: While we look forward to changes to the stroke DRGs in the near
therapy have increased severity; and (2) improved therapies for treating patients future to ensure patient access to
reperfusion therapy is a good means to with strokes, we are unable to create emerging drug therapies once approved.
segregate these patients into a separate DRGs that recognize as yet unapproved Response: While we did not propose
DRG. treatment modalities. When the FDA a specific change to the stroke DRGs in
Comment: One commenter has approved additional the proposed notice, we have decided to
encouraged CMS to modify DRGs 14 pharmaceuticals for the treatment of modify the DRGs to distinguish those
and 15 using one of two options. The either ischemic or hemorrhagic stroke, cases in which tPA is used as a
first option would be to create DRG ‘‘A’’ we will evaluate the data and make DRG treatment modality based on the strong
where hemorrhagic and ischemic changes as appropriate. We point out support for this change voiced by
strokes were combined, but only that the DRG titles cannot possibly commenters. When we reviewed the
supportive care was given, while DRG acknowledge all the codes located data represented in the above table, we
‘‘B’’ would contain those hemorrhagic therein. The important part of the DRG noted that the average standardized
and ischemic stroke cases in which is the structure of the logic; that is, what charges for all cases in DRG 14 were
reperfusion or hemostatic agents were codes are assigned to the DRG. $18,997, but that the subset of 2,085
administered. Comment: One commenter cases in which tPA was used had
Alternatively, the commenter recommended that CMS commit to average standardized charges of
suggested that DRGs 14 and 15 could be creating a surgical DRG for ischemic $35,128. We noted that the cases in DRG
modified by creating four new DRGs. stroke patients who are treated with 14 without hemorrhage that did not
DRG ‘‘A’’ would contain cases of surgical interventions. The commenter report the use of tPA had average
hemorrhagic stroke and supportive care, included several scenarios of possible standardized charges of $18,763, which
DRG ‘‘B’’ would contain cases of diagnosis and procedure coding was comparable with the figures for all
hemorrhagic stroke treated with combinations that CMS could use to cases in the DRG. Given that these cases
hemostatic agents, DRG ‘‘C’’ would identify stroke cases and increase the are easily identifiable through the use of
contain cases of ischemic stroke and scope of our analysis. procedure code 99.10, and that the
supportive care, and DRG ‘‘D’’ would Response: Our goal was not to review average standardized charges are
contain cases of ischemic stroke treated all stroke cases within the MedPAR $16,131 higher for the cases using tPA,
with reperfusion agents. database, but to identify those cases in we decided to carve these cases out of
Response: This commenter is medical DRG 14, and possibly DRG 15, the existing DRGs 14 and 15, and
suggesting that the DRG system that might have included the represent them in a new DRG. We are
recognize treatment of hemorrhage administration of tPA as identified by changing the structure of stroke DRGs
strokes with hemostatic agents as well procedure code 99.10. DRGs that not to award higher payment for a
as ischemic strokes with reperfusion identify a precise surgical procedure specific drug but to recognize the need
agents. While we anticipate great already exist; all of the combinations of for better overall care for this group of
industry strides in the treatment of procedure codes suggested by the patients. Even though a tPA is indicated
stroke, currently no approved commenter already appropriately group only for a small proportion of stroke
hemostatic agent is on the market. to DRGs within MDC 1. patients (only those experiencing
According to the manufacturer(s) of Comment: One commenter stated that ischemic strokes treated within 3 hours
hemostatic agents, it is unlikely that because code 99.10 was not of the onset of symptoms), our data
these agents will be available for use reimbursable [did not have an impact on suggest that there are enough patients to
during FY 2006. Therefore, we do not DRG assignment], hospital coders often support the DRG change. While our goal
is to make payment relate more closely improvements in treatment and DRGs 1 and 2 and that the results of the
to resource use, we also note that use of technology. data do not justify creation of a new
a tPA in a carefully selected patient DRG. We believe that unruptured
b. Unruptured Cerebral Aneurysms
population will lead to better outcomes cerebral aneurysms are appropriately
and overall care and may lessen the In the FY 2004 IPPS final rule (68 FR assigned to DRGs 1 and 2. Therefore, we
need for postacute care. With regard to 45353), we created DRG 528 are not making any modifications to the
the potential need to modify stroke (Intracranial Vascular Procedures With a DRG assignment for unruptured cerebral
DRGs in the future, we note that we Principal Diagnosis of Hemorrhage) in aneurysms.
perform an update to the DRGs and MDC 1. We received a comment at that
time that suggested we create another 5. MDC 5 (Diseases and Disorders of the
modify DRGs every year. We reiterate
DRG for intracranial vascular Circulatory System)
that should additional types of therapy
be approved, we will evaluate them, and procedures for unruptured cerebral a. Severity Adjusted Cardiovascular
after judicious study, will make aneurysms. For the FY 2004 IPPS final Procedures
appropriate DRG title and/or logic rule (68 FR 45353) and the FY 2005
IPPS final rule (69 FR 48957), we In response to the FY 2006 IPPS
changes as required. proposed rule, one commenter noted
In this final rule, after consideration evaluated the data for cases in the
MedPAR file involving unruptured that section 507(c) of Pub. L. 108–173
of public comments received and based required MedPAC to conduct a study to
on our analysis of MedPAR data that cerebral aneurysms assigned to DRG 1
(Craniotomy Age >17 With CC) and DRG determine how the DRG system should
supports the creation of a DRG that be updated to better reflect the cost of
identifies embolic stroke combined with 2 (Craniotomy Age >17 Without CC) and
concluded that the average charges were delivering care in a hospital setting. The
tPA treatment, we are creating new DRG commenter noted that MedPAC reported
559 (Acute Ischemic Stroke with Use of consistent with those for other cases
found in DRGs 1 and 2. Therefore, we that the ‘‘cardiac surgery DRGs had high
Thrombolytic Agent). From a data relative profitability ratios.’’ While the
consistency standpoint, we believe that did not propose a change to the DRG
assignment for unruptured cerebral commenter noted that it may take time
adding a new DRG identifying these to conduct and complete a thorough
cases will be less disruptive to our aneurysms.
We have reviewed data for evaluation of the MedPAC payment
stakeholders than creating three new recommendations for all DRGs, the
unruptured cerebral aneurysms cases in
DRGs, two of which would mimic commenter strongly encouraged CMS to
DRGs 1 and 2. In our analysis of these
existing DRGs 14 and 15. The GROUPER FY 2004 MedPAR data, we found 1,136 revise the cardiac DRGs through patient
logic for DRGs 14 and 15 will not be unruptured cerebral aneurysm cases severity refinements as part of the final
affected by this change; that is, the assigned to DRG 1 and 964 unruptured rule to be effective for FY 2006. In
GROUPER content of DRGs 14 and 15 cerebral aneurysm cases assigned to section IX.A. of the preamble to this
will be the same in FY 2006 as it was DRG 2. Although the average charges for final rule, we are responding in detail to
in FY 2005. The structure of the new the unruptured cerebral aneurysm cases this comment by making significant
DRG 559 includes the following codes: in DRG 1 ($53,455) and DRG 2 ($34,028) revisions to a number of cardiovascular
Principal Diagnosis were slightly higher than the average DRGs that currently contain patients
charges for all cases in DRG 1 ($51,466) with a wide range of severity and
• 433.01, Occlusion and stenosis of and DRG 2 ($30,346), we do not believe resource consumption in order to reflect
basilar artery, with cerebral infarction these differences are significant enough more accurately the resources required
• 433.11, Occlusion and stenosis of to warrant a change in these two DRGs to care for different kinds of
carotid artery, with cerebral infarction at this time. Therefore, we did not cardiovascular patients. Accordingly, in
• 433.21, Occlusion and stenosis of propose a change in the structure of response to the issues raised by the
vertebral artery, with cerebral infarction these DRGs relating to unruptured commenter and as an interim step until
• 433.31, Occlusion and stenosis of cerebral aneurysm cases for FY 2006. we can complete a comprehensive
multiple and bilateral arteries, with Comment: Several commenters agreed review of MedPAC’s recommendations,
cerebral infarction that the minimal differences in charges we are deleting current DRGs 107, 109,
• 433.81, Occlusion and stenosis of for unruptured cerebral aneurysms cases 111, 116, 478, 516, 517, 526, and 527,
other specified precerebral artery, with compared to all cases assigned to DRGs and creating new DRGs 547 through 558
cerebral infarction 1 and 2 do not justify a change in the in their place.
• 433.91, Occlusion and stenosis of DRG assignment for these cases. One We received several comments on the
unspecified precerebral artery, with commenter stated that unruptured FY 2006 IPPS proposed rule that
cerebral infarction cerebral aneurysm cases should be recommended that we split additional
• 434.01, Cerebral thrombosis, with reclassified into a new DRG. The cardiovascular DRGs based on the
cerebral infarction commenter stated that a new DRG is presence or absence of heart failure,
• 434.11, Cerebral embolism, with warranted to understand the true weight acute myocardial infarction, and shock.
cerebral infarction of these procedures and to establish As indicated in section IX.A. of this
• 434.91, Cerebral artery occlusion, reimbursement that recognizes the cost final rule, we conducted a focused
unspecified, with cerebral infarction of medical devices used to treat review of a number of different
and unruptured cerebral aneurysms. cardiovascular DRGs and are making
Response: Our analysis is based on revisions to them based on a newly
Nonoperating Room Procedure the most recent charge information designated list of ‘‘major cardiovascular
• 99.10, Injection or infusion of available reflecting the overall resources conditions.’’
thrombolytic agent used to treat unruptured cerebral We believe these new DRGs will help
We will continue to monitor stroke aneurysms in Medicare patients. We to address a number of the concerns
DRGs in the future. As noted above, concur with the commenters that there raised by these commenters. We intend
should treatment modalities change, we are minimal differences in the charges to monitor these DRGs carefully in
will be open to making changes to the for the unruptured cerebral aneurysm upcoming years and welcome input
DRG structure that will recognize cases compared to all cases assigned to regarding the success of these DRGs in
reflecting patient severity and resource DRG 536 (Cardiac Defibrillator Implant catheterization. Code 37.26 is classified
use. With Cardiac Catheterization Without as a cardiac catheterization within these
Acute Myocardial Infarction, Heart DRGs. Therefore, the submission of code
b. Automatic Implantable Cardioverter/
Failure, or Shock) 37.26 affects the DRG assignment for
Defibrillator
While conducting our review, we defibrillator cases and leads to the
As part of our annual review of DRGs, noted that there had been considerable assignment of DRGs 535 or 536. When
for FY 2006, we performed a review of comments from hospital coders on code a cardiac catheterization is performed,
cases in the FY 2004 MedPAR file 37.26 (Cardiac electrophysiologic the case is assigned to DRGs 535 or 536,
involving the implantation of a stimulation and recording studies depending on whether or not the patient
defibrillator in the following DRGs: (EPS)), which is included in these also had an acute myocardial infarction,
DRG 515 (Cardiac Defibrillator Implant DRGs. These comments from hospital heart failure, or shock. The following
Without Cardiac Catheterization) coders were directed to both CMS and chart shows the number of cases in each
DRG 535 (Cardiac Defibrillator Implant the American Hospital Association. The
DRG, along with their average length of
With Cardiac Catheterization With procedure codes for these three DRGs
stay and average charges, found in the
Acute Myocardial Infarction, Heart describe the procedures that are
data:
Failure, or Shock) considered to be a cardiac
Number of Average Average

DRG cases length of stay charges
515 ............................................................................................................................................... 25,236 4.32 $83,659.76

535 ............................................................................................................................................... 12,118 8.27 113,175.43
536 ............................................................................................................................................... 18,305 5.39 94,453.62
We have received a number of defibrillator code 37.94 (Implantation or be reported with an AICD insertion. A
questions from hospital coders replacement of automatic cardioverter/ report of this meeting can be found on
regarding the correct use of code 37.26. defibrillator, total system [AICD]) which the Web site: http://www.cms.hhs.gov/
There is considerable confusion about states that EPS is included in code paymentsystem/icd9.
whether or not code 37.26 should be 37.94. We discussed modifying this
We performed an analysis of cases
reported when the procedure is instruction at the October 7–8, 2004
within DRGs 535 and 536 with cardiac
performed as part of the defibrillator meeting of the ICD–9–CM Coordination
implantation. Currently, the ICD–9–CM and Maintenance Committee. We catheterization and with and without
instructs the coder not to report code received a number of comments code 37.26 and with code 37.26 only
37.26 when a defibrillator is inserted. opposing a modification to the use of reported without cardiac catheterization
There is an inclusion term under the code 37.26 that would also allow it to and found the following:

DRG cases length-of-stay charges
535—Cardiac Catheterization Without Code 37.26 .................................................................... 5,060 10.63 $127,130.79

535—With Code 37.26 Only Without Cardiac Catheterization ................................................... 5,264 5.61 98,900.13
535—With Cardiac Catheterization and Code 37.26 .................................................................. 1,794 9.44 115,701.09
536—Cardiac Catheterization Without Code 37.26 .................................................................... 4,799 8.11 110,493.86
536—With Code 37.26 Only Without Cardiac Catheterization ................................................... 10,829 3.85 85,390.88
536—With Cardiac Catheterization and Code 37.26 .................................................................. 2,677 6.76 102,359.21
The data show that when code 37.26 inappropriate to base a defibrillator DRG cardiac catheterizations for DRGs 535
is the only procedure reported from the assignment on the EPS code. Cases and 536. If a defibrillator is implanted
list of cardiac catheterizations, the identified with this code capture and an EPS is performed with no other
average charges and the average length patients who require less resource use type of cardiac catheterization, the case
of stay are considerably lower. For than patients who have a cardiac would be assigned to DRG 515.
example, the average standardized catheterization. CMS issued a National Coverage
charges for a defibrillator implant with Data reflected in the chart above show Determination for implantable
only an EPS are $85,390.88 in DRG 536, that the average standardized charges cardioverter defibrillators, effective
while the average standardized charges for DRG 515 were $83,659.76. These January 27, 2005, that expands coverage
for DRG 536 with a cardiac average charges are closer to those in and requires, in certain cases, that
catheterization, but not an EPS, are DRG 536 with code 37.26 and without patient data be reported when the
$110,493.86. The average standardized any other cardiac catheterization code defibrillator is implanted for the clinical
charges for all cases in DRG 536 are reported. While the cases in DRG 535 indication of primary prevention of
$94,453.62. The data show similar with code 37.26 and without a cardiac sudden cardiac death. The submission
findings for DRG 535, with lower catheterization have higher average of data on patients receiving an
lengths of stay and average charges charges than the average charges for implantable cardioverter defibrillator for
when the only code reported from the cases in DRG 515, these cases have primary prevention to a data collection
cardiac catheterization list is an EPS. much lower average charges than the system is needed for the determination
When we also consider the average charges for overall cases in DRG that the implantable cardioverter
acknowledged coding problems in the 535. For these reasons, we proposed to defibrillator is reasonable and necessary
use of code 37.26, we believe it is remove code 37.26 from the list of and for quality improvement. These
data will be made available in some a variety of disparate procedures with and 536. It is our experience that most
form to providers and practitioners to varying purposes, sites of service, and of these patients will not be receiving a
inform their decisions, monitor intensity, and that the resultant data are cardiac catheterization and will be less
performance quality, and benchmark not representative of any one of these. resource-intensive than the acute heart
and identify best practices. We made a Other commenters stated that the code failure patients receiving an implantable
temporary registry available for use contains three separate procedures of defibrillator. We note that the Bernstein
when the policy became effective and varying intensity: Electrophysiology Research Call publication of April 27,
used the Quality Net Exchange for data study, intraoperative device 2005 stated that this DRG change could
submission because Medicare- interrogation, and noninvasive ‘‘dampen the elective implantation of
participating hospitals already use the programmed stimulation. Several de-novo CRT–D or dual chamber
Exchange to report data. commenters believed that the payment devices into relatively stable patients.’’
We intend to transition from the change would have a severe financial The article further states that CMS
temporary registry using the Quality Net impact on their hospitals. They believed ‘‘realizes that the new prophylactic ICD
Exchange to a more sophisticated it is inappropriate to make the change [implantable cardioverter defibrillators]
follow-on registry that will have the without the data to justify the change. eligibility requirements do not require
ability to collect longitudinal data. Several commenters stated that the an EP test, and that EP tests per se do
Some providers have suggested that change would have a significant impact not consume sufficient resources to
CMS increase reimbursement for on the use of CRT–D implants because justify the reimbursement differentials
implantable cardioverter defibrillators the devices are more costly. The seen between DRGs 515 versus 535 and
to compensate the provider for reporting commenters suggested that, before 536.’’ We believe it is particularly
data. ICD data reporting includes considering a revision to DRGs 535 and important to make the change to DRGs
elements of patient demographics, 536 for code 37.26, CMS should resolve 515, 535, and 536 at this time, given the
clinical characteristics and indications, the coding confusion. The commenters expansion of Medicare coverage of
medications, provider information, and asked that the code be discussed at the implantable defibrillators and the
complications. Since these data September 29, 2005 ICD–9–CM evidence that suggests that patients who
elements are commonly found in patient Coordination and Maintenance receive an EP test, but not a cardiac
medical records, it is CMS’ expectation Committee meeting and suggested that catheterization, are less expensive than
that these data are readily available to separate codes be created for the other patients receiving these devices.
the individuals abstracting and different procedures currently captured We will address code 37.26 at our
reporting data. Therefore, we believe by code 37.26. According to the September 29–30, 2005 meeting of the
that increased reimbursement is not commenters, the new codes that are ICD–9–CM Coordination and
needed at this time. created could go into effect on October Maintenance Committee meeting. The
Comment: One commenter stated that 1, 2006. The commenters suggested that, public is encouraged to participate in
there has been considerable confusion once data are available, CMS should this meeting and offer suggestions for
surrounding the use of code 37.26. The consider a revision to DRGs 535 and 536 code modifications. Information on this
commenter indicated that coders are for EPS procedures. meeting can be found at: http://
unclear whether code 37.26 should be Response: We agree with the
reported when an electrophysiologic www.cms.hhs.gov/paymentsystems/
commenter that there is considerable
study (EPS) is performed as part of a icd9.
confusion regarding the use of code
defibrillator implantation or only when 37.26. It is possible that code 37.26 is Comment: Five commenters stated
defibrillator device checks are being used for a variety of that CMS’ data show that the average
performed. The commenter pointed out electrophysiologic procedures such as charges for cases with code 37.26 are
that the continuing efforts of the EPS, noninvasive programmed electrical significantly higher than those in DRG
Editorial Advisory Board for Coding stimulation, and programmed electrical 515. The commenters suggested that the
Clinic to clarify the use of this code stimulation. However, as indicated in volume of cases is significant enough to
have led to changes in coding advice the proposed rule and above in this final create a new DRG for cases with cardiac
published in Coding Clinic for ICD–9– rule, our data show that the cases coded defibrillator implant without cardiac
CM by the American Hospital with 37.26 that were not separately catheterization, but with code 37.26.
Association. However, the commenter coded with a cardiac catheterization had Response: Given the extensive
stated, while the change in coding average charges of $98,900.13 in DRG comments concerning coding problems
advice was intended to clarify use of 535 and $85,390.88 in DRG 536 with code 37.26, we do not believe it is
code 37.26, coders continue to have compared to $127,130.79 and appropriate to create a new DRG that
questions about it. The commenter $110,493.86, respectively, for all other would specifically capture defibrillator
supported our proposal to remove code cases in these DRGs. For this reason, we implants with this code. Therefore, we
37.26 from the list of cardiac believe it is appropriate to include code are not creating the suggested new DRG
catheterizations for DRGs 535 and 536 37.26 in DRG 515 and no longer assign at this time. As stated earlier, we will
and agreed with CMS’ plans to continue it to DRGs 535 and 536 that are for continue to work with the coding and
working to clarify use of this code or patients who receive a cardiac health care community to modify code
modify the code through the ICD–9–CM catheterization. 37.26 so that it will lead to more
Coordination and Maintenance As we discussed earlier in this section consistent reporting. Once we have
Committee. The commenter suggested of the preamble, Medicare significantly better data, we will evaluate additional
that, once the coding issues are resolved expanded coverage of implantable DRG modifications.
and consistent data are collected, CMS defibrillators on January 27, 2005 (Pub. After consideration of the public
should reexamine the DRG No. 100–3, section 20.4) to patients who comments received on the proposed
assignment(s) for code 37.26. have a prior history of heart disease but rule, in this final rule, we are
Other commenters opposed our are not in acute heart failure. These implementing the modification of DRGs
proposal to remove code 37.26 from prophylactic defibrillator implants are 535 and 536 as proposed for FY 2006.
DRGs 535 and 536. These commenters expected to significantly increase the We are removing code 37.26 from the
stated that code 37.26 is used to capture number of patients in DRGs 515, 535, list of cardiac catheterizations for DRGs
535 and 536 and adding the code in reflect the exact number of procedures procedures such as multiple vessel
DRG 515. performed or the exact number of vessels angioplasty or atherectomy (as evidenced by
treated. Similarly, when codes 36.06 and the presence of procedure code 36.05), as
c. Coronary Artery Stents 36.07 are used, they document the insertion indicators of complex cases for this purpose.
In the FY 2005 IPPS final rule (69 FR of at least one stent. However, these stenting Specifically, the commenters recommended
codes do not identify how many stents were replacing the current structure with the
48971 through 48974), we addressed inserted in a procedure, nor distinguish following four DRGs:
two comments from industry insertion of a single stent from insertion of • Recommended restructured DRG 516
representatives about the DRG multiple stents. Even the use of one of the (Complex percutaneous cardiovascular
assignments for coronary artery stents. stenting codes in conjunction with multiple- procedures with non-drug-eluting stents).
These commenters had expressed PTCA code 36.05 does not distinguish • Recommended restructured DRG 517
concern about whether the insertion of a single stent from multiple (Noncomplex percutaneous cardiovascular
reimbursement for stents is adequate, stents. The use of code 36.05 in conjunction procedures with non-drug-eluting stents).
with code 36.06 or code 36.07 indicates only • Recommended restructured DRG 526
especially for insertion of multiple (Complex percutaneous cardiovascular
performance of PTCA in more than one
stents. They also expressed concern procedures with drug-eluting stents).
vessel, along with insertion of at least one
about whether the current DRG stent. The precise numbers of PTCA-treated • Recommended restructured DRG 527
structure represents the most clinically vessels, the number of vessels into which (Noncomplex percutaneous cardiovascular
coherent classification of stent cases. In stents were inserted, and the total number of procedures with drug-eluting stents).
the FY 2006 proposed rule (70 FR 23318 stents inserted in all treated vessels cannot be The commenter argued that this structure
through 23319), we included the determined. Therefore, the capabilities of the would provide an improvement in both
current coding structure do not permit the clinical and resource coherence over the
following discussion regarding the
distinction between single and multiple current structure that classifies cases
commenter’s concerns: according to the type of stent inserted and
vessel stenting that would be required under
The current DRG structure incorporates the recommended restructuring of the the presence or absence of AMI alone,
stent cases into the following two pairs of coronary stent DRGs. without considering other complicating
DRGs, depending on whether bare metal or We agree that the DRG classification of conditions. The commenter also presented an
drug-eluting stents are used and whether cases involving coronary stents must be analysis, based on previous MedPAR data,
acute myocardial infarction (AMI) is present: clinically coherent and provide for adequate that evaluated charges and lengths of stay for
• DRG 516 (Percutaneous Cardiovascular reimbursement, including those cases cases with expected high resource use and
Procedures with AMI) requiring multiple stents. For this reason, we reclassified cases into its recommended new
• DRG 517 (Percutaneous Cardiovascular created four new ICD–9–CM codes structure of paired ‘‘complex’’ and
Procedures with Nondrug-Eluting Stent identifying multiple stent insertion (codes ‘‘noncomplex’’ DRGs. The commenter’s
without AMI) 00.45, 00.46, 00.47, and 00.48) and four new analysis showed some evidence of clinical
• DRG 526 (Percutaneous Cardiovascular and resource coherence in the recommended
codes identifying multiple vessel treatment
Procedures with Drug-Eluting Stent with DRG structure. However, we did not adopt
(codes 00.40, 00.41, 00.42, and 00.43) at the
AMI) the proposal in the FY 2005 IPPS final rule.
October 7, 2004 ICD–9–CM Coordination and
• DRG 527 (Percutaneous Cardiovascular First, the data presented by the commenter
Maintenance Committee Meeting. These
Procedures with Drug-Eluting Stent without still represented preliminary experience
AMI) eight new codes can be found in Table 6B of
under a relatively new DRG structure.
The commenters presented two this proposed rule. We have worked closely
Second, the analysis did not reveal
recommendations for refinement and with the coronary stent industry and the
significant gains in resource coherence
restructuring of the current coronary stent clinical community to identify the most
compared to existing DRGs for stenting cases.
DRGs. One of the recommendations involved logical code structure to identify new codes
Therefore, we were reluctant to adopt this
restructuring these DRGs to create two for both multiple vessel and multiple stent
approach because of comments and concern
additional stent DRGs that are closely use. Effective October 1, 2005, code 36.05
about whether the overall level of payment
patterned after the existing pairs, and would will be deleted and the eight new codes will
in the coronary stent DRGs was adequate.
reflect insertion of multiple stents with and be used in its place. Coders are encouraged
However, we indicated that this issue
without AMI. The commenters recommended to use as many codes as necessary to describe
deserved further study and consideration,
incorporating either stenting code 36.06 each case, using one code to describe the and that we would conduct an analysis of
(Insertion of nondrug-eluting coronary artery angioplasty or atherectomy, and one code this recommendation and other approaches
stent(s)) or code 36.07 (Insertion of drug- each for the number of vessels treated and to restructuring these DRGs with updated
eluting coronary artery stent(s)) when they the number of stents inserted. Coders are data in the FY 2006 proposed rule.’’
are reported along with code 36.05 (Multiple encouraged to record codes accurately, as
vessel percutaneous transluminal coronary these data will potentially be the basis for In response to those comments, we
angioplasty [PTCA] or coronary atherectomy future DRG restructuring. While we agree analyzed the MedPAR data to determine
performed during the same operation, with or that use of multiple vessel and stent codes the impact of certain secondary
without mention of thrombolytic agent). The will provide useful information in the future diagnoses or complicating conditions on
commenter’s first concern was that hospitals on hospital costs associated with the four stent DRGs. Specifically, we
may be steering patients toward coronary percutaneous coronary procedures, we examined the data in DRGs 516, 517,
artery bypass graft surgery in place of believe it remains premature to proceed with
a restructuring of the current coronary stent
526, and 527, based on the presence of
stenting in order to avoid significant
DRGs on the basis of the number of vessels coronary stents (codes 36.06 and 36.07)
financial losses due to what it considered the
inadequate reimbursement for inserting treated or the number of stents inserted, or and the following additional diagnoses:
multiple stents. both, in the absence of data reflecting use of • Congestive heart failure
In our response to comments in the FY this new coding structure. The commenter’s (represented by codes 398.91
2005 IPPS final rule, we indicated that it was second recommendation was that we (Rheumatic heart failure (congestive)),
premature to act on this recommendation distinguish ‘‘complex’’ from ‘‘noncomplex’’ 402.01 (Hypertensive heart disease,
because the current coding structure for cases in the stent DRGs by expanding the malignant, with heart failure), 402.11,
coronary artery stents cannot distinguish higher weighted DRGs (516 and 526) to (Hypertensive heart disease, benign,
cases in which multiple stents are inserted include conditions other than AMI. The with heart failure), 402.91 (Hypertensive
from those in which only a single stent is commenter recommended recognizing
inserted. Current codes are able to identify certain comorbid and complicating
heart disease, unspecified, with heart
performance of PTCA in more than one conditions, including hypertensive renal failure), 404.01 (Hypertensive heart and
vessel by use of code 36.05. However, while failure, congestive heart failure, diabetes, renal disease, malignant, with heart
this code indicates that PTCA was performed arteriosclerotic cardiovascular disease, failure), 404.03 (Hypertensive heart and
in more than one vessel, its use does not cerebrovascular disease, and certain renal disease, malignant, with heart
failure and renal failure), 404.11 wall, initial episode of care), 410.51 higher average charges, but the same
(Hypertensive heart and renal disease, (Acute myocardial infarction of other argument could be raised for many other
benign, with heart failure), 404.13 lateral wall, initial episode of care), procedures across other MDCs.
(Hypertensive heart and renal disease, 410.61 (True posterior wall infarction, Generally, we have taken into account
benign, with heart failure and renal initial episode of care), 410.71 the higher costs of cases with
failure), 404.91 (Hypertensive heart and (Subendocardial infarction, initial complications by maintaining a general
renal disease, unspecified, with heart episode of care), 410.81 (Acute list of comorbidities and complications
failure), 404.93 (Hypertensive heart and myocardial infarction of other specified (the CC) list), and, where appropriate,
renal disease, unspecified, with heart sites, initial episode of care), 410.91 distinguishing pairs of DRGs by ‘‘with
failure and renal failure), 428.0 (Acute myocardial infarction of and without CCs.’’ (This system also
(Congestive heart failure, unspecified), unspecified site, initial episode of specifies exclusions from each pair, to
and 428.1 (Left heart failure)). care)). account for cases where a condition on
• Arteriosclerotic cardiovascular • Renal failure (represented by codes
the CC list is an expected and normal
disease (represented by code 429.2 403.01 (Hypertensive renal disease,
constituent of the diagnoses reflected in
(Cardiovascular disease, unspecified)). malignant, with renal failure), 403.11
• Cerebrovascular disease (Hypertensive renal disease, benign, the paired DRGs.)
(represented by codes 430 with renal failure), 403.91 (Hypertensive Thus, we proposed to restructure the
(Subarachnoid hemorrhage), 431 renal disease, unspecified, with renal coronary stent DRGs on the basis of the
(Intracerebral hemorrhage), 432.0 failure), 585 (Chronic renal failure), standard CC list to differentiate cases
(Nontraumatic extradural hemorrhage), V42.0 (Organ or tissue replaced by that require greater resources. We
432.1, Subdural hemorrhage, 432.9, transplant, kidney), V45.1 (Renal believed this list to be more inclusive of
(Unspecified intracranial hemorrhage), dialysis status), V56.0 (Extracorporeal true comorbid or complicating
433.01 (Occlusion and stenosis of dialysis), V56.1 (Fitting and adjustment conditions than selection of specific
basilar artery, with cerebral infarction), of extracorporeal dialysis catheter), secondary diagnosis codes. Therefore,
433.11 (Occlusion and stenosis of V56.2 (Fitting and adjustment of we anticipated that restructuring these
carotid artery, with cerebral infarction), peritoneal dialysis catheter)). Any renal DRGs on this basis would result in a
433.21 (Occlusion and stenosis of failure with congestive heart failure will logical arrangement of cases with regard
vertebral artery, with cerebral be captured in the 404.xx codes listed to both clinical coherence and resource
infarction), 433.31 (Occlusion and above. consumption. We compared the existing
stenosis of multiple and bilateral We reviewed the cases in the four CC list with the list of the codes
precerebral arteries, with cerebral coronary stent DRGs and found that recommended by the commenter as
infarction), 433.81 (Occlusion and most of the additional or ‘‘complicated’’ secondary diagnoses. All of the
stenosis of other specified precerebral cases did, in fact, have higher average recommended codes already appear on
artery, with cerebral infarction), 434.01 charges in most instances. However, the CC list except for codes 429.2, 432.9,
(Cerebral thrombosis with cerebral these results could potentially be V56.1, and V56.2. Code 429.2 represents
infarction), 434.11 (Cerebral embolism duplicated for many DRGs, or sets of a very vague diagnosis (arteriosclerotic
with cerebral infarction), 434.91 DRGs, within the PPS structure. That is, cardiovascular disease (ASCVD)). Code
(Cerebral artery occlusion with cerebral cases with selected complicating factors 432.9 represents a nonspecific principal
infarction, unspecified), 436 (Acute, but will tend to have higher average lengths diagnosis that is rejected by the MCE
ill-defined, cerebrovascular disease)). of stay and average charges than cases when reported as the principal
• Secondary diagnosis of acute without those complicating factors. diagnosis. Codes V56.1 and V56.2
myocardial infarction (represented by Because cases with the selected describe conditions relating to dialysis
codes 410.01 (Acute myocardial complicating factors necessarily contain for renal failure. Therefore, we believe
infarction of anterolateral wall, initial sicker patients, longer lengths of stay that our proposal to utilize the existing
episode of care), 410.11 (Acute and higher average charges are to be CC list encompassed most of the cases
myocardial infarction of other anterior expected. For example, cases in which on the recommended list, as well as
wall, initial episode of care), 410.21 patients with a cardiac condition also other cases with additional CCs
(Acute myocardial infarction of have renal failure are quite likely to requiring additional resources. We
inferolateral wall, initial episode of consume higher resources than patients examined the MedPAR data for the
care), 410.31 (Acute myocardial only with a cardiac condition. The cases in the coronary stent DRGs,
infarction of inferoposterior wall, initial presence of code 403.11 (Hypertensive distinguishing cases that include CCs
episode of care), 410.41 (Acute renal disease, malignant, with renal and those that do not. The following
myocardial infarction of other inferior failure) may distinguish cases with table displays the results:
Number of Average length- Average

DRG cases of-stay charges
DRG 516—All Cases ................................................................................................................. 37,325 4.79 $40,278

DRG 516 Cases With CC .......................................................................................................... 25,806 5.5 43,691
DRG 516 Cases Without CC ..................................................................................................... 11,519 3.0 32,631
DRG 517—All Cases ................................................................................................................. 64,022 2.58 32,145
DRG 517 Cases With CC .......................................................................................................... 50,960 2.8 33,178
DRG 526—All Cases ................................................................................................................. 51,431 4.36 45,924
DRG 526 Cases With CC .......................................................................................................... 32,904 5.2 49,751
DRG 527—All Cases ................................................................................................................. 176,956 2.23 36,087
DRG 527 Cases With CC .......................................................................................................... 137,641 2.4 37,142
The data show a clear differentiation access to stent procedures is on their proper use. In addition, CMS’
in average charges between the cases in discouraged. MedLearn site at http://
DRG 516 and 526 ‘‘with CC’’ and those Response: We created new ICD–9–CM www.cms.hhs.gov/medlearn/
‘‘without CC.’’ Therefore, the data procedure codes effective for discharges icd9code.asp#top contains coding
suggested that a ‘‘with and without CC’’ on or after October 1, 2005, to capture information.
split in DRG 516 and 526 was both the number of stents inserted and Comment: One commenter
warranted. At the same time, the data the number of vessels treated. Absent recommended that the use of the eight
did not show such a clear accurate charge data, we cannot predict new codes describing number of vessels
differentiation, in either average charges the correct relative weight for a DRG and number of stents be used on both
or lengths of stay, among the cases in containing more than one stent. We coronary and peripheral vessels.
DRGs 517 and 527. reiterate that we will continue to Response: The note that will appear at
As a result of this analysis, in the monitor the MedPAR data, and will the top of the 00.4 (Adjunct Vascular
proposed rule, we had originally make future evidence-based changes to System Procedures) section of Tabular
proposed to delete DRGs 516 and 526, the DRG structure and logic as section of the ICD–9–CM Procedure
and to substitute four new DRGs in their warranted. Coding Book will read as follows:
place. These new DRGs were to have Comment: Several commenters ‘‘These codes can apply to both
been patterned after existing DRGs 516 supported the maintenance of separate coronary and peripheral vessels. These
and 526, except that they would be split reimbursement structures for drug- codes are to be used in conjunction with
based on the presence or absence of a eluting stents and recommended that we other therapeutic procedure codes to
secondary diagnosis on the existing CC continue to separate drug-eluting and provide additional information on the
list. Specifically, we intended to create bare metal stents in different DRGs until number of vessels upon which a
DRG 547 (Percutaneous Cardiovascular such time as the bare metal stents procedure was performed or the number
Procedure with AMI with CC), DRG 548 represent an insignificant proportion of of stents inserted, or both. As
(Percutaneous Cardiovascular Procedure the total coronary stent discharges. appropriate, hospitals should code both
with AMI without CC), DRG 549 Response: We recognize that the the number of vessels operated on
(Percutaneous Cardiovascular Procedure resources surrounding bare metal stents (00.40 through 00.43) and the number of
with Drug-Eluting Stent with AMI with and drug-eluting stents differ stents inserted (00.45 through 00.48).
CC), and DRG 550 (Percutaneous appreciably and will continue to keep Comment: One commenter stated that
Cardiovascular Procedure with Drug- these cases separate from each other by the time CMS gets data on the eight
Eluting Stent with AMI without CC). As until such time as it is appropriate, new codes, it will be FY 2008, and
we noted above, the MedPAR data did according to the evidence provided in hospitals will have had inadequate
not support restructuring DRGs 517 and our MedPAR data, that these cases can reimbursement for multiple stents until
527 based on the presence or absence of be combined. then. The commenter suggested that
a CC. Therefore, we proposed to retain Comment: Several commenters CMS incorporated additional payment
these two DRGs in their current forms. supported CMS’ proposal to create eight for multiple stents and multiple vessels
We believed this revised structure new procedure codes; four codes treated into the FY 2007 weights.
would result in a more inclusive and describing the number of vessels treated Response: We will follow the use of
comprehensive array of cases within and four codes describing the number of these codes, but may not be prepared to
MDC 5 without selectively recognizing stents inserted. In addition, two make any DRG changes based on their
certain secondary diagnoses as commenters suggested that CMS should use with only one year’s worth of data.
‘‘complex.’’ issue a separate communication Comment: One commenter stated that
We received a number of comments reiterating the correct use of these DRGs should not be restructured for
on the proposed restructuring of DRGs codes. multiple stent insertion without
516, 517, 526, and 527 in the FY 2006 Response: We take this opportunity to adequate data to support our
IPPS proposed rule. clear up a misconception. The codes decisionmaking process.
Comment: All of the commenters published in Tables 6A through 6F are Response: We agree and intend to
approved of the proposed restructuring not proposed codes. They are final closely follow the use of these eight new
of these DRGs, especially with regard to codes, and as such, are not subject to codes in the MedPAR data.
dividing DRGs 516 and 526 on the basis comment. Absent any typographical Comment: One commenter was not
of the presence or absence of errors or late changes to the codes, they convinced that the proposed new
complicating secondary diagnoses. may be considered available for use on structure of DRGs 516 and 526, with and
Response: We appreciate the October 1 of the following fiscal year. without comorbidities and
comments submitted in support of this This year, because of the changes made complications should be the permanent
proposal. by the March 31, 2005 and April 1, 2005 solution for all coronary stent DRGs.
Comment: One commenter noted that ICD–9–CM Coordination and This commenter agreed that the new
the average patient receives 1.5 stents, Maintenance Committee, the codes in structure of these DRGs should not
and expressed the desire for CMS to the proposed rule were not as complete preclude subsequent restructuring of the
begin ‘‘appropriate reimbursement’’ in as those codes published in this final stent DRGs.
FY 2006, consistent with the additional rule. The codes contained in Tables 6A Response: We agree that restructuring
expense involved when multiple stents through 6F of this final rule include all DRGs 516 and 526 in the proposed
are inserted. One commenter remained new codes for FY 2006, which will go manner might not be a permanent
concerned that the DRG weights into effect on October 1, 2005. solution for classifying all stent DRGs.
significantly underestimate the true CMS partners with the American However, we have now decided not to
costs of performing drug-eluting stent Hospital Association with regard to adopt the proposed restructuring of
procedures, especially for multiple correct coding advice published in the DRGs 516 and 526 that was described in
vessel, multiple stent procedures, and Coding Clinic for ICD–9–CM. AHA’s the proposed rule. We have now
expressed concern that the proposed fourth edition of the year always determined that it is appropriate to
relative weights could result in financial includes the new codes for the restructure nine DRGs in MDC 5,
losses for hospitals, with the result that upcoming year and includes examples including DRGs 516, 517, 526, and 527,
on the basis of the presence or absence Procedural Terminology (CPT) coding restructure the coronary stent DRGs
of a major cardiovascular condition. We structure, which is the basis upon based on the number of vessels treated.
are making this change in the DRG which physicians are paid. We will continue to monitor and
structure in response to public Accordingly, in this final rule, for FY analyze clinical and resource trends in
comments concerning our response to 2006, we are deleting DRGs 516, 517, this area. For example, we have found
MedPAC’s recommendations to better 526, and 527 for percutaneous indications in the current data that
recognize severity in the DRG system. placement of both drug-eluting and treatment may be moving toward use of
The full text of the changes we are nondrug-eluting stents. We are creating drug-eluting stents, and away from use
making to the cardiovascular DRG, four new DRGs in their places. Rather of bare metal stents. Specifically, cases
including the coronary artery stent than divide these DRG pairs based on in DRGs 516 and 517, which utilize bare
DRGs, can be found in section IX.A. of whether the patient had an acute metal stents, comprise only 44.4
this final rule. myocardial (AMI), we are splitting each percent, or less than half, of the cases in
Comment: One commenter requested pair of DRGs based on the presence or the four coronary stent DRGs in the
that CMS adopt an ICD–9–CM code that absence of a major cardiovascular MedPAR data we analyzed. As use of
was discussed at the October 7, 2004 condition. Although, as discussed in the drug-eluting stents becomes the
ICD–9–CM Coordination and proposed rule, in the past we have standard of treatment, we may consider
Maintenance Committee. That code, had expressed concerns regarding over time whether to dispense with the
it been adopted, would have been 00.44 selectively recognizing secondary distinction between these stents and the
(Procedure on bifurcated vessels) in the diagnoses or complicating conditions, older bare metal stent technology in the
new series of codes describing the particularly conditions from other structure of the coronary stent DRGs. In
number of vessels treated. The MDCs, in making DRG assignments, we addition, we will continue to consider
commenter stated that the creation of believe these concerns are not relevant whether the structure of these DRGs
this code is critical to understanding the to the new cardiovascular DRGs. While ought to reflect differences in the
contemporary approaches to treatment we are adopting an approach for number of vessels treated or the number
of coronary artery disease. The distinguishing patients with complex of stents inserted, or both. As we
commenter further stated that treatment conditions, with a few exceptions, our discussed above, a new coding structure
of stenosis [of a blood vessel] at a approach uses complex cardiovascular capable of identifying multiple vessel
bifurcation represents 25 to 30 percent conditions (or diagnoses within the treatment and the insertion of multiple
of percutaneous coronary interventions MDC) to decide whether a patient stents will go into effect on October 1,
and recommended that coders use one should be assigned to the higher 2005. It remains premature to
code for number of vessels, one code for weighted DRG. In those cases where we restructure the coronary stent DRGs on
number of stents, and an additional have used a diagnosis from another the basis of the number of vessels
code to note that a bifurcated vessel was MDC in assigning a patient to the MCV treated or the number of stents inserted,
treated. According to the commenter, a DRG, the condition is generally a closely or both, until data reflecting the use of
new code for the treatment of a related vascular condition that is linked these new codes become available. After
bifurcated vessel is necessary because to the patient’s cardiovascular illness. we have pertinent data in our historical
the existing codes that describe the We believe that this revised structure MedPAR database, we will analyze
number of vessels treated (codes 00.40 identifies subgroups of significantly those data in order to determine
through 00.43) will only be used by more severe patients who use greater whether a restructuring of the DRGs
coders for the counting of hospital resources more accurately than based on multiple vessel treatment or
uninterrupted, straight vessels. was possible under the previous DRGs. insertion of multiple stents, or both, is
Response: We did not choose to create The new DRG titles are: warranted.
a new code for procedure on a • DRG 555 (Percutaneous We refer the reader to Table 6B of this
bifurcated vessel for two reasons. First, Cardiovascular Procedure With Major final rule for the descriptions of four
we do not believe that level of Cardiovascular Diagnosis (formerly DRG new ICD–9–CM codes identifying
granularity is needed in order to 516) multiple stent insertion (codes 00.45,
accurately code stent insertion for • DRG 556 (Percutaneous 00.46, 00.47, and 00.48) and four new
bifurcated vessels. We believe that the Cardiovascular Procedure With Non- codes identifying multiple vessel
codes for multiple stents and vessels Drug-Eluting Stent Without Major treatment (codes 00.40, 00.41, 00.42,
will provide the necessary information Cardiovascular Diagnosis (formerly DRG and 00.43). Coders are encouraged to
about resource use for the procedure. 517) use as many codes as necessary to
Second, we are concerned that coders • DRG 557 (Percutaneous describe each case, using new code
will not have sufficient information Cardiovascular Procedure With Drug- 00.66 (Percutaneous transluminal
documented in the medical record to Eluting Stent With Major Cardiovascular coronary angioplasty [PTCA] or
identify procedures on bifurcated Diagnosis (formerly DRG 526) coronary atherectomy) and one code
vessels as opposed to a specific number • DRG 558 (Percutaneous each for the number of vessels treated
of procedures on a specific number of Cardiovascular Procedure With Drug- and the number of stents inserted.
vessels. Because procedures on Eluting Stent Without Major Coders are encouraged to record codes
bifurcated vessels are so prevalent (25 to Cardiovascular Diagnosis (formerly DRG accurately, irrespective of whether the
30 percent, according to the 527) code has an impact on the DRG
commenter), they should be considered We refer the reader to section IX.A. of assignment, as these data will
technical variants rather than distinct the preamble to this final rule for a full potentially be the basis for future DRG
entities to be coded separately. We presentation of the changes to the DRGs restructuring.
solicited input from the industry when for coronary artery stents for FY 2006.
creating the new coronary stent codes, Although we are adopting some d. Insertion of Left Atrial Appendage
and we believe that the new codes as restructuring of the coronary stent DRGs Device
they exist adequately capture resource for FY 2006, it is important to note that Atrial fibrillation is a common heart
utilization. We also note that this level this change does not preclude proposals rhythm disorder that can lead to a
of detail is not present in the Current in subsequent years to further cardiovascular blood clot formation
leading to increased risk of stroke. catheterization laboratory using DRG 108 (Other Cardiothoracic
According to product literature, nearly standard transseptal technique, with the Procedures) was more representative of
all strokes are from embolic clots arising patient generally under local anesthesia. the complexity of the procedure than
in the left atrial appendage of the heart: The procedure takes approximately 1 placement in DRG 518. The
an appendage for which there is no hour, and most patients stay overnight manufacturer indicated that the
useful function. Standard therapy uses in the hospital. suggested placement of procedure code
anticoagulation drugs. However, these In the FY 2005 IPPS final rule (69 FR 37.90 in DRG 108 was justified because
drugs may be contraindicated in certain 48978, August 11, 2004), we discussed another percutaneous procedure,
the DRG assignment of new ICD–9–CM
patients and may cause complications described by ICD–9–CM procedure code
procedure code 37.90 (Insertion of left
such as bleeding. The underlying 35.52 (Repair of atrial septal defect with
atrial appendage device) for clinical
concept behind the left atrial appendage trials, effective for discharges occurring prosthesis, closed technique), was
device is to block off the left atrial on or after October 1, 2004, to DRG 518 assigned to DRG 108. As we indicated
appendage, so that the blood clots (Percutaneous Cardiovascular Procedure in the FY 2005 final rule (69 FR 48978),
formed therein cannot travel to other without Coronary Artery Stent or Acute this comment prompted us to examine
sites in the vascular system. The device Myocardial Infarction). In that final rule, data in the FY 2003 MedPAR file for
is implanted using a percutaneous we addressed the DRG assignment of cases of code 35.52 assigned to DRG 108
catheter procedure under fluoroscopy procedure code 37.90 in response to a and DRG 518 in comparison to all cases
through the femoral vein. Implantation comment from a manufacturer who assigned to DRG 108. We found the
is performed in a hospital suggested that placement of the code in following:

DRG 108 With Code 35.52 Reported ....................................................................................... 523 2.69 $29,231
DRG 108—All cases .................................................................................................................. 5,293 10.1 76,274
DRG 518—All cases .................................................................................................................. 39,553 4.3 31,955
Therefore, we concluded that cases for both clinical coherence and We examined data from the FY 2004
procedure code 35.52 showed a decided charge data as part of the IPPS FY 2006 MedPAR file and found results for cases
similarity to the cases found in DRG process of identifying the most assigned to DRG 108 and DRG 518 that
518, not DRG 108. At that time, we appropriate DRG assignment for are similar to last year’s findings as
determined that we would analyze the procedure code 35.52. indicated in the chart below:

DRG cases length-of-stay charges
DRG 108 With Code 35.52 Reported ......................................................................................... 872 2.42 $29,579
DRG 108—All cases .................................................................................................................... 8,264 9.81 81,323
DRG 518—All cases .................................................................................................................... 38,624 3.49 27,591
From this comparison, we found that analysis, we proposed to move procedures presently assigned to DRG
when an atrial septal defect is procedure code 35.52 out of DRG 108 518 because of the cost of the closure
percutaneously repaired, and procedure and place it in DRG 518. device and additional testing, such as
code 35.52 is the only code reported in Comment: One commenter agreed that electrocardiography. The commenter
DRG 108, there is a significant the left atrial appendage device recommended that CMS not move code
discrepancy in both the average charges procedure code should be moved out of 35.52 out of DRG 108 until better data
and the average length of stay between DRG 108 and into DRG 518 based on can be gathered and a more appropriate
the cases with procedure code 35.52 significantly lower average charges and reimbursement calculation can be
reported in DRG 108 and the total cases length of stay as compared to the developed.
in DRG 108. The total cases in DRG 108 majority of cases within the current Response: This year, CMS undertook
have average charges of $51,744 greater classification. an extensive review of MDC 5 after
than the 872 cases in DRG 108 reporting Response: Even though this comment issuance of the FY 2006 IPPS proposed
procedure code 35.52 as the only did not exactly reflect our proposal rule in response to MedPAC’s
procedure. The total cases in DRG 108 regarding the left atrial appendage recommendations regarding
also have an average length of stay of device, we are interpreting the restructuring the Medicare DRG system
7.39 days greater than the average length commenter’s statement to mean that it to improve payment accuracy under the
of stay for cases in DRG 108 with agreed that code 35.52 should be IPPS. A discussion of the results of that
procedure code 35.52 reported. In removed from DRG 108. review and our subsequent decision in
comparison, the total cases in DRG 518 Comment: One commenter addressed response to a comment on the proposed
have average charges of only $1,988 the proposed removal of code 35.52 rule to make changes to nine
lower than the cases in DRG 108 with from DRG 108. The commenter cardiovascular DRGs, can be found in
only procedure code 35.52 reported. In acknowledged that the resource section IX.A. of this preamble. During
addition, the length of stay in total cases intensity for patients undergoing that review, we evaluated each surgical
in DRG 518 is more closely related to percutaneous atrial septal defect repair DRG within MDC 5. In addition, within
cases in DRG 108 with only procedure is less than that of open repair, but did each DRG, we evaluated each procedure
code 35.52 reported. Based on this not believe that the costs are akin to code to determine the number of cases,
the average length of stay, and the 108 and into DRG 518 with cases that 108 or DRG 111 (Major Cardiovascular
average standardized charges. In DRG resemble it in average length of stay, Procedures Without CC).
108, the results were the same as in the average charges, and clinical coherence. Response: Based on our data review
table shown above in this section, and We believe that this move will result in and discussion above, we do not believe
published in the FY 2006 IPPS proposed a more coherent group of cases in DRG that placement of code 37.90 is
rule. Code 35.52 had an average length 518 that reflect all percutaneous appropriate in DRG 108. Code 37.90 is
of stay of approximately one fourth of procedures. a percutaneously placed device utilizing
the rest of the cases in that DRG, and Comment: Three commenters did not local anesthesia, and with an expected
had average charges that were greater believe that the left atrial appendage length of stay of one day.
than $51,700 less than the remainder of device, represented by new code 37.90, We reviewed cases in the MedPAR
the cases in DRG 108. In addition, code should be placed in DRG 518. They file assigned to both DRG 110 (Major
35.52 represents a closed technique believed that DRG 518 does not cover Cardiovascular Procedures With CC)
approach, unlike the other cases in DRG the costs for the procedure and device, and DRG 111. The results of the review
108. We believe this is compelling and suggested placement in another show that both open and percutaneous
evidence that this procedure is not most DRG that would include similar procedures are grouped in these paired
appropriately assigned to DRG 108. procedures and a better reimbursement. DRGs. A comparison of the MedPAR
Therefore, we are finalizing our Two commenters suggested that a more data in DRGs 110, 111, and 518 is
proposal to move code 35.52 out of DRG appropriate DRG would be either DRG shown in the following table:
Average
Number of Average length
DRG standardized
cases of stay charges
DRG 110 .................................................................................................................................... 53,527 1 8.4 $66,475

DRG 111 .................................................................................................................................... 9,438 1 3.43 26,941
DRG 518—All cases .................................................................................................................. 38,624 3.49 27,591
DRG 518 with code 37.90 ......................................................................................................... 0 0 0
1 Days.
As shown in the table, code 37.90 in financially align ventricular assist • 37.54, Replacement or repair of
DRG 518 has not been reported in the device (VAD) procedures by creating other implantable component of total
database yet. It is a new code; therefore, DRG 525 (Heart Assist System Implant). replacement heart system*
it has no payment history. We note that We also noted that cases in which a • 37.62, Insertion of non-implantable
the cases in DRG 518 closely match heart transplant also occurred during heart assist system
those in DRG 111 in terms of both the same hospitalization episode would • 37.63, Repair of heart assist system
average length of stay and average continue to be assigned to DRG 103 • 37.65, Implant of external heart
charges. However, we also note that (Heart Transplant). assist system
DRGs 110 and 111 are paired DRGs with After further data review during the *These codes represent noncovered
significantly different average charges subsequent 2 years, we decided to services for Medicare beneficiaries.
and lengths of stay. Even with a CC, we realign the DRGs containing VAD codes However, it is our longstanding practice
believe it is unlikely that an for FY 2005. In the August 11, 2004 to assign every code in the ICD–9–CM
endovascular placement of a left atrial final rule (69 FR 48927), we announced classification to a DRG. Therefore, they
appendage device will approximate the changes to DRG 103, DRG 104 (Cardiac have been assigned to DRG 525.
costs of cases to be assigned to DRG 110. Valve and Other Major Cardiothoracic Since that decision, we have been
Therefore, in our view, there is the Procedure with Cardiac encouraged by a manufacturer to
potential for significant overpayment if Catheterization), DRG 105 (Cardiac reevaluate DRG 525 for FY 2006. The
we were to assign the left atrial Valve and Other Major Cardiothoracic manufacturer requested that we again
appendage device to DRG pairs 110 and Procedures Without Cardiac review the data surrounding cases
111. We continue to believe that Catheterization), and DRG 525. reporting code 37.65, and suggested
placement of the left atrial appendage In summary, these changes moving these cases into DRG 103. The
device in DRG 518 is appropriate absent included— manufacturer pointed out the following:
any evidence that would convince us • Moving code 37.66 (Insertion of Code 37.65 describes the implantation
otherwise. Therefore, we are not making implantable heart assist system) out of of an external heart assist system and is
any changes in our proposal in this final DRG 525 and into DRG 103. currently approved by the FDA as a
rule. We will continue to monitor its • Renaming DRG 525 as ‘‘Other Heart bridge-to-recovery device. From the
data in our annual review of DRGs and Assist System Implant.’’ standpoint of clinical status, the
the IPPS. • Moving code 37.62 (Insertion of patients in DRG 103 and the patients
As we proposed, in this final rule we non-implantable heart assist system) out receiving an external heart assist system
are moving procedure code 35.52 out of of DRGs 104 and 105 and back into DRG are similar because their native hearts
DRG 108 and placing it in DRG 518. We 525. cannot support circulation, and absent a
believe that this move will result in a DRG 525 currently consists of any heart transplant, a mechanical pump is
more coherent group of cases in DRG principal diagnosis in MDC 5, plus the needed for patient survival. The surgical
518 that reflect all percutaneous following surgical procedure codes: procedures for implantation of both an
procedures. • 37.52, Implantation of total internal VAD and an external VAD are
replacement heart system* very similar. However, the external
e. External Heart Assist System Implant
• 37.53, Replacement or repair of heart assist system (code 37.65) is a less
In the August 1, 2002 final rule (67 FR thoracic unit of total replacement heart expensive device than the implantable
49989), we attempted to clinically and system* heart assist system (code 37.66).
Further, the Medicare charge data show that only a subset of patients receiving reflective of the average resources
that patients in DRG 525 receiving the an implantable heart assist system are required to treat a particular case. Our
external heart assist system had an best served by this device (code 37.66). goal is that physicians and hospitals
average length of stay that was more The manufacturer also suggested that should make treatment decisions based
than 28 days less than all patients in the initial use of the least expensive on the clinical needs of the patient and
DRG 103. therapeutically appropriate device not financial incentives.
The manufacturer suggested that the yields both the best clinical outcomes
payment differential between DRGs 103 When we reviewed the FY 2004
and the lowest total system costs.
and 525 provides an incentive to choose We note that, under the DRG system, MedPAR data, we were able to
the higher paying device, and asserted our intent is to create payments that are demonstrate the following comparisons:

DRG 103—All cases .................................................................................................................. 633 37.5 $313,583

DRG 103 with code 37.65 reported .......................................................................................... 9 81.3 625,065
DRG 525—All cases .................................................................................................................. 291 13.66 173,854
DRG 525 with code 37.65 reported .......................................................................................... 110 9.26 206,497
DRG 525 without code 37.65 reported ..................................................................................... 181 16.34 154,015
Note: This table does not contain the same data that appear in the table in the proposed rule (70 FR 23322). The row containing ‘‘DRG 103
without code 37.65’’ had values of ‘‘0’’ in all fields. These entries were confusing and therefore deleted.
The above table shows that the 37.8 DRG 525. For these reasons, we did not required than was originally anticipated
percent of cases in DRG 525 that propose to make any changes to the for the patient’s native heart to recover.
reported code 37.65 have average structure of either DRG 103 or DRG 525. The commenters stated that, originally,
charges that are nearly $33,000 higher Comment: Six commenters mentioned patients were supported an average of 5
than the average charges for all cases in the high cost of the external heart assist to 7 days, but it has been found that
the DRG. However, the average charges device and for treatment for patient outcomes were better with a
for the subset of cases with code 37.65 implantation of the device, and longer support period, perhaps as long
in DRG 525 ($206,497) are more than requested that CMS increase payment to as 30 to 60 days. These commenters
$107,086 lower than the average charges cover the cost of caring for the patients cited the increased expenses related to
for all cases in DRG 103 ($313,583). that can benefit from this technology. supporting the patient and the major
Furthermore, the average length of stay Two commenters agreed with CMS’ financial commitment on the part of the
for the subset of patients in DRG 525 assessment that the cost associated with hospitals choosing to treat this severely
receiving an external heart assist system implantation of an external heart assist ill group of patients as reasons for
was 9.26 days compared to 37.5 days for system are considerably less than a requesting increased payment for this
the 633 cases in DRG 103. heart transplant or insertion of an population of cases.
We note that the analysis above implantable heart assist system. One One commenter offered the following
presents the difference in average commenter echoed CMS’ concerns that four proposals to address the payment
charges, not costs. Because hospitals’ movement of code 37.65 to DRG 103 differences between the external heart
charges are higher than costs, the would result in overpayment for that assist device and an implantable device:
• Create a new DRG for patients
difference in hospital costs will be less service and would result in a decrease
requiring heart assist devices who also
than the figures shown here. of the relative weight of the heart
sustained an Acute Myocardial
Moving all cases containing code transplant DRG, ultimately resulting in
Infarction (AMI) because these patients
37.65 from DRG 525 to DRG 103 would underpayment of heart transplant cases.
have higher resource consumption than
have two consequences. The cases in Both commenters agreed with CMS’
patients with other diagnoses in MDC 5.
DRG 103 reporting code 37.65 would be decision not to include the implantation • Assign all cases with AMI and a
appreciably overpaid, which would be of external heart assist systems in DRG procedure code of 37.65 to DRG 103.
inconsistent with our goal of coherent 103. • Increase the overall weight of DRG
reimbursement structure within the Several commenters noted that 525 to better align it with ‘‘true hospital
DRGs. In addition, the relative weight of significant achievements in the areas of charges.’’
DRG 103 would ultimately decrease by patient selection, implantation • Allow a second DRG payment or an
moving the less resource-intensive technique, and post-implant add-on payment for heart
external heart procedures into the same management have been made transplantations if recovery of the
DRG with the more expensive heart surrounding this technology. They patient’s native heart is first attempted.
transplant cases. The net effect would added that improvements in the Response: We appreciate the
be an underpayment for heart transplant external heart assist device itself have commenters’ thorough understanding of
cases. Alternatively, we also been reported to make the newer the IPPS DRG grouping and payment
reconsidered our position on moving devices safer and more durable. One process. We are aware that the external
the insertion of an implantable heart commenter noted that observations from heart assist device cases represent a very
assist system (code 37.66) back into personal experience and research resource-intensive group of patients. For
DRG 525. However, as shown in the FY demonstrate that recent improvements this reason, we carefully reviewed the
2005 IPPS final rule (69 FR 48929), the to the device have resulted in increased suggestions from the commenter about
resource costs associated with caring for survival rates from 35 percent (the potential DRG payment policy changes
a patient receiving an implantable heart national average) to nearly 50 percent. that we could make to address the issue.
assist system are far more similar to Several commenters mentioned that, We reviewed the MedPAR data in DRG
those cases receiving a heart transplant with experience, they have discovered 525, using ICD–9–CM codes 410.01
in DRG 103 than they are to cases in that a longer period of support is through 410.91 to identify AMIs. In
addition, we reviewed all cases of ICD–9–CM code 37.65. The results are
patients who received the external heart summarized in the following table:
assist device procedure represented by
Average length
Number of Average
of stay
cases charges
(days)
DRG 525—Cases with Any Diagnosis of AMI .......................................................................... 46 8.5 $195,758

DRG 525—Cases of Principal Diagnosis of AMI ...................................................................... 31 8.9 210,369
DRG 525—Cases with Secondary Diagnosis of AMI ............................................................... 15 7.7 165,562
DRG 525—Cases with No Diagnosis of AMI ............................................................................ 71 9.2 204,472
DRG 525—All Cases ................................................................................................................. 291 13.66 206,497
We do not believe that these data concerned that the relative weight device expired during the hospital stay.
demonstrate that the presence of an AMI determination would be viewed as Thus, the shorter length of stay and the
has significant impact on either the arbitrary and capricious, and we would higher average charges for these patients
length of stay or the average lose the advantage of having an compared to other patients in DRG 525
standardized charges. All cases with objective methodology that bases the are likely explained by the high cost of
AMI have lower lengths of stay than relative weight on average hospital the device and the fact that these
both the average of all cases in DRG 525 charges. For this reason, we are not patients are severely ill and frequently
(13.66 days) and the 71 cases in which adopting the commenter’s suggestion to expire.
no AMI was documented (9.2 days). select a relative weight for external heart Upon further analysis of the data, we
Likewise, only those cases with a assist device cases outside of our did find that there was a single
principal diagnosis of AMI have slightly traditional process. subgroup of patients who are
higher charges than either the group The commenter’s fourth suggestion comparable in resource usage and
without AMI, or the total of all cases. was to make two payments for a single length of stay to those included in DRG
Because the data do not justify it, we are inpatient stay when the patient receives 103. These patients received both the
rejecting the suggestion of creating a the external heart assist system, external heart assist device and later
new DRG for patients receiving an recovery of the patient’s native heart is had it removed after a lengthy period of
external heart assist device, as identified attempted and fails, and the patient rest and recovery. We note that
by procedure code 37.65, with any receives a heart transplant. In cases commenters provided information
diagnosis of AMI. where the patient received the external indicating that survival rates are
With respect to the commenter’s heart assist system and later receives a improving for patients receiving more
second suggestion, our data clearly heart transplant, the case is already paid advanced versions of these devices. In
demonstrate in the above table that using DRG 103. In this situation, the addition, commenters provided
patients with an AMI and procedure relative weight for DRG 103 will reflect information indicating that longer
code 37.65 have average standardized the average charges for all patients in periods of support with the external
charges of $210,369. The first table in the DRG, including those described in heart assist device are improving
this section that was included in the the scenario presented by the patients’ survival chances and
proposed rule shows that cases in DRG commenter. Thus, to the extent that opportunity to be discharged with their
103 have average standardized charges hospital charges for these patients are native heart. According to information
of $313,583. We believe that the relative already reflected in the relative weight included with the comments, the data
weight of DRG 103 would eventually for the DRG, we do not believe that it show a 50-percent survival rate with an
decrease by moving all of the less is necessary for Medicare to make a average total length of stay of 43 days
resource-intensive external heart second payment. To arbitrarily select for all AMI heart recovery patients. On
procedures into the same DRG with the one DRG, or a group of DRGs, and add average, a surviving patient will receive
more expensive heart transplant cases. an additional DRG payment to those 31 days of average support time
For these reasons, we are rejecting the cases is contrary to our stated goal of followed by an additional 38 days in the
commenter’s proposal to assign cases having a system in which all cases are hospital after the device is removed.
with AMI and code 37.65 to DRG 103. fairly considered by the same Based on the commenter’s information
With regard to the suggestion recalibration formula. Therefore, we do from a later year than our MedPAR data,
(received many times) to selectively not intend to either determine an it is clear that patients weaned from the
increase the relative weight of specific additional DRG payment or an add-on external heart assist system have longer
DRGs, the DRG relative weights are payment for this category of patients. lengths of stay and are very different
annually recalibrated based on Medicare We reiterate that our data do not from the average patients having this
hospital discharges using the most support the argument that patients procedure that are in our FY 2004 data.
current charge information available (FY receiving the external heart assist device Given the newness of this procedure,
2004 MedPAR file for the FY 2006 have longer lengths of stay than other the Medicare charge data included a
relative weights). We use a complex patients in DRG 525, even though the limited number of patients having the
mathematical algorithm to determine data show that their average charges are device implanted and removed.
the relative weights that is fully higher, as noted in the above table. In However, the Medicare charge data did
explained in section II. of this preamble. determining the possible reasons for support that patients receiving both an
The DRG relative weights are neither higher average charges and lower implant and removal of an external
arbitrarily nor capriciously assigned. lengths of stay, we further examined the heart assist system in a single hospital
However, if we adopted the suggestion Medicare billing data. We found that stay had an average length of stay
to select a relative weight for a specific almost 76 percent of the Medicare exceeding 50 days and average charges
DRG outside of this process, we are beneficiaries receiving the external heart of $378,000 that are more comparable to
patients in DRG 103 than DRG 525. occurs during the same hospitalization for the purpose of carotid artery dilation
While we did not suggest a change to episode would continue to be assigned concurrent with carotid stent
DRG 103 in the proposed rule, we to DRG 103. placement, is considered to be a
believe that consideration of the In order to accurately monitor these reasonable and necessary service only
comments is best served by recognizing patients and obtain more information on when provided in the context of such
this unique subset of patients and patients with these conditions, we clinical trials and, therefore, is
making a DRG change which intend to have the Quality Improvement considered a covered service for the
acknowledges the increased resources Organizations (QIOs, formerly the PROs) purposes of these trials. Performance of
required for improvements in their care. review all cases in DRG 103 under the PTA in the carotid artery when used to
The commenter has provided us with auspices of their eighth scope of work treat obstructive lesions outside of
data showing that with superior patient to determine whether implantation and approved protocols governing Category
selection, and increased duration of care during the admission were B IDE clinical trials remains a
treatment with an improved device, the reasonable and necessary to promote the noncovered service. At its April 1, 2004
patients are more likely to be discharged recovery of the injured myocardium and meeting, the ICD–9–CM Coordination
from the hospital with the native heart lead to improvement of the patient’s and Maintenance Committee discussed
intact. While we have limited Medicare condition. For medical review under creation of a new code or codes to
data and the data are from a different this contract, the QIOs determine identify carotid artery stenting, along
year than the commenter’s data, our whether items and services are with a concomitant percutaneous
data do support that patients having an reasonable and medically necessary and angioplasty or atherectomy (PTA) code
external heart assist device implanted whether the quality of such services for delivery of the stent(s). We
and removed during the same admission meets professionally recognized established codes for carotid artery
are comparable to in costs and average standards of health care. In addition, in stenting procedures for use with
length of stay to heart transplant and hospitals subject to the IPPS, the QIOs discharges occurring on or after October
implantable heart assist system patients review the validity of diagnostic 1, 2004 inpatients who are enrolled in
in DRG 103. While we did not suggest information, the completeness, an FDA-approved clinical trial and are
a change to DRG 103 in the proposed adequacy, and quality of care provided, using on-label FDA-approved stents and
rule, we believe that consideration of and the appropriateness of admissions embolic protection devices. These codes
the comments is best served by and discharges. We will continue to are as follows:
recognizing this unique subset of examine the claims data in upcoming
years to determine if CMS’ • 00.61 (Percutaneous angioplasty or
patients, and making a DRG change that atherectomy of precerebral (extracranial
acknowledges the increased resources consideration surrounding the unique
circumstances of these patients and this vessel(s)); and
required for improvement in their care. • 00.63 (Percutaneous insertion of
Because we believe that this therapy treatment modality were in the best
interest of both the patients and the carotid artery stent(s)).
offers a treatment option to patients who We assigned procedure code 00.61 to
have limited alternatives, we are making Medicare program.
four MDCs and seven DRGs. The most
a change to the DRG using the limited f. Carotid Artery Stent likely scenario is that in which cases are
Medicare data we have available rather Stroke is the third leading cause of assigned to MDC 1 (Diseases and
than waiting a year to receive more death in the United States and the Disorders of the Nervous System) in
supporting data. leading cause of serious, long-term DRGs 533 (Extracranial Procedures with
For the reasons stated above, for FY disability. Approximately 70 percent of CC) and 534 (Extracranial Procedures
2006, we are reconfiguring DRG 103 in all strokes occur in people age 65 and without CC). Other DRG assignments
the following manner: Those patients older. The carotid artery, located in the can be found in Table 6B of the
who have both the implantation of the neck, is the principal artery supplying Addendum to the FY 2005 IPPS final
external VAD (code 37.65) and the the head and neck with blood. rule (69 FR 49624).
explantation of that VAD (code 37.64) Accumulation of plaque in the carotid In the FY 2005 IPPS final rule, we
prior to the hospital discharge will be artery can lead to stroke either by indicated that we would continue to
assigned to DRG 103. The revised DRG decreasing the blood flow to the brain monitor DRGs 533 and 534 and
103 contains the following codes: or by having plaque break free and lodge procedure code 00.61 in combination
• 33.6, Combined heart-lung in the brain or in other arteries to the with procedure code 00.63 in upcoming
transplantation head. The percutaneous transluminal annual DRG reviews. For the FY 2006
• 37.51, Heart transplantation angioplasty (PTA) procedure involves IPPS proposed rule and this final rule,
• 37.66, Insertion of implantable we used proxy codes to evaluate the
inflating a balloon-like device in the
heart assist system costs and DRG assignments for carotid
narrowed section of the carotid artery to
Or reopen the vessel. A carotid stent is then artery stenting because codes 00.61 and
• 37.65, Implant of external heart deployed in the artery to prevent the 00.63 were only approved for use
assist system vessel from closing or restenosing. A beginning October 1, 2004, and
And distal filter device (embolic protection MedPAR data for this period are not yet
• 37.64, Removal of heart assist system. device) may also be present, which is available. We used procedure code
By making this change, Medicare will intended to prevent pieces of plaque 39.50 (Angioplasty or atherectomy of
be making higher payments for patients from entering the bloodstream. other noncoronary vessel(s)) in
who receive both an implant and an Effective July 1, 2001, Medicare combination with procedure code 39.90
explant of an external heart assist covers PTA of the carotid artery (Insertion of nondrug-eluting peripheral
system during a single hospital stay. concurrent with carotid stent placement vessel stent(s)) in DRGs 533 and 534 as
Our intent in establishing this policy is when furnished in accordance with the the proxy codes for carotid artery
to recognize the higher costs of patients FDA-approved protocols governing stenting. For this evaluation, we used
who have a longer length of stay and are Category B Investigational Device principal diagnosis code 433.10
discharged alive with their native heart. Exemption (IDE) clinical trials. PTA of (Occlusion and stenosis of carotid
Cases in which a heart transplant also the carotid artery, when provided solely artery, without mention of cerebral
infarction) to reflect the clinical trial The following chart shows our
criteria. findings:

DRG cases length of stay charges
DRG 533—All cases .................................................................................................................... 44,677 3.73 $24,464

DRG 533 with codes 39.50 and 39.90 reported ......................................................................... 1,586 3.13 29,737
DRG 534—All cases .................................................................................................................... 42,493 1.79 15,873
DRG 534 with codes 39.50 and 39.90 reported ......................................................................... 1,397 1.54 22,002
The patients receiving a carotid stent no change to the DRG assignment for system by insertion of vascular
(codes 39.50 and 39.90) represented 3.5 carotid artery stenting. catheters. Patients receiving this
percent of all cases in DRG 534. On Response: We agree and will not be procedure require mechanical
average, patients receiving a carotid making a change to the DRG assignment ventilation. ECMO is performed for a
stent had slightly shorter average for carotid artery stenting. small number of severely ill patients
lengths of stay than other patients in Comment: Nine commenters who are at high risk of dying without
DRGs 533 and 534. While the average encouraged CMS to create two new this procedure. Most often it is done for
charges for patients receiving a carotid DRGs for carotid stent procedures and neonates with persistent pulmonary
artery stent were higher than for other split these new DRGs on the basis of the hypertension and respiratory failure for
patients in DRG 534, in our view, the presence or absence of comorbidities or whom other treatments have failed,
small number of cases and the complications. They believed that, even certain severely ill neonates receiving
magnitude of the difference in average though the current volume of carotid major cardiac procedures or
charges are not sufficient to justify a artery stenting cases appears small, the diaphragmatic hernia repair, and certain
change in the DRGs. recent availability of FDA-approved older children and adults, most of
Because we have a paucity of data for devices, new and ongoing clinical trials, whom are receiving major cardiac
the carotid stent device and its multiple post-market registries, as well procedures.
insertion, we believe it is premature to as expanded Medicare coverage, will Prior to the proposed rule, we
revise the DRG structure at this time. result in a large increase in the number received several letters from institutions
We expect to revisit this analysis once of cases. They also expressed concern that perform ECMO. The commenters
data become available on the new codes that the potential increase in patient stated that, in the CMS GROUPER logic,
for carotid artery stents. volume and their perceived inadequate this procedure has little or no impact on
We received 11 comments on our payment for carotid artery stent cases the DRG assignment in the newborn,
presentation of the carotid stent device will create a financial hardship on pediatric, and adult population.
issue in the FY 2006 IPPS proposed facilities providing this technology, According to these letters, patients
rule. potentially resulting in decreased receiving ECMO are highly resource
Medicare beneficiary access to this intensive and should have a unique
Comment: One commenter DRG that reflects the costs of these
beneficial therapy.
recommended that CMS include carotid Response: We continue to believe that resources. The commenters
stenting in the DRG for carotid the most appropriate changes to the recommended the creation of a new
endarterectomy in FY 2006 and ensure IPPS and the structure of the DRGs are DRG for ECMO with a DRG weight equal
that the data it is collecting for setting based on evidence of a significant to or greater than the DRG weight for
payment rates in FY 2007 appropriately difference in average costs between tracheostomy.
accounts for the cost of the device. technology itself and the DRG where its ECMO is assigned to procedure code
Response: Code 38.12 code is assigned. Because the ICD–9– 39.65 (Extracorporeal membrane
(Endarterectomy, other vessels of head CM procedure codes are new, we do not oxygenation). This code is classified as
and neck) describes the open have data showing that carotid artery an O.R. procedure and is assigned to
endarterectomy procedure, and is stents are more costly than other cases DRG 104 (Cardiac Valve and Other
assigned to DRGs 533 and 534 which is in DRGs 533 and 534. Further, using Major Cardiothoracic Procedure With
the same DRG assignment as the codes 39.50 and 39.90 as proxies for Cardiac Catheterization) and DRG 105
endovascular endarterectomy. carotid artery stenting, we did not (Cardiac Valve and Other Major
Therefore, both the open observe a substantial difference in Cardiothoracic Procedure Without
endarterectomy and the placement of average charges between cases using Cardiac Catheterization). When ECMO
carotid stent result in assignment to the these codes and other cases in the DRGs. is performed with other O.R.
same DRG, which reflects CMS’ policy For this reason, we do not have procedures, the case is assigned to the
of placing new codes in predecessor sufficient evidence to warrant a DRG higher weighted DRG. For example,
DRGs. We point out that codes 00.61 change at this time. when ECMO and a tracheostomy are
and 00.63 must be used together to In this final rule, we are retaining performed during the same admission,
allow payment for carotid stenting. code 00.61 in DRGs 533 and 534 for FY the case would be assigned to DRG 541
Code 00.63 is not recognized by the 2006. We will continue to monitor the (Tracheostomy with Mechanical
GROUPER program as a stand-alone Medicare charge data in our annual Ventilation 96+ Hours or Principal
O.R. procedure and, as such, has no review of DRGs and the IPPS. Diagnosis Except Face, Mouth, and
impact on DRG assignment. Therefore, Neck Diagnoses With Major O.R.).
we anticipate that the cost of the device g. Extracorporeal Membrane We note that the primary focus of
will be reflected in the hospital charges. Oxygenation (ECMO) updates to the Medicare DRG
Comment: One commenter agreed Extracorporeal membrane classification system is changes relating
with our presentation in the proposed oxygenation (ECMO) is a procedure to to the Medicare patient population, not
rule and suggested that we should make create a closed chest, heart-lung bypass the pediatric patient population.
Because ECMO is primarily a pediatric make appropriate modifications to our assignment, we have reviewed the FY
procedure and rarely performed in an payment system when it is being used 2004 MedPAR data and found 78 ECMO
adult population, we have few cases in for children or other patients who are cases in 13 DRGs.
our data to use to evaluate resource not generally found in the Medicare The following table illustrates the
costs. We are aware that other insurers population. results of our findings:
sometimes use Medicare’s rates to make To evaluate the appropriateness of
payments. We advise private insurers to payment under the current DRG
Average
Average
Number of Average length charges for all
DRG with code 39.65 reported charges for
cases of stay cases in the
ECMO cases DRG
4 ..................................................................................................................... 23 9 $147,766 $120,496

105 ................................................................................................................. 21 8 131,700 89,831
541 ................................................................................................................. 14 62.9 561,210 273,656
All Other DRGs .............................................................................................. 20 18.1 308,341 NA
The average charges for all ECMO from ‘‘Tracheostomy With Mechanical FY 2004 IPPS final rule, we stated that
cases were approximately $258,821, and Ventilation 96+ Hours or Principal we did not have sufficient MedPAR data
the average length of stay was Diagnosis Except Face, Mouth, and available on the reporting of codes 49.75
approximately 20.7 days. The average Neck Diagnoses Without Major O.R. and 49.76 to make a determination on
charges for the ECMO cases are closer to Procedure’’ to ‘‘Tracheostomy With DRG reassignment of these codes. We
the average charges for DRG 541 Mechanical Ventilation 96+ Hours or agreed that, if warranted, we would give
($273,656) than to the average charges of Principal Diagnosis Except Face, Mouth, further consideration to the DRG
DRG 104 ($147,766) and DRG 105 and Neck Without Major O.R.’’ assignments of these codes because it is
($131,700). Of the 78 ECMO cases, 14 our customary practice to review DRG
6. MDC 6 (Diseases and Disorders of the
cases are already assigned to DRG 541. assignment(s) for newly created codes to
Digestive System): Artificial Anal
We believe that the data indicate that determine clinical coherence and
Sphincter
DRG 541 would be a more appropriate similar resource consumption after we
DRG assignment for cases where ECMO In the FY 2003 IPPS final rule (67 FR have had the opportunity to collect
is performed. We further note that under 50242), we created two new codes for MedPAR data on utilization, average
the All Payer DRG System used in New procedures involving an artificial anal lengths of stay, average charges, and
York State, cases involving ECMO are sphincter, effective for discharges distribution throughout the system. In
assigned to the tracheostomy DRG. occurring on or after October 1, 2002: the FY 2005 IPPS final rule, we
Thus, the assignment of ECMO cases to Code 49.75 (Implantation or revision of reviewed the FY 2003 MedPAR data for
the tracheostomy DRG for Medicare artificial anal sphincter) is used to the presence of codes 49.75 and 49.76
would be similar to how these cases are identify cases involving implantation or and determined that these procedures
grouped in another DRG system. For revision of an artificial anal sphincter were not a clinical match with the other
these reasons, we proposed to reassign and code 49.76 (Removal of artificial procedures in DRGs 157 and 158.
ECMO cases reporting code 39.65 to anal sphincter) is used to identify cases Therefore, for FY 2005, we moved
DRG 541. We also proposed to change involving the removal of the device. In procedure codes 49.75 and 49.76 out of
the title of DRG 541 to: ‘‘ECMO or Table 6B of that final rule, we assigned DRGs 157 and 158 and into DRGs 146
Tracheostomy With Mechanical both codes to one of four MDCs, based and 147 (Rectal Resection With and
Ventilation 96+ Hours or Principal on principal diagnosis, and one of six Without CC, respectively). This change
Diagnosis Except Face, Mouth and Neck DRGs within those MDCs: MDC 6 had the effect of doubling the payment
Diagnoses With Major O.R. Procedure’’. (Diseases and Disorders of the Digestive for the cases with procedure codes 49.75
Comment: Several commenters System), DRGs 157 and 158 (Anal and and 49.76 assigned to DRGs 146 and 147
supported the proposed modification to Stomal Procedures With and Without based on increases in the relative
ECMO cases reporting code 39.65 to CC, respectively); MDC 9 (Diseases and weights. One commenter suggested that
DRG 541. Disorders of the Skin, Subcutaneous we create a new DRG for ‘‘Complex
Response: We appreciate the Tissue and Breast), DRG 267 (Perianal Anal/Rectal Procedure with Implant.’’
commenters’ support. and Pilonidal Procedures); MDC 21 However, we noted that the DRG
Accordingly, in this final rule, we are (Injuries, Poisonings, and Toxic Effects structure is a system of averages and is
adopting as final the proposed change to of Drugs), DRGs 442 and 443 (Other O.R. based on groups of patients with similar
ECMO cases reporting code 39.65 to Procedures for Injuries With and characteristics. At that time, we
DRG 541 with minor modification. To Without CC, respectively); and MDC 24 indicated that we would continue to
further clarify the change, we are (Multiple Significant Trauma), DRG 486 monitor procedure codes 49.75 and
changing the title of DRG 541 to ‘‘ECMO (Other O.R. Procedures for Multiple 49.76 and the DRGs to which they are
or Tracheostomy With Mechanical Significant Trauma). assigned.
Ventilation 96+ Hours or Principal In the FY 2004 IPPS final rule (68 FR For the FY 2006 proposed rule, we
Diagnosis Except Face, Mouth, and 45372), we discussed the assignment of reviewed the FY 2004 MedPAR data for
Neck With Major O.R.’’ This title has these codes in response to a request we the presence of codes 49.75 and 49.76.
been modified since the proposed rule received to consider reassignment of We found that these two procedures are
(70 FR 23324) to delete the term these two codes to different MDCs and still of low incidence. Among the six
‘‘Diagnoses’’ from the title. For DRGs. The requester believed that the possible DRG assignments, we found a
consistency purposes, we are also average charges ($44,000) for these total of 18 cases reported with codes
changing the DRG title for DRG 542 codes warranted reassignment. In the 49.75 and 49.76 for the implant,
revision, or removal of the artificial anal total joint replacements have been surface can produce significant debris
sphincter. We found 13 of these cases in shown to be highly cost-effective particles that can cause peri-prosthetic
DRGs 146 and 147 (compared to 12,558 procedures, resulting in dramatic bone resorption (also known as
total cases in these DRGs), and the improvements in quality of life for osteolysis) and mechanical loosening of
remaining 5 cases in DRGs 442 and 443 patients suffering from disabling the prosthesis. Wear of the bearing
(compared to 19,701 total cases in these arthritic conditions involving the hip or surface can also lead to instability or
DRGs). knee. In addition, they reported that the prosthetic dislocation, or both, and is a
We believe the number of cases with medical literature indicates success common cause of revision hip or knee
codes 49.75 and 49.76 in these DRGs is rates of greater than 90 percent for replacement surgery.
too low to provide meaningful data of implant survivorship, reduction in pain, Depending on the cause of failure of
statistical significance. Therefore, we and improvement in function at a 10- to the hip replacement, the type of
did not propose any further changes to 15-year followup. However, despite implants used in the previous surgery,
the DRGs for these procedures at this these excellent results with primary the amount and quality of the patient’s
time. Neither did we propose to change total joint replacement, factors related to remaining bone stock, and factors
the structure of DRGs 146 or 147 at this implant longevity and evolving patient related to the patient’s overall health
time. demographics have led to an increase in and anatomy, revision hip replacement
Comment: One commenter agreed that the volume of revision total joint surgery can be relatively straightforward
we should maintain the current DRG procedures performed in the United or extremely complex. Revision hip
assignment for codes 49.75 and 49.76. States over the past decade. replacement can involve replacing any
The commenter recommended that CMS Total hip replacement is an operation part or all of the implant, including the
continue to monitor the use of these that is intended to reduce pain and femoral or acetabular components, and
codes and their DRG assignment. restore function in the hip joint by the bearing surface (the femoral head
Response: We acknowledge the replacing the arthritic hip joint with a and acetabular liner), and may involve
support of the commenter and will prosthetic ball and socket joint. The major reconstruction of the bones and
continue to monitor utilization of the prosthetic hip joint consists of a metal soft tissues around the hip. All of these
services with codes 49.75 and 49.76. alloy femoral component with a procedures differ significantly in their
For FY 2006, we are retaining codes modular femoral head made of either clinical indications, outcomes, and
49.75 and 49.76 within DRGs 146 and metal or ceramic (the ‘‘ball’’) that resource intensity.
147, as proposed. articulates with a metal acetabular The AAOS surgeons provided the
component with a modular liner made following summary of the types of
7. MDC 8 (Diseases and Disorders of the of either metal, ceramic, or high-density revision knee replacement procedures:
Musculoskeletal System and Connective polyethylene (the ‘‘socket’’). Among revision knee replacement
Tissue) The AAOS surgeons stated that, in a procedures, patients who underwent
a. Hip and Knee Replacements normal knee, four ligaments help hold complete revision of all components
the bones in place so that the joint had longer operative times, higher
Orthopedic surgeons representing the works properly. When a knee becomes complication rates, longer lengths of
American Association of Orthopaedic arthritic, these ligaments can become stay, and significantly higher resource
Surgeons (AAOS) requested that we scarred or damaged. During knee utilization, according to studies
subdivide DRG 209 (Major Joint and replacement surgery, some of these conducted by the AAOS. Revision of the
Limb Reattachment Procedures of Lower ligaments, as well as the joint surfaces, isolated modular tibial insert
Extremity) in MDC 8 by creating a new are substituted or replaced by the new component was the next most resource-
DRG for revision of lower joint artificial prostheses. Two types of intensive procedure, and primary total
procedures. The AAOS made a fixation are used to hold the prostheses knee replacement was the least
presentation at the October 7–8, 2004 in place. Cemented designs use resource-intensive of all the procedures
meeting of the ICD–9–CM Coordination polymethyl methacrylate to hold the studied.
and Maintenance Committee meeting. A prostheses in place. Cementless designs • Isolated Modular Tibial Insert
summary report of this meeting can be rely on bone growing into the surface of Exchange. Isolated removal and
found at the CMS Web site: http://www. the implant for fixation. exchange of the modular tibial bearing
cms.hhs.gov/paymentsystems/icd9/. We The surgeons stated that all hip and surface involves replacing the modular
also received written comments on this knee replacements have an articular polyethylene bearing surface without
request prior to the issuance of the FY bearing surface that is subject to wear removing the femoral, tibial, or patellar
2006 IPPS proposed rule. (the acetabular bearing surface in the components of the prosthetic joint.
The AAOS surgeons stated that cases hip and the tibial bearing surface in the Common indications for this procedure
involving patients who require a knee). Traditionally, these bearing include wear of the polyethylene
revision of a prior replacement of a knee surfaces have been made of metal-on- bearing surface or instability (for
or hip require significantly more metal or metal-on-polyethylene, example, looseness) of the prosthetic
resources than cases in which patients although newer materials (both metals knee joint. Patient recovery times are
receive an initial joint replacement. and ceramics) have been used more much shorter with this procedure than
They pointed out that total joint recently. Earlier hip and knee implant with removal and exchange of either the
replacement is one of the most designs had nonmodular bearing tibial, femoral, or patellar components.
commonly performed and successful surfaces, but later designs included • Revision of the Tibial Component.
operations in orthopedic surgery. The modular articular bearing surfaces to Revision of the tibial component
surgeons mentioned that, in 2002, over reduce inventory and potentially involves removal and exchange of the
300,000 hip replacement and 350,000 simplify revision surgery. Wear of the entire tibial component, including both
knee replacement procedures were articular bearing surface occurs over the metal base plate and the modular
performed in the United States. They time and has been found to be related polyethylene bearing surface. Common
also pointed out that these procedures to many factors, including the age and indications for tibial component
are a frequent reason for Medicare activity level of the patient. In some revision are wear of the modular bearing
hospitalization. The surgeons stated that cases, wear of the articular bearing surface, aseptic loosening (often
associated with osteolysis), or infection. the ligaments in the knee, complete total reported on a recently completed study
Depending on the amount of associated knee revision at times requires comparing detailed hospital resource
bone loss and the integrity of the implantation of a highly constrained or utilization and clinical characteristics in
ligaments around the knee, tibial ‘‘hinged’’ knee replacement in order to over 10,000 primary and revision hip
component revision may require the use ensure stability of the knee joint. and knee replacement procedures at 3
of specialized implants with stems that • Reimplantation from previous high volume institutions: The
extend into the tibial canal and/or the resection or cement spacer. In cases of Massachusetts General Hospital, the
use of metal augments or bone graft to deep infection of a prosthetic knee, Mayo Clinic, and the University of
fill bony defects. removal of the implants with California at San Francisco. The
• Revision of the Femoral implantation of an antibiotic- purpose of this study was to evaluate
Component. Revision of the femoral impregnated cement spacer, followed by differences in clinical outcomes and
component involves removal and 6 weeks of intravenous antibiotics is resource utilization among patients who
exchange of the metal implant that often required in order to clear the underwent different types of primary
covers the end of the thigh-bone (the infection. Revision knee replacement and revision hip or knee replacement
distal femur). Common indications for from an antibiotic impregnated cement procedures. The study found significant
femoral component revision are aseptic spacer often involves complex bony differences in operative time,
loosening with or without associated reconstruction due to extensive bone complication rates, hospital length of
osteolysis/bone loss, or infection. loss that occurs as a result of the stay, discharge disposition, and resource
Similar to tibial revision, femoral infection and removal of the often well- utilization among patients who
component revision that is associated fixed implants. As noted above, the underwent different types of revision
with extensive bone loss often involves clinical outcomes following revision hip or knee replacement procedures.
the use of specialized implants with from a spacer are often poor due to Among revision hip replacement
stems that extend into the femoral canal limited functional capacity while the procedures, patients who underwent
and/or the use of metal augments or spacer is in place, prolonged periods of both femoral and acetabular component
bone graft to fill bony defects. protected weight bearing (following revision had longer operative times,
• Revision of the Patellar Component. reconstruction of extensive bony higher complication rates, longer
Complications related to the patella- defects), and the possibility of chronic lengths of stay, significantly higher
femoral joint are one of the most infection. resource utilization, and were more
common indications for revision knee The surgeons stated that the current likely to be discharged to a subacute
replacement surgery. Early patellar ICD–9–CM codes did not adequately care facility. Isolated femoral
implant designs had a metal backing capture the complex nature of revisions component revision was the next most
covered by high-density polyethylene; of hip and knee replacements. resource-intensive procedure, followed
these implants were associated with a Currently, code 81.53 (Revision of hip by isolated acetabular revision. Primary
high rate of failure due to fracture of the replacement) captures all ‘‘partial’’ and hip replacement was the least resource
relatively thin polyethylene bearing ‘‘total’’ revision hip replacement intensive of all the procedures studied.
surface. Other common reasons for procedures. Code 81.55 (Revision of Similarly, among revision knee
isolated patellar component revision knee replacement) captures all revision replacement procedures, patients who
include poor tracking of the patella in knee replacement procedures. These underwent complete revision of all
the femoral groove leading to wear and two codes currently capture a wide components had longer operative times,
breakage of the implant, fracture of the variety of procedures that differ in their higher complication rates, longer
patella with or without loosening of the clinical indications, resource intensity, lengths of stay, and significantly higher
patellar implant, rupture of the and clinical outcomes. resource utilization. Revision of one
quadriceps or patellar tendon, and An AAOS representative made a component was the next most resource-
infection. presentation at the October 7–8, 2004 intensive procedure. Primary total knee
• Revision of All Components (Tibial, ICD–9–CM Coordination and replacement was the least resource
Femoral, and Patellar). The most Maintenance Committee. Based on the intensive of all the procedures studied.
common type of revision knee comments received at the October 7–8, In addition, the commenters indicated
replacement procedure is a complete 2004 meeting and subsequent written that the data showed that extensive
total knee revision. A complete revision comments, new ICD–9–CM procedure bone loss around the implants and the
of all implants is more common in knee codes were developed to better capture presence of a peri-prosthetic fracture
replacements than hip replacements the variety of ways that revision of hip were the most significant predictors of
because the components of an artificial and knee replacements can be higher resource utilization among all
knee are not compatible across vendors performed: Codes 00.70 through 00.73 revision hip and knee replacement
or types of prostheses. Therefore, even and code 81.53 for revisions of hip procedures, even when controlling for
if only one of the implants is loose or replacements and codes 00.80 through other significant patient and procedural
broken, a complete revision of all 00.84 and code 81.55 for revisions of characteristics.
components is often required in order to knee replacements. These new and For the FY 2006 IPPS proposed rule,
ensure that the implants are compatible. revised procedure codes, which will be we examined data in the FY 2004
Complete total knee revision often effective on October 1, 2005, can be MedPAR file on the current hip
involves extensive surgical approaches, found in Table 6B and Table 6F of this replacement procedures (codes 81.51,
including osteotomizing (for example, final rule. The commenters stated that 81.52, 81.53) as well as the
cutting) the tibia bone in order to claims data using these new and replacements and revisions of knee
adequately expose the knee joint and specific codes should provide improved replacement procedures (codes 81.54
gain access to the implants. These data on these procedures for future DRG and 81.55) in DRG 209. We found that
procedures often involve extensive bone modifications. revisions were significantly more
loss, requiring reconstruction with However, the commenters requested resource intensive than the original hip
specialized implants with long stems that CMS consider DRG modifications and knee replacements. We found
and metal augments or bone graft to fill based on current data using the existing average charges for revisions of hip and
bony defects. Depending on the status of revision codes. The commenters knee replacements were approximately
$7,000 higher than average charges for replacements were 21 percent higher percent higher than for initial knee
the original joint replacements, as than the average charges for initial hip replacements.
shown in the following charts. The replacements. The average charges for
average charges for revisions of hip revisions of knee replacements were 25
Average
Number of Average
DRG length of stay
cases charges
(days)
209—All cases ............................................................................................................................. 430,776 4.57 $30,695.41

209 With hip replacement codes 81.51 and 81.52 reported ....................................................... 181,460 5.21 31,795.84
209 With hip revision code 81.53 reported ................................................................................. 20,894 5.57 38,432.04
209 With knee replacement code 81.54 reported ....................................................................... 209,338 3.92 28,525.66
209 With knee revision code 81.55 reported .............................................................................. 18,590 4.64 35,671.66
We note that there were no cases in percent of total hip and knee • 00.73, Revision of hip replacement,
DRG 209 for reattachment of the foot, arthroplasty procedures. acetabular liner and/or femoral head
lower leg, or thigh (codes 84.29, 84.27, One commenter recommended that only
and 84.28). CMS consider the number of individual • 00.80, Revision of knee
To address the higher resource costs components used in the joint replacement, total (all components)
associated with hip and knee revisions replacement when future DRG revisions • 00.81, Revision of knee
relative to the initial joint replacement are made. The commenter stated the replacement, tibial component
procedure, we proposed to delete DRG hospital’s costs will vary based on the • 00.82, Revision of knee
209, create a proposed new DRG 544 number of parts replaced during the replacement, femoral component
(Major Joint Replacement or procedure. According to the commenter, • 00.83, Revision of knee
Reattachment of Lower Extremity), and we may be overpaying simple head and/ replacement, patellar component
• 00.84, Revision of knee
create a proposed new DRG 545 or liner exchanges in hips, and patellar/
replacement, tibial insert (liner)
(Revision of Hip or Knee Replacement). insert exchanges in knees relative to • 81.53, Revision of hip replacement,
We proposed to assign the following primary hip and knee procedures. The not otherwise specified
codes to the new proposed DRG 544: commenter indicated that, with the • 81.55, Revision of knee
81.51, 81.52, 81.54, 81.56, 84.26, 84.27, more specific ICD–9–CM codes, CMS replacement, not otherwise specified
and 84.28. will be able to evaluate further changes We believe that the creation of the
We proposed to assign the following in the joint replacement and revision new DRGs for revisions of hip and knee
codes to the proposed new DRG 545: DRGs. replacements should resolve payment
00.70, 00.71, 00.72, 00.73, 00.80, 00.81, We did not receive any comments that issues for hospitals that perform the
00.82, 00.83, 00.84, 81.53, and 81.55. opposed the proposed DRG revisions for more difficult revisions of joint
In response to the FY 2006 IPPS hip and knee replacements. replacements. In addition, as stated
proposed rule, we received the Response: We appreciate the support earlier, we have worked with the
following public comments: of the commenters. We will use the data orthopedic community to develop new
Comment. Four commenters obtained from use of the new codes to procedure codes that better capture data
supported our proposal to delete DRG consider future DRG revisions for joint on the types of revisions of hip and knee
209 and to create proposed new DRGs replacement and revision procedures. replacements. These new codes will be
544 and DRG 545. One commenter In this final rule, for FY 2006, we are implemented on October 1, 2005. Once
stated that the proposed rule reveals adopting the DRG revisions relating to we receive claims data using these new
that the average joint revision charges hip and knee replacements as proposed. codes, we will review data to determine
are $7,000 higher than original joint We are deleting DRG 209 and creating if additional DRG modifications are
replacements, which supports the point new DRG 544 (Major Joint Replacement needed. This effort may include
that joint revision procedures are more or Reattachment of Lower Extremity) assigning some of the revision codes,
resource-intensive than initial and new DRG 545 (Revision of Hip or such as 00.83 and 00.84, to a separate
replacements. Knee Replacement). The new DRG 544 DRG. As stated earlier, the AAOS has
Another commenter commended CMS includes the following code found that some of the procedures may
for its efforts to provide appropriate assignments: not be as resource intensive. Therefore,
payment for revision hip and knee • 81.51, Total hip replacement the AAOS has requested that CMS
arthroplasty by proposing to split DRG • 81.52, Partial hip replacement closely examine data from the use of the
209 into DRG 544 and 545, and to • 81.54, Total knee replacement new codes and consider future
expand the scope of the relevant ICD– • 81.56, Total ankle replacement revisions.
9–CM procedure codes included in • 84.26, Foot reattachment
these DRGs. The commenter stated that • 84.27, Lower leg/ankle reattach b. Kyphoplasty
the new codes, in particular, are an • 84.28, Thigh reattachment In the FY 2005 IPPS final rule (69 FR
important component in aligning The new DRG 545 includes the 48938), we discussed the creation of
hospital reimbursement with hospital following code assignments: new codes for vertebroplasty (81.65) and
costs and patient benefits of total joint • 00.70, Revision of hip replacement, kyphoplasty (81.66), which went into
arthroplasty. The commenter both acetabular and femoral effect on October 1, 2004. Prior to
encouraged CMS to continue its components October 1, 2004, both of these surgical
dialogue with industry and providers • 00.71, Revision of hip replacement, procedures were assigned to code 78.49
regarding further DRG changes to acetabular component (Other repair or plastic operation on
primary joint arthroplasty procedures, • 00.72, Revision of hip replacement, bone). For FY 2005, we assigned these
which represent approximately 90 femoral component codes to DRGs 233 and 234 (Other
Musculoskeletal System and Connective code 81.66 be assigned to DRGs 497 and MedPAR file on kyphoplasty and
Tissue O.R. Procedure With and 498 (Spinal Fusion Except Cervical vertebroplasty. Prior to October 1, 2004,
Without CC, respectively) in MDC 8 With and Without CC, respectively). both procedures were assigned in code
(Table 6B of the FY 2005 final rule). (In The commenters stated that kyphoplasty 78.49, which was assigned to DRGs 233
the FY 2005 IPPS final rule (69 FR requires special inflatable bone tamps and 234 in MDC 8. We stated that we
48938), we indicated that new codes and bone cement and is a significantly would continue to review this area as
81.65 and 81.66 were assigned to DRGs more resource intensive procedure than part of our annual review of MedPAR
223 and 234. We made a typographical vertebroplasty. The commenters further data. While we do not have separate
error when indicating that these codes stated that, while kyphoplasty involves data for kyphoplasty because code 81.66
were assigned to DRG 223. Codes 81.65 internal fixation of the spinal fracture
was not established until October 1,
and restoration of vertebral heights,
and 81.66 have been assigned to DRGs 2004, for the FY 2006 IPPS proposed
vertebroplasty involves only fixation.
233 and 234.) Last year, we received The commenters indicated that hospital rule, we did examine data on code
comments opposing the assignment of costs for kyphoplasty procedures are 78.49, which includes both kyphoplasty
code 81.66 to DRGs 233 and 234. The more similar to resources used in a and vertebroplasty procedures reported
commenters supported the creation of spinal fusion. in DRGs 233 and 234. The following
the codes for kyphoplasty and We stated in the FY 2005 IPPS final chart illustrates our findings:
vertebroplasty, but recommended that rule that we did not have data in the
Average
Number of Average
DRG length of stay
cases charges
(days)
233—All cases ............................................................................................................................. 14,066 6.66 $28,967.78

233 With code 78.49 reported ..................................................................................................... 8,702 5.91 25,402.71
233 Without code 78.49 reported ................................................................................................ 5,364 7.88 34,571.39
234—All cases ............................................................................................................................. 7,106 2.79 18,954.80
234 With code 78.49 reported ..................................................................................................... 4,437 2.61 18,426.11
234 Without code 78.94 reported ................................................................................................ 2,669 3.09 19,833.71
We do not believe these data findings • 81.63, Fusion or refusion of 4–8 • 84.65, Insertion of total spinal disc
support moving cases represented by vertebrae prosthesis, lumbosacral
code 78.49 out of DRGs 233 and 234. • 81.64, Fusion or refusion of 9 or • 84.66, Revision or replacement of
While we cannot distinguish cases that more vertebrae artificial spinal disc prosthesis, cervical
are kyphoplasty from cases that are Prior to the creation of these codes, • 84.67, Revision or replacement of
vertebroplasty, cases represented by we received a comment recommending artificial spinal disc prosthesis, thoracic
code 78.49 have lower charges than do the establishment of new DRGs that • 84.68, Revision or replacement of
other cases within DRGs 233 and 234. would be differentiated based on the artificial spinal disc prosthesis,
Therefore, in the FY 2006 IPPS number of vertebrae fused. In the FY lumbosacral
proposed rule, we did not propose to 2005 IPPS final rule (69 FR 48936), we • 84.69, Revision or replacement of
change the DRG assignment of code stated that we did not yet have any artificial spinal disc prosthesis, not
81.66 to DRGs 233 and 234. reported cases utilizing these multiple otherwise specified
Comment: Two commenters level spinal fusion codes. We stated that We also created the following two
supported our proposal not to change we would wait until sufficient data were codes effective October 1, 2004, for
the DRG assignment of code 81.66 available prior to making a final these new types of spinal surgery that
(Kyphoplasty). Both commenters agreed determination on whether to create are also a more conservative approach to
with our proposal to keep code 81.66 in separate DRGs based on the number of back pain than is spinal fusion:
DRGs 233 and 234. They also agreed vertebrae fused. We also stated that • 81.65, Vertebroplasty
• 81.66, Kyphoplasty
that we should wait for bill data using spinal fusion surgery was an area
We do not yet have data in the
the new kyphoplasty code prior to undergoing rapid changes.
MedPAR file on these new types of
considering any DRG modification. Effective October 1, 2004, we created
procedures. Therefore, we cannot yet
Response: We appreciate the a series of codes that describe a new
determine what effect these new types
commenters’ support for our proposal. type of spinal surgery, spinal disc
of procedures will have on the
In this final rule, for FY 2006, we are replacement. Our medical advisors
frequency of spinal fusion procedures.
retaining the assignment of code 81.66 describe these procedures as a more However, we do have data in the
in DRGs 233 and 234. As we proposed, conservative approach for back pain MedPAR file on multiple level spinal
we will consider whether further than the spinal fusion surgical procedures for analysis for this year’s
changes are warranted once additional procedure. These codes are as follows: IPPS rule. We examined data in the FY
hospital charge data are available using • 84.60, Insertion of spinal disc 2004 MedPAR file on spinal fusion
the new code. prosthesis, not otherwise specified cases in the following DRGs:
• 84.61, Insertion of partial spinal • DRG 496 (Combined Anterior/
c. Multiple Level Spinal Fusion disc prosthesis, cervical Posterior Spinal Fusion)
On October 1, 2003, the following • 84.62, Insertion of total spinal disc • DRG 497 (Spinal Fusion Except
ICD–9–CM codes were created to prosthesis, cervical Cervical With CC)
identify the number of levels of vertebra • 84.63, Insertion of spinal disc • DRG 498 (Spinal Fusion Except
fused during a spinal fusion procedure: prosthesis, thoracic Cervical Without CC)
• 81.62, Fusion or refusion of 2–3 • 84.64, Insertion of partial spinal • DRG 519 (Cervical Spinal Fusion
vertebrae disc prosthesis, lumbosacral With CC)
• DRG 520 (Cervical Spinal Fusion spinal fusion patients, an even greater • 737.32, Progressive infantile
Without CC) impact was made by the presence of a idiopathic scoliosis
Multiple level spinal fusion is principal diagnosis of curvature of the • 737.33, Scoliosis due to radiation
captured by code 81.63 (Fusion or spine or malignancy. The following list • 737.34, Thoracogenic scoliosis
refusion of 4–8 vertebrae) and code of diagnoses describes conditions that • 737.39, Other kyphoscoliosis and
81.64 (Fusion or refusion of 9 or more have a significant impact on resource scoliosis
vertebrae). Code 81.62 includes the use for spinal fusion patients: • 737.40, Curvature of spine,
fusion of 2–3 vertebrae and is not • 170.2, Malignant neoplasm of unspecified
considered a multiple level spinal vertebral column, excluding sacrum and • 737.41, Curvature of spine
fusion. Orthopedic surgeons stated at coccyx associated with other conditions,
the October 7–8, 2004 ICD–9–CM • 198.5, Secondary malignant kyphosis
Coordination and Maintenance neoplasm of bone and bone marrow • 737.42, Curvature of spine
Committee meeting that the most simple • 732.0, Juvenile osteochondrosis of associated with other conditions,
and common type of spinal fusion spine lordosis
involves fusing either 2 or 3 vertebrae. • 733.13, Pathologic fracture of • 737.43, Curvature of spine
These surgeons stated that there was not vertebrae associated with other conditions,
a significant difference in resource • 737.0, Adolescent postural kyphosis scoliosis
utilization for cases involving the fusion • 737.10, Kyphosis (acquired) • 737.8, Other curvatures of spine
of 2 versus 3 vertebrae. For this reason, (postural) • 737.9, Unspecified curvature of
the orthopedic surgeons recommended • 737.11, Kyphosis due to radiation spine
that fusion of 2 and 3 vertebrae remain • 737.12, Kyphosis, postlaminectomy • 754.2, Congenital scoliosis
grouped into one ICD–9–CM code. • 737.19, Kyphosis (acquired), other • 756.51, Osteogenesis imperfecta
We reviewed the Medicare charge • 737.20, Lordosis (acquired) The majority of fusion patients with
data to determine whether the number (postural) these diagnoses were in DRGs 497 and
of vertebrae fused or specific diagnoses • 737.21, Lordosis, postlaminectomy 498. The chart below reflects our
have an effect on average length of stay • 737.22, Other postsurgical lordosis findings. We also include in the chart
and resource use for a patient. We found • 737.29, Lordosis (acquired), other statistics for cases in DRGs 497 and 498
that, while fusing 4 or more levels of the • 737.30, Scoliosis [and with spinal fusion of 4 or more
spine results in a small increase in the kyphoscoliosis], idiopathic vertebrae and cases with a principal
average length of stay and a somewhat • 737.31, Resolving infantile diagnosis of curvature of the spine or
larger increase in average charges for idiopathic scoliosis bone malignancy.
Average length
Number of Average
DRG of stay
cases charges
(days)
497 ............................................................................................................................................. 27,346 6.08 $64,471.82

498 ............................................................................................................................................. 17,943 3.80 48,440.80
497 and 498 With spinal fusions of 4 or more vertebrae reported ........................................... 7,881 6.3 77,352.00
497 and 498 With principal diagnosis of curvature of the spine or bone malignancy .............. 2,006 8.91 95,315.00
Thus, these diagnoses result in a 737.9, 754.2, and 756.51. We proposed incorporate new types of spinal
significant increase in resource use. that the proposed DRG 546 would not procedures such as kyphoplasty and
While the fusing of 4 or more vertebrae include cases currently assigned to spinal disc prostheses into the spinal
resulted in average charges of $77,352, DRGs 496, 519, or 520 that have a fusion DRGs.
the impact of a principal diagnosis of principal diagnosis of curvature of the Comment: A number of commenters
curvature of the spine or bone spine or malignancy and that the supported our proposal to create new
malignancy was substantially greater structure of DRGs 496, 519, and 520 DRG 546 (Spinal Fusions Except
with average charges of $95,315. would remain the same. Cervical With Principal Diagnosis of
Based on this analysis, we proposed As part of our meeting with the AAOS Curvature of the Spine or Malignancy)
to create a new DRG 546 for noncervical on DRG 209 in February 2005 to include all noncervical spinal fusions
spinal fusions with a principal (discussed under section II.B.6.a. of this previously assigned to DRGs 497 and
diagnosis of curvature of the spine and preamble), the AAOS offered to work 498 that have a principal diagnosis of
malignancies: proposed new DRG 546 with CMS to analyze clinical issues and curvature of the spine or malignancy.
(Spinal Fusions Except Cervical With make revisions to the spinal fusion One commenter stated that the addition
Principal Diagnosis of Curvature of the DRGs (DRGs 496 through 498 and 519 of new DRG 546, with its higher weight,
Spine or Malignancy). We proposed to and 520). Therefore, we limited our would help reimburse hospitals more
include in the proposed new DRG cases proposed changes to the spinal fusion adequately for the resources used in
all noncervical spinal fusions cases DRGs for FY 2006 to the creation of the treating patients with significant spinal
previously assigned to DRGs 497 and proposed DRG 546 discussed above. deformities and other problems. One
498 that have a principal diagnosis of However, we indicated that we look commenter stated that the cost
curvature of the spine or malignancy forward to working with the AAOS to associated with a multilevel spine
and with the following codes listed obtain its clinical recommendations fusion when the patient has a diagnosis
above: 170.2, 198.5, 732.0, 733.13, concerning our proposed changes and of curvature of the spine or malignancy
737.0, 737.10, 737.11, 737.12, 737.19, potential additional modifications to the exceeds the current Medicare
737.20, 737.21, 737.22, 737.29, 737.30, spinal fusion DRGs. We also solicited reimbursement.
737.31, 737.32, 737.33, 737.34, 737.39, comments from the public on our Several commenters noted that the
737.40, 737.41, 737.42, 737.43, 737.8, proposed changes and how to following four ICD–9–CM diagnosis
codes are manifestation codes that • 732.8, Other specified forms of • 737.33, Scoliosis due to radiation
cannot be reported as a principal osteochondropathy • 737.34, Thoracogenic scoliosis
diagnosis: • 756.19, Anomalies of spine; Other • 737.39, Other kyphoscoliosis and
• 737.40, Curvature of spine, Response: We discussed these scoliosis
unspecified additional diagnosis codes • 737.8, Other curvatures of spine
• 737.41, Curvature of spine recommended by the commenter with • 737.9, Unspecified curvature of
associated with other conditions, our medical advisors and they agree that spine
kyphosis the first three listed codes (213.2, 238.0, • 754.2, Congenital scoliosis
• 737.42, Curvature of spine and 239.2) should be added because • 756.51, Osteogenesis imperfecta
associated with other conditions, they are neoplasm codes. Therefore, The secondary diagnoses that will
lordosis they are clinically similar to the other lead to the new DRG 546 assignment
• 737.43, Curvature of spine neoplasm codes on our proposed list. are:
associated with other conditions, Our medical advisors did not support • 737.40, Curvature of spine,
scoliosis the addition on the latter four codes unspecified
The commenter pointed out that these • 737.41, Curvature of spine
because they are vague codes that do not
codes can only be reported as a associated with other conditions,
necessarily represent significant
secondary diagnosis. Therefore, the kyphosis
conditions. Therefore, in this final rule,
commenters stated that our proposed • 737.42, Curvature of spine
we are adding codes 213.2, 238.0, 239.2
DRG logic for DRG 546 would not work associated with other conditions,
to our list of conditions in DRG 546. We
with these four codes. lordosis
are not adding codes 721.7, 724.3, 732.8, • 737.43, Curvature of spine
Response: We appreciate the support or 756.19.
of the commenters for the creation of the associated with other conditions,
After careful consideration of the
new DRG 546. We agree that this new scoliosis
public comments received, in this final
DRG would better align Medicare rule, we are establishing a new DRG 546 d. CHARITETM Spinal Disc
payment with hospital costs for treating (Spinal Fusions Except Cervical with Replacement Device
these more severe orthopedic cases. We Curvature of the Spine or Malignancy).
also agree that codes 737.40, 737.41, As we noted in our discussion of
New DRG 546 will be composed of all applications for new technology add-on
737.42, and 737.43 are not to be noncervical spinal fusions previously
reported as a principal diagnosis payments for FY 2006 in section II.E. of
assigned to DRGs 497 and 498 that have the IPPS proposed rule (70 FR 23362),
because they are manifestation codes. a principal or secondary diagnosis of
We inadvertently included them among the applicant for new technology for
curvature of the spine or a principal CHARITETM requested a DRG
the list of principal diagnoses that diagnosis of a malignancy. The
would be assigned to DRG 546. In this reassignment for cases involving
principal diagnosis codes that will lead implantation of the CHARITETM
final rule, we are removing codes to this DRG assignment are the
737.40, 737.41, 737.42, and 737.43 from Artificial Disc. CHARITETM is a
following: prosthetic intervertebral disc. On
the list of principal diagnosis codes that • 170.2, Malignant neoplasm of
would lead to an assignment of DRG October 26, 2004, the FDA approved the
vertebral column, excluding sacrum and CHARITETM Artificial Disc for single
546. However, we will retain these coccyx
codes as a secondary diagnosis that will level spinal arthroplasty in skeletally
• 198.5, Secondary malignant mature patients with degenerative disc
result in an assignment to DRG 546 neoplasm of bone and bone marrow disease between L4 and S1. The
because they describe curvature of the • 213.2, Benign neoplasm of bone and applicant requested a DRG assignment
spine. Therefore, patients admitted with articular cartilage; vertebral column,
an orthopedic diagnosis who receive a for these cases from DRG 499 (Back and
excluding sacrum and coccyx Neck Procedures Except Spinal Fusion
spinal fusion will be assigned to DRG • 238.0, Neoplasm of uncertain
546 if codes 737.40, 737.41, 737.42, and With CC) and 500 (Back and Neck
behavior of other and unspecified sites
737.43 are present as a secondary Procedures Except Spinal Fusion
and tissues; Bone and articular cartilage
Without CC) to DRGs 497 (Spinal
diagnosis. Consistent with this change • 239.2, Neoplasms of unspecified
in the GROUPER logic, we will also Fusion Except Cervical With CC) and
nature; bone, soft tissue, and skin
remove the term ‘‘principal diagnosis’’ • 732.0, Juvenile osteochondrosis of 498 (Spinal Fusion Except Cervical
from the proposed title so that DRG 546 spine Without CC). The applicant argued that
will be titled ‘‘Spinal Fusions Except • 733.13, Pathologic fracture of the costs of an inpatient stay to implant
Cervical With Curvature of the Spine or vertebrae an artificial disc prosthesis are similar
Malignancy.’’ • 737.0, Adolescent postural kyphosis to spinal fusion and inclusion in DRGs
Comment: One commenter suggested • 737.10, Kyphosis (acquired) 497 and 498 should be made consistent
that CMS consider adding the following (postural) with section 1886(d)(5)(K) of the Act
diagnoses to the list of codes that would • 737.11, Kyphosis due to radiation that indicates a clear preference for
be assigned to the new DRG 546: • 737.12, Kyphosis, postlaminectomy assigning a new technology to a DRG
• 213.2, Benign neoplasm of bone and • 737.19, Kyphosis (acquired), other based on similar clinical or anatomical
articular cartilage; vertebral column, • 737.20, Lordosis (acquired) characteristics and costs. As indicated
excluding sacrum and coccyx (postural) in section II.E. of this final rule, we did
• 238.0, Neoplasm of uncertain • 737.21, Lordosis, postlaminectomy not find that CHARITETM meets the
behavior of other and unspecified sites • 737.22, Other postsurgical lordosis substantial clinical improvement
and tissues; Bone and articular cartilage • 737.29, Lordosis (acquired), other criterion and are not considering a DRG
• 239.2, Neoplasms of unspecified • 737.30, Scoliosis [and reassignment under the new technology
nature; Bone, soft tissue, and skin kyphoscoliosis], idiopathic provisions. However, we did evaluate
• 721.7, Spondylosis and allied • 737.31, Resolving infantile whether to reassign CHARITETM to a
disorders; Traumatic spondylopathy idiopathic scoliosis different DRG using the Secretary’s
• 724.3, Other and unspecified • 737.32, Progressive infantile authority under section 1886(d)(4) of the
disorders of back; Sciatica idiopathic scoliosis Act.
On October 1, 2004, we created new a new procedure code to a DRG based not yet available due to the fact that give
codes for the insertion of spinal disc on the assignment of its predecessor that FDA approval and the code used to
prostheses (codes 84.60 through 84.69). code until we have Medicare charge identify these patients was not effective
In the FY 2005 IPPS proposed and final data to evaluate a DRG modification. We until October 2004. Thus, as with all
rules, we described the new DRG also agree that the spinal fusion cases new technology applications, the data
assignments for these new codes in are well-established based on several supporting whether the technology
Table 6B of the Addendum to those years of utilization and cost experience. meets the cost criterion came directly
rules. We received a number of Without Medicare data that shows from the applicant and not from
comments on the FY 2005 IPPS Medicare charges for CHARITETM Medicare’s data systems. While the
proposed rule recommending that we artificial discs in DRGs 499 and 500 and applicant also supplied data from the
change the assignments for these codes until we receive Medicare charge data FY 2003 MedPAR file, we note that
from DRG DRGs 499 and 500 to the using the new procedure codes, it is these cases did not actually involve the
DRGs for spinal fusion (DRGs 497 and difficult to evaluate a request for a DRG CHARITETM artificial disc. Rather the
498). In the FY 2005 IPPS final rule (69 modification. applicant modified the claims data for
FR 48938), we indicated that DRGs 497 Comment: Eight commenters opposed spinal fusion cases by removing the
and 498 are limited to spinal fusion our proposal of keeping CHARITETM medical and surgical costs associated
procedures. Because the surgery artificial discs in DRGs 499 and 500 with the spinal fusions. The applicant
involving the CHARITETM is not a until we received Medicare charge data. then replaced these costs with costs
spinal fusion, we decided not to include These commenters recommended that represented to be those of a typical
this procedure in these DRGs. However, the CHARITETM spinal disc procedure CHARITETM artificial disc. These data
we stated that we would continue to (code 84.65) be moved out of DRGs 499 are acceptable to evaluate whether a
analyze this issue and solicited further and 500 and into the spinal fusion DRGs new technology meets the cost criterion
public comments on the DRG (DRG 497 and 498). According to the in a new technology application
assignment for spinal disc prostheses. commenters, the current DRG because, by definition, there is limited
We received a number of public assignment to DRGs 499 and 500 or no Medicare data upon which to
comments in response to the FY 2006 provides a very significant economic evaluate a new technology’s costs.
proposed rule. A summary of the disincentive for hospitals to use However, these data do not meet the
comments and our responses follow. CHARITETM in the Medicare standards that we apply for making a
Comment: One commenter supported population. Based on information change to a DRG. That is, we use the
our recommendation to keep the submitted with its new technology predecessor code for a new technology
CHARITETM spinal disc procedure code application, these commenters argued until we have evidence from Medicare’s
in DRGs 499 and 500. The commenter that hospital resources for patients data systems that suggest a change to the
took no position on CMS’ decision on receiving CHARITETM artificial discs DRG assignment is warranted.
whether to grant add-on payment for are most closely comparable to patients As stated previously, we do not have
new technology for the CHARITETM in DRGs 497 and 498 (the data provided Medicare charge information to evaluate
spinal disc procedure. However, the to support the new technology a DRG change at this time. For this
commenter stated that until further data application are discussed in detail in reason, we are not making a change to
becomes publicly available, it would be section II.E. of this final rule). The the DRG assignment for CHARITÉTM.
premature to reassign spinal disc commenters also stated that the Health However, we will consider whether a
prostheses to DRGs 497 and 498. The Service Cost Review Commission DRG reassignment for CHARITÉTM is
commenter stated that waiting for (HSCRC) of Maryland developed new warranted for FY 2007, once we have
Medicare data would be consistent with artificial disc DRGs for its DRG system. information from Medicare’s data
the approach CMS used in considering Response: With respect to the system that will assist us in evaluating
changes to DRGs 497 and 498 for commenter’s point regarding the the cost of these patients.
account for multilevel spinal fusion. HSCRC, we acknowledge that they
(We did not propose a change for FY recently decided to create new DRGs for 8. MDC 18 (Infectious and Parasitic
2006 to account for multilevel spinal artificial disc patients. We understand Diseases (Systemic or Unspecified
fusions because sufficient data were not that the HSCRC established these new Sites)): Severe Sepsis
available in MedPAR under the new DRGs with relative weights that are As we did for FY 2005, we received
multilevel spine fusion procedure higher than DRGs 499 and 500 and less a request to consider the creation of a
codes.) The commenter also stated that than the spinal fusion DRGs (DRGs 497 separate DRG for the diagnosis of severe
the spinal fusion DRGs were well- and 498). We are unaware of the criteria sepsis for FY 2006. Severe sepsis is
established based on several years of that the HSCRC uses for creating described by ICD–9–CM code 995.92
utilization and accrual of cost separate DRGs. Currently, we do not (Systemic inflammatory response
experience. Without a fuller have a basis for creating a separate DRG syndrome due to infection with organ
understanding of the expected resource for spinal disc protheses because we dysfunction). Patients admitted with
use of cases with spinal disc prostheses, have no FY 2004 Medicare charge data sepsis as a principal diagnosis currently
the commenter was concerned that that could be used to set the FY 2006 are assigned to DRG 416 (Septicemia
reassignment of these procedures to relative weight. Therefore, we are Age >17) and DRG 417 (Septicemia Age
DRGs 497 and 498 may have the unable to adopt an option similar to that 0–17) in MDC 18 (Infectious and
potential to cause an inappropriate of the HSCRC at this time. Parasitic Diseases (Systemic or
reduction in future weights for spinal For its new technology application, Unspecified Sites)). The commenter
fusion. Therefore, the commenter we note that the applicant supplied cost requested that all cases in which severe
recommended that spinal disc data for 376 total cases where sepsis is present on admission, as well
replacements be kept in DRGs 499 and CHARITETM was actually used, as those cases in which it develops after
500 until data are available to evaluate including 12 cases involving Medicare admission (which are currently
this change. patients. The data for the 12 Medicare classified elsewhere), be included in
Response: We agree with the patients did not come from the MedPAR this new DRG. We again addressed this
commenter that our policy is to assign data systems because that information is issue in the FY 2006 IPPS proposed rule
(70 FR 23329) as we had in the FY 2005 data. The commenter stated that severe medical advisors evaluated the request
IPPS final rule (69 FR 48975). In both sepsis is a systemic inflammatory and determined that the most
instances, we did not believe the current syndrome in response to infection that appropriate DRG classification for a
clinical definition of severe sepsis is is associated with acute organ patient with drug-induced dementia
specific enough to identify a meaningful dysfunction. The commenter suggested was within MDC 20. The medical
cohort of patients in terms of clinical that CMS use the SIRS ICD–9–CM codes advisors indicated that because the
coherence and resource utilization to for infection plus organ dysfunction dementia is drug induced, it is
warrant a separate DRG. Sepsis is found along with an ICD–9–CM procedure appropriately classified to DRGs 521
across hundreds of medical and surgical code for organ support such as through 523 in MDC 20. Therefore, we
DRGs, and the term ‘‘organ dysfunction’’ ventilation management (code 96.7x), did not propose a new DRG
implicates numerous currently existing acute renal replacement (codes 39.95 classification for the principal diagnosis
diagnosis codes. While we recognize and 54.98), or vasopressor support (code code 292.82.
that Medicare beneficiaries with severe 00.17), to identify these patients. The In the FY 2005 IPPS final rule, we
sepsis are quite ill and require extensive commenter recommended that CMS addressed a comment from an
hospital resources, we do not believe create two new DRGs, one for medical organization representing hospital
that they can be identified adequately to severe sepsis patients with organ coders that disagreed with our decision
justify removing them from all of the support and another for surgical severe to keep code 292.82 in DRGs 521
other DRGs in which they appear. For sepsis patients with organ support. The through 523. The commenter stated that
this reason, we did not propose a new commenter recommended that these DRGs 521 through 523 are described as
DRG for severe sepsis for FY 2006. two DRGs be assigned as pre-MDCs. alcohol/drug abuse and dependence
Comment: Two commenters Response: There were extensive DRGs, and that drug-induced dementia
expressed concerns about the discussions about the problems in using can be caused by an adverse effect of a
sequencing instructions for severe the current SIRS codes at the March 31– prescribed medication or a poisoning.
sepsis. They pointed out that current April 1, 2005 ICD–9–CM Coordination The commenter did not believe that
ICD–9–CM coding guidelines mandate and Maintenance Committee meeting. A assignment to DRGs 521 through 523
that a code from category 038.x be summary report of this meeting can be was appropriate if the drug-induced
sequenced as the principal diagnosis found at the Web site: http:// dementia is due to one of these events
followed by code 995.92 for patients www.cdc.gov/nchs/icd9cm. As stated and the patient is not alcohol or drug
admitted in respiratory failure who also earlier, NCHS has scheduled further dependent. The commenter
have severe sepsis. The commenters discussions on this topic for the recommended that admissions for drug-
expressed concerns that this sequencing September 29–30 Committee meeting. induced dementia be classified to DRGs
instruction results in lower hospital Given the considerable confusion 521 through 523 only if there is a
reimbursement for patients with severe among the coding community regarding secondary diagnosis indicating alcohol/
sepsis placed on mechanical ventilation. the use of these codes, we believe it drug abuse or dependence.
These commenters did not recommend would be premature to consider new The commenter recommended that
that CMS create a new DRG for patients DRGs for severe sepsis patients at this drug-induced dementia that is due to
with severe sepsis. Instead, they time. Therefore, we are not making the adverse effect of a drug or poisoning
suggested that the codes or guidelines, revisions to the DRG for severe sepsis be classified to the same DRGs as other
or both, be modified so that other patients at this time. We will continue types of dementia, such as DRG 429
conditions can be sequenced as the to work with NCHS to improve the (Organic Disturbances and Mental
principal diagnosis. codes so that our data on these patients Retardation). The commenter believed
Response: We share the concern of the improve. We will continue to examine that when drug-induced dementia is
commenters about sequencing data on these patients as we consider caused by a poisoning, either accidental
guidelines for patients with severe future modifications. or intentional, the appropriate
sepsis and respiratory failure. The poisoning code would be sequenced as
current ICD–9–CM codes for systemic 9. MDC 20 (Alcohol/Drug Use and the principal diagnosis and, therefore,
inflammatory response syndrome Alcohol/Drug Induced Organic Mental these cases would likely already be
(SIRS), codes 995.91 through 995.94, Disorders): Drug-Induced Dementia assigned to DRGs 449 and 450
that include severe sepsis mandate these In the FY 2005 IPPS final rule (69 FR (Poisoning and Toxic Effects of Drugs,
sequencing guidelines. However, the 48939, August 11, 2004), we discussed Age Greater than 17, With and Without
National Center for Health Statistics a request that CMS modify DRGs 521 CC, respectively) and DRG 451
(NCHS) discussed modifications to through 523 by removing the principal (Poisoning and Toxic Effects of Drugs,
these codes at the April 1, 2005 ICD–9– diagnosis code 292.82 (Drug-induced Age 0–17). The commenter stated that
CM Coordination and Maintenance dementia) from these alcohol and drug these would be the appropriate DRG
Committee meeting. NCHS has abuse DRGs. These DRGs are as follows: assignments for drug-induced dementia
scheduled this topic for further • DRG 521 (Alcohol/Drug Abuse or due to a poisoning. We received a
discussion at the September 29–30, Dependence With CC). similar comment from a hospital
2005 Committee meeting. Suggestions • DRG 522 (Alcohol/Drug Abuse or organization.
for revising these codes and any Dependence With Rehabilitation In the FY 2005 IPPS final rule, we
resulting guidelines should be sent to Therapy Without CC). acknowledged that the commenters
Donna Pickett, NCHS, 3311 Toledo • DRG 523 (Alcohol/Drug Abuse or raised additional issues surrounding the
Road, Room 2402, Hyattsville, MD 2082, Dependence Without Rehabilitation DRG assignment for code 292.82 that
or to the e-mail address dfp4@cdc.gov. Therapy Without CC). should be considered. The commenters
Comment: One commenter expressed The commenter indicated that a provided alternatives for DRG
disappointment that CMS did not create patient who has a drug-induced assignment based on sequencing of the
a new DRG for severe sepsis. The dementia should not be classified to an principal diagnosis and reporting of
commenter disagreed with our alcohol/drug DRG. However, the additional secondary diagnoses. We
statement that these patients could not commenter did not propose a new DRG recognized that patients may develop
be easily identified within our Medicare assignment for code 292.82. Our drug-induced dementia from drugs that
are prescribed, as well as from drugs dementia due to an adverse effect of a a. Newborn Age Edit
that are not prescribed. However, drug would result in code 292.82, In the past, we have discussed and
because dementia develops as a result of followed by the appropriate E code as a received comments concerning revision
use of a drug, we believed the current secondary diagnosis, grouping to one of of the pediatric portions of the Medicare
DRG assignment to DRGs 521 through the alcohol and drug abuse DRGs (521 IPPS DRG classification system, that is,
523 remained appropriate. Some through 523). The commenter indicated MDC 15 (Newborns and Other Neonates
commenters have agreed with the an adverse effect of a drug should not With Conditions Originating in the
current DRG assignment of code 292.82 be confused with alcohol or drug abuse Perinatal Period). Most recently, we
since the dementia was caused by use and recommended that CMS examine addressed these comments in both the
of a drug. We agree that if either the potential impact of not reassigning FY 2005 proposed rule (69 FR 28210)
accidental or intentional poisoning code 292.82 into a new DRG from both and the FY 2005 IPPS final rule (69 FR
caused the drug-induced dementia, the a quality of care and a financial 48938). In those rules, we indicated that
appropriate poisoning code should be perspective. we would be responsive to specific
sequenced as the principal diagnosis. As Response: We appreciate the requests for updating MDC 15 on a
one commenter stated, these cases commenter’s recommendation. limited, case-by-case basis.
would be assigned to DRGs 449 through However, as we indicated above and in We have recently received a request
451. We encouraged hospitals to the FY 2006 IPPS proposed rule, drug- through the Open Door Forum to revise
examine the coding for these types of induced dementia develops as a result the MCE ‘‘newborn age edit’’ by
cases to determine if there were any of use of a drug. Therefore, it is removing over 100 codes located in
coding or sequencing errors. As appropriate to assign the code to DRGs Chapter 15 of ICD–9–CM that are
suggested by the commenter, if code 521, 522, or 523. As we indicated in the identified as ‘‘newborn’’ codes. This
292.82 were reported as a secondary FY 2006 proposed rule (70 FR 23330), request was made because these codes
diagnosis and not a principal diagnosis we did receive suggestions that drug- usually cause an edit or denial to be
in cases of poisoning or adverse drug induced dementia due to the adverse
reactions, the number of cases on DRGs triggered when they are used on
effects of a drug or poisoning be children greater than 1 year of age.
521 through 523 would decline. assigned to DRGs 429, 449, 450, or 451.
In the FY 2005 IPPS final rule, we However, the underlying issue with
However, we believe these DRGs should these particular edits is that other
agreed to analyze this area for FY 2006 only be assigned when the hospital uses
and to look at the alternative DRG payers have adopted the CMS Medicare
the appropriate poisoning or other codes Code Editor in a wholesale manner,
assignments suggested by the
sequenced as the principal diagnosis. In instead of adapting it for use in their
commenters. As indicated in the FY
addition, the data analyzed from the FY own patient populations.
2006 IPPS proposed rule, we examined
2004 MedPAR file did not support a We acknowledge that Medicare DRGs
data from the FY 2004 MedPAR file on
modification to DRGs 521 through 523. are sometimes used to classify other
cases in DRGs 521 through 523 with a
Our data show that hospital charges for patient groups. However, CMS’ primary
principal diagnosis of code 292.82. We
patients assigned to DRGs 521 through focus of updates to the Medicare DRG
found that there were only 134 cases
523 with a principal diagnosis of code classification system is on changes
reported with the principal diagnosis
292.82 and no drug abuse secondary relating to the Medicare patient
code 292.82 in DRGs 521 through 523
diagnosis were similar to other patients population, not the pediatric or neonatal
without a diagnosis of drug and alcohol
abuse. The average standardized charges in these DRGs. Given that no other patient populations.
for cases with a principal diagnosis of secondary diagnosis codes were used, it There are practical considerations
code 292.82 that did not have a is not possible to know whether these regarding the assumption of a larger role
secondary diagnosis of drug/alcohol patients were more clinically similar to for the Medicare DRGs in the pediatric
abuse or dependence were $12,244.35, patients in DRGs 426, 449, 450, 451, or or neonatal areas, given the difference
compared to the average standardized 521 through 523. Absent any other between the Medicare population and
charges for all cases in DRG 521, which diagnoses other than code 292.82, we that of newborns and children. There
were $10,543.69. There were no cases in have no evidence that these patients are also challenges surrounding the
DRG 522 with a principal diagnosis of were clinically different than other development of DRG classification
code 292.82. We found only 24 cases in patients in DRGs 521 through 523. systems and applications appropriate to
DRG 523 with a principal diagnosis of After consideration of the comments children. We do not have the clinical
code 292.82. Given the small number of received, as we proposed, in this final expertise to make decisions about these
cases in DRG 522 and 523, and the rule we are not changing the DRG patients, and must rely on outside
similarity in average standardized assignment for drug-induced dementia clinicians for advice. In addition,
charges between those cases in DRG 521 (code 292.82) for FY 2006. because newborns and other children
with a principal diagnosis of code are generally not eligible for Medicare,
10. Medicare Code Editor (MCE)
292.82 and without a secondary we must rely on outside data to make
Changes
diagnosis of drug/alcohol abuse or decisions. We recognize that there are
dependence to the overall average for all As explained under section II.B.1. of evolving alternative classification
cases in the DRG, we do not believe the this preamble, the Medicare Code Editor systems for children and encourage
data suggest that a modification to DRGs (MCE) is a software program that detects payers to use the CMS MCE as a
521 through 523 is warranted. and reports errors in the coding of template while making modifications
Therefore, we did not propose changes Medicare claims data. Patient diagnoses, appropriate for pediatric patients.
to the current structure of DRGs 521 procedure(s), discharge status, and Therefore, we would encourage those
through 523 for FY 2006. demographic information go into the non-Medicare systems needing a more
Comment: One commenter expressed Medicare claims processing systems and comprehensive pediatric system of edits
concern that CMS did not propose any are subjected to a series of automated to update their systems by choosing
DRG change to code 292.82, drug- screens. The MCE screens are designed from other existing systems or programs
induced dementia. The commenter to identify cases that require further that are currently in use. Because of our
stated that a patient admitted with review before classification into a DRG. reluctance to assume expertise in the
pediatric arena, as we proposed we are defective biosynthesis of testicular post-approval studies. Therefore, as the
not making the commenter’s suggested androgen. This disorder is included in coverage indication has changed, we
changes to the MCE ‘‘newborn age edit’’ code 257.2 (Other testicular proposed to remove codes 00.61, 00.63,
for FY 2006. hypofunction). Therefore, we also and V70.7 from the MCE noncovered
Comment: One commenter requested proposed to remove code 257.2 from the procedure edit.
that CMS reconsider making the ‘‘Male Only’’ gender edit in the MCE. We did not receive any comments on
necessary revisions to the ‘‘newborn age We did not receive any comments on this proposal. Therefore, in this final
edit’’ and other pediatric data. The these proposals. Therefore, in this final rule, we are adopting the proposal as
commenter suggested that if CMS rule, we are adopting the proposals as final without modification.
continues its current stance regarding final without modification.
f. Error in Non-Covered Procedure
the internal level of expertise to develop
d. Tobacco Use Disorder Edit Edit—code 36.32
newborn and pediatric edits, then these
edit should be removed from the MCE. We have become aware of the possible It has come to our attention that an
Response: We believe the need to add code 305.1 (Tobacco use entry in the Non-Covered Procedures
commenter’s recommendation to disorder) to the MCE in order to make section of the MCE was made in error.
remove the newborn and pediatric edits admissions for tobacco use disorder a Procedure code 36.32 (Other
from the MCE has merits and will noncovered Medicare service when transmyocardial revascularization) is
consider it for FY 2007. However, we code 305.1 is reported as the principal covered as a late or last resort for
believe it is important that we have an diagnosis. On March 22, 2005, CMS patients with severe (Canadian
opportunity to analyze this issue further published a final decision memorandum Cardiovascular Society classification
and consider any comments from and related national coverage Classes III or IV) angina (stable or
interested parties before eliminating determination (NCD) on smoking unstable). The angina symptoms must
these edits. cessation counseling services on its Web be caused by areas of the heart not
site: (http://www.cms.hhs.gov/coverage/ amenable to surgical therapies.
b. Newborn Diagnoses Edit ). Among other things, this NCD Therefore, as code 36.32 is erroneously
Last year, in our changes to the MCE, provides that: ‘‘Inpatient hospital stays in the Non-Covered Procedure edit in
we inadvertently added code 796.6 with the principal diagnosis of 305.1, the MCE, we are removing it from the
(Abnormal findings on neonatal Tobacco Use Disorder, are not edits for FY 2006.
screening) to both the MCE edit for reasonable and necessary for the
effective delivery of tobacco cessation 11. Surgical Hierarchies
‘‘Maternity Diagnoses—age 12 through
55’’, and the MCE edit for ‘‘Diagnoses counseling services. Therefore, we will Some inpatient stays entail multiple
Allowed for Females Only’’. In the FY not cover tobacco cessation services if surgical procedures, each one of which,
2006 IPPS proposed rule, we proposed tobacco cessation is the primary reason occurring by itself, could result in
to remove code 796.6 from these two for the patient’s hospital stay.’’ assignment of the case to a different
edits and add it to the ‘‘Newborn Therefore, in order to maintain internal DRG within the MDC to which the
Diagnoses’’ edit. consistency with CMS programs and principal diagnosis is assigned.
We did not receive any comments on decisions, we proposed to add code Therefore, it is necessary to have a
this proposal. Therefore, in this final 305.1 to the MCE edit ‘‘Questionable decision rule within the GROUPER by
rule, we are adopting the proposal as Admission-Principal Diagnosis Only’’ in which these cases are assigned to a
final without modification. order to make tobacco use disorder a single DRG. The surgical hierarchy, an
noncovered admission. ordering of surgical classes from most
c. Diagnoses Allowed for ‘‘Males Only’’ We did not receive any comments on resource-intensive to least resource-
Edit this proposal. Therefore, in this final intensive, performs that function.
We have received a request to remove rule, we are adopting the proposal as Application of this hierarchy ensures
two codes from the ‘‘Diagnoses Allowed final without modification. that cases involving multiple surgical
for Males Only’’ edit, related to procedures are assigned to the DRG
androgen insensitivity syndrome (AIS). e. Noncovered Procedure Edit
associated with the most resource-
AIS is a new term for testicular Effective October 1, 2004, CMS intensive surgical class.
feminization. Code 257.8 (Other adopted the use of code 00.61 Because the relative resource intensity
testicular dysfunction) is used to (Percutaneous angioplasty or of surgical classes can shift as a function
describe individuals who, despite atherectomy of precerebral (extracranial) of DRG reclassification and
having XY chromosomes, develop as vessel(s) (PTA)) and code 00.63 recalibrations, we reviewed the surgical
females with normal female genitalia (Percutaneous insertion of carotid artery hierarchy of each MDC, as we have for
and mammary glands. Testicles are stent(s). Both codes are to be recorded previous reclassifications and
present in the same general area as the to indicate the insertion of a carotid recalibrations, to determine if the
ovaries, but are undescended and are at artery stent or stents. At the time of the ordering of classes coincides with the
risk for development of testicular creation of the codes, the coverage intensity of resource utilization.
cancer, so are generally surgically indication for carotid artery stenting A surgical class can be composed of
removed. These individuals have been was only for patients in a clinical trial one or more DRGs. For example, in
raised as females, and would continue setting, and diagnostic code V70.7 MDC 11, the surgical class ‘‘kidney
to be considered female, despite their (Examination of participation in a transplant’’ consists of a single DRG
XY chromosome makeup. Therefore, as clinical trial) was required for payment (DRG 302) and the class ‘‘kidney, ureter
AIS is coded to 257.8, and has posed a of these cases. However, effective and major bladder procedures’’ consists
problem associated with the gender edit, October 12, 2004, Medicare covers PTA of three DRGs (DRGs 303, 304, and 305).
in the FY 2006 IPPS proposed rule, we of the carotid artery concurrent with the Consequently, in many cases, the
proposed to remove this code from the placement of an FDA-approved carotid surgical hierarchy has an impact on
‘‘Males Only’’ edit in the MCE. stent for an FDA-approved indication more than one DRG. The methodology
A similar clinical scenario can occur when furnished in accordance with for determining the most resource-
with certain disorders that cause a FDA-approved protocols governing intensive surgical class involves
weighting the average resources for each average charge than the class ordered • DRG 552 above DRG 557
DRG by frequency to determine the below it. (Percutaneous Cardiovascular Procedure
weighted average resources for each Based on the preliminary With Drug Eluting Stent With Major CV
surgical class. For example, assume recalibration of the DRGs, in the FY Diagnosis);
surgical class A includes DRGs 1 and 2 2006 IPPS proposed rule (70 FR 23332), • DRG 557 above DRG 555
and surgical class B includes DRGs 3, 4, we proposed to revise the surgical (Percutaneous Cardiovascular Procedure
and 5. Assume also that the average hierarchy for MDC 5 (Diseases and With Major CV Diagnosis);
charge of DRG 1 is higher than that of Disorders of the Circulatory System) and • DRG 555 above DRG 558
DRG 3, but the average charges of DRGs MDC 8 (Diseases and Disorders of the (Percutaneous Cardiovascular Procedure
4 and 5 are higher than the average Musculoskeletal System and Connective With Drug Eluting Stent Without Major
charge of DRG 2. To determine whether Tissue) as follows: CV Diagnosis);
surgical class A should be higher or In MDC 5, we proposed reordering— • DRG 558 above DRG 556
lower than surgical class B in the • DRG 116 (Other Permanent Cardiac (Percutaneous Cardiovascular Procedure
surgical hierarchy, we would weight the Pacemaker Implant) above DRG 549 Without Major CV Diagnosis);
average charge of each DRG in the class (Percutaneous Cardiovascular Procedure • DRG 556 above DRG 518
by frequency (that is, by the number of With Drug-Eluting Stent With AMI With (Percutaneous Cardiovascular Procedure
cases in the DRG) to determine average CC). Without Coronary Artery Stent Or AMI);
resource consumption for the surgical • DRG 549 above DRG 550 • DRG 518 above DRG 553 (Other
class. The surgical classes would then (Percutaneous Cardiovascular Procedure Vascular Procedures With CC With
be ordered from the class with the With Drug-Eluting Stent With AMI Major CV Diagnosis);
highest average resource utilization to Without CC). • DRG 553 above DRG 554 (Other
that with the lowest, with the exception • DRG 550 above DRG 547 Vascular Procedures With CC Without
of ‘‘other O.R. procedures’’ as discussed (Percutaneous Cardiovascular Procedure Major CV Diagnosis);
below. With AMI With CC). • DRG 554 above DRG 479 (Other
This methodology may occasionally • DRG 547 above DRG 548 Vascular Procedures Without CC).
result in assignment of a case involving (Percutaneous Cardiovascular Procedure In MDC 8, we proposed to reorder—
multiple procedures to the lower- With AMI Without CC). • DRG 496 (Combined Anterior/
weighted DRG (in the highest, most • DRG 548 above DRG 527 Posterior Spinal Fusion) above DRG 546
resource-intensive surgical class) of the (Percutaneous Cardiovascular Procedure (Spinal Fusions Except Cervical With
available alternatives. However, given With Drug-Eluting Stent Without AMI). Curvature of the Spine or Malignancy).
that the logic underlying the surgical • DRG 527 above DRG 517 • DRG 546 above DRGs 497 and 498
hierarchy provides that the GROUPER (Percutaneous Cardiovascular Procedure (Spinal Fusions Except Cervical With
search for the procedure in the most With Non-Drug Eluting Stent Without and Without CC, respectively).
resource-intensive surgical class, in AMI). • DRG 217 (Wound Debridement and
cases involving multiple procedures, • DRG 517 above DRG 518 Skin Graft Except Hand, For
this result is sometimes unavoidable. (Percutaneous Cardiovascular Procedure Musculoskeletal and Connective Tissue
We note that, notwithstanding the Without Coronary Artery Stent or AMI). Disease) above DRG 545 (Revision of
foregoing discussion, there are a few • DRG 518 above DRGs 478 and 479 Hip or Knee Replacement).
instances when a surgical class with a (Other Vascular Procedures With and • DRG 545 above DRG 544 (Major
lower average charge is ordered above a Without CC, respectively). Joint Replacement or Reattachment).
surgical class with a higher average Comment: Several commenters agreed • DRG 544 above DRGs 519 and 520
charge. For example, the ‘‘other O.R. with the proposed changes in the (Cervical Spinal Fusion With and
procedures’’ surgical class is uniformly surgical hierarchy for MDC 5. Without CC, respectively).
ordered last in the surgical hierarchy of Response: We appreciate the Comment: Several commenters agreed
each MDC in which it occurs, regardless commenters’ support. However, because with the proposed changes in the
of the fact that the average charge for the in this final rule we are deleting 9 DRGS surgical hierarchy for MDC 8.
DRG or DRGs in that surgical class may and creating 12 new DRGs in MDC 5, as Response: We appreciate the
be higher than that for other surgical discussed under ‘‘MedPAC commenters’ support. Based on a test of
classes in the MDC. The ‘‘other O.R. Recommendations’’ in section IX.A of the proposed revisions using the March
procedures’’ class is a group of this preamble, we are reordering the 2005 update of the FY 2004 MedPAR
procedures that are only infrequently following DRGs in MDC 5: file and the revised GROUPER software,
related to the diagnoses in the MDC, but • DRG 106 (Coronary Bypass With
we found that the revisions to MDC 8
are still occasionally performed on PTCA) above DRGs 547 and 548
are still supported by the data.
patients in the MDC with these (Coronary Bypass With Cardiac
Accordingly, in this final rule, we are
diagnoses. Therefore, assignment to Catheterization With and Without Major
adopting the proposed change in the
these surgical classes should only occur CV Diagnosis, respectively);
surgical hierarchy for MDC 8 as final,
if no other surgical class more closely • DRGs 547–548 above DRGs 549 and
without modification.
related to the diagnoses in the MDC is 550 (Coronary Bypass Without Cardiac
appropriate. Catheterization With and Without Major 12. Refinement of Complications and
A second example occurs when the CV Diagnosis, respectively); Comorbidities (CC) List
difference between the average charges • DRG 113 (Amputation For
for two surgical classes is very small. Circulatory System Disorders Except a. Background
We have found that small differences Upper Limb or Toe) above DRG 551 As indicated earlier in this preamble,
generally do not warrant reordering of (Permanent Cardiac Pacemaker Implant under the IPPS DRG classification
the hierarchy because, as a result of With Major CV Diagnosis or AICD Lead system, we have developed a standard
reassigning cases on the basis of the or Generator); list of diagnoses that are considered
hierarchy change, the average charges • DRG 551 above DRG 552 (Other complications or comorbidities (CCs).
are likely to shift such that the higher- Permanent Cardiac Pacemaker Implant Historically, we developed this list
ordered surgical class has a lower Without Major CV Diagnosis); using physician panels that classified
each diagnosis code based on whether are assigned to DRGs that have a CC because prior versions of the DRGs
the diagnosis, when present as a split fall into the DRG with CC. While Definitions Manual used age as a
secondary condition, would be this fact is not new, we have found that surrogate for a CC and the split was ‘‘CC
considered a substantial complication or a much higher proportion of cases are and/or age greater than 69’’.)
comorbidity. A substantial complication being grouped to the DRG with a CC The vast majority of patients being
or comorbidity was defined as a than had occurred in the past. In our treated in inpatient settings have a CC
condition that, because of its presence review of the DRGs included in Table 7b as currently defined, and we believe
with a specific principal diagnosis, of the September 1, 1987 Federal that it is possible that the CC distinction
would cause an increase in the length of Register rule (52 FR 33125), we found has lost much of its ability to
stay by at least 1 day in at least 75 the following percentages of cases differentiate the resource needs of
percent of the patients. assigned a CC in those DRGs that had a patients. The original definition used to
CC split (DRG Definitions Manual, develop the CC list (the presence of a CC
b. Comprehensive Review of the CC List
GROUPER Version 5.0 (1986 data)): would be expected to extend the length
In previous years, we have made • Cases with CC: 61.9 percent of stay of at least 75 percent of the
changes to the standard list of CCs, • Cases without CC: 38.1 percent patients who had the CC by at least one
either by adding new CCs or deleting When we compared the above 1986 day) was used beginning in 1981 and
CCs already on the list, but we have DRG data to the 2004 DRG data that has been part of the IPPS since its
never conducted a comprehensive were included in the DRGs Definitions inception in 1983. There has been no
review of the list. There are currently Manual, GROUPER Version 22.0, we substantive review of the CC list since
3,285 diagnosis codes on the CC list. found the following: its original development. In reviewing
There are 121-paired DRGs that are split • Cases with CC: 79.9 percent this issue, our clinical experts found
on the presence or absence of a CC. • Cases without CC: 20.1 percent several diseases that appear to be
We have reviewed these paired DRGs (We used DRGs Definitions Manual, obvious candidates to be on the CC list,
and found that the majority of cases that GROUPER Version 5.0, for this analysis but currently are not:
Code Code description 2004 count
041.7 ................. Pseudomonas Infection in Conditions Classified Elsewhere and/or of Unspecified Site .................................... 47,350
253.6 ................. Disorders of Neurohypophysis ............................................................................................................................. 23,613
414.12 ............... Dissection of Coronary Artery .............................................................................................................................. 2,377
359.4 ................. Toxic Myopathy .................................................................................................................................................... 1,875
031.2 ................. Disseminated Disease Due to Mycobacteria ....................................................................................................... 1,428
451.83 ............... Phlebitis and Thrombophlebitis of Deep Veins of Upper Extremities .................................................................. 376
Conversely, our medical experts examples of common conditions that are higher treatment costs when present as
believe the following conditions are on the CC list, but are not likely lead to a secondary diagnosis:
Code Code description 2004 count
424.0 ................. Mitral Valve Disorder ............................................................................................................................................ 401,359

305.00 ............... Alcohol Abuse Unspecified Use ........................................................................................................................... 69,099
578.1 ................. Blood in Stool ....................................................................................................................................................... 53,453
723.4 ................. Brachial Neuritis/Radiculitis, Not Otherwise Specified ......................................................................................... 5,829
684 .................... Impetigo ................................................................................................................................................................ 1,230
293.84 ............... Anxiety Disorder in Conditions Classified Elsewhere .......................................................................................... 1,153
We note that the above conditions are 20.0 of the APR–DRGs, and not a CC at charges or costs of a case to evaluate
examples only of why we believe the CC all under GROUPER Version 21.0 of the whether to include the condition on the
list needs a comprehensive review. In AP–DRGs. CC list. Using a statistical algorithm, we
addition to this review, we note that Given the long period of time that has may classify each diagnosis based on its
these conditions may be treated elapsed since the original CC list was effect on hospital charges (or costs)
differently under several DRG systems developed, the incremental nature of relative to other cases when present as
currently in use. For instance, ICD–9– changes to it, and changes in the way a secondary diagnosis to obtain better
CM code 414.12 (Dissection of coronary inpatient care is delivered, as indicated information on when a particular
artery) is listed as a ‘‘Major CC’’ under in the FY 2006 IPPS proposed rule, we condition is likely to increase hospital
the All Patient (AP) DRGs, GROUPER are planning a comprehensive and costs. For example, code 293.84
Version 21.0 and an ‘‘Extreme’’ CC systematic review of the CC list for the (Anxiety disorder in conditions
under the All Patient Refined (APR) IPPS rule for FY 2007. As part of this classified elsewhere), which is currently
DRGs, GROUPER Version 20.0, but is process, we plan to consider revising listed as a CC, might be removed from
not listed as a CC at all in GROUPER the standard for determining when a the CC list if analysis of the data
Version 22.0 of the DRGs Definitions condition is a CC. For instance, we may indicates that the data do not support
Manual used by Medicare. Similarly, use an alternative to classifying a the fact that it represents a significant
ICD–9–CM code 424.0 (Mitral valve condition as a CC based on how it increase in resource utilization, and a
disorder) is a CC under GROUPER affects the length of stay of a case. code such as 359.4 (Toxic myopathy),
Version 22.0 of the DRGs Definitions Similar to other aspects of the DRG which is currently not listed as a CC,
Manual for Medicare’s DRG system, a system, we may consider the effect of a could be added to the CC list if the data
minor CC under the GROUPER Version specific secondary diagnosis on the support it. In addition to using hospital
charge data as a basis for a review, we major revision of the list would greatly about patients’ secondary diagnoses and
would expect to supplement the process improve the extent to which the IPPS minimize opportunities for hospitals to
with review by our medical experts. payment rates recognize the effects of benefit financially from patient
Further, we may also consider doing a differences in patient severity of illness. selection.
comparison of the Medicare DRG CC list MedPAC noted that the CC distinction • Study the need for a general/
with other DRG systems such as the AP– is based entirely on the presence or standard list of CCs that addresses
DRGs and the APR–DRGs to determine absence of any CC, implicitly assuming patient conditions across all body
how the same secondary diagnoses are that all CCs have equal effects on systems and a list of special severity
treated under these systems. severity of illness and costs. Even if the conditions that are unique to specific
By performing a comprehensive CC review process were to correctly population/diseases.
review of the CC list, we expect to revise identify all secondary diagnoses that • Consider abandoning length of stay
the DRG classification system to better significantly affect hospitals’ costs, as an indicator for severity because, in
reflect resource utilization and remove MedPAC’s research and CMS’ earlier today’s clinical environment, length of
conditions from the CC list that only work have shown that simply stay is determined more by postacute
have a marginal impact on a hospital’s distinguishing between patients with care referral dynamics than patient
costs. We believe that a comprehensive and without CCs fails to capture large, need.
review of the CC list would be predictable differences in costs among • Consider differentiating
consistent with MedPAC’s patients. MedPAC stated that further comorbidities from complications. The
recommendation that we improve the differentiation is necessary to make the former are predictable and can be used
DRG system to better recognize severity. most effective use of information about to easily affect admission selection.
We will provide more detail about how patients’ secondary diagnoses and to • Compare the existing CC list with
we expect to undertake this analysis in help minimize opportunities for those used with other DRG systems.
the future, and any significant structural hospitals to benefit financially from • Conduct the comprehensive review
changes to the CC list will only be patient selection. and analysis cautiously, systemically,
adopted after a notice and comment Response: There has not been a and thoroughly, using external expertise
rulemaking that fully explains the comprehensive review of the CC list in and maintaining transparency and
methodology we plan to use in over 20 years. Such a review may stakeholder involvement throughout the
conducting this review. In the FY 2006 indicate that a more focused list will process, and do not rush the analysis
IPPS proposed rule, we encouraged better distinguish the effects of CCs on simply to meet the deadline for the FY
comment regarding possible ways that severity of illness than earlier analysis. 2007 IPPS rule.
more meaningful indicators of clinical Until this comprehensive review and • Use open door forums to inform the
severity and their implications for analysis are complete, we will not know public of progress.
resource use can be incorporated into whether there is merit in adopting a • Consider combining the cases from
our comprehensive review and possible modification of the CC list or whether each DRG pair in one homogenous DRG.
restructuring of the CC list. it will be necessary to adopt a more Under such a change, hospitals would
Comment: Several commenters agreed comprehensive change to the DRG still receive the same total
with CMS that changes in resource system such as APR–DRGs. We reimbursement for the same patients but
utilization and in inpatient hospital currently plan to continue with our would have more financial incentive to
care, particularly the focus on comprehensive review of the CC list. In improve the quality and efficiency of
decreasing length of stay, may be addition, we expect shortly to engage a care.
resulting in the CC distinction not being contractor highly experienced with DRG • Before inclusion as a CC condition,
able to differentiate resource utilization development to study the APR–DRGs a diagnosis should meet the following
and patient severity as well as it has in over the next year. We appreciate the four criteria: (1) The patient group
the past. Several commenters agreed commenters’ suggestions about waiting represents a higher cost in that DRG
that it may be valuable to conduct a to adopt MedPAC’s recommendations than those without the comorbid
substantial and comprehensive review until ICD–10–CM and ICD–10–PCS have condition; (2) the condition cannot be
of the CC list for the future. While some been implemented. While we do not prevented, in any possible way, by
commenters applauded CMS’ efforts to have a proposal in place at this time to superior care in the hospital; (3) the
keep refining the DRG system, the implement ICD–10–CM and ICD–10– condition is not related to the principal
commenters believed that review of the PCS, before adopting any major changes diagnosis; and (4) there is at least some
CC list can only be taken as an interim to the DRG system, we will consider the indication that the patient would face
step and a more refined DRG system can implications of potential future changes inadequate options for finding
only be accomplished with more to our coding systems as part of our appropriate medical care without a
specific clinical classification systems analysis of MedPAC’s recommendation. more appropriate payment.
capable of providing more complete Comment: Commenters gave Response: We appreciate these many
information about a patient’s condition numerous suggestions for performing suggestions. As we indicated above, we
and the services provided to treat those the analysis of the CC list. The will continue to conduct a thorough
conditions—namely, ICD–10–CM and suggestions include: review of the CC list. We also will be
ICD–10–PCS. Some commenters • Analyze all diagnosis and engaging a contractor shortly to assist us
suggested waiting to adopt the MedPAC procedures codes reported on the claim, with evaluating APR–DRGs and other
recommendations until these new not just nine diagnosis codes and six mechanisms to better recognize severity
coding classification systems are procedure codes. in our payment systems.
implemented. • Examine the impact of multiple CCs
MedPAC stated that a comprehensive on hospital resource consumption and c. CC Exclusions List for FY 2006
review and revision of the CC list might length of stay. In the September 1, 1987 final notice
lead to a desirable improvement in the • Examine further differentiation (52 FR 33143) concerning changes to the
extent to which payment rates reflect beyond simply distinguishing between DRG classification system, we modified
patient severity of illness. However, patients with and without CCs to make the GROUPER logic so that certain
MedPAC does not expect that even a the most effective use of information diagnoses included on the standard list
of CCs would not be considered valid As proposed, we are making a limited include the identification accession
CCs in combination with a particular revision of the CC Exclusions List to number (PB) 88–133970) should be
principal diagnosis. We created the CC take into account the changes that will made to the following address: National
Exclusions List for the following be made in the ICD–9–CM diagnosis Technical Information Service, United
reasons: (1) To preclude coding of CCs coding system effective October 1, 2005. States Department of Commerce, 5285
for closely related conditions; (2) to (See section II.B.14. of this preamble for Port Royal Road, Springfield, VA 22161;
preclude duplicative or inconsistent a discussion of ICD–9–CM changes.) We or by calling (800) 553–6847.
coding from being treated as CCs; and are making these changes in accordance Users should be aware of the fact that
(3) to ensure that cases are appropriately with the principles established when we all revisions to the CC Exclusions List
classified between the complicated and created the CC Exclusions List in 1987. (FYs 1989, 1990, 1991, 1992, 1993,
uncomplicated DRGs in a pair. As we We receive one comment that agreed 1994, 1995, 1996, 1997, 1998, 1999,
indicated above, we developed a list of with the revised CC Exclusion List 2001, 2002, 2003, 2004, and 2005) and
diagnoses, using physician panels, to based on the information provided. those in Tables 6G and 6H of this final
include those diagnoses that, when Tables 6G and 6H in the Addendum rule for FY 2006 must be incorporated
present as a secondary condition, would to this final rule contain the revisions to into the list purchased from NTIS in
be considered a substantial the CC Exclusions List that will be order to obtain the CC Exclusions List
complication or comorbidity. In effective for discharges occurring on or applicable for discharges occurring on
previous years, we have made changes after October 1, 2005. Each table shows or after October 1, 2005. (Note: There
to the list of CCs, either by adding new the principal diagnoses with changes to was no CC Exclusions List in FY 2000
CCs or deleting CCs already on the list. the excluded CCs. Each of these because we did not make changes to the
We did not receive any comments principal diagnoses is shown with an ICD–9–CM codes for FY 2000.)
specific to the diagnosis codes on the asterisk, and the additions or deletions Alternatively, the complete
FY 2006 CC list. Therefore, as we to the CC Exclusions List are provided documentation of the GROUPER logic,
proposed in the FY 2006 IPPS proposed in an indented column immediately including the current CC Exclusions
rule, we are not deleting any of the following the affected principal List, is available from 3M/Health
diagnosis codes on the CC list for FY diagnosis. Information Systems (HIS), which,
2006. CCs that are added to the list are in under contract with CMS, is responsible
In the May 19, 1987 proposed notice Table 6G—Additions to the CC for updating and maintaining the
(52 FR 18877) and the September 1, Exclusions List. Beginning with GROUPER program. The current DRG
1987 final notice (52 FR 33154), we discharges on or after October 1, 2005, Definitions Manual, Version 22.0, is
explained that the excluded secondary the indented diagnoses will not be available for $225.00, which includes
diagnoses were established using the recognized by the GROUPER as valid $15.00 for shipping and handling.
following five principles: CCs for the asterisked principal Version 23.0 of this manual, which will
• Chronic and acute manifestations of diagnosis. include the final FY 2006 DRG changes,
the same condition should not be CCs that are deleted from the list are will be available in hard copy for
in Table 6H—Deletions from the CC $250.00. Version 23.0 of the manual is
considered CCs for one another.
• Specific and nonspecific (that is, Exclusions List. Beginning with also available on a CD for $200.00; a
discharges on or after October 1, 2005, combination hard copy and CD is
not otherwise specified (NOS))
the indented diagnoses will be available for $400.00. These manuals
diagnosis codes for the same condition
recognized by the GROUPER as valid may be obtained by writing 3M/HIS at
should not be considered CCs for one
CCs for the asterisked principal the following address: 100 Barnes Road,
another.
diagnosis. Wallingford, CT 06492; or by calling
• Codes for the same condition that
Copies of the original CC Exclusions (203) 949–0303. Please specify the
cannot coexist, such as partial/total,
List applicable to FY 1988 can be revision or revisions requested.
unilateral/bilateral, obstructed/
obtained from the National Technical
unobstructed, and benign/malignant, 13. Review of Procedure Codes in DRGs
Information Service (NTIS) of the
should not be considered CCs for one 468, 476, and 477
Department of Commerce. It is available
another. Each year, we review cases assigned
in hard copy for $152.50 plus shipping
• Codes for the same condition in to DRG 468 (Extensive O.R. Procedure
and handling. A request for the FY 1988
anatomically proximal sites should not Unrelated to Principal Diagnosis), DRG
CC Exclusions List (which should
be considered CCs for one another. 476 (Prostatic O.R. Procedure Unrelated
• Closely related conditions should to Principal Diagnosis), and DRG 477
the FY 1994 final rule (58 FR 46278) September 1,
not be considered CCs for one another. 1993, for the FY 1994 revisions; the FY 1995 final (Nonextensive O.R. Procedure Unrelated
The creation of the CC Exclusions List rule (59 FR 45334), September 1, 1994, for the FY to Principal Diagnosis) to determine
was a major project involving hundreds 1995 revisions; the FY 1996 final rule (60 FR 45782)
whether it would be appropriate to
of codes. We have continued to review September 1, 1995, for the FY 1996 revisions; the
FY 1997 final rule (61 FR 46171), August 30, 1996, change the procedures assigned among
the remaining CCs to identify additional for the FY 1997 revisions; the FY 1998 final rule these DRGs.
exclusions and to remove diagnoses (62 FR 45966), August 29, 1997, for the FY 1998 DRGs 468, 476, and 477 are reserved
from the master list that have been revisions; the FY 1999 final rule (63 FR 40954), July
for those cases in which none of the
shown not to meet the definition of a 31, 1998, for the FY 1999 revisions; the FY 2001
final rule (65 FR 47064), August 1, 2000, for the FY O.R. procedures performed are related
CC.1 2001 revisions; the FY 2002 final rule (66 FR 39851) to the principal diagnosis. These DRGs
August 1, 2001, for the FY 2002 revisions; the FY are intended to capture atypical cases,
1 See the FY 1989 final rule (53 FR 38485) 2003 final rule (67 FR 49998), August 1, 2002, for
September 30, 1988, for the revision made for the the FY 2003 revisions; the FY 2004 final rule (68
that is, those cases not occurring with
discharges occurring in FY 1989; the FY 1990 final FR 45364) August 1, 2003, for the FY 2004 sufficient frequency to represent a
rule (54 FR 36552) September 1, 1989, for the FY revisions; and the FY 2005 final rule (69 FR 49848) distinct, recognizable clinical group.
1990 revision; the FY 1991 final rule (55 FR 36126) August 11, 2004, for the FY 2005 revisions. In the DRG 476 is assigned to those discharges
September 4, 1990, for the FY 1991 revision; the FY FY 2000 final rule (64 FR 41490) July 30, 1999, we
1992 final rule (56 FR 43209) August 30, 1991, for did not modify the CC Exclusions List because we
in which one or more of the following
the FY 1992 revision; the FY 1993 final rule (57 FR did not make any changes to the ICD–9–CM codes prostatic procedures are performed and
39753) September 1, 1992, for the FY 1993 revision; for FY 2000. are unrelated to the principal diagnosis:
• 60.0, Incision of prostate are arrayed two ways for comparison c. Adding Diagnosis or Procedure Codes
• 60.12, Open biopsy of prostate purposes. We look at a frequency count to MDCs
• 60.15, Biopsy of periprostatic tissue of each major operative procedure code. Based on our review this year, as we
• 60.18, Other diagnostic procedures We also compare procedures across proposed, we are not adding any
on prostate and periprostatic tissue MDCs by volume of procedure codes diagnosis codes to MDCs. We did not
• 60.21, Transurethral prostatectomy within each MDC. receive any comments on our proposal
• 60.29, Other transurethral We identify those procedures and are therefore not adding any
prostatectomy occurring in conjunction with certain diagnosis codes to any MDCs.
• 60.61, Local excision of lesion of principal diagnoses with sufficient
prostate frequency to justify adding them to one 14. Changes to the ICD–9–CM Coding
• 60.69, Prostatectomy, not elsewhere of the surgical DRGs for the MDC in System
classified which the diagnosis falls. Based on this As described in section II.B.1. of this
• 60.81, Incision of periprostatic year’s review, we did not identify any preamble, the ICD–9–CM is a coding
tissue procedures in DRGs 468 or 477 that system used for the reporting of
• 60.82, Excision of periprostatic should be removed to one of the surgical diagnoses and procedures performed on
tissue DRGs. We did not receive any a patient. In September 1985, the ICD–
• 60.93, Repair of prostate comments on this provision. Therefore, 9–CM Coordination and Maintenance
• 60.94, Control of (postoperative) in this final rule, we are not making any Committee was formed. This is a
hemorrhage of prostate changes for FY 2006. Federal interdepartmental committee,
• 60.95, Transurethral balloon
b. Reassignment of Procedures Among co-chaired by the National Center for
dilation of the prostatic urethra
DRGs 468, 476, and 477 Health Statistics (NCHS), the Centers for
• 60.96, Transurethral destruction of
Disease Control and Prevention, and
prostate tissue by microwave We also annually review the list of CMS, charged with maintaining and
thermotherapy ICD–9–CM procedures that, when in updating the ICD–9–CM system. The
• 60.97, Other transurethral combination with their principal Committee is jointly responsible for
destruction of prostate tissue by other diagnosis code, result in assignment to approving coding changes, and
thermotherapy DRGs 468, 476, and 477, to ascertain if developing errata, addenda, and other
• 60.99, Other operations on prostate any of those procedures should be modifications to the ICD–9–CM to
All remaining O.R. procedures are reassigned from one of these three DRGs reflect newly developed procedures and
assigned to DRGs 468 and 477, with to another of the three DRGs based on technologies and newly identified
DRG 477 assigned to those discharges in average charges and the length of stay. diseases. The Committee is also
which the only procedures performed We look at the data for trends such as responsible for promoting the use of
are nonextensive procedures that are shifts in treatment practice or reporting Federal and non-Federal educational
unrelated to the principal diagnosis.2 practice that would make the resulting programs and other communication
a. Moving Procedure Codes from DRG DRG assignment illogical. If we find techniques with a view toward
468 or DRG 477 to MDCs these shifts, we would propose to move standardizing coding applications and
cases to keep the DRGs clinically similar upgrading the quality of the
We annually conduct a review of or to provide payment for the cases in
procedures producing assignment to classification system.
a similar manner. Generally, we move The Official Version of the ICD–9–CM
DRG 468 or DRG 477 on the basis of only those procedures for which we
volume, by procedure, to see if it would contains the list of valid diagnosis and
have an adequate number of discharges procedure codes. (The Official Version
be appropriate to move procedure codes to analyze the data.
out of these DRGs into one of the of the ICD–9–CM is available from the
It has come to our attention that Government Printing Office on CD–
surgical DRGs for the MDC into which
procedure code 26.12 (Open biopsy of ROM for $25.00 by calling (202) 512–
the principal diagnosis falls. The data
salivary gland or duct) is assigned to 1800.) The Official Version of the ICD–
2 The original list of the ICD–9–CM procedure DRG 468 (Extensive O.R. Procedure 9–CM is no longer available in printed
codes for the procedures we consider nonextensive Unrelated to Principal Diagnosis). We manual form from the Federal
procedures, if performed with an unrelated believe this to be an error, as code 26.31 Government; it is only available on CD–
principal diagnosis, was published in Table 6C in (Partial sialoadenectomy), which is a ROM. Users who need a paper version
section IV. of the Addendum to the FY 1989 final
rule (53 FR 38591). As part of the FY 1991 final rule
more extensive procedure than code are referred to one of the many products
(55 FR 36135), the FY 1992 final rule (56 FR 43212), 26.12, is assigned to DRG 477. available from publishing houses.
the FY 1993 final rule (57 FR 23625), the FY 1994 Therefore, we proposed to correct this The NCHS has lead responsibility for
final rule (58 FR 46279), the FY 1995 final rule (59 error by moving code 26.12 out of DRG the ICD–9–CM diagnosis codes included
FR 45336), the FY 1996 final rule (60 FR 45783),
the FY 1997 final rule (61 FR 46173), and the FY
468 and reassigning it to DRG 477. We in the Tabular List and Alphabetic
1998 final rule (62 FR 45981), we moved several received one comment in support of our Index for Diseases, while CMS has lead
other procedures from DRG 468 to DRG 477, and proposal to move code 26.12 out of DRG responsibility for the ICD–9–CM
some procedures from DRG 477 to DRG 468. No 468 and reassign it to DRG 477. procedure codes included in the
procedures were moved in FY 1999, as noted in the
final rule (63 FR 40962); in FY 2000 (64 FR 41496);
Therefore, we are adopting as final our Tabular List and Alphabetic Index for
in FY 2001 (65 FR 47064); or in FY 2002 (66 FR proposal to move procedure code 26.12 Procedures.
39852). In the FY 2003 final rule (67 FR 49999) we out of DRG 468 and reassigning it to The Committee encourages
did not move any procedures from DRG 477. DRG 477. We received no comments participation in the above process by
However, we did move procedure codes from DRG
468 and placed them in more clinically coherent
opposing our plan of not moving any health-related organizations. In this
DRGs. In the FY 2004 final rule (68 FR 45365), we procedure codes from DRG 476 to DRGs regard, the Committee holds public
moved several procedures from DRG 468 to DRGs 468 or 477 or from DRG 477 to DRG 468. meetings for discussion of educational
476 and 477 because the procedures are Therefore, as we proposed, we are not issues and proposed coding changes.
nonextensive. In the FY 2005 final rule (69 FR
48950), we moved one procedure from DRG 468 to
moving any procedure codes from DRG These meetings provide an opportunity
477. In addition, we added several existing 476 to DRGs 468 or 477, or from DRG for representatives of recognized
procedures to DRGs 476 and 477. 477 to DRGs 468 or 476. organizations in the coding field, such
as the American Health Information Division of Acute Care, C4–08–06, 7500 503(a) amended section 1886(d)(5)(K) of
Management Association (AHIMA), the Security Boulevard, Baltimore, MD the Act by adding a clause (vii) which
American Hospital Association (AHA), 21244–1850. Comments may be sent by states that the ‘‘Secretary shall provide
and various physician specialty groups, E-mail to: for the addition of new diagnosis and
as well as individual physicians, health Patricia.Brooks1@cms.hhs.gov. procedure codes in April 1 of each year,
information management professionals, The ICD–9–CM code changes that but the addition of such codes shall not
and other members of the public, to have been approved will become require the Secretary to adjust the
contribute ideas on coding matters. effective October 1, 2005. The new ICD– payment (or diagnosis-related group
After considering the opinions 9–CM codes are listed, along with their classification) * * * until the fiscal year
expressed at the public meetings and in DRG classifications, in Tables 6A and that begins after such date.’’ This
writing, the Committee formulates 6B (New Diagnosis Codes and New requirement improves the recognition of
recommendations, which then must be Procedure Codes, respectively) in the new technologies under the IPPS system
approved by the agencies. Addendum to this final rule. As we by providing information on these new
The Committee presented proposals stated above, the code numbers and technologies at an earlier date. Data will
for coding changes for implementation their titles were presented for public be available 6 months earlier than
in FY 2006 at a public meeting held on comment at the ICD–9–CM would be possible with updates
October 7–8, 2004, and finalized the Coordination and Maintenance occurring only once a year on October
coding changes after consideration of Committee meetings. Both oral and 1.
comments received at the meetings and written comments were considered While section 503(a) states that the
in writing by January 12, 2005. Those before the codes were approved. In the addition of new diagnosis and
coding changes are announced in Tables FY 2006 IPPS proposed rule, we only procedure codes on April 1 of each year
6A through 6F of the Addendum to this solicited comments on the proposed shall not require the Secretary to adjust
final rule. The Committee held its 2005 classification of these new codes. the payment, or DRG classification
meeting on March 31–April l, 2005. For codes that have been replaced by under section 1886(d) of the Act until
New codes for which there was a new or expanded codes, the the fiscal year that begins after such
consensus of public support and for corresponding new or expanded date, we have to update the DRG
which complete tabular and indexing diagnosis codes are included in Table software and other systems in order to
changes were made by May 2005 are 6A. New procedure codes are shown in recognize and accept the new codes. We
included in the October 1, 2005 update Table 6B. Diagnosis codes that have also publicize the code changes and the
to ICD–9–CM. Code revisions that were been replaced by expanded codes or need for a mid-year systems update by
discussed at the March 31–April 1, 2005 other codes or have been deleted are in providers to capture the new codes.
Committee meeting were not finalized Table 6C (Invalid Diagnosis Codes). Hospitals also have to obtain the new
in time to include them in the FY 2006 These invalid diagnosis codes will not code books and encoder updates, and
IPPS proposed rule. These additional be recognized by the GROUPER make other system changes in order to
codes are included in Tables 6A through beginning with discharges occurring on capture and report the new codes.
6F of this final rule and are marked with or after October 1, 2005. Table 6D The ICD–9–CM Coordination and
an asterisk (*). contains invalid procedure codes. These Maintenance Committee holds its
Copies of the minutes of the invalid procedure codes will not be meetings in the Spring and Fall in order
procedure codes discussions at the recognized by the GROUPER beginning to update the codes and the applicable
Committee’s October 7–8, 2004 meeting with discharges occurring on or after payment and reporting systems by
can be obtained from the CMS Web site: October 1, 2005. Revisions to diagnosis October 1 of each year. Items are placed
http://www.cms.hhs.gov/ code titles are in Table 6E (Revised on the agenda for the ICD–9–CM
paymentsystems/icd9/. The minutes of Diagnosis Code Titles), which also Coordination and Maintenance
the diagnoses codes discussions at the includes the DRG assignments for these Committee meeting if the request is
October 7–8, 2004 meeting are found at: revised codes. Table 6F includes revised received at least 2 months prior to the
http://www.cdc.gov/nchs/icd9.htm. procedure code titles for FY 2006. meeting. This requirement allows time
Paper copies of these minutes are no In the September 7, 2001 final rule for staff to review and research the
longer available and the mailing list has implementing the IPPS new technology coding issues and prepare material for
been discontinued. These Web sites also add-on payments (66 FR 46906), we discussion at the meeting. It also allows
provide detailed information about the indicated we would attempt to include time for the topic to be publicized in
Committee, including information on proposals for procedure codes that meeting announcements in the Federal
requesting a new code, attending a would describe new technology Register as well as on the CMS Web site.
Committee meeting, and timeline discussed and approved at the April The public decides whether or not to
requirements and meeting dates. meeting as part of the code revisions attend the meeting based on the topics
We encourage commenters to address effective the following October. As listed on the agenda. Final decisions on
suggestions on coding issues involving stated previously, ICD–9–CM codes code title revisions are currently made
diagnosis codes to: Donna Pickett, Co- discussed at the March 31–April 1, 2005 by March 1 so that these titles can be
Chairperson, ICD–9–CM Coordination Committee meeting that received included in the IPPS proposed rule. A
and Maintenance Committee, NCHS, consensus and that were finalized are complete addendum describing details
Room 2402, 3311 Toledo Road, included in Tables 6A through 6F of of all changes to ICD–9–CM, both
Hyattsville, MD 20782. Comments may this final rule. tabular and index, are publicized on
be sent by E-mail to: dfp4@cdc.gov. Section 503(a) of Pub. L. 108–173 CMS and NCHS web pages in May of
Questions and comments concerning included a requirement for updating each year. Publishers of coding books
the procedure codes should be ICD–9–CM codes twice a year instead of and software use this information to
addressed to: Patricia E. Brooks, Co- a single update on October 1 of each modify their products that are used by
Chairperson, ICD–9–CM Coordination year. This requirement was included as health care providers. This 5-month
and Maintenance Committee, CMS, part of the amendments to the Act time period has proved to be necessary
Center for Medicare Management, relating to recognition of new for hospitals and other providers to
Hospital and Ambulatory Policy Group, technology under the IPPS. Section update their systems.
A discussion of this timeline and the Web page at: http://www.cms.hhs.gov/ concerning this change to the effective
need for changes are included in March paymentsystems/icd9. Summary tables date of certain ICD–9–CM codes.
31–April 1, 2005 ICD–9–CM showing new, revised, and deleted code Comment: Five commenters
Coordination and Maintenance titles are also posted on the following recommended that CMS modify its DRG
Committee minutes. The public agreed CMS Web page: http:// GROUPER and instruct fiscal
that there was a need to hold the fall www.cms.hhs.gov/medlearn/ intermediaries to expand the number of
meetings earlier, in September or icd9code.asp. Information on ICD–9– diagnoses processed from 9 to 25 and
October, in order to meet the new CM diagnosis codes, along with the the number of procedures processed
implementation dates. The public Official ICD–9–CM Coding Guidelines, from 6 to 25. The commenters were
provided comment that additional time can be found on the Web page at: concerned that CMS was not evaluating
would be needed to update hospital http://www.cdc.gov/nchs/icd9.htm. all reported diagnoses and procedures
systems and obtain new code books and Information on new, revised, and that could possibly affect a patient’s
coding software. There was considerable deleted ICD–9–CM codes is also severity of illness or the resources used,
concern expressed about the impact this provided to the AHA for publication in or both. The commenters pointed out
new April update would have on the Coding Clinic for ICD–9–CM. AHA that the current DRG GROUPER only
providers. also distributes information to considers 9 diagnoses and up to 6
In the FY 2005 IPPS final rule, we publishers and software vendors. procedures; that hospitals submit claims
implemented section 503(a) by CMS also sends copies of all ICD–9– to CMS in electronic format, and that
developing a mechanism for approving, CM coding changes to its contractors for the HIPAA compliant electronic
in time for the April update, diagnoses use in updating their systems and transaction standard, HIPAA 837i,
and procedure code revisions needed to providing education to providers. allows up to 25 diagnoses and 25
describe new technologies and medical procedures. The commenters stated that
These same means of disseminating
services for purposes of the new fiscal intermediaries are currently
information on new, revised, and
technology add-on payment process. We ignoring or omitting the additional
deleted ICD–9–CM codes will be used to
also established the following process codes (beyond 9 diagnoses and 6
notify providers, publishers, software
for making these determinations. Topics procedures) submitted by hospital
vendors, contractors, and others of any
considered during the Fall ICD–9–CM providers, since these additional
changes to the ICD–9–CM codes that are
Coordination and Maintenance diagnoses and procedures are not
implemented in April. Currently, code
Committee meeting are considered for needed by the GROUPER to assign a
an April 1 update if a strong and titles are also published in the IPPS DRG. Several commenters stated that,
convincing case is made by the proposed and final rules. The code titles while it is important for inpatient acute
requester at the Committee’s public are adopted as part of the ICD–9–CM hospitals, it is even more crucial for
meeting. The request must identify the Coordination and Maintenance LTCHs whose patients are medically
reason why a new code is needed in Committee process. The code titles are complex and have multiple illnesses
April for purposes of the new not subject to comment in the proposed beyond the nine diagnoses allowed by
technology process. The participants at or final rules. We will continue to CMS. Several commenters further stated
the meeting and those reviewing the publish the October code updates in this that a list of CCs qualifying for
Committee meeting summary report are manner within the IPPS proposed and comorbidity adjustments for inpatient
provided the opportunity to comment final rules. For codes that are psychiatric facility services was only
on this expedited request. All other implemented in April, we will assign recently introduced under the new IRP
topics are considered for the October 1 the new procedure code to the same PPS. Thus, the commenter added, these
update. Participants at the Committee DRG in which its predecessor code was hospitals have not historically used the
meeting are encouraged to comment on assigned so there will be no DRG impact software available to sort and rearrange
all such requests. There were no as far as DRG assignment. This mapping secondary diagnosis cods so that all CCs
requests for an expedited April l, 2005 was specified by section 503(a) of Pub. possibly affecting the DRG grouping are
implementation of an ICD–9–CM code L. 108–173. Any midyear coding prioritized. One commenter stated that
at the October 7–8, 2004 Committee updates will be available through the the continued use of more limited
meeting. Therefore, there were no new Web sites indicated above and through diagnosis and procedure codes acts as a
ICD–9–CM codes implemented on April the Coding Clinic for ICD–9–CM. disincentive for the reporting of
1, 2005. Publishers and software vendors additional codes, and will result in less
We believe that this process captures currently obtain code changes through precise assignment of DRGs.
the intent of section 503(a). This these sources in order to update their Response: The commenters are correct
requirement was included in the code books and software systems. We that the current Medicare GROUPER
provision revising the standards and will strive to have the April 1 updates does not process codes submitted
process for recognizing new technology available through these Web sites 5 electronically on the 837i electronic
under the IPPS. In addition, the need for months prior to implementation (that is, format beyond the first 9 diagnoses and
approval of new codes outside the early November of the previous year), as the first 6 procedures. This limitation is
existing cycle (October 1) arises most is the case for the October 1 updates. not being imposed by the GROUPER.
frequently and most acutely where the Codebook publishers are evaluating how CMS made the decision to process only
new codes will capture new they will provide any code updates to the first 9 diagnosis codes and first 6
technologies that are (or will be) under their subscribers. Some publishers may procedure codes. While HIPAA requires
consideration for new technology add- decide to publish mid-year book CMS to accept up to 25 ICD–9–CM
on payments. Thus, we believe this updates. Others may decide to sell an diagnosis and procedure codes on the
provision was intended to expedite data addendum that lists the changes to the HIPAA 837i electronic format, it does
collection through the assignment of October 1 code book. Coding personnel not require that CMS process that many
new ICD–9–CM codes for new should contact publishers to determine diagnosis and procedure codes.
technologies seeking higher payments. how they will update their books. CMS As suggested by the commenters,
Current addendum and code title and its contractors will also consider there is value in retaining additional
information is published on the CMS developing provider education articles data on patient conditions that would
result from expanding Medicare’s data Maintenance Committee ‘‘appeared to accurately reflect the cost of treatment.
system so it can accommodate be advocating a higher threshold for the At that time, we indicated that we
additional diagnosis and procedure award of new codes based on the ever would take this comment into
codes. We will consider this issue decreasing number of available codes consideration when we analyzed the
further as we contemplate further under ICD–9–CM.’’ Many of the MedPAR data for this proposed rule for
refinements to our DRG system to better commenters indicated that the coding FY 2006.
recognize patient severity. However, system’s limitations are making it Our review of the most recent
while it would be a simple matter to difficult to compare outcomes and MedPAR data shows a total of 1,370
modify our GROUPER software to efficacy between older and newer cases overall in DRG 299, of which 471
accept and evaluate 25 diagnosis and 25 technologies, identify costs associated had a principal diagnosis coded as
procedure codes, extensive lead time to with the new technology, or revise 277.1. The average length of stay for all
allow for modifications to our internal reimbursement policies to appropriately cases in DRG 299 was 5.17 days, while
and contractors’ electronic systems reflect the cost of patient care when new the average length of stay for porphyria
would be necessary before we could technology is used. One commenter cases with code 277.1 was 6.0 days. The
process and store this additional indicated that failure to recognize the average charges for all cases in DRG 299
information. We are unable to move looming problems with the ICD–9–CM were $15,891, while the average changes
forward with this recommendation coding system will impede efforts to for porphyria cases with code 277.1
without carefully evaluating meet the President’s goal of adopting were $21,920. Based on our analysis of
implementation issues. Nevertheless, electronic health records by 2013. these data, we did not believe that there
we plan to proceed with this evaluation Many of the commenters referred to is a sufficient difference between the
as we consider further changes to our ICD–10–PCS as the next generation of average charges and average length of
DRG systems. coding systems. They stated that ICD– stay for these cases to justify proposing
10–PCS would modernize and expand a change to the DRG assignment for
Comment: Many commenters
CMS’ capacity to keep pace with treating this condition.
recommended that CMS act Comment: One commenter agreed
immediately to adopt coordinated changes in medical practice and
technology. In addition, these with our proposal not to modify the
implementation of ICD–10–CM and DRG assignment for acute intermittent
ICD–10–PCS in the United States. Some commenters stated that the structure of
ICD–10–PCS would incorporate all new porphyria, code 277.1, to DRG 229 due
of these commenters noted that Pub. L. to the minor variance in average charges
108–173 (MMA) included report procedures as unique codes that would
explicitly identify the technology used and length of stay between porphyria
language urging the Secretary to move cases and other cases in this DRG.
forward with the implementation of to perform the procedure.
Response: We agree that it is Response: We appreciate the
ICD–10 as quickly as possible. The commenter’s support of our proposal.
commenters noted that the National becoming increasingly difficult to
update ICD–9–CM. However, we are Review of the MedPAR data did not
Committee on Vital and Health demonstrate a significant disparity in
Statistics (NCVHS) raised concerns continuing to make revisions to ICD–9–
CM and create codes that recognize new the average charges compared to average
about the viability of ICD–9–CM in 2003 length of stay.
and stated it was ‘‘increasingly unable medical technology. We continue to
For FY 2006, as we proposed, we are
to address the needs for accurate data update ICD–10–PCS on an annual basis
not modifying the DRG assignment for
for health care billing, quality to keep it up to date with changing
code 277.1 (Acute intermittent
assurance, public health reporting, and technology. We agree that it is important
porphyria) to DRG 229.
health services research.’’ The to have an accurate and precise coding
commenter further noted that the system for this purpose. However, as b. Prosthetic Cardiac Support Device
NCVHS recommended in 2003 that noted by many of the commenters, the (Code 37.41)
DHHS act expeditiously to initiate the transition from one coding system to Code 37.41 (Implantation of
regulatory process for adoption of ICD– another raises many complex prosthetic cardiac support device
10–CM and ICD–10–PCS. The operational issues. The Department will around the heart) was addressed in the
commenter stated that, as of 2005, ‘‘we continue to study this matter as we FY 2006 IPPS proposed rule only as a
are still awaiting a process from HHS to consider whether to adopt ICD–10. notification in Table 6B that the new
begin this important transition.’’ While 15. Other Issues code was being created to describe a
some of the commenters acknowledged prosthetic cardiac support device (70 FR
the complexities involved with the a. Acute Intermittent Porphyria 23594). Code 37.41 was deemed to be an
transition from ICD–9–CM to ICD–10, Acute intermittent porphyria is a rare O.R. procedure and was assigned to
the commenters still recommended that metabolic disorder. The condition is MDC 5 (Diseases and Disorders of the
we act quickly to begin adoption of described by code 277.1 (Disorders of Circulatory System), DRGs 110 and 111
ICD–10. Other commenters also porphyrin metabolism). Code 277.1 is (Major Cardiovascular Procedures With
indicated that the 4-digit structure of assigned to DRG 299 (Inborn Errors of and Without CC, respectively). This
ICD–9–CM is limiting the ability of the Metabolism) under MDC 10 (Endocrine, device is being marketed as the
procedure coding system to identify Nutritional, and Metabolic Diseases and CorCapTM Cardiac Support Device and
new procedures and new technologies Disorders). is intended to prevent and reverse heart
and it is becoming increasingly In the FY 2005 final rule (69 FR failure by improving the heart’s
outdated. According to these 48981), we discussed the DRG structure and function.
commenters, it is becoming more assignment of acute intermittent This topic was discussed at the ICD–
difficult each year to make changes to porphyria. This discussion was a result 9–CM Coordination and Maintenance
the ICD–9–CM coding system because of of correspondence that we received Meeting on October 7, 2004. At that
the availability of new codes. One during the comment period for the FY time, there was no specific ICD–9–CM
commenter noted that several 2005 proposed rule in which the code that more precisely identified this
participants at the March 31–April 1, commenter suggested that Medicare procedure, so coders were advised to
2005 ICD–9–CM Coordination and hospitalization payments do not use code 37.99 (Other operations on
heart and pericardium) to describe the panel had not seen sufficient evidence pancreatic islet cell transplantation in
operation. Code 37.99 is currently of benefit for patients with heart failure. clinical trials was addressed in detail in
assigned to DRGs 110 and 111. The FDA’s concerns included the the FY 2005 IPPS final rule (69 FR
As is our established pattern, we efficacy of the device in achieving a 48950). At that time, we discussed
assign a new code to its predecessor longer lifespan for patients, and the section 733(b) of Pub. L. 108–173,
code’s DRG until we obtain a pattern of possibility that the device’s benefits did which provides that Medicare
use of the code in the MedPAR data file. not outweigh the risks of surgery. In payments, beginning no earlier than
After we have evidence-based addition, the FDA advisory panel had October 1, 2004, for the routine costs as
justification for reassignment of codes other concerns, including whether the well as the costs of the transplantation
within DRGs, we are better able to make application of this device around the and appropriate related items and
decisions about the most appropriate ventricles of the heart might make services will be allowed for Medicare
placement of those new codes. future heart surgeries more difficult. beneficiaries who are participating in
We received 11 comments on this Code 37.41 is too new to be included clinical trials as if such transplantations
topic as part of the comments on the FY in the MedPAR data. Therefore, we will were covered under Medicare Part A or
2006 IPPS proposed rule. continue to monitor this prosthetic Part B. In addition, the DRG payment
Comment: Most of the commenters cardiac support device in future IPPS will be supplemented by an add-on
responding were cardiovascular updates. As noted above, should FDA payment that includes pre-transplant
surgeons who were principal approve this device and should there be tests and services, pancreas
investigators participating in the United an evidence-based justification for procurement, and islet isolation
States’ CorCapTM clinical trials. All of reassignment of codes within these services. Cases were assigned to DRG
the commenters requested that we DRGs, we will be open to making 315 (Other Kidney and Urinary Tract
reconsider the assignment of the changes to the DRG structure. Procedures).
prosthetic cardiac support device from We received one comment on this
DRGs 110 and 111 to DRG 108, where c. Coronary Intravascular Ultrasound topic as part of the public comments on
the resources [in DRG 108] more closely (IVUS) (Procedure Code 00.24) the FY 2006 IPPS proposed rule.
approximate those associated with Procedure code 00.24 (Coronary Comment: One commenter was
implantation of the device. The intravascular ultrasound) was addressed concerned that the proposed relative
commenters stated that procedures in in the FY 2005 IPPS proposed rule only weight for DRG 315 published in the FY
DRG 108 are more clinically similar to as a notification in Table 6B that for FY 2006 IPPS proposed rule represented a
the implantation of the prosthetic 2005 a new code had been created to decrease of almost 33 percent. The
cardiac support device, being describe this imaging technique (69 FR commenter also indicated that it
exclusively performed on the internal or 49624). Code 00.24 describes ultrasonic continues to believe that this procedure
external structures of the heart and imaging within the coronary vessels. It is inappropriately classified, and
generally requiring access through a was not assigned ‘‘O.R.’’ status within suggested that these cases be reassigned
sternotomy. the GROUPER program; that is, the into pre-MDC DRG 513 (Pancreas
One commenter likened this presence or absence of this code does Transplant). The commenter believed
procedure to the maze procedure, not affect a claim’s DRG assignment or the suggested DRG change is justified
described by code 37.33 (Excision or payment. because islet cell and pancreas
destruction of other lesion or tissue of We received one comment on this transplants involve substantially similar
heart, open approach). Another procedure code as part of the public patient populations. The commenter
commenter compared it to comments on the FY 2006 IPPS further pointed out that the transplants
transmyocardial revascularization, proposed rule. both serve the same clinical function—
described by code 36.31 (Open chest Comment: One commenter noted that that of freeing the patient from insulin
transmyocardial revascularization). Both IVUS is an added cost to hospitals. The dependence. The commenter requested
of these procedure codes are assigned to commenter stated that it has conducted that CMS identify those admissions in
DRG 108. Commenters also stated that an analysis of coronary IVUS resource DRG 315 that involve islet cell
classification of this procedure to DRGs use in calendar year 2004 hospital data transplantation and determine the
110 and 111 would establish a financial to determine possible impact. The actual costs involved to decide whether
disincentive for hospitals to adopt this commenter reported its findings that, in islet cell transplant cases should be
potentially life-saving and cost-reducing DRGs 516, 517, 526, and 527, cases reclassified to DRG 513.
treatment for Medicare beneficiaries utilizing IVUS had higher total charges Response: We do not understand why
suffering from a problem that may and higher total costs. The commenter the commenter believes that the relative
otherwise require implantation of a requested that CMS perform an analysis weight for DRG 315 decreased by 33
ventricular assist device or heart of FY 2005 coronary IVUS cases and percent. The FY 2006 proposed relative
transplant. consider reassigning ICD–9–CM weight (2.0801 (see Table 5 of the FY
Response: As noted above, we have procedure code 00.24 to DRGs where 2006 proposed rule, 70 FR 23587)) is
classified procedure 37.41 to the same the average resource use most closely approximately 0.3 percent less than the
DRG as its predecessor code, in approximates the resource use of cases FY 2005 relative weight (2.0861 (see
accordance with our established policy. in which an IVUS technique has been Table 5 of the FY 2005 final rule, 69 FR
Until we have Medicare billing data that employed. 49603)). We have reviewed the MedPAR
will allow us to assess whether the new Response: We will perform the data for the first quarter of FY 2005, and
procedure code has been correctly requested data analysis using FY 2005 have found no cases of islet cell
assigned, our default position is to MedPAR data for the FY 2007 annual transplantation in DRG 315. Therefore,
assign a new procedure code to the IPPS update. we do not have a basis for comparison
same DRG as its predecessor code. Of of islet cell transplantation cases to the
major concern to CMS is the late June d. Islet Cell Transplantation remainder of the cases in DRG 315. We
2005 decision by an FDA advisory panel Islet cell transplantation was not a also take this opportunity to clarify that
urging FDA to reject approval of the topic addressed in the FY 2006 IPPS the DRGs are groupings of cases that are
CorCapTM device on the basis that the proposed rule. The issue of payment for similar both from a clinical perspective
as well as a resource-intensity between October 1, 2003 and September • Statistical outliers were eliminated
perspective. While the commenter’s 30, 2004, based on bills received by by removing all cases that are beyond
position is that the same clinical CMS through March 31, 2005, from all 3.0 standard deviations from the mean
endpoint is attempted with both islet hospitals subject to the IPPS and short- of the log distribution of both the
cell transplantation and pancreas term acute care hospitals in Maryland charges per case and the charges per day
transplant, the result or endpoint of (which are under a waiver from the IPPS for each DRG.
treatment results is not one of the axis under section 1814(b)(3) of the Act). The • The average charge for each DRG
upon which the DRGs are structured. In FY 2004 MedPAR file includes data for was then recomputed (excluding the
addtion, the pancreas transplant approximately 12,006,022 Medicare statistical outliers) and divided by the
involves an open abdominal procedure discharges. Discharges for Medicare national average standardized charge
in which one pancreas is surgically beneficiaries enrolled in a per case to determine the relative
removed and a cadaveric pancreas is Medicare+Choice managed care plan are weight.
transplanted. Conversely, islet cells are excluded from this analysis. The data The new weights are normalized by
infused via catheter. Therefore, from the excludes CAHs, including hospitals that an adjustment factor of 1.47462 so that
standpoint of clinical similarity, we do subsequently became CAHs after the the average case weight after
not believe that the cases are period from which the data were taken. recalibration is equal to the average case
comparable enough to consider putting The methodology used to calculate weight before recalibration. This
the islet cell transplantation into DRG the DRG relative weights from the FY adjustment is intended to ensure that
513. 2004 MedPAR file is as follows: recalibration by itself neither increases
Comment: The same commenter was • To the extent possible, all the nor decreases total payments under the
concerned about payment for islet cell claims were regrouped using the DRG IPPS.
transplants under a National Institutes classification revisions discussed in When we recalibrated the DRG
of Health (NIH) clinical trial. The section II.B. of this preamble. weights for previous years, we set a
commenter believed that the $18,848 • The transplant cases that were used threshold of 10 cases as the minimum
islet cell isolation add-on amount is to establish the relative weight for heart number of cases required to compute a
insufficient. This commenter also and heart-lung, liver and/or intestinal, reasonable weight. We used that same
believed that the data used to calculate and lung transplants (DRGs 103, 480, case threshold in recalibrating the DRG
the add-on amount were inadequate to and 495) were limited to those weights for FY 2006. Using the FY 2004
form the basis for establishing payment. Medicare-approved transplant centers MedPAR data set, there are 41 DRGs
Response: The $18,848 isolation add- that have cases in the FY 2004 MedPAR that contain fewer than 10 cases. We
on amount was based on the best data file. (Medicare coverage for heart, heart- compute the weights for these low-
available, and we remain convinced that lung, liver and/or intestinal, and lung volume DRGs by adjusting the FY 2005
it is an appropriate payment for transplants is limited to those facilities weights of these DRGs by the percentage
isolating the islet cells from one that have received approval from CMS change in the average weight of the
pancreas. However, we have learned as transplant centers.) cases in the other DRGs.
that it typically requires two isolations • Organ acquisition costs for kidney, Section 1886(d)(4)(C)(iii) of the Act
to acquire enough cells for one infusion. heart, heart-lung, liver, lung, pancreas, requires that, beginning with FY 1991,
Therefore, while we will maintain the and intestinal (or multivisceral organs) reclassification and recalibration
current rate of $18,848 per isolation, we transplants continue to be paid on a changes be made in a manner that
will pay up to two islet isolations per reasonable cost basis. Because these assures that the aggregate payments are
discharge. If only one islet isolation is acquisition costs are paid separately neither greater than nor less than the
necessary, Medicare will make an add- from the prospective payment rate, it is aggregate payments that would have
on payment of $18,848; if two are necessary to subtract the acquisition been made without the changes.
necessary, Medicare will make an add- charges from the total charges on each Although normalization is intended to
on payment of $37,696. In cases that transplant bill that showed acquisition achieve this effect, equating the average
require two islet isolations, CMS will charges before computing the average case weight after recalibration to the
pay for two pancreata. Pancreata will charge for the DRG and before average case weight before recalibration
continue to be paid as a cost pass- eliminating statistical outliers. does not necessarily achieve budget
through. • Charges were standardized to neutrality with respect to aggregate
We will review the MedPAR data as remove the effects of differences in area payments to hospitals because payments
requested using more complete FY 2005 wage levels, indirect medical education to hospitals are affected by factors other
MedPAR data during our next annual and disproportionate share payments, than average case weight. Therefore, as
IPPS update for FY 2007. and, for hospitals in Alaska and Hawaii, we have done in past years and as
the applicable cost-of-living adjustment. discussed in section II.A.4.a. of the
C. Recalibration of DRG Weights • The average standardized charge Addendum to this final rule, we are
We are using the same basic per DRG was calculated by summing the making a budget neutrality adjustment
methodology for the FY 2006 standardized charges for all cases in the to ensure that the requirement of section
recalibration as we did for FY 2005 (FY DRG and dividing that amount by the 1886(d)(4)(C)(iii) of the Act is met.
2005 IPPS final rule (69 FR 48981)). number of cases classified in the DRG. Comment: One commenter noted that
That is, we have recalibrated the DRG A transfer case is counted as a fraction there is a reduction in the proposed
weights based on charge data for of a case based on the ratio of its transfer weights for DRG 103 (Heart Transplant
Medicare discharges using the most payment under the per diem payment or Implant of Heart Assist System) and
current charge information available methodology to the full DRG payment DRG 512 (Simultaneous Pancreas/
(the FY 2004 MedPAR file). for nontransfer cases. That is, a transfer Kidney Transplant). According to the
The MedPAR file is based on fully case receiving payment under the commenter, the proposed weights
coded diagnostic and procedure data for transfer methodology equal to half of represent a 6-percent reduction in DRG
all Medicare inpatient hospital bills. what the case would receive as a 103 and an 11-percent reduction in DRG
The FY 2004 MedPAR data used in this nontransfer would be counted as 0.5 of 512. The commenter inquired as to
final rule include discharges occurring a total case. whether these reductions may have
resulted from a methodological change LTCH PPS annual payment rate update above, the patient classification system
in the way organ acquisition costs are cycle to be effective July 1 through June used under the LTCH PPS (LTC–DRGs)
addressed in the DRG weighting 30 instead of October 1 through is based on the patient classification
process. September 30. In addition, because the system used under the IPPS (CMS–
Response: There is no change in the patient classification system utilized DRGs), which historically had been
calculation of the DRG relative weight. under the LTCH PPS is based directly updated annually and effective for
Organ acquisition costs for kidney, on the DRGs used under the IPPS for discharges occurring on or after October
heart, heart-lung, liver, lung, pancreas, acute care hospitals, in that same final 1 through September 30 each year. As
and intestinal (or multivisceral organs) rule, we explained that the annual mentioned above, the ICD–9–CM coding
transplants continue to be paid on a update of the long-term care diagnosis- update process has been revised, as
reasonable cost basis. Because these related group (LTC–DRG) classifications discussed in greater detail in the FY
acquisition costs are paid separately and relative weights will continue to 2005 IPPS final rule (69 FR 48954
from the prospective payment rate, it is remain linked to the annual through 48957) and in section II.B. 14.
necessary to subtract the acquisition reclassification and recalibration of the of this final rule. Specifically, section
charges from the total charges on each CMS–DRGs used under the IPPS. In that 503(a) of Pub. L. 108–173 includes a
transplant bill that showed acquisition same final rule, we specified that we requirement for updating ICD–9–CM
charges before computing the average will continue to update the LTC–DRG codes as often as twice a year instead of
charge for the DRG. classifications and relative weights to be the current process of annual updates
As described above, the relative effective for discharges occurring on or on October 1 of each year. This
weight for each DRG is calculated by after October 1 through September 30 requirement is included as part of the
comparing the average charge for cases each year. Furthermore, we stated that amendments to the Act relating to
within each DRG (after removing we will publish the annual update of recognition of new medical technology
statistical outliers) with the national the LTC–DRGs in the proposed and final under the IPPS. Section 503(a) of Pub L.
average charge per case. Therefore, there rules for the IPPS. 108–173 amended section 1886(d)(5)(K)
are several factors that can cause a shift In the past, the annual update to the of the Act by adding a new clause (vii)
in the relative weight of a DRG from one IPPS DRGs has been based on the which states that ‘‘the Secretary shall
fiscal year to the next. For example, annual revisions to the ICD–9–CM codes provide for the addition of new
even though the average charges of cases and was effective each October 1. As diagnosis and procedure codes in [sic]
within DRG 103 increased from discussed in the FY 2005 IPPS final rule April 1 of each year, but the addition of
$278,096 in the FY 2005 final rule to (69 FR 48954 through 48957) and in the such codes shall not require the
$285,317 in the proposed rule, it did not Rate Year (RY) 2006 LTCH PPS final Secretary to adjust the payment (or
increase by an equal or greater rule (70 FR 24173 through 24175), with diagnosis-related group classification)
percentage than the national average. As the implementation of section 503(a) of * * * until the fiscal year that begins
a result, the DRG weight for DRG 103 Pub. L. 108–173, there is the possibility after such date.’’ This requirement will
declined. For DRG 512, the average that one feature of the GROUPER improve the recognition of new
charges decreased from $85,630 in the software program may be updated twice technologies under the IPPS by
FY 2005 final rule to $83,113 in the during a Federal fiscal year (October 1 accounting for those ICD–9–CM codes
proposed rule which accounts for the and April 1) as required by the statute in the MedPAR claims data at an earlier
decline in the weight. for the IPPS. Specifically, ICD–9–CM date. Despite the fact that aspects of the
Comment: One commenter pointed diagnosis and procedure codes for new
GROUPER software may be updated to
out three typographical errors in DRG medical technology may be created and
recognize any new technology ICD–9–
titles in Table 5 (List of Diagnosis added to existing DRGs in the middle of
CM codes, as discussed in the RY 2006
Related Groups (DRGs), Relative the Federal fiscal year on April 1.
LTCH PPS final rule (70 FR 24173
Weighting Factors, Geometric and However, this policy change will have
through 24175) and the FY 2006 IPPS
Arithmetic Mean Length of Stay) in the no effect on the LTC–DRG relative
proposed rule (70 FR 23338 through
Addendum to the FY 2006 IPPS weights which will continue to be
23339), there will be no impact on
proposed rule. The commenter updated only once a year (October 1),
either LTC–DRG assignments or
indicated that the title for DRG 14 nor will there be any impact on
payments under the LTCH PPS at that
should read ‘‘Intracranial Hemorrhage Medicare payments under the LTCH
PPS. The use of the ICD–9–CM code set time. That is, changes to the LTC–DRGs
or Cerebral Infarction’’ based on the (such as the creation or deletion of LTC–
change in FY 2005 IPPS final rule (69 is also compliant with the current
requirements of the Transactions and DRGs) and the relative weights will
FR 48927) and the title for DRG 315 continue to be updated in the manner
Code Sets Standards regulations at 45
should read ‘‘Other Kidney & Urinary and timing (October 1) as they are now.
CFR Parts 160 and 162, promulgated in
Tract Procedures’’ based on the change As noted above and as described in
accordance with the Health Insurance
in the FY 2003 IPPS final rule (67 FR both the RY 2006 LTCH PPS final rule
Portability and Accountability Act of
49993). The commenter also pointed out (70 FR 24174) and the FY 2006 IPPS
1996 (HIPAA), Pub. L. 104–191.
a misspelling of the word ‘‘Malignant’’ As we explained in the FY 2006 IPPS proposed rule (70 FR 23339), updates to
in the title for DRG 276. proposed rule (70 FR 23338 through the GROUPER for both the IPPS and the
Response: The commenter is correct. 23339), in the health care industry, LTCH PPS (with respect to relative
We have made these corrections in historically annual changes to the ICD– weights and the creation or deletion of
Table 5 in the Addendum to this final 9–CM codes were effective for DRGs) are made in the annual IPPS
rule. discharges occurring on or after October proposed and final rules and are
D. LTC–DRG Reclassifications and 1 each year. Thus, the manual and effective each October 1. We explained
Relative Weights for LTCHs for FY 2006 electronic versions of the GROUPER in the FY 2005 IPPS final rule (69 FR
software, which are based on the ICD– 48955 and 48956), and in section
1. Background 9–CM codes, were also revised annually II.B.13. of this preamble, that since we
In the June 6, 2003 LTCH PPS final and effective for discharges occurring on do not publish a midyear IPPS rule,
rule (68 FR 34122), we changed the or after October 1 each year. As noted April 1 code updates discussed above
will not be published in a midyear IPPS As we proposed in the FY 2006 IPPS as we discussed in the August 30, 2002
rule. Rather, we will assign any new proposed rule (70 FR 23339), in this LTCH PPS final rule (67 FR 55985),
diagnosis or procedure codes to the final rule we are making revisions to the which implemented the LTCH PPS, and
same DRG in which its predecessor code LTC–DRG classifications and relative the FY 2006 IPPS proposed rule (70 FR
was assigned, so that there will be no weights, effective October 1, 2005 23340), we use low-volume quintiles in
impact on the DRG assignments. Any through September 30, 2006 (FY 2006), determining the LTC–DRG weights for
coding updates will be available using the latest available data. As we LTC–DRGs with less than 25 LTCH
through the Web sites indicated in the proposed in that same IPPS proposed cases, because LTCHs do not typically
same rule and provided above in section rule, the final LTC–DRGs and relative treat the full range of diagnoses as do
II.B. of this preamble and through the weights for FY 2006 in this final rule are acute care hospitals. Specifically, we
Coding Clinic for ICD–9–CM. Publishers based on the final IPPS DRGs group those low-volume LTC–DRGs
and software vendors currently obtain (GROUPER Version 23.0) discussed in (LTC–DRGs with fewer than 25 cases)
code changes through these sources in section II. of the preamble to this final into 5 quintiles based on average charge
order to update their code books and rule. per discharge. We also adjust for cases
software system. If new codes are in which the stay at the LTCH is less
implemented on April 1, revised code 2. Changes in the LTC–DRG than or equal to five-sixths of the
books and software systems, including Classifications geometric average length of stay; that is,
the GROUPER software program, will be a. Background short-stay outlier cases (§ 412.529), as
necessary because we must use current Section 123 of Pub. L. 106–113 discussed below in section II.D.4. of this
ICD–9–CM codes. Therefore, for specifically requires that the PPS for
preamble.
purposes of the LTCH PPS, because
LTCHs be a per discharge system with b. Patient Classifications into DRGs
each ICD–9–CM code must be included
a DRG-based patient classification Generally, under the LTCH PPS,
in the GROUPER algorithm to classify
system reflecting the differences in Medicare payment is made at a
each case into a LTC–DRG, the
patient resources and costs in LTCHs predetermined specific rate for each
GROUPER software program used under
while maintaining budget neutrality. discharge; that is, payment varies by the
the LTCH PPS would need to be revised
Section 307(b)(1) of Pub. L. 106–554 LTC–DRG to which a beneficiary’s stay
to accommodate any new codes.
As we discussed in the FY 2005 IPPS modified the requirements of section is assigned. Just as cases are classified
final rule (69 FR 48956) and in section 123 of Pub. L. 106–113 by specifically for acute care hospitals under the IPPS
II.B.14. of this preamble, in requiring that the Secretary examine (see section II.B. of this preamble), cases
implementing section 503(a) of Pub. L. ‘‘the feasibility and the impact of basing are classified into LTC–DRGs for
108–173, there will only be an April 1 payment under such a system [the payment under the LTCH PPS based on
update if new technology codes are LTCH PPS] on the use of existing (or the principal diagnosis, up to eight
requested and approved. We note that refined) hospital diagnosis-related additional diagnoses, and up to six
any new codes created for April 1 groups (DRGs) that have been modified procedures performed during the stay,
implementation will be limited to those to account for different resource use of as well as age, sex, and discharge status
diagnosis and procedure code revisions long-term care hospital patients as well of the patient. The diagnosis and
primarily needed to describe new as the use of the most recently available procedure information is reported by
technologies and medical services. hospital discharge data.’’ the hospital using the ICD–9–CM codes.
However, we reiterate that the process In accordance with section 307(b)(1) As discussed in section II.B. of this
of discussing updates to the ICD–9–CM of Pub. L. 106–554 and § 412.515 of our preamble, the CMS–DRGs are organized
has been an open process through the existing regulations, the LTCH PPS uses into 25 major diagnostic categories
ICD–9–CM Coordination and information from LTCH patient records (MDCs), most of which are based on a
Maintenance Committee since 1995. to classify patient cases into distinct particular organ system of the body; the
Requestors will be given the LTC–DRGs based on clinical remainder involve multiple organ
opportunity to present the merits for a characteristics and expected resource systems (such as MDC 22, Burns).
new code and make a clear and needs. The LTC–DRGs used as the Accordingly, the principal diagnosis
convincing case for the need to update patient classification component of the determines MDC assignment. Within
ICD–9–CM codes for purposes of the LTCH PPS correspond to the DRGs most MDCs, cases are then divided into
IPPS new technology add-on payment under the IPPS for acute care hospitals. surgical DRGs and medical DRGs. Some
process through an April 1 update. Thus, as we proposed in the FY 2006 surgical and medical DRGs are further
However, as we explained in the FY IPPS proposed rule (70 FR 23339), in differentiated based on the presence or
2006 IPPS proposed rule (70 FR 23339), this final rule, we are establishing the absence of CCs. (See section II.B. of this
at the October 2004 ICD–9–CM use of the IPPS GROUPER Version 23.0 preamble for further discussion of
Coordination and Maintenance for FY 2006 to process LTCH PPS claims surgical DRGs and medical DRGs.)
Committee meeting, there were no for LTCH discharges occurring from Because the assignment of a case to a
requests for an April 1, 2005 October 1, 2005 through September 30, particular LTC–DRG will help
implementation of ICD–9–CM codes, 2006. The final changes to the CMS– determine the amount that is paid for
and the next update to the ICD–9–CM DRG classification system used under the case, it is important that the coding
coding system would not occur until the IPPS for FY 2006 (GROUPER is accurate. As used under the IPPS,
October 1, 2005 (FY 2006). Presently, as Version 23.0) are discussed in section classifications and terminology used
there were no coding changes suggested II.B. of the preamble to this final rule. under the LTCH PPS are consistent with
for an April 1, 2005 update, the ICD–9– Under the LTCH PPS, we determine the ICD–9–CM and the Uniform
CM coding set implemented on October relative weights for each of the DRGs to Hospital Discharge Data Set (UHDDS),
1, 2004, will continue through account for the difference in resource as recommended to the Secretary by the
September 30, 2005 (FY 2005). The use by patients exhibiting the case National Committee on Vital and Health
update to the ICD–9–CM coding system complexity and multiple medical Statistics (‘‘Uniform Hospital Discharge
for FY 2006 is discussed above in problems characteristics of LTCH Data: Minimum Data Set, National
section II.B.14. of this preamble. patients. In a departure from the IPPS, Center for Health Statistics, April
1980’’) and as revised in 1984 by the additional information within a bill data from the December 2004
Health Information Policy Council specified timeframe (§ 412.513(c)). update of the MedPAR file, which were
(HIPC) of the U.S. Department of Health The LTCH GROUPER is used both to the best available data at that time, and
and Human Services. We point out classify past cases in order to measure we proposed to use the proposed
again that the ICD–9–CM coding relative hospital resource consumption Version 23.0 of the CMS GROUPER
terminology and the definitions of to establish the LTC–DRG weights and used under the IPPS (as discussed in
principal and other diagnoses of the to classify current cases for purposes of that same proposed rule) to classify
UHDDS are consistent with the determining payment. The records for cases. To calculate the LTC–DRG
requirements of the Transactions and all Medicare hospital inpatient relative weights for FY 2006 in this final
Code Sets Standards under HIPAA (45 discharges are maintained in the rule, we obtained total Medicare
CFR Parts 160 and 162). MedPAR file. The data in this file are allowable charges from FY 2004
The emphasis on the need for proper used to evaluate possible DRG Medicare hospital bill data from the
coding cannot be overstated. classification changes and to recalibrate March 2005 update of the MedPAR file,
Inappropriate coding of cases can the DRG weights during our annual which are the most recent available
adversely affect the uniformity of cases update (as discussed in section II. of this data, and we used the Version 23.0 of
in each LTC–DRG and produce preamble). The LTC–DRG relative the CMS GROUPER used under the IPPS
inappropriate weighting factors at weights are based on data for the (as discussed in section II.B. of this
recalibration and result in inappropriate population of LTCH discharges, preamble) to classify cases. In the FY
payments under the LTCH PPS. LTCHs reflecting the fact that LTCH patients 2006 IPPS proposed rule (70 FR 23341),
are to follow the same coding guidelines represent a different patient-mix than we stated that ‘‘consistent with the
used by acute care hospitals to ensure patients in short-term acute care methodology under the IPPS, we are
accuracy and consistency in coding hospitals. proposing to recalculate the FY 2006
practices. There will be only one LTC– LTC–DRG relative weights based on the
3. Development of the FY 2006 LTC– best available data.’’ For this final rule,
DRG assigned per long-term care DRG Relative Weights
hospitalization; it will be assigned at the we are using the best available data, that
time of discharge of the patient. a. General Overview of Development of is, the March 2005 update of the
Therefore, it is mandatory that the the LTC–DRG Relative Weights MedPAR file.
coders continue to report the same As we discussed in the FY 2006 IPPS
As we stated in the August 30, 2002 proposed rule (70 FR 23341), we have
principal diagnosis on all claims and LTCH PPS final rule (67 FR 55981), one
include all diagnosis codes that coexist excluded the data from LTCHs that are
of the primary goals for the all-inclusive rate providers and LTCHs
at the time of admission, that are implementation of the LTCH PPS is to that are reimbursed in accordance with
subsequently developed, or that affect pay each LTCH an appropriate amount demonstration projects authorized
the treatment received. Similarly, all for the efficient delivery of care to under section 402(a) of Pub. L. 90–248
procedures performed during that stay Medicare patients. The system must be (42 U.S.C. 1395b–1) or section 222(a) of
are to be reported on each claim. able to account adequately for each Pub. L. 92–603 (42 U.S.C. 1395b–1).
Upon the discharge of the patient LTCH’s case-mix in order to ensure both Therefore, in the development of the
from a LTCH, the LTCH must assign fair distribution of Medicare payments final FY 2006 LTC–DRG relative
appropriate diagnosis and procedure and access to adequate care for those weights, we have excluded the data of
codes from the ICD–9–CM. Completed Medicare patients whose care is more the 19 all-inclusive rate providers and
claim forms are to be submitted costly. To accomplish these goals, we the 3 LTCHs that are paid in accordance
electronically to the LTCH’s Medicare adjust the LTCH PPS standard Federal with demonstration projects that had
fiscal intermediary. Medicare fiscal prospective payment system rate by the claims in the FY 2004 MedPAR file.
intermediaries enter the clinical and applicable LTC–DRG relative weight in In the FY 2005 IPPS final rule (69 FR
demographic information into their determining payment to LTCHs for each 48984), we discussed coding
claims processing systems and subject case. Under the LTCH PPS, relative inaccuracies that were found in the
this information to a series of automated weights for each LTC–DRG are a claims data for a large chain of LTCHs
screening processes called the Medicare primary element used to account for the in the FY 2002 MedPAR file, which
Code Editor (MCE). These screens are variations in cost per discharge and were used to determine the LTC–DRG
designed to identify cases that require resource utilization among the payment relative weights for FY 2004. As we
further review before assignment into an groups (§ 412.515). To ensure that discussed in the same final rule, after
LTC–DRG can be made. Medicare patients classified to each notifying the large chain of LTCHs
After screening through the MCE, LTC–DRG have access to an appropriate whose claims contained the coding
each LTCH claim will be classified into level of services and to encourage inaccuracies to request that they
the appropriate LTC–DRG by the efficiency, we calculate a relative weight resubmit those claims with the correct
Medicare LTCH GROUPER. The LTCH for each LTC–DRG that represents the diagnosis, from an analysis of LTCH
GROUPER is specialized computer resources needed by an average claims data from the December 2003
software and is the same GROUPER inpatient LTCH case in that LTC–DRG. update of the FY 2003 MedPAR file, it
used under the IPPS. After the LTC– For example, cases in an LTC–DRG with appeared that such claims data no
DRG is assigned, the Medicare fiscal a relative weight of 2 will, on average, longer contain coding errors. Therefore,
intermediary determines the prospective cost twice as much as cases in an LTC– it was not necessary to correct the FY
payment by using the Medicare LTCH DRG with a weight of 1. 2003 MedPAR data for the development
PPS PRICER program, which accounts of the FY 2005 LTC–DRGs and relative
for LTCH hospital-specific adjustments b. Data
weights established in the same final
and payment rates. As provided for In the FY 2006 IPPS proposed rule (70 rule.
under the IPPS, we provide an FR 23341), we proposed to calculate the As noted above, in the FY 2006 IPPS
opportunity for the LTCH to review the proposed LTC–DRG relative weights for proposed rule, we proposed to calculate
LTC–DRG assignments made by the FY 2006 using total Medicare allowable the proposed LTC–DRG relative weights
fiscal intermediary and to submit charges from FY 2004 Medicare hospital for FY 2006 using the December 2004
update of the MedPAR file, which were for all cases are fully accounted for in four categories of alleged problems:
the most recent available data at that computing the final FY 2006 LTC–DRG missing discharges related to the
time. As stated above, in this final rule, relative weights. exhaustion of Medicare Part A benefits;
we are using the March 2005 update of The commenter who commissioned inaccurate representation of interrupted
the FY 2004 MedPAR file for the the study gave a number of examples of stay cases; cases not reported in the
determination of the FY 2006 LTC–DRG the alleged irregularities/errors in LTCH MedPAR file due to ‘‘an atypical level
relative weights as these are the best claims in the FY 2004 MedPAR file. The of suspension of LTCH claims’’; and
available data. As we discussed in the commenter’s findings from a cases with incorrectly reported charges
FY 2006 IPPS proposed rule (70 FR comparison of one provider’s internal (overstated or understated). Our analysis
23341), based on an analysis of LTCH records and data reported in the revealed that rather than being distinct
claims data from the FY 2004 MedPAR December 2004 update of the FY 2004 problems, three of the concerns raised
file, it appears that such claims data do MedPAR file, which were used in by the commenters—the benefits-
not contain coding inaccuracies found setting the proposed LTC–DRG relative exhausted cases, the interrupted stay
previously in LTCH claims data. weights, were extrapolated to all LTCHs cases, and missing hospital claims—are
Therefore, it was not necessary to and then the proposed FY 2006 LTC– caused by the same basic problems.
correct the FY 2004 MedPAR data for DRG relative weights were recalculated That is, the December 2003 update of
the development of the FY 2006 LTC– ‘‘to correct for these errors.’’ The the FY 2004 MedPAR file did not
DRGs and relative weights presented in commenter challenged the integrity of include some patient claims from the
that proposed rule or in this final rule. the proposed LTC–DRG relative records of the one LTCH in question.
Comment: Several commenters cited a weights, as well as the final relative Because the MedPAR file represents a
study that concluded that the claims weights, which would be based on a total beneficiary stay (total single
data used to develop the proposed LTC– more recent update (March 2005) of the episode of care) in an inpatient hospital
DRG relative weights (that is, the FY 2004 MedPAR file, in keeping with once a beneficiary has been physically
December 2004 update of the FY 2004 our historical practice that uses the best discharged from the inpatient hospital,
MedPAR file) contain irregularities or available data for computing payment as described below, we evaluated the
errors. The commenters’ concern was adjustments for all Medicare PPSs. reasons why such a situation could
based on a comparison, by a private Response: After an extensive analysis occur under normal claims processing
research group that was commissioned of the data submitted by one of the procedures.
by one of the commenters, of the LTCH commenters, we do not agree with the The MedPAR file is a discharge file
FY 2004 MedPAR data to the internal commenters’ assertion that the proposed for inpatient claims and, therefore,
records of one LTCH. The commenters FY 2006 LTC–DRG relative weights are during the creation of the MedPAR file,
were specifically concerned that the based on faulty claims data in the FY inpatient hospital data without a
MedPAR data may underrepresent 2004 MedPAR file. We believe that the discharge date would not be included.
interrupted stay cases and cases during use of highly case-specific and interim When a claim is processed for payment
which the beneficiary exhausted data drawn from the claims records of calculation, the data from the fiscal
Medicare Part A benefits. In addition to one LTCH to challenge the integrity of intermediary are included in the
the possible underrepresentation of the LTCH claims in the entire FY 2004 Medicare Common Working File (CWF),
interrupted stay and exhausted benefit MedPAR file is inappropriate. Our at which time payment authorization or
cases, these commenters indicated that analysis did not reveal systemic denial will be made and, if authorized,
they had reviewed the FY 2004 problems that would have undermined a remittance will be generated to the
MedPAR data used to develop the the data upon which we based the provider. After the remittance is
proposed FY 2006 LTC–DRG relative proposed FY 2006 LTC–DRG relative generated, the National Claims History
weights and asserted that there are some weights or the data upon which we are (NCH) is updated to reflect all of the
cases in the FY 2004 MedPAR file that basing our final FY 2006 LTC–DRG claims submitted for an entire stay,
include overstated or understated relative weights in this final rule (as which may include one claim or
charges. They also indicated that there discussed above). As indicated by our multiple claims. The NCH inpatient
were ‘‘missing’’ LTCH cases that they analysis of the issues presented by the hospital data are used in the creation of
believe should be included in the commenter, detailed below, we the MedPAR file and all adjustments are
MedPAR file. The commenters further continue to believe that the March 2005 resolved prior to the creation of a stay
believed that the missing LTCH cases update of the FY 2004 MedPAR file is record in the MedPAR file. The creation
may be the consequence of ‘‘a high level the best available data for setting the FY of the MedPAR file takes all claims
of suspended claims which were 2006 LTC–DRG relative weights and it submitted for a beneficiary at the same
occurring due to the transition [to a accurately reflects LTCH charges per facility and collapses all the data so that
different billing system during FY discharge. one record is created that represents a
2004].’’ Specifically, the commenters The comments were based on the single record of the entire stay at the
stated that because payment for these commenters’ analysis of one LTCH’s facility.
suspended claims was received by April data and the results of that analysis A claim that is correctly coded and
2004, their claims and associated were extrapolated to the universe of submitted timely by the provider will be
charges for these cases should have been LTCHs. We reviewed the LTCH data captured by the specific update of the
reflected in the December 2004 update used by the commenter and compared NCH files, the data source for the
of the FY 2004 MedPAR file that was that data to the data in both the MedPAR file. However, if there are
used to compute the proposed FY 2006 December 2004 update of the FY 2004 issues with the claim, the claim may be
LTC–DRG relative weights. MedPAR file that were used to suspended. Therefore, even though the
The commenters believed that such determine the proposed FY 2006 LTC– hospital will have a record of the stay,
errors or irregularities may be the source DRG relative weights and in the March until the issue with the claim is
of the observed decrease in the average 2005 update of the FY 2004 MedPAR resolved, it will not process into the
charges of many LTC–DRGs. Therefore, file that are being used to determine the NCH and, therefore, will not be
they urged CMS to reexamine the final FY 2006 LTC–DRG relative weights recorded in the MedPAR file. Issues
MedPAR data to ensure that the charges in this final rule. The commenter raised leading to claim suspension may
include submission-systems failures by longer be financially responsible for that (§ 412.531). The one LTCH upon which
the provider, including the absence of treatment. In that same final rule, we the commenter bases his concerns had
crucial information or incorrect coding also established that we would include records of 102 interrupted stay cases
of patient status by the provider. data for all inpatient days that a discharged during FY 2004. Of these, it
Alternatively, issues may arise during Medicare beneficiary was physically in is claimed that 44 were reported
the fiscal intermediary processing of the the LTCH for purposes of meeting the correctly in the December 2004 update
claim, as a result of data processing length of stay requirements to qualify as of the FY 2004 MedPAR file upon
problems or broader standard systems a LTCH as set forth under § 412.23(e) which the proposed LTC–DRG relative
issues. The fiscal intermediary may also (67 FR 55974) and for developing LTC– weights were based. If an episode of
delay processing the claim pending DRG relative weights (67 FR 55984). care is governed by the greater than 3
resolution of policy issues in specific Therefore, for purposes of these two days interruption of stay policy, both
situations. A fiscal intermediary may policies, data from the fiscal year during segments of the stay at the LTCH are
need to contact a subject-matter which the patient is physically paid as one. The commenter claimed
specialist at Medicare, for example, for discharged from the LTCH will include that, in such cases, only one-half of
assistance in determining whether a the total day count for the patient’s particular interrupted stay cases in that
particular atypical patient discharge, entire stay as well as the total charges LTCH that were reported were included
treatment, and readmittance scenario for the entire length of stay, including in the December 2004 update of the FY
would be governed by the payment data from noncovered days, even where 2004 MedPAR file. The commenter also
rules established under either of the the Medicare payment to the LTCH was claimed that in other interrupted stay
interrupted stay policies at § 412.531. made in a prior fiscal year, based on the cases, the entire stay was absent from
Therefore, there are several reasons earlier bill submitted by the LTCH when the December 2004 update of the FY
why claims could be held in suspension the patient’s benefits exhausted. 2004 MedPAR file. We reviewed the
and hence not be ‘‘resolved’’ either for In response to the commenter’s commenter’s claims and concluded that
payment purposes or for inclusion in allegation that the data from the most of these cases are included in the
the MedPAR file. We understand that, at December 2004 update of the FY 2004 recent March 2005 update of the FY
any one time, there may be as many as MedPAR file did not capture 16 of 35 2004 MedPAR file. We believe that
25 percent of a hospital’s claims in benefits-exhaust claims for one specific these cases were not included in the
suspension pending resolution of one or LTCH, CMS’ analysis revealed that 5 of December 2004 update of the FY 2004
more of the above issues. This statistic these 16 cases noted by the commenter MedPAR file because the provider’s
is not reflective of any unique problems are, in fact, included in the more recent final bill was in suspension.
in the processing procedure but rather is March 2005 update of the FY 2004 It is likely that the cases appear in the
a standard feature of a dynamic claims MedPAR file. This indicates that if the March 2005 update of the FY 2004
payment process. In recognition of this bill did not appear on the earlier MedPAR file because the patient was
fact, and in order to enable a cash flow December update due to a processing finally physically discharged or issues
to a provider where there may be a suspension, these 5 cases appear in the relating to the claim were otherwise
disproportionate number of unresolved March 2005 update of the MedPAR file settled and the claims were no longer in
claims in suspension, our regulations at because the issue for which the bill was suspension. Other claims reported by
§ 412.541(f) provide for accelerated suspended has been resolved by that the LTCH but still not included in the
payments, which are reconciled with time. Furthermore, an additional 7 of March 2005 update of the FY 2004
actual remittances at a future date. the 16 claims that the hospital identified MedPAR file are appropriately not in
The commenter’s first concern was as ‘‘discharged’’ represented the MedPAR file because they are still
that a substantial number of benefits- beneficiaries who were still in the in suspension for various reasons (as
exhaust claims from the one LTCH were hospital at the end of FY 2004 noted above and discussed in greater
not included in the March 2004 update (September 30, 2004), even though detail below).
of the FY 2004 MedPAR file. Our case- Medicare was no longer making As stated above, there may be one or
level analysis revealed several reasons payments for their care (and they had even several valid and appropriate
for this, which are discussed below. been ‘‘discharged for payment reasons why the interrupted stay cases
Primarily, we believe that there has purposes’’ under § 412.503). As noted are suspended. We understand that the
been some degree of confusion on by above, only at physical discharge will initial implementation of certain LTCH
that LTCH as to the policy distinction data be included in the corresponding PPS system changes resulted in
established under the LTCH PPS MedPAR file. Once those 7 patients are problems, including the mechanics of
between a discharge for payment discharged physically from the LTCH in claim submission. Specifically, for
purposes and a patient’s physical question, their data will appear in the many fiscal intermediaries, the
discharge. In the August 30, 2002 final MedPAR file for the fiscal year of their implementation of the 3-day or less
rule for the LTCH PPS, we established discharge. Accordingly, we do not interruption of stay policy at
regulations at § 412.503 specifying that believe that the absence from the March § 412.531(a) (69 FR 25690) initially led
a Medicare patient is considered 2005 update of the FY 2004 MedPAR to submission of overlapping claims,
‘‘discharged’’ for payment purposes file of the four discharges for this one inappropriate payments, recoupment of
when the patient no longer has any LTCH represents a systematic and payments, and subsequent withdrawal
Medicare covered days (that is, when serious underrepresentation of benefits- and resubmission of claims, and
Medicare Part A benefits are exhausted). exhaust cases in the LTCH FY 2004 required considerable provider
At that point, a LTCH may submit a MedPAR file. education and resulted in initial
‘‘discharge’’ claim to its fiscal The commenter also claimed that the suspension of the claims during FY
intermediary and Medicare will issue a MedPAR file had inaccurately reported 2004. However, this is no longer a
payment for covered care (CMS Pub. interrupted stay cases, that is, a LTCH significant problem for fiscal
100–4 Chapter 1, Section 50.2) delivered stay that has an intervening stay at an intermediaries. In fact, the fiscal
until the benefits were exhausted. The acute care hospital for 9 days or less, an intermediary that services the LTCH
patient may continue to receive care at IRF for 27 days or less, or a SNF for 45 cited by the commenter noted that
the LTCH, but Medicare Part A will no days or less during the LTCH stay several of its providers worked
aggressively and in a timely manner to Furthermore, the fiscal intermediary of charges for LTCHs throughout the
ensure that their claims governed by that serves the LTCH in question also country in the FY 2004 MedPAR data
this policy were being submitted noted experiencing some difficulties that affects the final LTC–DRG relative
according to CMS instructions, and paid with its conversion to the FISS billing weights.
and reported accurately. However, other system originally, but presently, it is no Based upon our detailed analysis of
LTCHs were still working to rectify their longer experiencing a significant the commenter’s assertions, we believe
claims submission procedures under the number of suspended claims as a result that there are no systematic errors in the
new policies or their internal records. of those issues. LTCH FY 2004 MedPAR data and we
Among those LTCHs that apparently We also analyzed the commenter’s continue to believe it is appropriate to
had data submission and payment assertions that, for a number of the base the FY 2006 LTC–DRG relative
problems, the fiscal intermediary LTCH bills in question, the LTCH’s weights on the March 2005 update of
identified the LTCH that was the subject internal records of charges included the FY 2004 MedPAR file. We believe
of the commenter’s original data either additional or fewer charges than that the December 2004 update of the
collection. Therefore, while we the amount reported as the charges in FY 2004 MedPAR file that we used to
acknowledge that there were initial the December 2004 update of the FY determine the proposed LTC–DRG
claims processing difficulties with 2004 MedPAR file. The commenter relative weights for FY 2006 in the FY
interrupted stay cases, based on our believed that, because the FY 2004 2006 IPPS proposed rule reflected the
conversations with the fiscal MedPAR file does not reflect all of the best available data at that time.
intermediary that services Moreover, we maintain that calculating
bill’s charges for this LTCH, there is a
approximately two-thirds of all LTCHs, the final LTC–DRG payment weights set
systemic problem that affects the
as well as with the fiscal intermediary forth in this final rule using the March
calculations of the FY 2006 LTC–DRG
that services the LTCH in question and 2005 update of the FY 2004 MedPAR
relative weights. We believe the FY
10 other LTCHs, we do not believe that file eliminates most of the issues raised
2004 MedPAR file is providing cases
there continues to be a significant issue. by the commenter, even with the
with accurate charge data for that fiscal
Furthermore, we believe that, currently, specific claims submitted by the one
year. Because all Medicare charges that
for the vast majority of LTCHs, internal LTCH cited by the commenter.
are reported in the MedPAR file are
records are consistent with the actual Furthermore, based on our analysis, we
taken directly from claims submitted by
payment adjustments made by their conclude that many of the issues
providers, in order to further evaluate experienced by that LTCH were unique
fiscal intermediaries that are reported in
the commenter’s assertion, we requested to that hospital and were not systemic
the MedPAR file. However, the few
that the fiscal intermediary serving this issues.
LTCHs that experience an inconsistency
LTCH review claims that the commenter In summary, as explained above, we
between their internal records and the
alleged exemplified the ‘‘discrepancy’’ do not believe there is evidence to
data reported in the MedPAR file do so
between the LTCH charges identified in support the contention that there is a
as a result of provider specific billing
its records and those that appear in the systemic flaw in the LTCH FY 2004
issues which are in no way indicative of
FY 2004 MedPAR file. A comparison of MedPAR data or the integrity of the FY
a widespread or even a significant
problem with the integrity of the FY the electronic claims submitted by the 2006 final LTC–DRG relative weights.
2003 MedPAR data. LTCH to the fiscal intermediary did not Rather, we believe that extrapolation to
As noted above, the commenter reveal any inconsistencies. That is, the the entire universe of LTCHs of the
believes that ‘‘an atypical level of charges on the electronic claims for issues of one particular LTCH with its
suspension of LTCH claims’’ results those cases matched those charges that own submission and reporting history
from dealing with the FY 2004 appeared in the most recent update as proof of the unreliability of our FY
conversion from the Arkansas Part A (March 2005) of the MedPAR file. 2004 MedPAR data is both misleading
Standard System (APASS) billing Therefore, the MedPAR data are and inaccurate. Therefore, in this final
system to the Fiscal Intermediary Share consistent with charge data submitted rule, we are using the LTCH claims data
System (FISS) billing system. The by the LTCH to CMS. Furthermore, as from the March 2005 update of the FY
commenter believed this transition we analyzed each of the commenter’s 2004 MedPAR file to determine the FY
resulted in inaccurate and specific allegations of systemic flaws in 2006 LTC–DRG relative weights using
underreported claims in the FY 2004 the FY 2004 MedPAR data, we have the methodology described below.
MedPAR data. While there were some concluded that the only way that the
actual charges could be higher or lower c. Hospital-Specific Relative Value
initial difficulties with the system Methodology
transition, our analysis of the MedPAR on the hospital’s own records than those
data again indicates that those charges that appear on the claim in the By nature, LTCHs often specialize in
difficulties have been addressed and, in NCH (upon which the MedPAR file is certain areas, such as ventilator-
fact, the MedPAR data accurately reflect derived) would be if the provider did dependent patients and rehabilitation
provider billings and are reliable. not include those charges on the bill and wound care. Some case types
Based on discussions with the fiscal submitted to the fiscal intermediary for (DRGs) may be treated, to a large extent,
intermediaries that process the vast processing. We note that this issue of a in hospitals that have, from a
majority of LTCH bills, we conclude discrepancy between billed charges and perspective of charges, relatively high
that, although initially there were some the MedPAR data is not an issue for (or low) charges. This nonarbitrary
problems with the system’s processing other providers. Therefore, we believe distribution of cases with relatively high
of a limited number of claims that were that any inconsistencies between (or low) charges in specific LTC–DRGs
impacted by either the 3-day or less charges for a few cases as listed in the has the potential to inappropriately
interrupted stay policy (§ 412.531(a)) or internal records of one LTCH and those distort the measure of average charges.
cases of exhaustion of Medicare reported for those same cases in the FY To account for the fact that cases may
benefits, the problems were typically 2004 MedPAR file are due to internal not be randomly distributed across
resolved in a timely manner and the data reporting practices of a specific LTCHs, we use a hospital-specific
claims are reflected in the March 2005 LTCH and are not indicative of a relative value method to calculate the
update of the FY 2004 MedPAR file. widespread problem with the reporting LTC–DRG relative weights instead of the
methodology used to determine the DRG than they would at a LTCH with low by average charge. For this final rule,
relative weights under the IPPS average costs which is needed to adjust this results in an assignment to a
described in section II.C. of this each LTCH’s relative charge value to specific low volume quintile of the
preamble. We believe this method will reflect its case-mix relative to the sorted 171 low-volume LTC–DRGs by
remove this hospital-specific source of average case-mix for all LTCHs. Because ascending order by average charge.
bias in measuring LTCH average we standardize charges in this manner, Because the number of LTC–DRGs with
charges. Specifically, we reduce the we count charges for a Medicare patient less than 25 LTCH cases is not evenly
impact of the variation in charges across at a LTCH with high average charges as divisible by five, the average charge of
providers on any particular LTC–DRG less resource intensive than they would the low-volume LTC–DRG was used to
relative weight by converting each be at a LTCH with low average charges. determine which low-volume quintile
LTCH’s charge for a case to a relative For example, a $10,000 charge for a case received the additional LTC–DRG. After
value based on that LTCH’s average in a LTCH with an average adjusted sorting the 171 low-volume LTC–DRGs
charge. charge of $17,500 reflects a higher level in ascending order, we group the first
Under the hospital-specific relative of relative resource use than a $10,000 fifth of low-volume LTC–DRGs with the
value method, we standardize charges charge for a case in a LTCH with the lowest average charge into Quintile 1.
for each LTCH by converting its charges same case-mix, but an average adjusted The highest average charge cases are
for each case to hospital-specific relative charge of $35,000. We believe that the
charge values and then adjusting those grouped into Quintile 5. Since the
adjusted charge of an individual case
values for the LTCH’s case-mix. The average charge of the 69th LTC–DRG in
more accurately reflects actual resource
adjustment for case-mix is needed to the sorted list is closer to the 68th LTC–
use for an individual LTCH because the
rescale the hospital-specific relative variation in charges due to systematic DRG’s average charge (assigned to
charge values (which, by definition, differences in the markup of charges Quintile 2) than to the average charge of
averages 1.0 for each LTCH). The among LTCHs is taken into account. the 70th LTC–DRG in the sorted list (to
average relative weight for a LTCH is its be assigned to Quintile 3), we placed it
case-mix, so it is reasonable to scale d. Low-Volume LTC–DRGs into Quintile 2. This process was
each LTCH’s average relative charge In order to account for LTC–DRGs repeated through the remaining low-
value by its case-mix. In this way, each with low-volume (that is, with fewer volume LTC–DRGs so that 1 low-
LTCH’s relative charge value is adjusted than 25 LTCH cases), in accordance volume quintile contains 35 LTC–DRGs
by its case-mix to an average that with the methodology established in the and 4 low-volume quintiles contain 34
reflects the complexity of the cases it August 30, 2002 LTCH PPS final rule LTC–DRGs.
treats relative to the complexity of the (67 FR 55984), we group those ‘‘low- In order to determine the relative
cases treated by all other LTCHs (the volume LTC–DRGs’’ (that is, DRGs that weights for the LTC–DRGs with low
average case-mix of all LTCHs). contained between 1 and 24 cases volume for FY 2006, in accordance with
In accordance with the methodology annually) into one of five categories the methodology established in the
established under § 412.523, as (quintiles) based on average charges, for
August 30, 2002 LTCH PPS final rule
implemented in the August 30, 2002 the purposes of determining relative
(67 FR 55984), we used the five low-
LTCH PPS final rule (67 FR 55989 weights. In the FY 2006 IPPS proposed
volume quintiles described above. The
through 55991), we standardize charges rule (70 FR 23341), we stated that we
would continue to employ this composition of each of the five low-
for each case by first dividing the
adjusted charge for the case (adjusted treatment of low volume LTC–DRGs in volume quintiles shown in the chart
for short-stay outliers under § 412.529 as determining the FY 2006 LTC–DRG below was used in determining the
described in section II.D.4. (step 3) of relative weights using the best available LTC–DRG relative weights for FY 2006.
this preamble) by the average adjusted LTCH data. In that same proposed rule, We determined a relative weight and
charge for all cases at the LTCH in using LTCH cases from the December (geometric) average length of stay for
which the case was treated. Short-stay 2004 update of the FY 2004 MedPAR each of the five low-volume quintiles
outliers under § 412.529 are cases with file, we identified 172 LTC–DRGs that using the formula that we apply to the
a length of stay that is less than or equal contained between 1 and 24 cases. For regular LTC–DRGs (25 or more cases), as
to five-sixths the average length of stay this final rule, using LTCH cases from described below in section II.D.4. of this
of the LTC–DRG. The average adjusted the March 2005 update of the FY 2004 preamble. We assigned the same relative
charge reflects the average intensity of MedPAR file, we identified 171 LTC– weight and average length of stay to
the health care services delivered by a DRGs that contained between 1 and 24 each of the LTC–DRGs that make up that
particular LTCH and the average cost cases. This list of LTC–DRGs was then low-volume quintile. We note that, as
level of that LTCH. The resulting ratio divided into one of the 5 low-volume this system is dynamic, it is possible
is multiplied by that LTCH’s case-mix quintiles, each containing a minimum of that the number and specific type of
index to determine the standardized 34 LTC–DRGs (171/5 = 34 with 1 LTC– LTC–DRGs with a low volume of LTCH
charge for the case. DRG as the remainder). In accordance cases will vary in the future. We use the
Multiplying by the LTCH’s case-mix with our established methodology, we best available claims data in the
index accounts for the fact that the same then make an assignment to a specific MedPAR file to identify low-volume
relative charges are given greater weight low-volume quintile by sorting the low- LTC–DRGs and to calculate the relative
in a LTCH with higher average costs volume LTC–DRGs in ascending order weights based on our methodology.
COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006

LTC–DRG Description
QUINTILE 1
17 ........................... NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC.

25 ........................... SEIZURE & HEADACHE AGE >17 W/O CC.
COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006—Continued

65 ........................... DYSEQUILIBRIUM.
69 ........................... OTITIS MEDIA & URI AGE >17 W/O CC.
86 ........................... PLEURAL EFFUSION W/O CC.
95 ........................... PNEUMOTHORAX W/O CC.
102 ......................... OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC.
133 ......................... ATHEROSCLEROSIS W/O CC.
140 ......................... ANGINA PECTORIS.
142 *** .................... SYNCOPE & COLLAPSE W/O CC.
143 ......................... CHEST PAIN.
171 ......................... OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC.
175 ......................... G.I. HEMORRHAGE W/O CC.
219 ......................... LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W/O CC.
237 ......................... SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH.
241 ......................... CONNECTIVE TISSUE DISORDERS W/O CC.
246 ......................... NON-SPECIFIC ARTHROPATHIES.
251 ......................... FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/O CC.
262 ......................... BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY.
273 ......................... MAJOR SKIN DISORDERS W/O CC.
281 ......................... TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC.
284 ......................... MINOR SKIN DISORDERS W/O CC.
301 ......................... ENDOCRINE DISORDERS W/O CC.
305 ......................... KIDNEY, URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O CC.
312 ......................... URETHRAL PROCEDURES, AGE >17 W CC.
319 ......................... KIDNEY & URINARY TRACT NEOPLASMS W/O CC.
328 ......................... URETHRAL STRICTURE AGE >17 W CC.
344 ......................... OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY.
428 ......................... DISORDERS OF PERSONALITY & IMPULSE CONTROL.
431 ......................... CHILDHOOD MENTAL DISORDERS.
441 ......................... HAND PROCEDURES FOR INJURIES.
445 ......................... TRAUMATIC INJURY AGE >17 W/O CC.
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 .
QUINTILE 2
11 ........................... NERVOUS SYSTEM NEOPLASMS W/O CC.

29 ........................... TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W/O CC.
44 ........................... ACUTE MAJOR EYE INFECTIONS.
46 ........................... OTHER DISORDERS OF THE EYE AGE >17 W CC.
83 ........................... MAJOR CHEST TRAUMA W CC.
93 ........................... INTERSTITIAL LUNG DISEASE W/O CC.
97 ........................... BRONCHITIS & ASTHMA AGE >17 W/O CC.
122 ......................... CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE.
128 ......................... DEEP VEIN THROMBOPHLEBITIS.
136 ......................... CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC.
139 ......................... CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC.
151 ......................... PERITONEAL ADHESIOLYSIS W/O CC.
173 ......................... DIGESTIVE MALIGNANCY W/O CC.
206 ......................... DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC.
208 ......................... DISORDERS OF THE BILIARY TRACT W/O CC.
250 ......................... FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC.
254 ......................... FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX FOOT AGE >17 W/O CC.
259 ......................... SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC.
276 ......................... NON-MALIGANT BREAST DISORDERS.
293 ......................... OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC.
306 ......................... PROSTATECTOMY W CC.
325 ......................... KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC.
332 ......................... OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC.
334 ......................... MAJOR MALE PELVIC PROCEDURES W CC.
336 ......................... TRANSURETHRAL PROSTATECTOMY W CC.
347 ......................... MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC.
348 ......................... BENIGN PROSTATIC HYPERTROPHY W CC.
399 ......................... RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC.
404 ......................... LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC.
425 ......................... ACUTE ADJUSTMENT REACTION & PSYCHOLOGICAL DYSFUNCTION.
432 ......................... OTHER MENTAL DISORDER DIAGNOSES.
433 ......................... ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA.
447 ......................... ALLERGIC REACTIONS AGE >17.
484 ......................... CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA.
503 ......................... KNEE PROCEDURES W/O PDX OF INFECTION.

QUINTILE 3
8 ............................. PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC.
21 ........................... VIRAL MENINGITIS.
31 ........................... CONCUSSION AGE >17 W CC.
61 ........................... MYRINGOTOMY W TUBE INSERTION AGE >17.
67 ........................... EPIGLOTTITIS.
100 ......................... RESPIRATORY SIGNS & SYMPTOMS W/O CC.
110 ......................... MAJOR CARDIOVASCULAR PROCEDURES W CC.
119 ......................... VEIN LIGATION & STRIPPING.
125 ......................... CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG.
152 ......................... MINOR SMALL & LARGE BOWEL PROCEDURES W CC.
177 ......................... UNCOMPLICATED PEPTIC ULCER W CC.
178 ......................... UNCOMPLICATED PEPTIC ULCER W/O CC.
181 ......................... G.I. OBSTRUCTION W/O CC.
185 ......................... DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17.
193 ......................... BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC.
195 ......................... CHOLECYSTECTOMY W C.D.E. W CC.
197 ......................... CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC.
223 ......................... MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC.
227 ......................... SOFT TISSUE PROCEDURES W/O CC.
235 ......................... FRACTURES OF FEMUR.
266 ......................... SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC.
270 ......................... OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC.
274 ......................... MALIGNANT BREAST DISORDERS W CC.
295 ......................... DIABETES AGE 0–35.
308 ......................... MINOR BLADDER PROCEDURES W CC.
369 ......................... MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS.
424 ......................... O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS.
443 ......................... OTHER O.R. PROCEDURES FOR INJURIES W/O CC.
449 ......................... POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC.
454 ......................... OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC.
467 ......................... OTHER FACTORS INFLUENCING HEALTH STATUS.
507 ......................... FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA.
531 ......................... SPINAL PROCEDURES WITH CC.
532 ......................... SPINAL PROCEDURES WITHOUT CC.
QUINTILE 4
22 ........................... HYPERTENSIVE ENCEPHALOPATHY.

40 ........................... EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17.
63 ........................... OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES.
117 ......................... CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT.
118 ......................... CARDIAC PACEMAKER DEVICE REPLACEMENT.
124 ......................... CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG.
150 ......................... PERITONEAL ADHESIOLYSIS W CC.
157 ......................... ANAL & STOMAL PROCEDURES W CC.
168 ......................... MOUTH PROCEDURES W CC.
191 ......................... PANCREAS, LIVER & SHUNT PROCEDURES W CC.
211 ......................... HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC.
216 ......................... BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE.
228 ......................... MAJOR THUMB OR JOINT PROC, OR OTH HAND OR WRIST PROC W CC.
288 ......................... O.R. PROCEDURES FOR OBESITY.
299 ......................... INBORN ERRORS OF METABOLISM.
303 ......................... KIDNEY, URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM.
310 ......................... TRANSURETHRAL PROCEDURES W CC.
323 ......................... URINARY STONES W CC, &/OR ESW LITHOTRIPSY.
339 ......................... TESTES PROCEDURES, NON-MALIGNANCY AGE >17.
341 ......................... PENIS PROCEDURES.
360 ......................... VAGINA, CERVIX & VULVA PROCEDURES.
406 ......................... MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC.
408 ......................... MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R. PROC.
419 ......................... FEVER OF UNKNOWN ORIGIN AGE >17 W CC.
476 ......................... PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS.
497 ......................... SPINAL FUSION W CC.
500 ......................... BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC.
502 ......................... KNEE PROCEDURES W PDX OF INFECTION W/O CC.
505 ......................... EXTENSIVE BURN OR FULL THICKNESS BURNS WITH MECH VENT 96+ HOURS WITHOUT SKIN GRAFT.
506 ......................... FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA.
539 ......................... LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITH CC.
551 ......................... PERMANENT CARDIAC PACEMAKER IMPLANT WITH MAJOR CV DIAGNOSIS OR AICD LEAD OR GNRTR.
552 ......................... OTHER PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT MAJOR CV DIAGNOSIS.

555 ......................... PERCUTANEOUS CARDIOVASCULAR PROC WITH MAJOR CV DIAGNOSIS.

556* ........................ PERCUTANEOUS CARDIOVASCULAR PROC WITH NON-DRUG-ELUTING STENT WITHOUT MAJOR CV DIAGNOSIS.
557* ........................ PERCUTANEOUS CARDIOVASCULAR PROC WITH DRUG-ELUTING STENT WITH MAJOR CV DIAGNOSIS.
QUINTILE 5
1 ............................. CRANIOTOMY AGE >17 W CC.

75 ........................... MAJOR CHEST PROCEDURES.
77 ........................... OTHER RESP SYSTEM O.R. PROCEDURES W/O CC.
154 ......................... STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC.
161 ......................... INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC.
200 ......................... HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY.
210 ......................... HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC.
218 ......................... LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W CC.
230 ......................... LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR.
268 ......................... SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES.
290 ......................... THYROID PROCEDURES.
304 ......................... KIDNEY, URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC.
345 ......................... OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY.
364 ......................... D&C, CONIZATION EXCEPT FOR MALIGNANCY.
365 ......................... OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES.
394 ......................... OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS.
401 ......................... LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC.
471 ......................... BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY.
482 ......................... TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES.
486 ......................... OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA.
488 ......................... HIV W EXTENSIVE O.R. PROCEDURE.
491 ......................... MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY.
493 ......................... LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W 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.
519 ......................... CERVICAL SPINAL FUSION W CC.
529 ......................... VENTRICULAR SHUNT PROCEDURES W CC.
533 ......................... EXTRACRANIAL VASCULAR PROCEDURES WITH CC.
543 ......................... CRANIOTOMY W IMPLANT OF CHEMO AGENT OR ACUTE COMPLEX CNS PDX.
544 ......................... MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY.
545 ......................... REVISION OF HIP OR KNEE REPLACEMENT.
556 ** ...................... PERCUTANEOUS CARDIOVASCULAR PROC WITH NON-DRUG-ELUTING STENT WITHOUT MAJOR CV DIAGNOSIS.
557 ** ...................... PERCUTANEOUS CARDIOVASCULAR PROC WITH DRUG-ELUTING STENT WITH MAJOR CV DIAGNOSIS.
* One of the original 171 low-volume LTC–DRGs initially assigned to a different low-volume quintile; reassigned to this low-volume quintile in
addressing nonmonotonicity (see step 4 below).
** One of the original 171 low-volume LTC–DRGs initially assigned to this low-volume quintile; reassigned to a different low-volume quintile in
addressing nonmonotonicity (see step 4 below).
*** One of the original 171 low-volume LTC–DRGs initially assigned to this low-volume quintile; removed from this low-volume quintile in ad-
dressing nonmonotonicity (see step 4 below).
4. Steps for Determining the FY 2006 we adjusted the number of cases in each of cases used to compute the LTC–DRG
LTC–DRG Relative Weights LTC–DRG for the effect of short-stay relative weights, the principle of
As we noted in the FY 2006 IPPS outlier cases under § 412.529, as also averaging that is a fundamental feature
proposed rule (70 FR 23346), the FY discussed in greater detail below. The of a PPS would be eroded or distorted.
2006 LTC–DRG relative weights are short-stay adjusted discharges and Response: We did not propose any
determined in accordance with the corresponding charges are used to policy change in the methodology for
methodology established in the August calculate ‘‘relative adjusted weights’’ in determining the LTC–DRG relative
30, 2002 LTCH PPS final rule (67 FR each LTC–DRG using the hospital- weights for FY 2006 in the FY 2006
55989 through 55991). In summary, specific relative value method described IPPS proposed rule. The commenters
LTCH cases must be grouped in the above. are mistaken in their belief that we did.
appropriate LTC–DRG, while taking into Comment: A few commenters Rather, the six steps for determining the
account the low-volume LTC–DRGs as expressed concern regarding what they proposed FY 2006 LTC–DRG relative
described above, before the FY 2006 believed to be a proposed change in the weights presented in the FY 2006 IPPS
LTC–DRG relative weights can be methodology to compute the LTC–DRG proposed rule (70 FR 23346 through
determined. After grouping the cases in relative weights. Specifically, they 23353) are the same steps that we have
the appropriate LTC–DRG, we asserted that removing statistical outlier used to determine the LTC–DRG relative
calculated the relative weights for FY cases and cases with a length of stay of weights since the implementation of the
2006 in this final rule by first removing 7 days or less may inappropriately LTCH PPS in FY 2003 (August 30, 2002
statistical outliers and cases with a remove too many cases from the relative LTCH IPPS final rule (67 FR 55989
length of stay of 7 days or less, as weight calculations. The commenters through 55991)). In every final rule in
discussed in greater detail below. Next, believed that, by narrowing the universe which we have updated the LTC–DRG
relative weights since the October 1, underpaid (69 FR 48990). Thus, we do the Secretary should use his or her
2002 implementation of the LTCH PPS not believe that it would be appropriate broad discretionary authority to assure
(68 FR 45375 through 45385, and 69 FR to compromise the integrity of the ‘‘the same level of payments projected
48989 through 49000), we reiterated the payment determination for those LTCH in the FY 2006 LTCH update
same steps of our established cases that actually benefit from and regulation’’ by making a budget
methodology to determine the annual receive a full course of treatment at a neutrality adjustment in developing the
update to the LTC–DRG relative LTCH, in order to include data from FY 2006 LTC–DRG relative weights.
weights. We continue to believe that these very short-stays. Consequently, we Response: We understand that these
this methodology continues to be valid, disagree with the commenters that commenters are concerned about the
and we do not find any reason at this removing aberrant LTCH cases (that is, estimated decrease in payments under
time to revise it. statistical outlier cases and cases with a LTCH PPS based upon changes in the
As we explained in the FY 2006 IPPS length of stay of 7 days or less) LTC–DRG relative weights for FY 2006.
proposed rule (70 FR 23346), we believe undermines the averaging principle However, we believe that this issue is
it is appropriate to remove statistical upon which PPSs are developed. distinct from the Secretary’s budget
outlier cases and cases with a length of Although we did not propose any neutrality obligation under the statute
stay of 7 days or less because including change in the methodology for for the first year of implementation of
those LTCH cases in the calculation of determining the LTC–DRG relative the LTCH PPS. After the first year of the
the relative weights could result in an weights for FY 2006, we disagree with LTCH PPS, the statute gives the
inaccurate relative weight, and therefore the assertions that removing statistical Secretary broad authority to determine
an inappropriate payment amount, that outlier cases and cases with a length of the appropriateness of system updates
does not truly reflect relative resource stay of 7 days or less inappropriately and matters such as annual updates and
use among the LTC–DRGs. Specifically, narrows the universe of cases used to policy changes. As we discussed in the
we continue to believe that statistical compute the LTC–DRG relative weights, FY 2005 IPPS final rule (69 FR 48999),
outlier cases may represent aberrations resulting in a distortion of the principle with respect to budget neutrality, we
in the data that distort the measure of of averaging. Rather, because each LTC– interpreted section 123(a)(1) of Pub. L.
average resource use and that, as we DRG relative weight represents the 106–113 to require that total payments
explained above, including them in the average resources required to treat cases under the LTCH PPS during FY 2003
calculation of the relative weights could in that particular LTC–DRG, relative to will be projected to equal estimated
result in an inappropriate payment the average resources used to treat cases payments that would have been made
amount. in all LTC–DRGs, we believe that, by for LTCHs’ operating and capital-related
In the RY 2006 LTCH PPS final rule removing cases that do not represent the inpatient hospital costs had the LTCH
(70 FR 23346) and as we discussed in ‘‘average resource use’’ of the mix of PPS not have been implemented. Thus
greater detail in the FY 2005 IPPS final LTCH cases within a DRG (that is, we believe the statute’s mandate for
rule (69 FR 48990), we also explained statistical outlier cases and cases with a budget neutrality applies only to the
that, generally, cases with a length of length of stay of 7 days or less), for the first year of implementation of the
stay 7 days or less are not representative reasons explained above, we are LTCH PPS (that is, FY 2003). Consistent
of either typical or perhaps even preserving the integrity of a system that with the broad discretional authority
appropriate LTCH patients. is based on averages. Therefore, in conferred upon the Secretary under
Furthermore, in general, in a hospital establishing the FY 2006 LTC–DRG section 123(a)(1) of Pub. L. 103–116, as
established solely to treat very long-stay relative weights in this final rule, we amended by section 307 of Pub. L. 106–
patients, and with a payment system have continued to remove statistical 554, the Secretary is exercising his
calibrated to reflect the costs incurred in outlier cases and cases with a length of broad authority to make updates the
treating such patients, stays of 7 days or stay of 7 days or less from the MedPAR LTCH PPS in a nonbudget neutral
less would not fully receive or benefit data used to compute the FY 2006 LTC– manner after FY 2003 for various
from treatment or the range of resource DRG relative weights. components of the LTCH PPS, including
use that is typical in a LTCH stay, and Comment: Four commenters believed the annual update of the LTC–DRG
full resources are often not used in the the estimated decrease in LTCH PPS classifications and relative weights.
earlier stages of admission to a LTCH. payments resulting from the proposed Consistent with this budget neutrality
We continue to believe that, if we were changes to the LTC–DRG relative requirement for the first year of
to include stays of 7 days or less in the weights is inconsistent with the implementation of the LTCH PPS, under
computation of the LTC–DRG relative statutory mandate that the LTCH PPS be § 412.523(d)(2) of the regulations, an
weights, the value of many relative maintained in a budget neutral manner. adjustment is made in determining the
weights would decrease and, therefore, These commenters recommended that standard Federal rate for FY 2003 so
payments would decrease to a level that we apply a budget neutrality adjustment that aggregate payments under the
may no longer be appropriate. to the LTC–DRG relative weights in LTCH PPS are estimated to equal the
Specifically, because LTCH cases with order to mitigate the estimated LTCH amount that would have been paid to
very short lengths of stay (that is, 7 days PPS payment reductions that we LTCHs under the reasonable cost-based
or less) do not use the same amount or estimated would result from the (TEFRA) payment system if the LTCH
type of resources as typical LTCH inlier proposed changes to the LTC–DRG PPS were not implemented. Therefore,
cases (that is, cases in which Medicare relative weights for FY 2006. Two of in the August 30, 2002 LTCH PPS final
covered days exceed five-sixths of the those commenters cited the statutory rule (67 FR 56027 through 56037),
geometric average length of stay for the language authorizing the establishment which implemented the LTCH PPS, in
LTC–DRG) and the patient is discharged of the LTCH PPS and argued that the order to maintain budget neutrality, we
prior to receiving a LTCH PPS high-cost language requires that the LTCH PPS adjusted the LTCH PPS Federal rate for
outlier payment, our simulations continue to operate under ‘‘budget FY 2003 so that aggregate payments
indicate that including these cases neutrality.’’ They further asserted that, under the LTCH PPS are estimated to
would significantly bias payments although we did not interpret this equal the amount that would have been
against LTCH inlier cases to a point language as mandating budget neutrality paid to LTCHs under the reasonable
where LTCH inlier cases would be beyond the initial year of the LTCH PPS, cost-based (TEFRA) payment system
had the LTCH PPS not been manner. A primary reason for waiting Response: A ‘‘dampening policy,’’ as
implemented. until after the transition is complete recommended by the commenters,
As we stated in the FY 2005 IPPS before evaluating aspects of the LTCH would limit the decrease in any of the
final rule (70 FR 48999 through 49000), PPS, including the budget neutrality LTC–DRG relative weights to a
we continue to believe that section 123 issue, is that the data available to maximum amount, which would reduce
of the Pub. L. 106–113 does not require analyze such issues are very limited the estimated decrease in LTCH PPS
that the annual update to the LTC–DRG because the LTCH PPS is still relatively payments that we projected in the FY
classifications and relative weights new and there is a lag time in data 2006 IPPS proposed rule as a result of
maintain budget neutrality. We believe availability. As several commenters the proposed changes to the LTC–DRG
we have satisfied the budget neutrality pointed out, the FY 2004 MedPAR data relative weights for FY 2006 (70 FR
requirement of section 123 of the Pub. are the first full year of LTCH PPS data 23667). The commenters believed that
L. 106–113 by establishing the LTCH since the LTCH PPS was implemented the estimated decrease in the LTCH PPS
PPS Federal rate for FY 2003 under for cost reporting periods beginning on payments resulting from the proposed
§ 412.523(d)(2) so that aggregate or after October 1, 2002 (FY 2003). In changes to the LTC–DRGs for FY 2006
payment under the LTCH PPS are addition, the fact that a number of would create a ‘‘destabilizing effect’’ on
projected equal to estimated aggregate LTCHs were and some are still LTCH PPS payments. For the reasons
payments under the reasonable cost- transitioning to 100 percent of the discussed below, we do not believe the
based payment system if the LTCH PPS Federal prospective payment rate may estimated decrease in LTCH PPS
were not implemented. Therefore, we make the available data on which to payments resulting from the changes we
disagree with the commenters that a base a budget neutrality adjustment are making to the LTC–DRG relative
budget neutrality adjustment to the even less appropriate because LTCHs weights for FY 2006 in this final rule
LTC–DRG relative weights or to the may still be modifying their behavior will lead to instability in LTCH PPS
LTCH PPS Federal rate is required by based on their transition to prospective payments, and therefore, we are not
statute or as a result of the annual payment and, therefore, our data may implementing a ‘‘dampening policy,’’ as
update to the LTC–DRGs under not yet fully reflect any operational recommended by the commenters.
§ 412.517 for FY 2006. changes LTCHs may have made in As discussed in the November 1, 2002
We agree with the commenters that, response to prospective payment. We OPPS final rule (67 FR 66749 through
under section 123 of the BBRA and continue to believe that, once we have 66750), we believed it was appropriate
section 307 of the BIPA, the Secretary progressed further through the 5-year to implement the ‘‘dampening policy’’
generally has broad authority in transition period, we will have a better under the OPPS referenced by the
developing the LTCH PPS, including opportunity to evaluate the impacts of commenters because many of the
whether and how to make adjustments the implementation of this new decreases in payment rates for some of
to the LTCH PPS. As we discussed in the APCs appeared to be linked to
payment system based on a number of
the RY 2006 LTCH PPS final rule (70 FR ‘‘changes in the methodology for those
years of LTCH PPS data, which will
24188), we will consider whether it is drugs and devices that will no longer be
most appropriately reflect LTCHs’
appropriate for us to propose a budget eligible for pass-through payments;
experience under a PPS.
neutrality adjustment in the annual miscoding; restructuring of APCs (in
update of some aspects of the LTCH PPS For the reasons stated above, we do
which movement of a single code from
under our broad discretionary authority not believe that a budget neutrality one APC to another may change the
under the statute to provide adjustment to the FY 2006 LTC–DRG median cost of both APCs), or use of
‘‘appropriate adjustments’’ to the LTCH relative weights or to the LTCH PPS data from the period following the
PPS. As several commenters noted, Federal rate is necessary or appropriate. implementation of the OPPS.’’ Although
LTCHs are still transitioning to a PPS Accordingly, in developing the FY 2006 Medicare payment for both hospital
and, while coding practices continue to LTC–DRGs and relative weights shown outpatient services and inpatient LTCH
improve, the FY 2004 claims data may in Table 11 of the Addendum of this services are reimbursed under a PPS
‘‘not yet fully reflect the nature and final rule, we have not applied an (respectively), there are significant
types of services, staff, and other adjustment for budget neutrality nor are distinctions between the two payment
resources’’ that LTCH provide to their we adjusting the 2006 LTCH PPS rate systems. For instance, under the LTCH
patients. In the RY 2005 LTCH PPS final year Federal rate established in the 2006 PPS, a single per LTC–DRG payment is
rule, we indicated that, until the 5-year LTCH PPS final rule (70 FR 24180) to made for all inpatient hospital services
transition from reasonable cost-based account for the estimated change in provided to a patient for each stay,
reimbursement to prospective payment LTCH PPS payments that will result where in contrast, under the OPPS,
is complete, we believe it may not be from the annual update to the LTC–DRG payments based on APCs may include
appropriate to update any aspects of the classifications and relative weights for distinct payment methodologies for
LTCH PPS in a budget neutral manner. FY 2006. certain drugs and devices that are
As noted above, the most recent Comment: Several commenters eligible for pass-through payments.
available LTCH PPS claims data are recommended implementing a Thus, there are significant distinctions
from discharges occurring during FY ‘‘dampening policy,’’ similar to that between the two payment systems that
2004. These LTCH claims data are from which was implemented for the warrant different considerations when
the second year of the LTCH PPS (FY Ambulatory Payment Classification evaluating the need for a ‘‘dampening
2004), which is the only first full year (APC) changes under the Hospital policy.’’ Below we discuss the reasons
since the LTCH PPS was implemented Outpatient PPS (OPPS) in CY 2003, we believe that a ‘‘dampening policy’’ to
for cost reporting periods beginning on which would reduce the decrease in any mitigate the effects of the changes in the
or after October 1, 2002 (FY 2003). relative weight in excess of a threshold LTC–DRG relative weights for FY 2006
Because it is still early in the 5-year (for example, 15 percent) by half, to on LTCH PPS payments are not
LTCH PPS transition period, we mitigate instability in LTCH PPS necessary or appropriate.
continue to believe that it is payments because of the ‘‘significant/ As noted by the commenters, many of
inappropriate to update any aspects of substantial’’ decrease in many of the the proposed FY 2006 LTC–DRG
the LTCH PPS in a budget neutral relative weights. relative weights decreased in
comparison to the FY 2005 LTC–DRG As we discussed above, we believe LTCH claims data in the FY 2004
relative weights, which would result in that there are no systemic errors in the MedPAR file. Furthermore, we believe
an aggregate estimated decrease in FY LTCH FY 2004 MedPAR data, and we that the decrease in many of the LTC–
2006 LTCH PPS payments. As we believe that the increase of relatively DRG relative weights is appropriate and
explained in the FY 2006 IPPS proposed lower charge cases being assigned to is reflective of the changing behaviors of
rule (70 FR 23667), we continue to LTC–DRGs with higher relative weights LTCHs’ response to a PPS environment.
observe an increase of relatively lower that we observed in the FY 2004 LTCH As we discussed above, we believe that
charge cases being assigned to LTC– claims data (which results in a decrease the LTCH claims data in the FY 2004
DRGs with higher relative weights in the in the many of the LTC–DRG relative MedPAR file accurately reflects the
prior year. The addition of these lower weights) accurately represents current resources that are expended to treat
charge cases results in a decrease in the LTCH costs. Specifically, an analysis of LTCH patients in each LTC–DRG.
many of the LTC–DRG relative weights a comparison of the FY 2003 LTCH Although many of the LTC–DRG relative
from FY 2005 to FY 2006. This decrease claims data (used to develop the FY weights (and consequently aggregate
in many of the LTC–DRG relative 2005 LTC–DRG relative weights) and LTCH PPS payments, excluding the
weights, in turn, will result in an the FY 2004 LTCH claims data (used to update to the LTCH PPS Federal rate
estimated decrease in LTCH PPS develop the FY 2006 LTC–DRG relative effective July 1, 2005 (70 FR 24217) will
payments. As we explained in that same weights) shows that, of the 155 LTC– be lower in FY 2006 as compared to FY
proposed rule, contributing to this DRGs that are used on a ‘‘regular basis’’ 2005, we do not believe that the
increased number of relatively lower (that is, nationally, LTCHs discharge, in payment rates for those LTC–DRGs are
charge cases being assigned to LTC– total, 25 or more of these cases inappropriate based on the LTCH claims
DRGs with higher relative weights in the annually), about 30 percent of those data in the FY 2004 MedPAR files.
prior year are improvements in coding LTC–DRGs have experienced a decrease Rather, we believe that the lower LTC–
practices, which are typically found in the average charge per case, which DRG relative weights (and consequently
when moving from a reasonable cost- generally results in a lower relative a reduction in aggregate LTCH PPS
based payment system to a PPS. A weight. In addition, about 45 percent of payments) are appropriate, given that
further analysis of the LTCH claims in those LTC–DRGs have experienced an the average resources used to treat a
the March 2005 update of the FY 2004 increase in the average charge that is LTCH patient in a particular LTC–DRG
MedPAR data, which we used to less than the increase (16 percent) in the are less than the average resources used
determine the FY 2006 LTC–DRG overall average charge across all LTC– to treat a LTCH patient in a particular
relative weights in this final rule, DRGs. In general, the LTC–DRG relative LTC–DRG based on FY 2003 LTCH
continue to show an increase of weights are determined by dividing the claims data. Therefore, we do not agree
relatively lower charge cases being average charge for each LTC–DRG by the with the commenters’ assertion that the
assigned to LTC–DRGs with higher average charge across all LTC–DRGs. changes to the LTC–DRG relative
relative weights in the prior year. As we Accordingly, those LTC–DRGs with an weights for FY 2006 will result in
explained the FY 2006 IPPS proposed increase in average charge of less than instability in LTCH PPS payments.
rule (70 FR 23667), the impact of 16 percent (that is, the increase in Rather, we believe that the changes to
including cases with relatively lower average charge across all LTC–DRGs) the LTC–DRG relative weights for FY
charges into LTC–DRGs that had a will also experience a reduction in their 2006 will result in appropriate
relatively higher relative weight in the relative weight because the average payments for the resources used to treat
version 22.0 (FY 2005) GROUPER is a charge for each of those LTC–DRGs is LTCH patients in a particular LTC–DRG.
decrease in the average relative weight being divided by a bigger number (that Accordingly, for the reasons discussed
for those LTC–DRGs, which, in turn, is, the average charge across all LTC– above, we are not implementing a
results in an estimated aggregate DRGs). Therefore, because we believe ‘‘dampening policy’’ in determining the
decrease in LTCH PPS payments. the FY 2004 LTCH claims data used to FY 2006 LTC–DRG relative weights in
A few commenters acknowledged that determine the FY 2006 LTC–DRG this final rule. We also note that the 4.2
with the move from cost-based relative weights accurately reflect the percent decrease in LTCH PPS
reimbursement to a PPS, LTCHs’ coding resources used by LTCHs to treat their payments estimated as a result of the
practices are still undergoing patients, and these data show either a changes we are making to the LTC–
refinement. Specifically, two decrease in the average charge of the DRGs and relative weights in this final
commenters stated that ‘‘the LTCH PPS, LTC–DRG or an increase in the average rule for FY 2006 (see section VII. of the
in its third year of implementation, is charge of the LTC–DRG that is less than Addendum to this final rule) is partially
still in transition; the initial 5-year the overall increase in the average offset by the projected 5.7 percent
phase-in will end September 2006. charge across all LTC–DRGs, we believe increase in LTCH PPS payments
During this time of transition, LTCH that the decrease in many of the LTC– estimated based on the updated rates
coding and data are still undergoing DRG relative weights is appropriate. and factors effective for discharges
improvement.’’ Therefore, it is not The LTC–DRG relative weights are occurring on or after July 1, 2005
unreasonable to observe relatively designed to reflect the average of established in the FY 2006 LTCH PPS
significant changes (either higher or resources used to treat representative final rule (70 FR 24217).
lower) in the average charge for many cases of the discharges within each Below we discuss in detail the steps
LTC–DRGs as LTCHs’ behavior coding LTC–DRG. As we discussed in greater for calculating the FY 2006 LTC–DRG
continues to change in response to the detail above, after our extensive analysis relative weights as presented in the FY
implementation of a PPS. As the of the FY 2004 MedPAR data, which we 2006 IPPS proposed rule (70 FR 23346
transition progresses, we expect that used to determine the FY 2006 LTC– through 23353). We note that, as we
LTCH’s behavior will result in fewer DRG relative weights, we concluded stated above in section II.D.3.b. of this
nonuniform changes in the average that there are no systematic errors in preamble, as we proposed, we have
charge of many LTC–DRGs, which may that data. Therefore, we continue to excluded the data of all-inclusive rate
impact the LTC–DRG relative weights believe it is appropriate to base the FY LTCHs and LTCHs that are paid in
from year to year. 2006 LTC–DRG relative weights on accordance with demonstration projects
that had claims in the FY 2004 MedPAR of the LTC–DRG, in accordance with cases (case-mix) is calculated by
file. § 412.529.) dividing the sum of all the LTCH’s LTC–
Step 1—Remove statistical outliers. We make this adjustment by counting DRG relative weights by its total number
The first step in the calculation of the a short-stay outlier as a fraction of a of cases. The LTCHs’ hospital-specific
FY 2006 LTC–DRG relative weights is to discharge based on the ratio of the relative charge values above are
remove statistical outlier cases. We length of stay of the case to the average multiplied by these hospital-specific
define statistical outliers as cases that length of stay for the LTC–DRG for case-mix indexes. These hospital-
are outside of 3.0 standard deviations nonshort-stay outlier cases. This has the specific case-mix adjusted relative
from the mean of the log distribution of effect of proportionately reducing the charge values are then used to calculate
both charges per case and the charges impact of the lower charges for the a new set of LTC–DRG relative weights
per day for each LTC–DRG. These short-stay outlier cases in calculating across all LTCHs. In this final rule, this
statistical outliers are removed prior to the average charge for the LTC–DRG. iterative process is continued until there
calculating the relative weights. As This process produces the same result is convergence between the weights
noted above, we believe that they may as if the actual charges per discharge of produced at adjacent steps, for example,
represent aberrations in the data that a short-stay outlier case were adjusted to when the maximum difference is less
distort the measure of average resource what they would have been had the than 0.0001.
use. Including those LTCH cases in the patient’s length of stay been equal to the Step 5—Adjust the FY 2006 LTC–DRG
calculation of the relative weights could average length of stay of the LTC–DRG. relative weights to account for
result in an inaccurate relative weight As we explained in the FY 2006 IPPS nonmonotonically increasing relative
that does not truly reflect relative proposed rule (70 FR 23346 through weights.
resource use among the LTC–DRGs. 23347), counting short-stay outlier cases
As explained in section II.B. of this
Step 2—Remove cases with a length of as full discharges with no adjustment in
preamble, the FY 2006 CMS DRGs, on
determining the LTC–DRG relative
stay of 7 days or less. which the FY 2006 LTC–DRGs are
weights would lower the LTC–DRG
The FY 2006 LTC–DRG relative based, contain ‘‘pairs’’ that are
relative weight for affected LTC–DRGs
weights reflect the average of resources differentiated based on the presence or
because the relatively lower charges of
used on representative cases of a absence of CCs. The LTC–DRGs with
the short-stay outlier cases would bring
specific type. Generally, cases with a CCs are defined by certain secondary
down the average charge for all cases
length of stay 7 days or less do not diagnoses not related to or inherently a
within a LTC–DRG. This would result in
belong in a LTCH because these stays do an ‘‘underpayment’’ to nonshort-stay part of the disease process identified by
not fully receive or benefit from outlier cases and an ‘‘overpayment’’ to the principal diagnosis, but the presence
treatment that is typical in a LTCH stay, short-stay outlier cases. Therefore, in of additional diagnoses does not
and full resources are often not used in this final rule, we adjust for short-stay automatically generate a CC. As we
the earlier stages of admission to a outlier cases under § 412.529 in this discussed in the FY 2005 IPPS final rule
LTCH. As explained above, if we were manner because it results in more (69 FR 48991), the value of
to include stays of 7 days or less in the appropriate payments for all LTCH monotonically increasing relative
computation of the FY 2006 LTC–DRG cases. weights rises as the resource use
relative weights, the value of many Step 4—Calculate the FY 2006 LTC– increases (for example, from
relative weights would decrease and, DRG relative weights on an iterative uncomplicated to more complicated).
therefore, payments would decrease to a basis. The presence of CCs in a LTC–DRG
level that may no longer be appropriate. The process of calculating the LTC– means that cases classified into a
We do not believe that it would be DRG relative weights using the hospital- ‘‘without CC’’ LTC–DRG are expected to
appropriate to compromise the integrity specific relative value methodology is have lower resource use (and lower
of the payment determination for those iterative. First, for each LTCH case, we costs). In other words, resource use (and
LTCH cases that actually benefit from calculate a hospital-specific relative costs) are expected to decrease across
and receive a full course of treatment at charge value by dividing the short-stay ‘‘with CC/without CC’’ pairs of LTC–
a LTCH, in order to include data from outlier adjusted charge per discharge DRGs.
these very short-stays. Thus, as (see step 3) of the LTCH case (after For a case to be assigned to a LTC–
explained above, in determining the FY removing the statistical outliers (see DRG with CCs, more coded information
2006 LTC–DRG relative weights, we step 1)) and LTCH cases with a length is called for (that is, at least one relevant
remove LTCH cases with a length of stay of stay of 7 days or less (see step 2) by secondary diagnosis), than for a case to
of 7 days or less. the average charge per discharge for the be assigned to a LTC–DRG ‘‘without
Step 3—Adjust charges for the effects LTCH in which the case occurred. The CCs’’ (which is based on only one
of short-stay outliers. resulting ratio is then multiplied by the principal diagnosis and no relevant
After removing cases with a length of LTCH’s case-mix index to produce an secondary diagnoses). Currently, the
stay of 7 days or less, we are left with adjusted hospital-specific relative LTCH claims data include both
cases that have a length of stay of greater charge value for the case. An initial accurately coded cases without
than or equal to 8 days. The next step case-mix index value of 1.0 is used for complications and cases that have
in the calculation of the FY 2006 LTC– each LTCH. complications (and cost more), but were
DRG relative weights is to adjust each For each LTC–DRG, the FY 2006 not coded completely. Both types of
LTCH’s charges per discharge for those LTC–DRG relative weight is calculated cases are grouped to a LTC–DRG
remaining cases for the effects of short- by dividing the average of the adjusted ‘‘without CCs’’ when only the principal
stay outliers as defined in § 412.529(a). hospital-specific relative charge values diagnosis was coded. Since the LTCH
(However, we note that even if a case (from above) for the LTC–DRG by the PPS was only implemented for cost
was removed in Step 2 (that is, cases overall average hospital-specific relative reporting periods beginning on or after
with a length of stay of 7 days or less), charge value across all cases for all October 1, 2002 (FY 2003), and LTCHs
it was paid as a short-stay outlier if its LTCHs. Using these recalculated LTC– were previously paid under cost-based
length of stay was less than or equal to DRG relative weights, each LTCH’s reimbursement, which is not based on
five-sixths of the average length of stay average relative weight for all of its patient diagnoses, coding by LTCHs for
these cases may not have been as August 30, 2002 LTCH PPS final rule LTC–DRG relative weights (69 FR
detailed as possible. (67 FR 55990), we believe this anomaly 78922).
Thus, in developing the FY 2003 may be due to coding inaccuracies and The third category of
LTC–DRG relative weights for the LTCH expect that, as was the case when we nonmonotonically increasing relative
PPS based on FY 2001 claims data, as first implemented the acute care weights for LTC–DRG pairs ‘‘with and
we discussed in the August 30, 2002 hospital IPPS, this problem will be self- without CCs’’ consists of one pair of
LTCH PPS final rule (67 FR 55990), we correcting, as LTCHs submit more LTC–DRGs where one of the LTC–DRGs
found on occasion that the data completely coded data in the future. has fewer than 25 LTCH cases and is
suggested that cases classified to the The first category of grouped to a low-volume quintile and
LTC–DRG ‘‘with CCs’’ of a ‘‘with CC’’/ nonmonotonically increasing relative the other LTC–DRG has 25 or more
‘‘without CC’’ pair had a lower average weights for FY 2006 LTC–DRG pairs LTCH cases and has its own LTC–DRG
charge than the corresponding LTC– ‘‘with and without CCs’’ contains one relative weight, and the LTC–DRG
DRG ‘‘without CCs.’’ Similarly, as pair of LTC–DRGs in which both the ‘‘without CCs’’ has the higher relative
discussed in the FY 2005 IPPS final rule LTC–DRG ‘‘with CCs’’ and the LTC– weight. We removed the low-volume
(69 FR 48991 through 48992), based on DRG ‘‘without CCs’’ had 25 or more LTC–DRG from the low-volume quintile
FY 2003 claims data, we also found on LTCH cases and, therefore, did not fall and combined it with the other LTC–
occasion that the data suggested that into one of the 5 low-volume quintiles. DRG for the computation of a new
cases classified to the LTC–DRG ‘‘with For those nonmonotonic LTC–DRG relative weight for each of these LTC–
CCs’’ of a ‘‘with CC’’/‘‘without CC’’ pair pairs, we combine the LTCH cases and DRGs. This new relative weight is
have a lower average charge than the compute a new relative weight based on assigned to both LTC–DRGs, so they
corresponding LTC–DRG ‘‘without CCs’’ the case-weighted average of the each have the same relative weight. In
for the FY 2005 LTC–DRG relative combined LTCH cases of the LTC– this final rule, for FY 2006, LTC–DRGs
weights. DRGs. The case-weighted average charge 142 and 143 fall into this category.
We believe this anomaly may be due Step 6—Determine a FY 2006 LTC–
is determined by dividing the total
to coding that may not have fully DRG relative weight for LTC–DRGs with
charges for all LTCH cases by the total
reflected all comorbidities that were no LTCH cases.
number of LTCH cases for the combined As we stated above, we determine the
present. Specifically, LTCHs may have
LTC–DRG. This new relative weight is relative weight for each LTC–DRG using
failed to code relevant secondary
then assigned to both of the LTC–DRGs charges reported in the March 2005
diagnoses, which resulted in cases that
in the pair. In this final rule, for FY update of the FY 2004 MedPAR file. Of
actually had CCs being classified into a
2006, LTC–DRGs 553 and 554 fall into the 526 LTC–DRGs for FY 2006, we
‘‘without CC’’ LTC–DRG. It would not
this category. identified 196 LTC–DRGs for which
be appropriate to pay a lower amount
for the ‘‘with CC’’ LTC–DRG because, in The second category of there were no LTCH cases in the
general, cases classified into a ‘‘with nonmonotonically increasing relative database. That is, based on data from the
CC’’ LTC–DRG are expected to have weights for LTC–DRG pairs ‘‘with and FY 2004 MedPAR file used in this final
higher resource use (and higher cost) as without CCs’’ consists of one pair of rule, no patients who would have been
discussed above. Therefore, previously LTC–DRGs that has fewer than 25 cases, classified to those LTC–DRGs were
when we determined the LTC–DRG and each LTC–DRG is grouped to treated in LTCHs during FY 2004 and,
relative weights in accordance with the different low-volume quintiles in which therefore, no charge data were reported
methodology established in the August the ‘‘without CC’’ LTC–DRG is in a for those LTC–DRGs. Thus, in the
30, 2002 LTCH PPS final rule (67 FR higher-weighted low-volume quintile process of determining the LTC–DRG
55990), we grouped both the cases than the ‘‘with CC’’ LTC–DRG. For those relative weights, we are unable to
‘‘with CCs’’ and ‘‘without CCs’’ together pairs, we combine the LTCH cases and determine weights for these 196 LTC–
for the purpose of calculating the LTC– determine the case-weighted average DRGs using the methodology described
DRG relative weights since the charge for all LTCH cases. The case- in steps 1 through 5 above. However,
implementation of the LTCH PPS in FY weighted average charge is determined because patients with a number of the
2003. As we stated in that same final by dividing the total charges for all diagnoses under these LTC–DRGs may
rule, we will continue to employ this LTCH cases by the total number of be treated at LTCHs beginning in FY
methodology to account for LTCH cases for the combined LTC–DRG. 2006, we assign relative weights to each
nonmonotonically increasing relative Based on the case-weighted average of the 196 ‘‘no volume’’ LTC–DRGs
weights until we have adequate data to LTCH charge, we determine within based on clinical similarity and relative
calculate appropriate separate weights which low-volume quintile the costliness to one of the remaining 330
for these anomalous LTC–DRG pairs. ‘‘combined LTC–DRG’’ is grouped. Both (526 ¥ 196 = 330) LTC–DRGs for which
We expect that, as was the case when LTC–DRGs in the pair are then grouped we are able to determine relative
we first implemented the IPPS, this into the same low-volume quintile, and weights, based on FY 2004 claims data.
problem will be self-correcting, as thus have the same relative weight. In As there are currently no LTCH cases
LTCHs submit more completely coded this final rule, for FY 2006, LTC–DRGs in these ‘‘no volume’’ LTC–DRGs, we
data in the future. 555, 556 and 557 fall into this category. determined relative weights for the 196
There are three types of ‘‘with CC’’ (We note, 3 LTC–DRGs make up this LTC–DRGs with no LTCH cases in the
and ‘‘without CC’’ pairs that could be non-monotonic ‘‘pair’’ of LTC–DRGs FY 2004 MedPAR file used in this final
nonmonotonic; that is, where the because these percutaneous rule by grouping them to the
‘‘without CC’’ LTC–DRG would have a cardiovascular procedure DRGs are appropriate low-volume quintile. This
higher average charge than the ‘‘with further split depending on the presence methodology is consistent with our
CC’’ LTC–DRG. For this final rule, using or absence of a drug eluting stint and methodology used in determining
the LTCH cases in the March 2005 the presence or absence of a major ‘‘CV’’ relative weights to account for the low-
update of the FY 2004 MedPAR file (the (cardiovascular) diagnosis, which is volume LTC–DRGs described above.
best available data at this time), we similar to the adjustment for non- Our methodology for determining
identified three types of nonmonotonic monotonicity for DRGs 521, 522 and 523 relative weights for the ‘‘no volume’’
LTC–DRG pairs. As we stated in the in the development of the FY 2005 LTC–DRGs is as follows: We crosswalk
the no volume LTC–DRGs by matching weight for the applicable low-volume each of the five quintiles and we assign
them to other similar LTC–DRGs for quintile to the no volume LTC–DRG if the no volume LTC–DRG the relative
which there were LTCH cases in the FY the LTC–DRG to which it is crosswalked weight of the low-volume quintile with
2004 MedPAR file based on clinical is grouped to one of the low-volume the closest weight. For this final rule, a
similarity and intensity of use of quintiles. If the LTC–DRG to which the list of the no volume FY 2006 LTC–
resources as determined by care no volume LTC–DRG is crosswalked is DRGs and the FY 2006 LTC–DRG to
provided during the period of time not one of the LTC–DRGs to be grouped which it is crosswalked in order to
surrounding surgery, surgical approach to one of the low-volume quintiles, we determine the appropriate low-volume
(if applicable), length of time of surgical compare the relative weight of the LTC– quintile for the assignment of a relative
procedure, post-operative care, and DRG to which the no volume LTC–DRG weight for FY 2006 is shown in the
length of stay. We assign the relative is crosswalked to the relative weights of chart below.
NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006

Low-volume
Cross-walked
LTC–DRG Description quintile as-
LTC–DRG signment
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 1.
30 ................. TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0–17 ......................................................... 29 Quintile 2.
32 ................. CONCUSSION AGE >17 W/O CC ................................................................................................. 25 Quintile 1.
33 ................. CONCUSSION AGE 0–17 .............................................................................................................. 25 Quintile 1.
36 ................. RETINAL PROCEDURES ............................................................................................................... 40 Quintile 4.
37 ................. ORBITAL PROCEDURES .............................................................................................................. 40 Quintile 4.
38 ................. PRIMARY IRIS PROCEDURES ..................................................................................................... 40 Quintile 4.
39 ................. LENS PROCEDURES WITH OR WITHOUT VITRECTOMY ......................................................... 40 Quintile 4.
41 ................. EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0–17 ..................................................... 40 Quintile 4.
42 ................. INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS ............................................... 40 Quintile 4.
43 ................. HYPHEMA ....................................................................................................................................... 40 Quintile 4.
45 ................. NEUROLOGICAL EYE DISORDERS ............................................................................................. 40 Quintile 4.
47 ................. OTHER DISORDERS OF THE EYE AGE >17 W/O CC ............................................................... 40 Quintile 4.
48 ................. OTHER DISORDERS OF THE EYE AGE 0–17 ............................................................................ 40 Quintile 4.
49 ................. ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0–17 .................................. 64 Quintile 4.
50 ................. SIALOADENECTOMY .................................................................................................................... 63 Quintile 4.
51 ................. SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY .......................................... 63 Quintile 4.
52 ................. CLEFT LIP & PALATE REPAIR ..................................................................................................... 63 Quintile 4.
53 ................. SINUS & MASTOID PROCEDURES AGE >17 ............................................................................. 63 Quintile 4.
54 ................. SINUS & MASTOID PROCEDURES AGE 0–17 ............................................................................ 63 Quintile 4.
55 ................. MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES ....................................... 63 Quintile 4.
56 ................. RHINOPLASTY ............................................................................................................................... 63 Quintile 4.
57 ................. T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 .............. 69 Quintile 1.
58 ................. T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0–17 ............. 69 Quintile 1.
59 ................. TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 ................................................... 69 Quintile 1.
60 ................. TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0–17 ................................................. 69 Quintile 1.
62 ................. MYRINGOTOMY W TUBE INSERTION AGE 0–17 ....................................................................... 69 Quintile 1.
66 ................. EPISTAXIS ...................................................................................................................................... 69 Quintile 1.
70 ................. OTITIS MEDIA & URI AGE 0–17 ................................................................................................... 69 Quintile 1.
71 ................. LARYNGOTRACHEITIS ................................................................................................................. 97 Quintile 2.
72 ................. OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0–17 ............................................................... 73 Quintile 3.
74 ................. OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0–17 ........................................... 69 Quintile 1.
81 ................. RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0–17 ................................................... 69 Quintile 1.
84 ................. MAJOR CHEST TRAUMA W/O CC ............................................................................................... 93 Quintile 2.
91 ................. ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY W/O CC ......... 90 Quintile 1.
98 ................. BRONCHITIS & ASTHMA AGE 0–17 ............................................................................................ 97 Quintile 2.
104 ............... CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W CARDIAC CATH .............. 110 Quintile 3.
105 ............... CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W/O CARDIAC CATH .......... 110 Quintile 3.
106 ............... CORONARY BYPASS W PTCA ..................................................................................................... 110 Quintile 3.
107 ............... CORONARY BYPASS W CARDIAC CATH ................................................................................... 110 Quintile 3.
108 ............... OTHER CARDIOTHORACIC PROCEDURES ............................................................................... 110 Quintile 3.
109 ............... CORONARY BYPASS W/O PTCA OR CARDIAC CATH .............................................................. 110 Quintile 3.
111 ............... MAJOR CARDIOVASCULAR PROCEDURES W/O CC ................................................................ 110 Quintile 3.
129 ............... CARDIAC ARREST, UNEXPLAINED ............................................................................................. 110 Quintile 3.
137 ............... CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0–17 ............................................... 136 Quintile 2.
146 ............... ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O CC ..... 148 Quintile 5.
147 ............... NASAL TRAUMA & DEFORMITY .................................................................................................. 148 Quintile 5.
149 ............... FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0–17 ........................................... 176 Quintile 3.
153 ............... MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC ....................................................... 152 Quintile 3.
155 ............... STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC ......................... 154 Quintile 5.
156 ............... STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0–17 ...................................... 154 Quintile 5.
158 ............... ANAL & STOMAL PROCEDURES W/O CC .................................................................................. 157 Quintile 4.
159 ............... HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC ............................. 177 Quintile 3.
160 ............... HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC ......................... 177 Quintile 3.
NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006—Continued

Low-volume
Cross-walked
LTC–DRG signment
162 ............... INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC ......................................... 178 Quintile 3.
163 ............... HERNIA PROCEDURES AGE 0–17 .............................................................................................. 178 Quintile 3.
164 ............... NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0–17 .................................................... 148 Quintile 5.
165 ............... CESAREAN SECTION W/O CC ..................................................................................................... 148 Quintile 5.
166 ............... LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC ................................. 148 Quintile 5.
167 ............... MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC ...................................................... 148 Quintile 5.
169 ............... MOUTH PROCEDURES W/O CC .................................................................................................. 185 Quintile 3.
184 ............... FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0–17 ....................................... 183 Quintile 1.
186 ............... DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0–17 ...................... 185 Quintile 3.
187 ............... DENTAL EXTRACTIONS & RESTORATIONS .............................................................................. 185 Quintile 3.
190 ............... PERIANAL & PILONIDAL PROCEDURES .................................................................................... 189 Quintile 1.
192 ............... PANCREAS, LIVER & SHUNT PROCEDURES W/O CC ............................................................. 191 Quintile 4.
194 ............... BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC .................. 193 Quintile 3.
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 5.
212 ............... HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0–17 ........................................... 210 Quintile 5.
220 ............... LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0–17 ............................ 218 Quintile 5.
224 ............... SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC .................... 227 Quintile 3.
229 ............... HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC .......................................... 237 Quintile 1.
232 ............... ARTHROSCOPY ............................................................................................................................. 237 Quintile 1.
234 ............... OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC ....................................... 237 Quintile 1.
252 ............... SEPTICEMIA AGE 0–17 ................................................................................................................. 253 Quintile 3.
255 ............... LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TR ............. 253 Quintile 3.
257 ............... TOTAL MASTECTOMY FOR MALIGNANCY W CC ..................................................................... 274 Quintile 3.
258 ............... TOTAL MASTECTOMY FOR MALIGNANCY W/O CC .................................................................. 274 Quintile 3.
260 ............... SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC .......................................................... 274 Quintile 3.
261 ............... BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION .................. 274 Quintile 3.
267 ............... MAJOR HEAD & NECK PROCEDURES ....................................................................................... 271 Quintile 3.
275 ............... MALIGNANT BREAST DISORDERS W/O CC .............................................................................. 274 Quintile 3.
279 ............... CELLULITIS AGE 0–17 .................................................................................................................. 273 Quintile 1.
282 ............... TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0–17 .................................................. 281 Quintile 1.
286 ............... EXTREME IMMATURITY ............................................................................................................... 292 Quintile 5.
289 ............... PARATHYROID PROCEDURES .................................................................................................... 63 Quintile 4.
291 ............... THYROGLOSSAL PROCEDURES ................................................................................................ 63 Quintile 4.
298 ............... PREMATURITY W MAJOR PROBLEMS ....................................................................................... 297 Quintile 2.
307 ............... PROSTATECTOMY W/O CC ......................................................................................................... 306 Quintile 2.
309 ............... MINOR BLADDER PROCEDURES W/O CC ................................................................................. 308 Quintile 3.
311 ............... TRANSURETHRAL PROCEDURES W/O CC ............................................................................... 310 Quintile 4.
313 ............... URETHRAL PROCEDURES, AGE >17 W/O CC .......................................................................... 312 Quintile 1.
314 ............... URETHRAL PROCEDURES, AGE 0–17 ....................................................................................... 305 Quintile 1.
322 ............... FULL TERM NEONATE W MAJOR PROBLEMS .......................................................................... 321 Quintile 1.
324 ............... NEONATE W OTHER SIGNIFICANT PROBLEMS ....................................................................... 321 Quintile 1.
326 ............... RECTAL RESECTION W/O CC ..................................................................................................... 321 Quintile 1.
327 ............... RECTAL RESECTION W CC ......................................................................................................... 321 Quintile 1.
329 ............... URETHRAL STRICTURE AGE >17 W/O CC ................................................................................ 305 Quintile 1.
330 ............... URETHRAL STRICTURE AGE 0–17 ............................................................................................. 305 Quintile 1.
333 ............... OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0–17 .................................................. 332 Quintile 2.
335 ............... MAJOR MALE PELVIC PROCEDURES W/O CC ......................................................................... 345 Quintile 5.
337 ............... TRANSURETHRAL PROSTATECTOMY W/O CC ........................................................................ 306 Quintile 2.
338 ............... TESTES PROCEDURES, FOR MALIGNANCY ............................................................................. 336 Quintile 2.
340 ............... TESTES PROCEDURES, NON-MALIGNANCY AGE 0–17 ........................................................... 339 Quintile 4.
342 ............... CIRCUMCISION AGE >17 ............................................................................................................. 339 Quintile 4.
343 ............... CIRCUMCISION AGE 0–17 ............................................................................................................ 339 Quintile 4.
349 ............... BENIGN PROSTATIC HYPERTROPHY W/O CC ......................................................................... 339 Quintile 4.
351 ............... STERILIZATION, MALE .................................................................................................................. 339 Quintile 4.
353 ............... PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY ................ 339 Quintile 4.
354 ............... UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC ................................. 339 Quintile 4.
355 ............... UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC ............................. 339 Quintile 4.
356 ............... FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES ............................... 339 Quintile 4.
357 ............... UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY .............................. 339 Quintile 4.
358 ............... UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC ................................................... 339 Quintile 4.
359 ............... UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC ................................................ 339 Quintile 4.
361 ............... LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION ........................................................... 110 Quintile 3.
362 ............... ENDOSCOPIC TUBAL INTERRUPTION ....................................................................................... 110 Quintile 3.
363 ............... D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY ..................................................... 110 Quintile 3.
367 ............... MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC ................................................... 110 Quintile 3.
370 ............... CESAREAN SECTION W CC ........................................................................................................ 369 Quintile 3.
371 ............... APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC ................................................. 368 Quintile 2.
372 ............... VAGINAL DELIVERY W COMPLICATING DIAGNOSES .............................................................. 110 Quintile 3.
NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006—Continued

Low-volume
Cross-walked
LTC–DRG signment
373 ............... VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES .......................................................... 110 Quintile 3.
374 ............... VAGINAL DELIVERY W STERILIZATION &/OR D&C .................................................................. 110 Quintile 3.
375 ............... VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C ............................................. 110 Quintile 3.
376 ............... POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE ............................. 110 Quintile 3.
377 ............... POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE ................................. 110 Quintile 3.
378 ............... ECTOPIC PREGNANCY ................................................................................................................ 369 Quintile 3.
379 ............... THREATENED ABORTION ............................................................................................................ 110 Quintile 3.
380 ............... ABORTION W/O D&C .................................................................................................................... 110 Quintile 3.
381 ............... ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY ..................................... 110 Quintile 3.
382 ............... FALSE LABOR ................................................................................................................................ 110 Quintile 3.
383 ............... OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS ...................................... 110 Quintile 3.
384 ............... OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS ................................... 110 Quintile 3.
385 ............... NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY .................... 110 Quintile 3.
386 ............... KIDNEY & URINARY TRACT INFECTIONS AGE 0–17 ................................................................ 87 Quintile 4.
387 ............... URINARY STONES W/O CC ......................................................................................................... 87 Quintile 4.
388 ............... PREMATURITY W/O MAJOR PROBLEMS ................................................................................... 110 Quintile 3.
389 ............... KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0–17 ................................................. 87 Quintile 4.
390 ............... VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0–17 ................................................... 87 Quintile 4.
391 ............... NORMAL NEWBORN ..................................................................................................................... 110 Quintile 3.
392 ............... SPLENECTOMY AGE >17 ............................................................................................................. 197 Quintile 3.
393 ............... SPLENECTOMY AGE 0–17 ........................................................................................................... 197 Quintile 3.
396 ............... RED BLOOD CELL DISORDERS AGE 0–17 ................................................................................ 399 Quintile 2.
402 ............... APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC ............................................. 395 Quintile 2.
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 4.
411 ............... HISTORY OF MALIGNANCY W/O ENDOSCOPY ......................................................................... 110 Quintile 3.
412 ............... HISTORY OF MALIGNANCY W ENDOSCOPY ............................................................................ 110 Quintile 3.
414 ............... OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC .................................... 399 Quintile 2.
417 ............... APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC .......................................... 416 Quintile 3.
420 ............... FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC ..................................................................... 419 Quintile 4.
422 ............... ADRENAL & PITUITARY PROCEDURES ..................................................................................... 419 Quintile 4.
446 ............... TRAUMATIC INJURY AGE 0–17 ................................................................................................... 445 Quintile 1.
448 ............... ALLERGIC REACTIONS AGE 0–17 .............................................................................................. 447 Quintile 2.
450 ............... POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC ............................................... 449 Quintile 3.
451 ............... POISONING & TOXIC EFFECTS OF DRUGS AGE 0–17 ............................................................ 449 Quintile 3.
455 ............... OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC ............................................... 449 Quintile 3.
478 ............... OTHER VASCULAR PROCEDURES W CC .................................................................................. 110 Quintile 3.
479 ............... OTHER VASCULAR PROCEDURES W/O CC .............................................................................. 110 Quintile 3.
481 ............... BONE MARROW TRANSPLANT ................................................................................................... 394 Quintile 5.
485 ............... OTHER HEART ASSIST SYSTEM IMPLANT ................................................................................ 487 Quintile 4.
492 ............... APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC ............................................. 410 Quintile 4.
494 ............... LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC .................................................. 493 Quintile 5.
496 ............... COMBINED ANTERIOR/POSTERIOR SPINAL FUSION .............................................................. 497 Quintile 4.
498 ............... SPINAL FUSION W/O CC .............................................................................................................. 497 Quintile 4.
504 ............... CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS ................................. 468 Quintile 5.
518 ............... PERCUTANEOUS CARDIVASCULAR PROC W/O CORONARY ARTERY STENT OR AMI ...... 125 Quintile 3.
520 ............... CERVICAL SPINAL FUSION W/O CC ........................................................................................... 497 Quintile 4.
522 ............... CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK ........................................... 521 Quintile 1.
523 ............... CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK ....................................... 521 Quintile 1.
525 ............... EXTENSIVE BURN OR FULL THICKNESS BURNS WITH MECH VENT 96+ HOURS WITH 468 Quintile 5.
SKIN GRAFT.
528 ............... INTRACRANIAL VASCULAR PROC W PDX HEMORRHAGE ..................................................... 1 Quintile 5.
530 ............... VENTRICULAR SHUNT PROCEDURES W/O CC ........................................................................ 529 Quintile 5.
534 ............... EXTRACRANIAL VASCULAR PROCEDURES WITHOUT CC ..................................................... 500 Quintile 4.
535 ............... ACUTE ISCHEMIC STROKE WITH USE OF THROMBOLYTIC AGENT ..................................... 515 Quintile 5.
536 ............... KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC .................................... 515 Quintile 5.
538 ............... LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND 228 Quintile 4.
FEMUR WITHOUT CC.
540 ............... LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITHOUT CC ...................... 399 Quintile 2.
546 ............... SPINAL FUSION EXCEPT CERVICAL WITH CURVATURE OF SPINE OR MALIGNANCY ...... 499 Quintile 5.
To illustrate this methodology for crosswalk information for FY 2006 procedure is similar in resource use and
determining the relative weights for the provided in the chart above. the length and complexity of the
201 LTC–DRGs with no LTCH cases, we Example 1: There were no cases in the procedures and the length of stay are
are providing the following examples, FY 2004 MedPAR file used for this final similar, we determined that LTC–DRG
which refer to the no volume LTC–DRGs rule for LTC–DRG 163 (Hernia 178 (Uncomplicated Peptic Ulcer
Procedures Age 0–17). Since the Without CC), which is assigned to low-
volume Quintile 3 for the purpose of present time, we would only include medical service or technology if, ‘‘based
determining the FY 2006 relative these six transplant LTC–DRGs in the on the estimated costs incurred with
weights, would display similar clinical GROUPER program for administrative respect to discharges involving such
and resource use. Therefore, we assign purposes. Because we use the same service or technology, the DRG
the same relative weight of LTC–DRG GROUPER program for LTCHs as is used prospective payment rate otherwise
178 of 0.7637 (Quintile 3) for FY 2006 under the IPPS, removing these LTC– applicable to such discharges under this
(Table 11 in the Addendum to this final DRGs would be administratively subsection is inadequate.’’
rule) to LTC–DRG 163. burdensome. The regulations implementing this
Example 2: There were no LTCH Again, we note that as this system is provision establish three criteria for new
cases in the FY 2004 MedPAR file used dynamic, it is entirely possible that the medical services and techniques to
in this final rule for LTC–DRG 91 number of LTC–DRGs with a zero receive an additional payment. First,
(Simple Pneumonia and Pleurisy Age 0– volume of LTCH cases based on the § 412.87(b)(2) defines when a specific
17). Since the severity of illness in system will vary in the future. We used medical service or technology will be
patients with bronchitis and asthma is the best most recent available claims considered new for purposes of new
similar in patients regardless of age, we data in the MedPAR file to identify zero medical service or technology add-on
determined that LTC–DRG 90 (Simple volume LTC–DRGs and to determine the payments. The statutory provision
Pneumonia and Pleurisy Age >17 relative weights in this final rule. contemplated the special payment
Without CC) would display similar Table 11 in the Addendum to this treatment for new medical services or
clinical and resource use characteristics final rule lists the LTC–DRGs and their technologies until such time as data are
and have a similar length of stay to respective relative weights, geometric available to reflect the cost of the
LTC–DRG 91. There were over 25 cases mean length of stay, and five-sixths of technology in the DRG weights through
in LTC–DRG 90. Therefore, it would not the geometric mean length of stay (to recalibration. There is a lag of 2 to 3
be assigned to a low-volume quintile for assist in the determination of short-stay years from the point a new medical
the purpose of determining the LTC– outlier payments under § 412.529) for service or technology is first introduced
DRG relative weights. However, under FY 2006. on the market and when data reflecting
our established methodology, LTC–DRG the use of the medical service or
91, with no LTCH cases, would need to 5. Other Public Comments Relating to technology are used to calculate the
be grouped to a low-volume quintile. the LTCH PPS Payment Policies DRG weights. For example, data from
We determined that the low-volume Comment: One commenter submitted discharges occurring during FY 2004 are
quintile with the closest weight to LTC– comments that addressed aspects of the used to calculate the FY 2006 DRG
DRG 90 (0.4970) (refer to Table 11 in the existing LTCH PPS, including the weights in this final rule. Section
Addendum to this final rule) would be hospital-within-hospital policy, which 412.87(b)(2) provides that a ‘‘medical
low-volume Quintile 1 (0.4499) (refer to was discussed in the FY 2005 IPPS final service or technology may be considered
Table 11 in the Addendum to this final rule (69 FR 49191), and the June 2004 new within 2 or 3 years after the point
rule). Therefore, we assign LTC–DRG 91 MedPAC recommendations concerning at which data begin to become available
a relative weight of 0.4499 for FY 2006. the definition of LTCHs, which was reflecting the ICD–9–CM code assigned
Furthermore, we are establishing discussed in the RY 2006 LTCH PPS to the new medical service or
LTC–DRG relative weights of 0.0000 for final rule (70 FR 5757), for which we technology (depending on when a new
heart, kidney, liver, lung, pancreas, and did not propose LTCH policy changes in code is assigned and data on the new
simultaneous pancreas/kidney the FY 2006 IPPS proposed rule. medical service or technology become
transplants (LTC–DRGs 103, 302, 480, Response: Because those comments available for DRG recalibration). After
495, 512, and 513, respectively) for FY pertain to specific aspects of the existing CMS has recalibrated the DRGs, based
2006 because Medicare will only cover LTCH PPS that were not specific on available data, to reflect the costs of
these procedures if they are performed proposed changes to the LTCH PPS an otherwise new medical service or
at a hospital that has been certified for presented in the FY 2006 IPPS proposed technology, the medical service or
the specific procedures by Medicare and rule, we are not responding to them at technology will no longer be considered
presently no LTCH has been so certified. this time. Rather, we believe it is more ‘new’ under the criterion for this
Based on our research, we found that section.’’
appropriate to address the issues in the
most LTCHs only perform minor The 2-year to 3-year period during
annual LTCH PPS proposed and final
surgeries, such as minor small and large which a technology or medical service
rules. We will consider the issues raised
bowel procedures, to the extent any can be considered new would ordinarily
in those comments in the context of
surgeries are performed at all. Given the begin with FDA approval, unless there
future rulemaking for the LTCH PPS.
extensive criteria that must be met to was some documented delay in bringing
become certified as a transplant center E. Add-On Payments for New Services the product onto the market after that
for Medicare, we believe it is unlikely and Technologies approval (for instance, component
that any LTCHs would become certified production or drug production had been
1. Background
as a transplant center. In fact, in the postponed until FDA approval due to
nearly 20 years since the Sections 1886(d)(5)(K) and (L) of the shelf life concerns or manufacturing
implementation of the IPPS, there has Act establish a process of identifying issues). After the DRGs have been
never been a LTCH that even expressed and ensuring adequate payment for new recalibrated to reflect the costs of an
an interest in becoming a transplant medical services and technologies under otherwise new medical service or
center. the IPPS. Section 1886(d)(5)(K)(vi) of technology, the special add-on payment
However, if in the future a LTCH the Act specifies that a medical service for new medical services or technology
applies for certification as a Medicare- or technology will be considered new if ceases (§ 412.87(b)(2)). For example, an
approved transplant center, we believe it meets criteria established by the approved new technology that received
that the application and approval Secretary after notice and opportunity FDA approval in October 2004 and
procedure would allow sufficient time for public comment. Section entered the market at that time may be
for us to determine appropriate weights 1886(d)(5)(K)(ii)(I) of the Act specifies eligible to receive add-on payments as a
for the LTC–DRGs affected. At the that the process must apply to a new new technology until FY 2007
(discharges occurring before October 1, revision of the regulations to Pub. L. 108–173, provides that there
2006), when data reflecting the costs of incorporate the change made by section shall be no reduction or adjustment in
the technology would be used to 503(b)(1) of Pub. L. 108–173.) aggregate payments under the IPPS due
recalibrate the DRG weights. Because Section 412.87(b)(1) of our existing to add-on payments for new medical
the FY 2007 DRG weights will be regulations provides that a new services and technologies. Therefore,
calculated using FY 2005 MedPAR data, technology is an appropriate candidate add-on payments for new medical
the costs of such a new technology for an additional payment when it services or technologies for FY 2005 and
would likely be reflected in the FY 2007 represents an advance in medical later years will not be budget neutral.
DRG weights. technology that substantially improves, Applicants for add-on payments for
Section 412.87(b)(3) further provides relative to technologies previously new medical services or technologies for
that, to receive special payment available, the diagnosis or treatment of FY 2007 must submit a formal request,
treatment, new medical services or Medicare beneficiaries. For example, a including a full description of the
technologies must be inadequately paid new technology represents a substantial clinical applications of the medical
otherwise under the DRG system. To clinical improvement when it reduces service or technology and the results of
assess whether technologies would be mortality, decreases the number of any clinical evaluations demonstrating
inadequately paid under the DRGs, we hospitalizations or physician visits, or that the new medical service or
establish thresholds to evaluate reduces recovery time compared to the technology represents a substantial
applicants for new technology add-on technologies previously available. (See clinical improvement, along with a
payments. In the FY 2004 IPPS final the September 7, 2001 final rule, 66 FR significant sample of data to
rule (68 FR 45385, August 1, 2003), we 46902, for a complete discussion of this demonstrate the medical service or
established the threshold at the criterion.) technology meets the high-cost
geometric mean standardized charge for The new medical service or threshold, no later than October 15,
all cases in the DRG plus 75 percent of technology add-on payment policy 2005. Applicants must submit a
1 standard deviation above the provides additional payments for cases complete database no later than
geometric mean standardized charge with high costs involving eligible new December 30, 2005. Complete
(based on the logarithmic values of the medical services or technologies while application information, along with
charges and transformed back to preserving some of the incentives under
final deadlines for submitting a full
charges) for all cases in the DRG to the average-based payment system. The
application, will be available after
which the new medical service or payment mechanism is based on the
publication of this final rule at our Web
technology is assigned (or the case- cost to hospitals for the new medical
site: http://www.cms.hhs.gov/providers/
weighted average of all relevant DRGs, service or technology. Under § 412.88,
hipps/default.asp. To allow interested
if the new medical service or technology Medicare pays a marginal cost factor of
parties to identify the new medical
occurs in many different DRGs). Table 50 percent for the costs of a new
services or technologies under review
10 in the Addendum to the FY 2004 medical service or technology in excess
before the publication of the proposed
IPPS final rule (68 FR 45648) listed the of the full DRG payment. If the actual
rule for FY 2007, the Web site will also
qualifying threshold by DRG, based on costs of a new medical service or
technology case exceed the DRG list the tracking forms completed by
the discharge data that we used to
payment by more than the 50-percent each applicant.
calculate the FY 2004 DRG weights.
However, section 503(b)(1) of Pub. L. marginal cost factor of the new medical 2. Public Input Before Publication of a
108–173 amended section service or technology, Medicare Notice of Proposed Rulemaking on Add-
1886(d)(5)(K)(ii)(I) of the Act to provide payment is limited to the DRG payment On Payments
for ‘‘applying a threshold * * * that is plus 50 percent of the estimated costs of
the lesser of 75 percent of the the new technology. Section 1886(d)(5)(K)(viii) of the Act,
standardized amount (increased to The report language accompanying as amended by section 503(b)(2) of Pub.
reflect the difference between cost and section 533 of Pub. L. 106–554 indicated L. 108–173, provides for a mechanism
charges) or 75 percent of 1 standard Congressional intent that the Secretary for public input before publication of a
deviation for the diagnosis-related group implement the new mechanism on a notice of proposed rulemaking regarding
involved.’’ The provisions of section budget neutral basis (H.R. Conf. Rep. whether a medical service or technology
503(b)(1) apply to classification for No. 106–1033, 106th Cong., 2nd Sess. at represents a substantial improvement or
fiscal years beginning with FY 2005. We 897 (2000)). Section 1886(d)(4)(C)(iii) of advancement. The process for
updated Table 10 from the Federal the Act requires that the adjustments to evaluating new medical service and
Register document that corrects the FY annual DRG classifications and relative technology applications requires the
2004 final rule (68 FR 57753, October 6, weights must be made in a manner that Secretary to—
2003), which contains the thresholds ensures that aggregate payments to • Provide, before publication of a
that we used to evaluate applications for hospitals are not affected. Therefore, in proposed rule, for public input
new service or technology add-on the past, we accounted for projected regarding whether a new service or
payments for FY 2005, using the section payments under the new medical technology represents an advance in
503(b)(1) measures stated above, and service and technology provision during medical technology that substantially
posted these new thresholds on our Web the upcoming fiscal year at the same improves the diagnosis or treatment of
site at: http://www.cms.hhs.gov/ time we estimated the payment effect of Medicare beneficiaries.
providers/hipps/newtech.asp. In the FY changes to the DRG classifications and • Make public and periodically
2005 IPPS final rule (in Table 10 of the recalibration. The impact of additional update a list of the services and
Addendum), we included the final payments under this provision was then technologies for which an application
thresholds that are being used to included in the budget neutrality factor, for add-on payments is pending.
evaluate applicants for new technology which was applied to the standardized • Accept comments,
add-on payments for FY 2006. (Refer to amounts and the hospital-specific recommendations, and data from the
section IV.D. of the preamble to the FY amounts. public regarding whether a service or
2005 IPPS final rule (69 FR 49084, Section 1886(d)(5)(K)(ii)(III) of the technology represents a substantial
August 11, 2004) for a discussion of a Act, as amended by section 503(d)(2) of improvement.
• Provide, before publication of a submitted, the DRGs associated with the have indicated in prior rules (for
proposed rule, for a meeting at which new technology are identified. We only example, see 66 FR 46914, September 7,
organizations representing hospitals, determine that a new DRG assignment is 2001), we believe that a product should
physicians, manufacturers, and any necessary or a new technology add-on be considered new 2 to 3 years from the
other interested party may present payment is appropriate when the date a product becomes available on the
comments, recommendations, and data reimbursement under these currently market (generally from the date of FDA
regarding whether a new service or assigned DRGs is not adequate for this approval unless an applicant can
technology represents a substantial new technology. The criterion for this demonstrate that there was a delay in
clinical improvement to the clinical determination is the cost threshold, making the product available on the
staff of CMS. which we discuss below. We discuss the market). Once a product becomes
In order to provide an opportunity for assignments of several new technologies available on the market, hospitals that
public input regarding add-on payments within the DRG payment system in use the new technology will begin
for new medical services and section II.B. of this final rule. including charges for the product on
technologies for FY 2006 before In this final rule, we evaluate whether their bills under either an existing or
publication of the FY 2006 IPPS new technology add-on payments will new ICD–9–CM code. These charges
proposed rule, we published a notice in continue in FY 2006 for the three will be used to set the DRG relative
the Federal Register on December 30, technologies that currently receive such weights two years later (that is, FY 2004
2004 (69 FR 78466) and held a town hall payments. In addition, we present our charge data are being used to set the FY
meeting at the CMS Headquarters Office evaluations of eight applications for 2006 DRG relative weights). Therefore, 2
in Baltimore, MD, on February 23, 2005. add-on payments in FY 2006. The eight to 3 years after the technology is
In the announcement notice for the applications for FY 2006 include two available on the market, there will be a
meeting, we stated that the opinions and applications for products that were full year of Medicare charge data used
alternatives provided during the denied new technology add-on to set the relative weights that will
meeting would assist us in our payments for FY 2005. reflect the cost of the device. We note
evaluations of applications by allowing Comment: Commenters argued that that a manufacturer can reasonably
public discussions of the substantial CMS’ interpretation of the newness predict when a product will become
clinical improvement criteria for each of criterion is inconsistent with the statute available on the market and, if
the FY 2006 new medical service and and that, as a result, CMS is prematurely warranted, could request a new ICD–9–
technology add-on payment denying eligibility for many CM code in order to distinctly identify
applications before the publication of technologies. Commenters believed that the new technology in our data. In the
the FY 2006 IPPS proposed rule. instead of basing the newness criterion FY 2005 final rule (69 FR 49002), we
Approximately 45 participants on FDA approval or market availability, provided a detailed explanation for why
registered and attended in person, while CMS should start the 2–3 year period using the date on which a specific ICD–
additional participants listened over an that a technology can be considered new 9–CM code is assigned to a technology
open telephone line. The participants from the later of the date that the is not an appropriate test of newness. In
focused on presenting data on the technology is assigned an ICD–9–CM that rule, we noted that, in many
substantial clinical improvement aspect code or is approved by the FDA. instances, a technology may have been
of their products, as well as the need for Commenters argued that neither the in use for several years, or even several
additional payments to ensure access to statutory language nor the regulatory decades, prior to the assignment of a
Medicare beneficiaries. In addition, we language refers to the date of FDA new code (69 FR 49003). Thus, we
received written comments regarding approval in determining whether a believe it is appropriate to continue to
the substantial clinical improvement technology is new. One commenter
criterion for the applicants. We determine newness based on the date on
further argued that CMS should ensure which a product becomes available for
considered these comments in our a maximum period of eligibility for new
evaluation of each new application for use in the Medicare population and the
technology add-on payments that takes date when hospitals can begin to use
FY 2006 in the proposed rule and in this into account a ‘‘host of ‘newness’
final rule. We have summarized these either an existing or new ICD–9–CM
factors’’ such as production and code to bill for the new service or
comments or, if applicable, indicated distribution, negotiation with hospitals,
that no comments were received, at the technology.
and physician education programs. The
end of the discussion of the individual commenter proposed that CMS Comment: One commenter indicated
applications. determine newness, based on the latest that, because Medicare does not pay for
Section 1886(d)(5)(K)(ix) of the Act, as of the following dates: devices during clinical trials, ‘‘little or
added by section 503(c) of Pub. L. 108– • Date of ICD–9–CM code assignment; no internal Medicare claims data exist
173, requires that, before establishing • Date of FDA approval plus six upon which to base an initial DRG
any add-on payment for a new medical months; or assignment for new technologies.’’ To
service or technology, the Secretary • The time/date at which 50 percent address this issue, commenters
shall seek to identify one or more DRGs of the Fiscal Intermediaries are suggested that CMS should accept
associated with the new technology, processing claims that include the external data while maintaining
based on similar clinical or anatomical technology in question. confidentiality for proprietary data.
characteristics and the costs of the The commenter further recommended Other commenters indicated that CMS
technology and assign the new that, given the numerous challenges of decisions regarding substantial clinical
technology into a DRG where the bringing a device to market, CMS improvement have been largely
average costs of care most closely should extend the period that a product subjective and made without
approximate the costs of care using the is considered new from two to three stakeholder input. Commenters
new technology. No add-on payment years to four or five years. requested that CMS include ‘‘a
shall be made with respect to such a Response: Section 1886(d)(5)(K)(vi) of consistent and reasonable set of
new technology. the Act provides the Secretary with requirements for manufacturers of novel
At the time an application for new broad discretion to define a ‘‘new technologies to meet’’ in order to be
technology add-on payments is medical service or technology.’’ As we eligible for new technology add-on
payments. Several commenters criteria, a new technology must be able While we do not believe a
indicated the process for applying for to offer a new treatment option for a determination about substantial clinical
new technology add-on payments is patient population unresponsive to, or improvement should be made prior to
particularly burdensome for smaller ineligible for, currently available FDA approval, two applicants have
companies. Commenters urged CMS to treatments; diagnose a previously received FDA approval for their
provide a preliminary assessment of undetectable condition or allow for products since the publication of the
substantial clinical improvement for earlier diagnosis; or significantly proposed rule. We met with these two
each technology in the proposed rule, in improve clinical outcomes. We applicants during the public comment
order for the public to respond CMS’ provided seven potential measures to period to discuss our concerns about
findings during the public comment evaluate this third standard. While our substantial clinical improvement. As
period. regulations provide specific criteria for indicated below, we are approving both
Response: With respect to the evaluating substantial clinical of these technologies for new
comment about the lack of Medicare improvement, by its very nature, this technology add-on payments beginning
claims data for making a DRG process involves judgment. Before in FY 2006.
assignment for a new medical product, making a final judgment about
we believe that the new technology substantial clinical improvement, we 3. FY 2006 Status of Technology
process is intended to address precisely carefully consider all of the information Approved for FY 2005 Add-On
this issue. In our evaluation of a new that is provided to us in a new Payments
technology application, we consider any technology application, as well as the a. INFUSE (Bone Morphogenetic
external data provided by the applicant viewpoints expressed through the Proteins (BMPs) for Spinal Fusions)
to make judgments as to whether a public meeting, during the comment
INFUSETM was approved by FDA for
product meets the three criteria we have period, and in meetings with individual
use on July 2, 2002, and became
established either to assign a new applicants.
technology to a different DRG or to We do not believe that our criteria available on the market immediately
approve a new technology for add-on present an inordinately cumbersome thereafter. In the FY 2004 IPPS final rule
payments. In addition, while we burden for smaller companies that want (68 FR 45388), we approved INFUSE
generally do not pay for an experimental to apply for new technology add-on for add-on payments under § 412.88,
device itself when used as part of a payments. Several small companies effective for FY 2004. This approval was
clinical trial, a hospital is not precluded have already approached us seeking on the basis of using INFUSE for
from including an existing or a newly advice on how to apply for new single-level, lumbar spinal fusion,
assigned ICD–9–CM code or V-Codes on technology add-on payments FY 2007 consistent with the FDA’s approval and
its bill for Medicare covered services. and later years. We encourage potential the data presented to us by the
Thus, we have been able to successfully applicants to contact us before their applicant. Therefore, we limited the
track devices that are (or were) in technology is available on the market to add-on payment to cases using this
clinical trials in our MedPAR data, and become familiar with the new technology for anterior lumbar fusions
have used these data to determine technology application process. in DRGs 497 (Spinal Fusion Except
whether several new technologies have With respect to providing preliminary Cervical With CC) and 498 (Spinal
met the cost threshold for new determinations of substantial clinical Fusion Except Cervical Without CC).
technology payment. We addressed the improvement in the proposed rule, we Cases involving INFUSE that are
concerns over submissions of external addressed this issue in the FY 2006 eligible for the new technology add-on
data and proprietary information in the proposed rule (70 FR 23359). We payment are identified by assignment to
FY 2005 final rule (69 FR 49004, August indicated that our decision about new DRGs 497 and 498 as a lumbar spinal
11, 2004). As indicated in that rule, we technology add-on payments follows a fusion, with the combination of ICD–9–
are continuing to consider this issue, logical sequence of determinations, CM procedure codes 84.51 (Insertion of
but we are not making any changes to moving from the newness criterion, to interbody spinal fusion device) and
our policy on the submission of external the cost criterion and finally to the 84.52 (Insertion of recombinant bone
data and proprietary information at this substantial clinical improvement morphogenetic protein).
time. criterion. Therefore, we are reluctant to The FDA approved INFUSE for use
We disagree that determinations import substantial clinical improvement on July 2, 2002. For FY 2005, INFUSE
regarding applications for add-on considerations into the logically prior was still within the 2-year to 3-year
payments are made without stakeholder decisions about whether technologies period during which a technology can
input. There is ample opportunity for satisfy the newness and cost criteria. We be considered new under the
applicants and other interested parties acknowledge that an applicant seeking regulations. Therefore, in the FY 2005
to make their views known to us new technology payment for a product IPPS final rule (69 FR 49007 through
throughout the application process, at expected to receive FDA approval 49009), we continued add-on payments
the public meeting, as well as during the between the proposed and final rule has for FY 2005 for cases receiving
comment period on the proposed rule. an interest in knowing CMS’ findings INFUSE for spinal fusions in DRGs 497
We have had numerous meetings with about substantial clinical improvement. (Spinal Fusion Except Cervical With
applicants where they have addressed Nevertheless, we believe that FDA CC) and 498 (Spinal Fusion Except
our concerns and/or brought further approval of a product is a logical prior Cervical Without CC).
information to our attention on the determination because substantial As we discussed in the new
merits of their technology. Our initial clinical improvement is a higher technology final rule (66 FR 46915),
new technology final rule (66 FR 46914, standard to meet than either of the FDA September 7, 2001 an approval of a new
September 7, 2001) provides the specific standards for allowing a product on the technology for special payment should
guidelines we consider to determine market. If a product does not meet the extend to all technologies that are
whether a technology is a substantial FDA standards for a pre-market (‘‘safe substantially similar. Otherwise, our
clinical improvement. In that final rule, and effective’’) or humanitarian device payment policy would bestow an
we indicated that, in order to meet the exemption (‘‘safe’’) approval, it cannot advantage to the first applicant to
substantial clinical improvement be a substantial clinical improvement. receive approval for a particular new
technology. In last year’s final rule (69 new technology add-on payments are c. Kinetra Implantable Neurostimulator
FR 49008), we discussed another identified by either one of the following for Deep Brain Stimulation
product, called OP–1 Putty, two ICD–9–CM procedure codes: 00.51 Medtronic, Inc. submitted an
manufactured by Stryker Biotech, that (Implantation of Cardiac application for approval of the Kinetra
promotes natural bone growth by using Resynchronization Defibrillator, Total implantable neurostimulator device for
a closely related bone morphogenetic System (CRT–D)) or 00.54 (Implantation new technology add-on payments for FY
protein called rhBMP-7. (INFUSE is or Replacement of Pulse Generator 2005. The Kinetra device was
rhBMP-2.) We also stated in last year’s Device Only (CRT–D)). InSync approved by the FDA on December 16,
final rule that we had determined that Defibrillation System received FDA 2003. The Kinetra implantable
the costs associated with the OP–1 Putty approval on June 26, 2002. However, neurostimulator is designed to deliver
are similar to those associated with another manufacturer, Guidant, received electrical stimulation to the subthalamic
INFUSE. Because the OP–1 Putty FDA approval for its CRT–D device on nucleus (STN) or internal globus
became available on the market in May May 2, 2002. As we discussed in the pallidus (GPi) in order to ameliorate
2004 (when it received FDA approval new technology final rule (66 FR 46915, symptoms caused by abnormal
for spinal fusions) for similar spinal September 7, 2001), an approval of a neurotransmitter levels that lead to
fusion procedures and because this new technology for special payment abnormal cell-to-cell electrical impulses
product also eliminates the need for the should extend to all technologies that in Parkinson’s Disease and essential
autograft bone surgery, we extended are substantially similar. Otherwise, our tremor. Before the development of
new technology add-on payments to this payment policy would bestow an Kinetra, treating bilateral symptoms of
technology as well for FY 2005. advantage to the first applicant to patients with these disorders required
As noted above, the period for which receive approval for a particular new
technologies are eligible to receive new the implantation of two
technology. In the FY 2005 final rule, neurostimulators (in the form of a
technology add-on payments is 2 to 3 we also noted that we would extend
years after the product becomes product called SoletraTM, also
new technology add-on payments for manufactured by Medtronic): one for the
available on the market and data CRT–D for the entire FY 2005 even
reflecting the cost of the technology are right side of the brain (to control
though the 2–3 year period of newness symptoms on the left side of the body),
reflected in the DRG weights. The FDA ended in May 2005 for CRT–D.
approved INFUSE bone graft on July 2, the other for the left side of the brain (to
Predictability is an important aspect of control symptoms on the right side of
2002. Therefore, data reflecting the cost the prospective payment methodology
of the technology are now reflected in the body). Additional procedures were
and, therefore, we believe it is required to create pockets in the chest
the DRG weights. In addition, by the appropriate to apply a consistent
end of FY 2005, the add-on payment cavity to place the two generators
payment methodology for new required to run the individual leads.
will have been made for 2 years. technologies throughout the fiscal year
Therefore, as we proposed, we are The Kinetra neurostimulator generator,
(69 FR 49016). implanted in the pectoral area, is
discontinuing new technology add-on As noted in the FY 2005 IPPS final
payment for INFUSE for FY 2006. designed to eliminate the need for two
rule (69 FR 49014), because CRT–Ds devices by accommodating two leads
Because we apply the same policies in were available upon the initial FDA
making new technology payment for that are placed in both the left and right
approval in May 2002, we considered sides of the brain to deliver the
OP–1 Putty as we do for INFUSE, we the technology to be new from this date.
are also discontinuing new technology necessary impulses. The manufacturer
As a result, for FY 2006, the CRT–D will argued that the development of a single
add-on payment for OP–1 Putty for FY be beyond the 2–3 year period during
2006. neurostimulator that treats bilateral
which a technology can be considered symptoms provides a less invasive
Comment: Several commenters agreed
new. Therefore, as we proposed, we are treatment option for patients, and
with our proposal to terminate add-on
discontinuing add-on payments for the simpler implantation, followup, and
payment for INFUSE bone graft for
CRT–D for FY 2006. programming procedures for physicians.
spinal fusions.
Response: We are finalizing our Comment: One commenter thanked The FDA approved the device in
proposal to terminate new technology CMS for approving add-on payments for December 2003. Therefore, for FY 2006,
add-on payments for INFUSE bone the CRT–D. The commenter also Kinetra qualifies under the newness
graft for spinal fusions in this final rule. indicated that add-on payment for this criterion because FDA approval was
device had contributed significantly to within the statutory timeframe of 2 to 3
b. InSync Defibrillator System (Cardiac patient access and broader physician years and its costs are not yet reflected
Resynchronization Therapy with adoption of this new treatment. Another in the DRG weights. Because there were
Defibrillation (CRT–D)) commenter requested that CMS no data available to evaluate costs
Cardiac Resynchronization Therapy continue to make add-on payment for associated with Kinetra, in the FY
(CRT), also known as bi-ventricular CRT–D to avoid financial problems that 2005 IPPS final rule, we conducted the
pacing, is a therapy for chronic heart hospitals will experience if payment is cost analysis using SoletraTM, the
failure. A CRT implantable system ceased. predecessor technology used to treat
provides electrical stimulation to the Response: We appreciate the this condition, as a proxy for Kinetra.
right atrium, right ventricle, and left commenter’s support of our decision to The preexisting technology provided the
ventricle to coordinate or resynchronize approve add-on payments for CRT–D. closest means to track cases that have
ventricular contractions and improve Consistent with section 1886(d)(5)(K)(ii) actually used similar technology and
cardiac output. of the Act, the regulations do not permit served to identify the need and use of
In the FY 2005 IPPS final rule (69 FR us to extend payment for CRT–D beyond the new device. The manufacturer
49016), we determined that cardiac the 2–3 year period during which a informed us that the cost of the Kinetra
resynchronization therapy with technology can be considered new. device is twice the price of a single
defibrillator (CRT–D) was eligible for Therefore, we are finalizing our SoletraTM device. Because most patients
add-on payments in FY 2005. Cases proposal to discontinue add on would receive two SoletraTM devices if
involving CRT–D that are eligible for payments for the CRT–D in FY 2006. the Kinetra device is not implanted,
we believed data regarding the cost of physician visits and less surgical trauma cases are identified by the presence of
SoletraTM would give a good measure of because only one generator implantation procedure codes 02.93 (Implantation or
the actual costs that would be incurred. procedure is required. Kinetra has a replacement of intracranial
Medtronic submitted data for 104 cases reed switch disabling function that neurostimulator leads) and 86.95
that involved the SoletraTM device (26 physicians can use to prevent (Insertion or replacement of dual array
cases in DRG 1 (Craniotomy Age > 17 inadvertent shutoff of the device, as neurostimulator pulse generator). If a
With CC), and 78 cases in DRG 2 occurs when accidentally tripped by claim has only the procedure code
(Craniotomy Age > 17 Without CC)). electromagnetic inference (caused by identifying the implantation of the
These cases were identified from the FY common products such as metal intracranial leads, or if the claim
2002 MedPAR file using procedure detectors and garage door openers). identifies only insertion of the
codes 02.93 (Implantation, intracranial Kinetra also provides significant generator, no add-on payment will be
neurostimulator) and 86.09 (Other patient control, allowing patients to made.
incision of skin and subcutaneous monitor whether the device is on or off, This technology received FDA
tissue). In the analysis presented by the to monitor battery life, and to fine-tune approval on December 16, 2003, and
applicant, the mean standardized the stimulation therapy within remains within the 2 to 3 year period
charges for cases involving SoletraTM in clinician-programmed parameters. during which it can be considered new.
DRGs 1 and 2 were $69,018 and While Kinetra provides the ability for Therefore, as we proposed, we are
$44,779, respectively. The mean patients to better control their continuing add-on payments for
standardized charge for these SoletraTM symptoms and reduce the complications Kinetra Implantable Neurostimulator
cases according to Medtronic’s data was associated with the existing technology, for deep brain stimulation for FY 2006.
$50,839. it does not eliminate the necessity for
Last year, we used the same two surgeries. Because the patients who Comment: Several commenters
procedure codes to identify 187 cases receive the device are often frail, the supported our decision to continue add-
involving the SoletraTM device in DRGs implantation generally occurs in two on payments for Kinetra Implantable
1 and 2 in the FY 2003 MedPAR file. phases: The brain leads are implanted in Neurostimulator for deep brain
Similar to the Medtronic data, 53 of the one surgery, and the generator is stimulation for FY 2006.
cases were found in DRG 1, and 134 implanted in another surgery, typically Response: In this final rule, we are
cases were found in DRG 2. The average on another day. However, implanting finalizing our proposal to continue add-
standardized charges for these cases in Kinetra does reduce the number of on payments for the Kinetra
DRGs 1 and 2 were $51,163 and potential surgeries compared to its Implantable Neurostimulator for deep
$44,874, respectively. Therefore, the predecessor (which requires two brain stimulation for FY 2006.
case-weighted average standardized surgeries to implant the two single-lead 4. FY 2006 Applications for New
charges for cases that included arrays to the brain and an additional Technology Add-On
implantation of the SoletraTM device surgery for implantation of the second
were $46,656. The new cost thresholds generator). Therefore, the Kinetra a. INFUSE Bone Graft (Bone
established under the revised criteria in device reduces the number of surgeries Morphogenetic Proteins (BMPs) for
Pub. L. 108–173 for DRGs 1 and 2 are from 3 to 2. Tibia Fractures)
$43,245 and $30,129, respectively. Last year, we solicited comments on
Bone Morphogenetic Proteins (BMPs)
Accordingly, the case-weighted (1) the issue of whether the device is
have been shown to have the capacity
threshold to qualify for new technology sufficiently different from the
to induce new bone formation and,
add-on payment, using the data we previously used technology to qualify as
therefore, to enhance the healing of
identified, was determined to be a substantially improved treatment for
fractures. Using recombinant
$33,846. Under this analysis, Kinetra the same patient symptoms; (2) the cost
techniques, some BMPs (also referred to
met the cost threshold. of the device; and (3) the approval of the
We note that an ICD–9–CM code was as rhBMPs) can be produced in large
device for add-on payment, given the
approved for dual array pulse generator quantities. This innovation has cleared
uncertainty over the frequency with
devices, effective October 1, 2004, for the way for the potential use of BMPs
which the patients receiving the device
IPPS tracking purposes. The new ICD– have the generator implanted in a in a variety of clinical applications such
9–CM code assigned to this device is second hospital stay, and the frequency as in delayed union and nonunion of
86.95 (Insertion or replacement of dual with which this implantation occurs in fractured bones and spinal fusions. One
array neurostimulator pulse generator), an outpatient setting. In response, we such product, rhBMP-2, is developed as
which includes dual array and dual received sufficient evidence to an alternative to bone graft with spinal
channel generators for intracranial, demonstrate that Kinetra does fusions.
spinal, and peripheral neurostimulators. represent a substantial clinical Medtronic Sofamor Danek
The code does not separately identify improvement over the previous (Medtronic) resubmitted an application
cases with the Kinetra device and is SoletraTM device. Specifically, the (previously submitted for consideration
only used to distinguish single versus increased patient control, reduced for FY 2005) for a new technology add-
dual channel-pulse generator devices. surgery, fewer complications, and on payment in FY 2006 for the use of
Because the code only became effective elimination of environmental INFUSE Bone Graft in open tibia
on October 1, 2004, we do not have any interference significantly improve fractures. In cases of open tibia
specific data regarding the costs of cases patient outcomes. Therefore, we fractures, INFUSE is applied using an
involving dual array pulse generator approved Kinetra for new technology absorbable collagen sponge, which is
devices. add-on payments for FY 2005. then applied to the fractured bone to
The manufacturer claimed that Cases receiving Kinetra for promote new bone formation and
Kinetra provides a range of substantial Parkinson’s disease or essential tremor improved healing. The manufacturer
improvements beyond previously on or after October 1, 2004, are eligible contends that patient access to this
available technology. These include a to receive an add-on payment of up to technology is restricted due to the
reduced rate of device-related $8,285, or half the cost of the device, increased costs of treating these cases
complications and hospitalizations or which is approximately $16,570. These with INFUSE. The FDA approved use
of INFUSE for open tibia fractures on similar product on the market that was efficacy, while the OP–1 product has
April 30, 2004. being used in long bone fractures and to merely demonstrated that it is safe to
Medtronic’s first application for a new explain why this product should not use in humans. Medtronic pointed to
technology add-on payment for affect our consideration of the the labeled indications and package
INFUSE Bone Graft in open tibia application for new technology add-on inserts provided with the two products,
fractures was denied. As we discussed payments for INFUSE. We based our stating that only INFUSE provides a
in the FY 2005 IPPS final rule (69 FR decision for FY 2005 on the record that substantial clinical improvement to
49010), the FY 2005 application for was placed at our disposal by the patients receiving a BMP product.
INFUSE for open tibia fractures was applicant and by commenters during the We do not believe that the different
denied because a similar product, OP– comment period. Nevertheless, we have types of FDA approvals for the two
1, was approved in 2001 for the considered the issues raised by these products are relevant to distinguish
treatment of nonunion of tibia fractures. two products again in the course of between the two products in
Comment: In comments presented at evaluating Medtronic’s new application determining whether either product
the February 2005 new technology town for approval of INFUSE for open tibia should be considered for new
hall meeting, Medtronic contended that fractures for new technology add-on technology add-on payments under the
there was no opportunity for public payments in FY 2006. IPPS. Manufacturers seek different types
comment on our decision that INFUSE As part of its FY 2006 application, of FDA approval for many different
for open tibia fractures was substantially Medtronic advanced several arguments reasons, including timing, the
similar to OP–1 Implant for recalcitrant designed to demonstrate that OP–1 and availability of adequate studies, the
long bone non-unions. Medtronic stated INFUSE are substantially different. availability of resources to pursue
that ‘‘the public had no opportunity to The application cites data from several research studies, and the size of the
comment on whether the follow-on studies as evidence of the clinical patient population that may be affected.
products were ‘substantially similar’ to superiority of INFUSE over OP–1. The FDA has stated that the HDE
the primary technologies under Medtronic presented studies at the approval process was established to
consideration. The absence of such February 2005 new technology town address cases involving devices used in
provisions led to unpredictability and hall meeting to provide evidence that the treatment or diagnosis of diseases
confusion about the new-technology INFUSE is superior to OP–1 in the affecting fewer than 4,000 individuals in
add-on program.’’ time it takes for critical-sized defects to the United States per year: ‘‘A device
Response: In the FY 2005 IPPS final heal: in radiographic assessment and manufacturer’s research and
rule, we noted that a commenter mechanical testing of the repaired bone; development costs could exceed its
brought the existence of the Stryker and in histology of the union for trial market returns for diseases or
Biotech OP–1 product to our attention subjects receiving INFUSE compared conditions affecting small patient
during the comment period on the IPPS with OP–1. (Study subjects were populations. FDA, therefore, developed
proposed rule for FY 2005. The canines whose ulnas had 2.5 cm each of and published [the regulation
commenter noted OP–1’s clinical bone removed and then equal amounts establishing the HDE process] to provide
similarity to INFUSE and contended of OP–1 and INFUSE were put into the an incentive for the development of
that the products should be treated the front legs in a head to head trial.) devices for use in the treatment or
same with respect to new technology Medtronic has also argued that these diagnosis of diseases affecting these
payments when the product is used for studies demonstrate that OP–1 has been populations.’’ (http://
tibia fractures. At that time, we shown to be less effective than using the www.accessdata.fda.gov/scripts/cdrh/
determined that, despite the differences patient’s own bone or the current cfdocs/cfHDE/HDEInformation.cfm) The
in indications under the respective FDA standard of care (nail fixation with soft fact that two products received different
approvals, the two products were in use tissue medical management). Medtronic types of approval does not demonstrate
for many of the same kinds of cases. argued that the INFUSE product is not either that they are substantially
Specifically, clinical studies on the only superior to OP–1 for patients with different for purposes of new technology
safety of OP–1 included patients with open tibia fractures, but also that it is add-on payments, or that one is new
complicated fractures of the tibia, and superior to any other treatment for these and the other is not. Nor do the different
those cases were similar to the cases serious injuries. types of FDA approval imply that one
described in the clinical trials for Medtronic also pointed out that the product could meet our substantial
INFUSE for open tibia fractures. In FDA approved OP–1 for Humanitarian clinical improvement criterion and the
addition, cases involving the use of OP– Device Exemption (HDE) status, other could not. Neither type of FDA
1 for long bone union and open tibia whereas INFUSE received a Pre-Market approval requires that products
fractures are assigned to the same DRGs Approval (PMA). To receive HDE establish substantial clinical
(DRGs 218 and 219 (Lower Extremity approval, a product only needs to meet improvement over existing technologies,
Procedures With and Without CC, a safety standard, while standards of as is required for approval of new
respectively)) as cases involving both safety and efficacy have to be met technology add-on payments.
INFUSE. Therefore, we denied new for a PMA approval. Medtronic argued Theoretically, a product that receives an
technology add-on payments for that, because the only point the FDA HDE approval could subsequently
INFUSE for open tibia fractures for FY manufacturer of OP–1 was able to prove meet our substantial clinical
2005 on the grounds that technology was that it did not harm those improvement criterion, while a product
using bone morphogenetic proteins to individuals that received it, the efficacy that receives an FDA PMA approval
treat severe long bone fractures of OP–1 not only has not been could fail to do so. We base our
(including open tibia fractures) and demonstrated for the general substantial clinical improvement
recalcitrant long bone fractures had population, but also more specifically, it determinations on the evidence
been in use for more than 3 years. has not been proven in the Medicare presented in the course of the
We note that Medtronic had ample population. Medtronic presented application process, and not on the type
opportunity, prior to the issuance of the arguments that INFUSE is a superior of FDA approval.
FY 2005 IPPS final rule, to bring to our product to OP–1 because the INFUSE For purposes of determining whether
attention the fact that there was a product has demonstrated safety and the use of rhBMPs for open tibia fracture
represents a new technology, the crucial • The technologies or services are have always based our decisions about
consideration is whether the costs of indicated for use in the same population new technology add-on payments on a
this technology are represented in the for the same condition. logical sequence of determinations,
weights of the relevant DRGs. Cases that • The technologies or services moving from the newness criterion to
involve treatment of non-healed and achieve the same level of substantial the cost criterion and finally to the
acute tibia fractures fall into the same improvement. substantial clinical improvement
DRGs. We have identified 10,047 cases Medtronic also argued that, according criterion. Specifically, we do not make
involving the use of rhBMPs in the FY to its proposed criteria, OP–1 would fail determinations about substantial
2004 MedPAR data file. This use on two of the three proposed tests for improvement unless a product has
includes the approved indications for substantial similarity: already been determined to be new and
INFUSE in spinal fusions (6,712 cases) • According to Medtronic, the OP–1 to meet the cost criterion. Therefore, we
and tibia DRGs (77 cases). However, we implant ‘‘arguably’’ uses the same or a are reluctant to import substantial
note that an additional 3,258 cases similar mechanism of action to achieve clinical improvement considerations
involving the off-label use of rhBMPs the therapeutic outcome. into the logically prior decision about
were found in 47 DRGs in the FY 2004 • OP–1 and INFUSE are indicated whether technologies are new.
MedPAR data. We also note that, in our for use in different populations and Furthermore, while we may sometimes
analysis of the FY 2003 MedPAR data, different conditions. According to need to make separate determinations
an additional 890 cases of off-label use Medtronic, INFUSE Bone Graft has an about whether similar products meet the
(identified by the presence of ICD–9– indication for acute, open tibia fractures
substantial clinical improvement
CM code 84.52) were found in 36 DRGs. only, used within 14 days, and is to be
criterion, we do not believe that it
Therefore, we note that the use of used with an intramedullary (IM) nail as
would be appropriate to make
rhBMPs, made by Medtronic or part of the primary procedure. There is
determinations about whether one
otherwise, has penetrated the cost data no limitation on the number of patients
product or another is clinically superior.
that were used to set the FY 2005 and that can receive the technology. OP–1
Implant is indicated only for recalcitrant Comment: In response to our request
FY 2006 DRG weights. Even if it were for comments on the issue of substantial
possible to differentiate between long-bone non-unions that have failed to
heal. The HDE approval also specifies similarity in the Federal Register
patients who would be eligible to announcement of the new technology
receive the OP–1 Implant for nonunions that use of OP–1 is limited to secondary
procedures (as would be expected with town hall meeting, Medtronic also
or the INFUSE bone graft for open tibia suggested revisions to the application
fractures, the patient populations both nonunions). The number of patients
able to receive the device is limited to process that are designed to assist in
fall into the same DRGs. In addition, as identifying substantially similar
we stated in last year’s final rule in 4,000 patients per year and there is
oversight from an Institutional Review products and provide the public with
connection with our decision to make opportunity for comment on specific
add-on payments for both products Board.
• Medtronic argues the products do instances in which substantial similarity
when used for spinal fusions, we have is an issue. The suggested proposed
determined that the costs associated not achieve the same level of substantial
improvement (as discussed above). revisions are:
with the two products are comparable • After receipt of all new applications
(69 FR 49009). Therefore, because BMP Response: We agree with Medtronic
that its first proposed criterion has some for a fiscal year, CMS should publish a
products have been used in treating
relevance in determining whether Federal Register notice specifically
both types of fractures included in the
products are substantially similar. In asking manufacturers to identify if they
same DRGs since 2001, we continue to
evaluating the application for new wish to receive consideration for
believe that the hospital charge data
technology add-on payments for products that may be substantially
used in developing the relative weights
INFUSE for open tibia fractures last similar to applications received. Such
of the relevant DRGs reflect the costs of
year, we made the determination that, notice would probably occur in January.
these products.
Prior to the publication of the FY while these products are not identical Responses would be required by a date
2006 IPPS proposed rule, we received chemically, the products do use the certain in advance of the new
the following public comments on the same mechanism of action to achieve technology town hall meeting, and
application for add-on payments for FY the therapeutic outcome. However, we would include justification of how the
2006. do not agree that the other two criteria products meet the ‘‘substantial
Comment: In our Federal Register recommended by Medtronic should be similarity’’ criteria.
announcement of the February 23, 2005 controlling considerations for this • The new technology town hall
new technology town hall meeting, held purpose. As we have discussed above, meeting should include a discussion of
on February 23, 2005, we solicited we believe that whether cases involving products identified by manufacturers as
comments on the issue of when different products are assigned to the ‘‘substantially similar’’ to other
products should be considered same DRGs is a more relevant approved products or pending
substantially similar. As a result, consideration than whether the applications.
Medtronic recommended several criteria products have the same specific • CMS should publish initial findings
for determining whether two or more indications. In addition, as we have about ‘‘substantial similarity’’ in the
products are substantially similar and already stated, we continue to believe proposed hospital inpatient rule, with
requested that we apply these criteria in that the hospital charge data used in opportunity for public comment.
determining whether OP–1 and developing the relative weights of the • CMS should publish ultimate
INFUSE are similar for new technology relevant DRGs reflect the costs of both findings in the inpatient final rule.
add-on payment purposes. The three of these products. Furthermore, we do Alternatively, Medtronic suggested
criteria recommended by Medtronic are: not necessarily agree that considerations that, if a manufacturer identifies a
• The technologies or services in about the degrees of clinical product that may be substantially
question use the same, or a similar, improvements offered by different similar to a technology with an
mechanism of action to achieve the products should enter into decisions approved add-on payment, the
therapeutic outcome. about whether products are new. We manufacturer may choose to submit an
application under the normal deadlines candidates to receive INFUSE. Based Response: We appreciate the
for the add-on payment program. on the data submitted by the applicant, commenters’ input on this technology.
Response: We appreciate Medtronic’s INFUSE would be used primarily in However, we continue to believe that
suggestions for evaluating similar two different DRGs: 218 and 219 (Lower INFUSE is not a new product because
technologies for new technology add-on Extremity and Humerus Procedures of its substantial similarity to OP–1.
payment. We have stated on several Except Hip, Foot, Femur Age > 17, With These products are both designed to
occasions that we wish to avoid creating and Without CC, respectively). The promote healing of broken bones even
situations in which similar products analysis performed by the applicant though they are FDA approved for
receive different treatment because only resulted in a case-weighted cost somewhat different indications.
one manufacturer has submitted an threshold of $24,461 for these DRGs. Furthermore, treatment of open tibia
application for new technology add-on The average case-weighted standardized fractures and non-unions of tibia
payments. As we discussed in the new charge for cases using INFUSE in these fractures will be paid using the same
technology final rule (66 FR 46915), an DRGs would be $39,537. Therefore, the DRGs. Because the OP–1 Implant
approval of a new technology for special applicant maintains that INFUSE for received FDA approval in 2001 and
payment should extend to all open tibia fractures meets the cost INFUSE is a similar product that will
technologies that are substantially criterion. be included in the same DRG, we do not
similar. Otherwise, our payment policy However, because the costs of believe that the product can be
would bestow an advantage to the first INFUSE and OP–1 are already considered new for the purposes of new
applicant to receive approval for a reflected in the relevant DRGs, these technology add-on payments. While the
particular new technology. products cannot be considered new. commenters argue that the MedPAR
In addition, we note that commenters Therefore, in the FY 2006 IPPS data do not include a sufficient number
on the FY 2005 proposed rule placed a proposed rule we proposed to deny new
great deal of emphasis on the fact that of cases for CMS to argue that payment
technology add-on payments for for BMP products are included in the
many manufacturers developing new INFUSE bone graft for open tibia
technologies are not aware of the DRG weights, we do not believe that
fractures for FY 2006. case volume is a relevant consideration
existence of the add-on payment
During the 60-day comment period on for making the determination as to
provision or lack the resources to apply
the FY 2006 IPPS proposed rule, we whether a product is new. Consistent
for add-on payment. Therefore,
commenters on that proposed rule received the following comments on with the statute, a technology no longer
argued that the regulations we have this application: qualifies as new once it is more than 2
established are already too stringent and Comment: Several commenters wrote to 3 years old irrespective of how
cumbersome, especially for small to support the application for INFUSE frequently it has been used in the
manufacturers to access the new bone graft for open tibia fractures for Medicare population. Thus, if a product
technology add-on payment process. new technology add-on payments. is more than 2 to 3 years old, we
The proposal by Medtronic would place These commenters disagreed with our consider its costs to be included in the
further burden on these small assertion that the costs for this DRG relative weights whether its use in
manufacturers, both to know that an technology are adequately reflected in the Medicare population has been
application has been made for a similar the DRG weights. The commenters frequent or infrequent. We also
product and to make representations on argued that the data include few claims recognize that, without financial
a product that may or may not be on the for OP–1 and do not justify denying incentive to code BMPs, it is possible
market. Therefore, we are reluctant to add-on payments to INFUSE. Further, that hospitals may not have included
adopt a process that places the formal commenters argued that the different procedure code 84.52 on hospital bills
burden on a competitor to seek equal types of FDA approval are relevant to for all instances when a BMP product
treatment. However, in the FY 2006 the discussion of newness and was used. Therefore, the incidence of
IPPS proposed rule, we solicited substantial clinical improvement of the actual use of BMPs for this period may
comments on the use of substantial BMP products. Commenters pointed to be higher than shown in the Medicare
similarity to determine whether the limited number of cases that would data. Nevertheless, even though
products qualify for new technology have been eligible to receive OP–1 due hospitals may not have coded all uses
add-on payments while we continued to to its limited FDA humanitarian device of procedure code 84.52, hospital bills
consider these issues. The comments we exemption (HDE) approval. Commenters would still include charges for all items
received in response to this request are noted that an HDE approval limits the and services furnished to a Medicare
addressed below in our discussion of number of patients that can receive the patient including use of a BMP product.
substantial similarity. product to 4,000 patients, and therefore Therefore, even though we may be not
We note that, in support of its the costs of the cases are not adequately be able to identify all uses of a BMP
application for add-on payments for FY reflected in the DRG weights. According product in the Medicare charge data,
2006, Medtronic submitted data on 236 to the commenters, CMS’ own analysis hospital charges for the DRG would
cases using INFUSE for open tibia supports this point because there were continue to reflect use of these products.
fractures in the FY 2003 MedPAR data only 77 cases in the FY 2004 MedPAR In addition, we note that open tibia
file, as identified by procedure code data, indicating that a patient received fractures are not common among the
79.36 (Reduction, fracture, open, a BMP product with no mention as to elderly population, and we would
internal fixation, tibia and fibula) and whether there were any cases in the therefore not expect to find a high
diagnosis codes of either 823.30 relevant DRGs for FY 2003. Therefore, incidence of these cases in the MedPAR
(Fracture of tibia alone, shaft, open) or commenters argued, the technology is data. Also, given the penetration that
823.32 (Fracture of fibula and tibia, not used frequently enough to be BMPs have made in DRGs 219 and 220,
shaft, open). Medtronic also noted that adequately reflected in the DRG in addition to many other DRGs, we
the patients in clinical trials with weights. In addition, commenters believe that the BMP technology is
malunion fractures (diagnosis code argued that OP–1 is only indicated for adequately reflected in our MedPAR
733.81) or nonunion fractures (diagnosis non-union fractures while INFUSE is data that were used to recalibrate the
code 733.82) would also be likely for open tibia fractures. DRG weights for FY 2006. Therefore, the
technology can no longer be considered Other commenters noted that CMS on payments to substantially similar
new for the purposes of new technology has no way to distinguish between products, they appear to disagree with
add-on payments. In this final rule, we manufacturers when similar products our application of the concept of
are finalizing our proposal to deny add- use the same ICD–9–CM codes. substantial similarity when we have
on payments for INFUSE bone graft for Therefore, the commenters argued, there denied add-on payments. (We note that
tibia fractures. is no need for competitors to apply for one commenter disagreed with both the
Comment: As discussed above, prior their own new technology add-on decision to extend new technology add-
to publication of the FY 2006 IPPS payment if a product has already been on payments to OP–1 for spinal fusions
proposed rule, we received a comment approved for add-on payments, despite and the decision to deny them to
offering suggestions for how to define the language contained in the new INFUSE for tibia fractures on the basis
when products are ‘‘substantially technology final rule stating that the of substantial similarity. Nevertheless,
similar.’’ We responded to this comment manufacturers of substantially similar this same commenter has also asked us
in the proposed rule (70 FR 23359), and products would be required to file a to use the concept of substantial
indicated that we welcomed further separate application for add-on payment similarity to extend new technology
comments on this issue. Several (66 FR 46915). add-on payments to the Talent
commenters raised concerns about CMS’ Response: With respect to the Endovascular Stent Graft.
responses to this comment. discussion of substantial similarity in This apparent policy contradiction is
One commenter indicated that CMS the new technology final rule, we did illustrated with the example of
‘‘is using the determination of indicate that a manufacturer of a INFUSE and OP–1. We extended new
‘substantial similarity’ as a basis to substantially similar product would technology add-on payments to OP–1
support a preliminary determination have to submit an application to be for spinal fusions without a separate
that these technologies are ‘not new’ awarded add-on payments. However, application because of its substantial
* * * when no such criter[ion] exists in we note that this statement was made similarity to INFUSE and without
the threshold criteria.’’ Another without any actual experience with the specifically finding that the product met
commenter indicated that the implementation of section 1886(d)(5)(K) all three criteria for add-on payments.
discussion of substantial similarity of the Act. After reviewing and We determined that OP–1 putty was
creates confusion between the issue of approving technologies for add-on substantially similar to another product
substantial similarity and the three add- payment for several years, we have that had been approved for new
on payment criteria. This commenter found that our original policy did not technology add-on payments. OP–1
indicated that the discussion of this adequately reflect the fact that putty was clearly new given the date it
issue in the proposed rule implies that substantially similar products will use was approved by the FDA and was
substantial similarity is a subfactor of the same ICD–9–CM codes and that it substantially similar to another new
the newness criterion, while prior rules would be impractical to create product that had been approved for new
have implied that it is a subfactor of the manufacturer-specific codes and also technology add-on payments. However,
substantial clinical improvement require each manufacturer to submit because the technology of using BMPs
criterion or a replacement for all three separate applications for products that for spinal fusions had already been
criteria. To support this point, the are essentially the same. Moreover, found to meet the newness, cost and
commenter stated that the new given that we cannot distinguish one substantial clinical improvement
technology final rule (66 FR 46915) manufacturer from another when criteria, we did not separately address
indicates that a substantially similar substantially similar technologies use these criteria. Rather, after determining
technology would still be required to the same ICD–9–CM code, there is no that the two products were substantially
submit data showing that the technology practical purpose for manufacturers of similar, we extended the approval of
was inadequately paid and meets the substantially similar products to apply add-on payments to OP–1. The
criterion for being new, thus implying separately for new technology add-on commenters appear to agree with this
that substantial similarity is a subfactor payments. Therefore, we have not decision and the concept of extending
of the substantial clinical improvement required that an application for add-on new technology add-on payments to
criterion. The commenter referenced the payments be submitted for a substantially similar products so that
discussion in the FY 2005 IPPS final substantially similar product that uses our payment policy does not bestow an
rule (69 FR 49008–49009) indicating the same ICD–9–CM code as a product advantage to the first applicant
that new technology add-on payments that has previously been approved for representing a particular new
would be extended to OP–1 putty add-on payments. In addition, we have technology to receive approval.
without the submission of an made an effort to identify competitors However, the commenters appear to
application for add-on payments as that might be eligible to receive new disagree with our denial of new
evidence that substantial similarity has technology add-on payments for their technology add-on payments to
replaced all three criteria. Commenters devices. In fact, we note that we have INFUSE for tibia fractures on the basis
further expressed concern over the discussed several such technologies in of its substantial similarity to OP–1.
detrimental effects that this standard this year’s and previous years’ rules and Because OP–1 Implant for recalcitrant
could have, denying patient access to have allowed for add-on payments for long bone unions had been in use for 3
therapies ‘‘merely because the therapy particular, new classes of technologies years and the costs for this technology
has the same mechanism of action as an that fall within the same ICD–9–CM had been included in the weights for the
existing treatment.’’ These commenters code (for example, CRT–D). DRGs where cases involving INFUSE
recommended that CMS eliminate We believe that these commenters for tibia fractures are assigned, in the
substantial similarity from our new raise interesting and complex policy final rule for FY 2005, we determined
technology add-on payment issues regarding the application of the that INFUSE could not longer be
deliberations, and grant add-on new technology add-on payment policy considered ‘‘new.’’ (69 FR 49012).
payments based solely on whether a to products that are substantially We believe that the concept of
product satisfies the newness, cost, and similar. While the commenters generally substantial similarity needs to be
substantial clinical improvement appear to agree with our policy when applied consistently both in the context
criteria specified in the regulations. we have extended new technology add- of extending and denying new
technology add-on payments. Thus, we improvement criteria. As we have criterion without a new technology
believe it is important to clarify whether indicated in the past, we believe that application and specific review in order
a finding of substantial similarity among continuing our current practice is the to determine whether the two products
products constitutes only a decision better policy because we avoid: achieve the same level of substantial
about the newness criterion or about all • Creating manufacturer-specific clinical improvement. Applying
three criteria. One commenter indicated codes for substantially similar products. Medtronic’s criteria, we do not believe
that our decision to extend new • Requiring different manufacturers that new technology add-on payments
technology add-on payments to OP–1 of substantially similar products from could be extended to a substantially
for spinal fusions because of its having to submit separate new similar product in the middle of a fiscal
similarity to INFUSE implies that our technology applications. year. Thus, for example, add-on
determination on substantial similarity • Having to compare the merits of payments for Medtronic’s Talent
replaced consideration of the three competing technologies on the basis of Endovascular Stent Graft, which has not
criteria. This commenter and others substantial clinical improvement. yet received FDA approval, could not
believed, however, that our • Bestowing an advantage to the first begin until at least FY 2007. Further, in
determination on substantial similarity applicant representing a particular new the absence of a finding that the
between OP–1 and INFUSE for tibia technology to receive approval. products achieve the same level of
fractures implies that we are applying The commenters also argued that the
substantial clinical improvement, we
the concept as a subfactor of newness. concept of substantial similarity is being
would need to establish a specific code
In both cases, we only made a applied without having been defined in
for the GORE TAG device that other
determination about the similarity of the the regulations. We do not believe that
manufacturers of similar products could
products and did not specifically make it would be appropriate at this time to
adopt rigid criteria to define substantial not use unless they also made a new
a finding as to whether all three criteria technology application and we made a
for add-on payments were met. When similarity. Such criteria would restrict
unduly our ability to make appropriate finding on the three criteria for
we denied new technology add-on determining substantial similarity
payments to INFUSE for open tibia determinations regarding whether a
product should qualify for new suggested by Medtronic. Thus, in this
fractures, we effectively made a logical circumstance, application of
prior determination about newness technology add-on payments. For
example, if we were to use the Medtronic’s suggested criteria for
based on our finding of substantial defining substantial similarity would
similarity and, as a result, we did not Medtronic definition of substantial
similarity described above, each bestow an advantage to GORE TAG until
need to evaluate either the cost or we could make a specific finding on the
substantial clinical improvement manufacturer of a competing technology
would have to submit a separate Talent Endovascular Stent Graft.
criteria. Similarly, when we extended
new technology add-on payments to application for an add-on payment and, In the proposed rule, we indicated
OP–1 for spinal fusions on the grounds potentially, we would have to create that whether a product uses the same or
that it is substantially similar to separate codes for each manufacturer’s a similar mechanism of action to
INFUSE, we effectively indicated that product if we found that one product achieve the therapeutic outcome has
both products were new but did not met all of the criteria for an add-on some relevance for determining
make a specific finding about cost and payment while the other did not. For substantial similarity. We also indicated
substantial clinical improvement with instance, Medtronic supported the that the whether the products are
respect to OP–1. Rather, we extended application of W. L. Gore & Associates, assigned to the same or a different DRG
the existing approval of add-on Inc. for its Endovascular Graft Repair of is also relevant for determining
payments for the new technology of the Thoracic Aorta (GORE TAG). If this substantial similarity and assessing if
using BMPs in spinal fusions to a device were to be approved for new the hospital charge data used in
substantially similar product in order to technology add-on payments, Medtronic developing the relative weights of the
avoid bestowing an advantage to the recommended that we extend these relevant DRGs reflects the costs of these
first product to receive an approval of payments to its Talent Endovascular products. In making a determination of
add-on payments for this particular new Stent Graft once it is approved by the substantial similarity, we believe both of
technology. FDA. As indicated below, we are these criteria should be met. If only one
We see two policy options to address approving for the GORE TAG device for of the criteria is met, we do not believe
this issue. Under the first option, we new technology add-on payments. If we the products should be considered
continue our current practice. That is, if were to use Medtronic’s criteria for substantially similar and new
we make a finding of substantial defining substantial similarity, for us to technology add-on payments should not
similarity among two products, we will extend new technology add-on be extended or denied on this basis. In
extend new technology add-on payment payments to its device for an the case of OP–1 and INFUSE, both are
without a further application from the endovascular thoracic aortic aneurysm bone morphogenetic products that are
manufacturer of the competing product repair, we would have to make a used to induce bone growth (‘‘use the
or a specific finding on cost and clinical determination that the products: (1) Use same or similar mechanism of action to
improvement. Also, we will deny new the same or a similar mechanism of achieve the therapeutic outcome’’)
technology add-on payments to action to achieve the therapeutic assigned to the same DRGs (DRGs 497
substantially similar products if one of outcome; (2) are indicated for use in the and 498 for spinal fusions and DRGs
the products no longer qualifies as a same population for the same condition; 218 and 219 for tibia fractures).
new medical technology without a and (3) achieve the same level of Furthermore, both of these products can
specific finding on the remaining two substantial clinical improvement. While be described by the same ICD–9–CM
criteria. Under the second option, we it may be possible to make a code (code 84.52, Insertion of
would depart from our current practice determination on the first of these two recombinant bone morphogenetic
and only extend new technology add-on criteria based on a description of the protein). Thus, our decisions to extend
payment to an applicant’s product after products and their FDA approved new technology add-on payments to
making a determination that it meets the indications, we believe it would not be OP–1 for spinal fusions and deny them
newness, cost, and substantial clinical possible to make a decision on the third to INFUSE for tibia fractures on the
basis of substantial similarity, applied, data and evidence demonstrating that payments for FY 2006. The applicant
the two above described criteria the System 100 was not marketed until used a combination of diagnosis codes
consistently. August 2002. to determine which cases could
We believe the above discussion We note the applicant submitted an potentially use the System 100. The
indicates that these are complex issues. application for FY 2005 and was denied applicant found 28,155 cases with the
While the application of the above two new technology add-on payments. Our following combination of ICD–9–CM
criteria worked well in the context of review indicated that the applicant did diagnosis codes: 428.0 through 428.9
OP–1 and INFUSE (as well as the not present sufficient objective clinical (Heart Failure), 402.91 (Unspecified
GORE TAG and Talent Endovascular evidence to determine that the System with Heart Failure), or 402.11
Stent Graft), it is possible that we 100 meets the substantial clinical (Hypertensive Heart Disease with Heart
should have the flexibility to consider improvement criterion (such as a large Failure), in combination with 276.6
these or other factors in some contexts prospective, randomized clinical trial) (Fluid Overload) and 782.3 (Edema).
but not in others. For these reasons, we even though it is indicated for use in The 28,155 cases were found among 148
will continue to analyze the question of patients with congestive heart failure, a DRGs with 50.1 percent of cases
substantial similarity, and welcome common condition in the Medicare mapped across DRGs 88, 89, 127, 277
further public input on this issue. population. However, for FY 2006, we and 316. The applicant eliminated those
In this final rule, we are finalizing our proposed to deny System 100 new DRGs with less than 150 cases, which
proposal to deny add-on payments for technology add-on payments on the resulted in a total of 22,620 cases that
INFUSE bone graft for open tibia basis of our determination that it is no could potentially use the System 100.
fractures for the reasons discussed longer new. Technology is no longer The case-weighted average standardized
above. b. AquadexTM System 100 Fluid considered new 2 to 3 years after data charge across all DRGs was $13,619.32.
Removal System (System 100) reflecting its costs begin to become The case-weighted threshold across all
CHF Solutions, Inc. resubmitted an available. Because data on the costs of DRGs was $16,125.42. Although the
application (previously submitted for the System 100 first became available in case-weighted threshold is greater than
consideration for FY 2005) for the 2002, the costs are currently reflected in the case-weighted standardized charge,
approval of the System 100 for new the DRG weights and the device is no it is necessary to include the
technology add-on payments for FY longer new. standardized charge for the circuits used
2006. The System 100 is designed to The applicant also submitted in each case. In order to establish the
remove excess fluid (primarily excess information for the cost and substantial charge per circuit, the applicant
water) from patients suffering from clinical improvement criteria. As stated submitted data regarding 76 actual cases
severe fluid overload through the last year, it is important to note at the that used the System 100. Based on
process of ultrafiltration. Fluid outset of the cost analysis that the these 76 cases, the standardized charge
retention, sometimes to an extreme console is reusable and is, therefore, a per circuit was $2,591. The applicant
degree, is a common problem for capital cost. Only the circuits and also stated that an average of two
patients with chronic congestive heart catheters are components that represent circuits is used per case. Therefore,
failure. This technology removes excess operating expenses. Section adding $5,182 for the charge of the two
fluid without causing hemodynamic 1886(d)(5)(K)(i) of the Act requires that circuits to the case-weighted average
instability. It also avoids the inherent the Secretary establish a mechanism to standardized charge of $13,619.32
nephrotoxicity and tachyphylaxis recognize the costs of new medical results in a total case-weighted
associated with aggressive diuretic services or technologies under the standardized charge of $18,801.32. This
therapy, the mainstay of current therapy payment system established under amount is greater than the case-weighed
for fluid overload in congestive heart subsection (d) of section 1886, which threshold of $16,125.42.
failure. establishes the system for paying for the The applicant contended that the
The System 100 consists of: (1) An S– operating costs of inpatient hospital System 100 represents a substantial
100 console; (2) a UF 500 blood circuit; services. The system of payment for clinical improvement for the following
(3) an extended length catheter (ELC); capital costs is established under reasons: It removes excess fluid without
and (4) a catheter extension tubing. The section 1886(g) of the Act, which makes the use of diuretics; it does not lead to
System 100 is designed to monitor the no mention of any add-on payments for electrolyte imbalance, hemodynamic
extracorporeal blood circuit and to alert a new medical service or technology. instability or worsening renal function;
the user to abnormal conditions. Therefore, it is not appropriate to it can restore diuretic responsiveness; it
Vascular access is established via the include capital costs in the add-on does not adversely affect the renin-
peripheral venous system, and up to 4 payments for a new medical service or angiotensin system; it reduces hospital
liters of excess fluid can be removed in technology and these costs should also length of stay for the treatment of
an 8-hour period. not be considered in evaluating whether congestive heart failure, and it requires
On June 3, 2002, FDA approved the a technology meets the cost criterion. only peripheral venous access. The
System 100 for use with peripheral The applicant has applied for add-on applicant also noted that there are some
venous access. On November 20, 2003, payments for only the circuits and clinical trials that have demonstrated
FDA approved the System 100 for catheter, which represent the operating the clinical safety and effectiveness as
expanded use with central venous expenses of the device. However, as well as cost effectiveness of the System
access and catheter extension use for stated in the FY 2005 IPPS final rule, we 100 in treating patients with fluid
infusion or withdrawal circuit line with believe that the catheters cannot be overload.
other commercially applicable venous considered new technology for this However, as stated above, we
catheters. According to the applicant, device. As a result, we considered only proposed to deny new technology add-
although the FDA first approved System the UF 500 disposable blood circuit as on payments for the System 100 because
100 in June 2002, it was not used by relevant to the evaluation of the cost it does not meet the newness criterion
hospitals until August 2002 because of criterion. We received no public comments
the substantial amount of time The applicant submitted data from the regarding this application for add-on
necessary to market and sell the device FY 2003 MedPAR file in support of its payments prior to publication of the FY
to hospitals. The applicant presented application for new technology add-on 2006 IPPS proposed rule. During the 60-
day comment period for the FY 2006 cases, the average standardized charge charges by 15 percent in order to update
IPPS proposed rule, we also received no was $40,722. The applicant maintained the data to FY 2005 charge levels. This
comments. Therefore, we are finalizing that this figure is well in excess of the computation resulted in a case-weighted
our proposal to deny new technology thresholds for DRGs 499 and 500 average standardized charge of $46,256.
add-on payments for the System 100 (regardless of a case weighted threshold) Although the analysis was completed
because it does not meet the newness of $24,828 and $17,299 respectively. with DRGs 497 and 498, it is necessary
criterion. Based on this analysis, the applicant to compare the average standardized
maintained that the CHARITÉTM meets charge to the thresholds of DRGs 499
c. CHARITÉTM Artificial Disc
the cost criterion because the average and 500 where these cases are grouped.
(CHARITÉTM)
standardized charge exceeds the charge As a result, the case-weighted threshold
DePuy SpineTM submitted an thresholds for DRGs 499 and 500. was $21,480. Similar to the analysis
application for new technology add-on above, the applicant stated that the case-
In addition, as stated above, the
payments for the CHARITÉTM Artificial weighted average standardized charge is
applicant submitted cases from the FY
Disc for FY 2006. This device is a greater than the case-weighted threshold
2003 MedPAR file. The applicant
prosthetic intervertebral disc. DePuy and, as a result, the applicant
searched the MedPAR file for ICD–9–
SpineTM stated that the CHARITÉTM maintained that the CHARITÉTM meets
CM procedure codes 81.06, 81.07, and
Artificial Disc is the first artificial disc the cost criterion.
81.08 in combination with diagnosis
approved for use in the United States. Comment: The applicant
codes 722.10, 722.2, 722.5, 722.52,
It is a 3-piece articulating medical commissioned two independent
device consisting of a sliding core that 722.6, 722.7, 722.73 and 756.12, to
consultants to conduct separate data
is placed between two metal endplates. identify a patient population that could
analyses demonstrating with actual
The sliding core is made from a medical be eligible for the CHARITÉTM Artificial
cases of CHARITÉTM that the device
grade plastic and the endplates are Disc and found a total of 12,680 cases.
meets the cost criterion. The consultants
made from medical grade cobalt However, these cases are from the FY
found 308 cases using CHARITÉTM
chromium alloy. The endplates support 2003 MedPAR file and precede the
including 9 Medicare cases. One
the core and have small teeth that are effective date of ICD–9–CM code 84.65
consultant found 94 cases with average
secured to the vertebrae above and that is currently used to track the
standardized charges of $43,065, and
below the disc space. The sliding core device. Of these 12,680 cases, 55.5
the other consultant found 214 cases
fits in between the endplates. percent were reported in DRG 497, and
with average standardized charges of
On October 26, 2004, the FDA 44.5 percent were reported in DRG 498. $45,791. As in the proposed rule, the
approved the CHARITÉTM Artificial As noted above, cases using the commenter noted that the average
Disc for single level spinal arthroplasty CHARITÉTM device group to the DRGs standardized charges per case are well
in skeletally mature patients with for back and neck procedures that in excess of the threshold for DRG 499.
degenerative disc disease (DDD) exclude spinal fusions (DRGs 499 and Response: We appreciate the
between L4 and S1. The FDA further 500). However, the applicant argues that commenter’s submission of additional
stated that DDD is defined as discogenic the CHARITÉTM could be a substitute data in support of its application. Based
back pain with degeneration of the disc for spinal fusion procedures found in on these data, it appears that the
confirmed by patient history and DRGs 497 and 498 and, therefore, used technology meets the cost criterion.
radiographic studies. These DDD cases from these DRGs to evaluate The applicant also contended that the
patients should have no more than 3 whether the CHARITÉTM meets the cost CHARITÉTM represents a substantial
mm of spondylolisthesis at an involved criterion and to argue that procedures clinical improvement over existing
level. Patients receiving the CHARITÉTM using the technology should be grouped technology. Use of the CHARITÉTM may
Artificial Disc should have failed at to the spinal fusion DRGs. The average eliminate the need for spinal fusion and
least 6 months of conservative treatment standardized charge per case was the use of autogenous bone, and the
prior to implantation of the CHARITÉTM $50,098 for DRG 497 and $41,290 for applicant stated that, based on the
Artificial Disc. Because the device is DRG 498. Using revenue codes 272 and Investigational Device Exemption (IDE)
within the statutory timeframe of 2 to 3 278 from the MedPAR file, the applicant study, ‘‘A Prospective Randomized
years and data is not yet reflected then subtracted the charges for surgical Multicenter Comparison of Artificial
within the DRGs, we consider the and medical supplies used in Disc vs. Fusion for Single Level Lumbar
CHARITÉTM Artificial Disc to meet the connection with spinal fusion Degenerative Disc Disease’’
newness criterion. procedures, which resulted in a (Blumenthal, S, et al, National American
We note that an ICD–9–CM code was standardized charge of all other charges Spine Society 2004 Abstract) that
effective October 1, 2004, for IPPS of $24,333 for DRG 497 and $22,183 for patients who received the CHARITÉTM
tracking purposes. The code assigned to DRG 498. Based on the actual cases Artificial Disc were discharged from the
the CHARITÉTM was 84.65 (Insertion of above, the applicant then estimated the hospital after an average of 3.7 days
total spinal disc prosthesis, average standardized charge for surgical compared to 4.2 days in the fusion
lumbosacral). and medical supplies per case for the group. Furthermore, the applicant stated
For analysis of the cost criterion, the CHARITÉTM was $20,033. The applicant that patients who received the
applicant submitted two sets of data: estimated that charges have grown by 15 CHARITÉTM Artificial Disc had a
one that used actual cases and one that percent from FY 2003 to FY 2005 and, statistically greater improvement in
used FY 2003 MedPAR cases. The cases therefore, deflated the average Oswetry Disability Index scores and
using CHARITÉTM map to DRGs 499 and standardized charge for surgical and Visual Analog Scale Pain scores
500. The applicant submitted 68 actual medical supplies of the CHARITÉTM by compared to the fusion group at 6 weeks
cases from 35 hospitals that used the 15 percent to $17,420. The applicant and 3, 6 and 12 months. The study also
CHARITÉTM. Of these 68 cases, only 3 then added the average standardized showed greater improvement from
were Medicare patients; the remaining charge for surgical and medical supplies baseline compared to the fusion group
cases were privately insured patients or of the CHARITÉTM to the standardized on the Physical Component Score at 3,
patients for whom the payer was charge of the remaining charges for DRG 6, and 23 months. In addition, the
unknown. Using data from the 68 actual 497 and 498 and also inflated the applicant states that patients receiving
the CHARITÉTM Artificial Disc returned We finally noted that the applicant • The CHARITÉTM provided
to normal activities in half the time, requested a DRG reassignment for cases maintenance of post operative disc
compared to patients who underwent of the CHARITÉTM Artificial Disc from height through 24 months compared to
fusion, and at the 2 year follow up, 15 DRGs 499 (Back and Neck Procedures anterior interbody fusion; disc space
percent of patients who underwent a Except Spinal Fusion With CC) and 500 height was maintained in greater than
fusion were dissatisfied with the (Back and Neck Procedures Except 99 percent of CHARITÉTM subjects
postoperative improvements compared Spinal Fusion Without CC) to DRGs 497 through 24 month followup.
to 2 percent who received the (Spinal Fusion Except Cervical With • The CHARITÉTM has the potential
CHARITÉTM Artificial Disc. Also, CC) and 498 (Spinal Fusion Except to reduce second surgical procedures for
patients who received the CHARITÉTM Cervical Without CC). The applicant adjacent disc disease by maintaining
Artificial Disc returned to work on argued that the costs associated with an motion (the manufacturer intends to
average of 12.3 weeks after surgery artificial disc surgery are similar to investigate this).
compared to 16.3 weeks after spinal fusion and inclusion in DRGs 497 • The CHARITÉTM provides early
circumferential fusion and 14.4 weeks and 498 would obviate the need to make improvement in pain and function as
with Bagby and Kuslich cages. The a new technology add-on payment. On measured by the Oswestry Disability
applicant finally stated that the motion October 1, 2004, we created new codes Index compared to anterior interbody
preserving technology of the for the insertion of spinal disc fusion at 6 weeks, 3 months, 6 months,
CHARITÉTM Artificial Disc may reduce prostheses (codes 84.60 through 84.69). and 12 months.
the risk of increase of degenerative disc In the FY 2005 IPPS proposed rule and • The CHARITÉTM provides
disease (DDD). The applicant explained the final rule, we described the new improvement in pain reduction as
that degeneration of adjacent discs due DRG assignments for these new codes in measured by the Visual Analog Scale
to increased stress has been strongly Table 6B of the Addendum to the rules. compared to anterior interbody fusion at
associated with spinal fusion utilizing We received a number of comments 6 weeks, 3 months, 6 months, and 12
instrumentation. In a follow up of 100 recommending that we change the DRG months.
patients (minimum 10 years) who • The CHARITÉTM provides
assignments from DRGs 499 and 500 in
received the CHARITÉTM Artificial Disc, improvement in quality of life on the
MDC 8 to the DRGs for spinal fusion
the incidence of adjacent level DDD was physical component score of the SF–36
(DRGs 497 and 498). In the FY 2005
2 percent. outcomes tool at 3 months, 6 months,
IPPS final rule (69 FR 48938), we and 24 months.
In the FY 2006 IPPS proposed rule, indicated that DRGs 497 and 498 are
we indicated that we were continuing to CMS requested comments on whether
limited to spinal fusion procedures. or not the results from the IDE study can
review the information on whether the Because the surgery involving the
CHARITÉTM Artificial Disc would be generalized to the Medicare
CHARITÉTM is not a spinal fusion, we population. The commenter
appear to represent a substantial clinical decided not to include this procedure in
improvement over existing technology commissioned a consultant to conduct a
these DRGs. However, in the FY 2006 survey to capture clinical information
for certain patient populations. Based IPPS proposed rule, we indicated that
on the studies submitted to the FDA and for the Medicare population 65 years or
we would continue to analyze this issue older and the Medicare population that
CMS, we remain concerned that the and solicited public comments on both
information presented may not had been implanted with the
the new technology application for the CHARITÉTM, noting that the under 65
definitively substantiate whether the CHARITÉTM and the DRG assignment
CHARITÉTM Artificial Disc is a Medicare disabled population
for spinal disc prostheses. represents 14 percent of all Medicare
substantial clinical improvement over
We received no public comments beneficiaries or approximately 5 million
spinal fusion. In addition, we are
regarding this application for new people. The consultant found data for
concerned that the cited IDE study
technology add-on payments prior to 18 Medicare beneficiaries and submitted
enrolled no patients over 60 years of
the publication of the FY 2005 IPPS the following results: Surgeons reported
age, which excludes much of the
proposed rule. However, we received that 94.4 percent of the patients
Medicare population. We also are
the following comments during the 60- demonstrated improvement in overall
concerned about the prevalence of
day comment period on the proposed outcome, pain, and function after the
osteoporosis within the Medicare
rule. CHARITÉTM had been implanted.
population, because it is a
contraindication for this device. In the Comment: The applicant noted that Surgeons also noted the following: 100
FY 2006 IPPS proposed rule, we invited on July 15, 2005, two new articles were percent of the patients reported an
comment on both of these points and on published in the journal ‘‘Spine.’’ 3 The improved level of activity; 50 percent of
the more general question of whether applicant maintained that the studies the patients achieved full recovery, the
the device satisfies the substantial demonstrate the following conclusions: other 50 percent had an improved level
clinical improvement criterion. • The CHARITÉTM obviates the iliac of activity compared to their
Despite the issues mentioned above, crest bone graft donor site morbidity. preoperative status; and 100 percent of
we noted in the FY 2006 IPPS proposed • The CHARITÉTM preserves the surgeons recommended the
rule that we were still considering segmental motion in flexion/extension CHARITÉTM for other Medicare patients
whether it is appropriate to approve through 24 months post implantation. who meet the clinical indications. The
new technology add-on payment status commenter believed that the above
3 A. Blumenthal et al., ‘‘A Prospective,
for the CHARITÉTM Artificial Disc for studies and the IDE trial demonstrate
Randomized, Multi Center FDA IDE Study of
FY 2006. If approved for add-on Lumbar Total Disc Replacement with the
that CHARITÉTM offers a substantial
payments, hospitals would be CHARITÉTM Artificial Disc vs. Lumbar Fusion: Part clinical improvement over fusion for
reimbursed for up to half of the costs for I—Evaluation of Clinical Outcomes.’’ Medicare beneficiaries.
the device. Because the manufacturer B. McAfee et al., ‘‘A Prospective, Randomized, The commenter also stated that
has stated that the cost for the Multi Center FDA IDE Study of Lumbar Total Disc Medicare beneficiaries with disabilities
Replacement with the CHARITÉTM Artificial Disc
CHARITÉTM Artificial Disc would be vs. Lumbar Fusion: Part II—Evaluation of
make up 21.8 percent of all discharges
$11,500, the maximum add-on payment Radiographic Outcomes and Correlation of Surgical in DRGs 496, 497, and 498. It is likely
for the device would be $5,750. Technique Accuracy with Clinical Outcomes.’’ that a significant number of these
patients could benefit from the studies 4 5 6 demonstrated excellent or further suggested that the CHARITÉTM
CHARITÉTM. In response to CMS’ good results, but did not explicitly should be considered experimental until
concern that CHARITÉTM is compare the surgery to spinal fusion. long term results by unbiased observers
contraindicated in patients with One study 7 showed promising short- can indicate to the orthopedic
osteoporosis, the commenter noted that term results, but had no long-term data community if the device is an
spinal fusion surgery is also not and indicated the need for further study. acceptable orthopedic procedure. We
indicated in this patient population. After reviewing all the information also are concerned about the very low
Nevertheless, the commenter noted that supplied by the applicant and in these number of Medicare beneficiaries who
the Medicare charge data included clinical studies discussed above, CMS have received the device (18). In
nearly 98,000 spinal fusions in FY 2004. acknowledges that the CHARITÉTM may addition, aside from a lack of long-term
have potential benefit for certain clinical evidence that demonstrates the
The commenter further stated that, carefully selected Medicare effectiveness of the device, we also note
although many patients above the age of beneficiaries. However, our medical significant controversy within the
65 do have osteoporosis, implanting officers could not find sufficient orthopedic and spine surgery
surgeons report seeing many patients evidence to support a finding that this community regarding the overall
over the age of 65 who are extremely device meets the criteria for being a effectiveness and safety of this device
active and do not have signs of substantial clinical improvement. regardless of a patient’s age, primarily
osteoporosis, as validated by a Specifically, we are concerned about the based on the lack of long term data to
Dexascan. lack of comparative data beyond 24 support its use. Therefore, due to the
months in the materials that were lack of good evidence of long-term
The commenter also requested that
submitted for review. While the clinical clinical benefit and safety, and because
CMS apply the substantial clinical
studies above cited by the manufacturer of the degree of controversy surrounding
improvement criteria consistently to suggest positive outcomes with the the device within the orthopedic and
CHARITÉTM and INFUSE bone graft for device for up to 24 months, other spine surgery community, we do not
spinal fusions. The commenter noted studies cast doubt on both its short-term believe it meets the criterion for
that in the FY 2004 IPPS final rule (68 and long-term performance, and raise substantial clinical improvement and
FR 45388, August 1, 2003), CMS troubling questions regarding longer we are denying the application for new
approved INFUSE for new technology term adverse outcomes. Specifically, as technology add-on payments for FY
add-on payment even though evidence mentioned above, one study 8 included 2006.
was submitted for a small number of 27 patients who received the device We finally note that we believe we
Medicare aged patients treated with the between 1989 and 2001. Of these have applied a consistent standard of
product. CMS acknowledged that there patients, 12 reported some short-term evidence. While the applicant stated
was some positive, though limited, benefit, while 14 others reported no there may be similarities between this
evidence for generalized application for benefit at all. The study found that device and INFUSE, as noted above,
the Medicare population, leading CMS patients in this study had ‘‘recurrent or we believe there are still many
to conclude that based on ‘‘[t]hese persistent back and leg pain [that] was unanswered questions regarding
results, combined with the benefits of caused mainly by disc degeneration on CHARITÉTM, including the lack of long-
the elimination of the need to harvest neighboring levels, hyperlordosis of the term clinical evidence and the overall
operated segment, subsidence and effectiveness of the device, which
bone graft from the iliac crest (and
migration.’’ In addition, the study preclude us from determining that it
associated complications), INFUSE
indicated that removal of the prosthesis meets the substantial clinical
does meet the substantial clinical improvement criterion.
is dangerous, and posterior fusion
improvement criteri[on].’’ The Comment: One commenter who had
without removing the prosthesis will
commenter added that, in addition to give suboptimal results. The study the CHARITÉTM implanted supported
eliminating the need for harvesting bone approving the CHARITÉTM for new
from the iliac crest, the CHARITÉTM 4 David TJ. ‘‘Lumbar disc prosthesis; Five years technology add-on payments. The
provides other significant clinical follow-up study on 96 patients [abstract]’’ Presented commenter explained that the device
improvements, including maintaining a at the 15th Annual Meeting of the North American has offered clinical benefits, such as
Spine Society (NASS), New Orleans, LA, 2000.
more normal range of motion, 5 Lemaire JP., ‘‘SB Charite III intervertebral disc pain relief, that other procedures or
restoration of disc height, potential to prosthesis: Biomechanical, clinical, and surgeries were unable to achieve. Other
reduce adjacent level disc disease, radiological correlations with a series of 100 cases commenters also supported approval of
earlier and sustained improvement in over a follow-up of more than 10 years’’, Rachis the CHARITÉTM, indicating that the
[Fr]. 2002;14:271–285, cited in DePuy Spine, Inc.
pain and function and earlier return to Charité Artificial Disc. Technical Monograph.
FDA prospective study showed a
normal activity and improvement in SA01–030–000. JC/AG. Raynham, MA: DePuy; reduction in length of stay of a half day
qualify of life. November 2004. and patients also returned to normal
6 Caspi I, Levinkopf M, Nerubay J., ‘‘Results of
activities in half of the time of spinal
Based on the comments above, the lumbar disk prosthesis after a follow-up period of fusion patients.
commenter noted that the CHARITÉTM 48 months’’, Israel Medical Association Journal.
Volume 5, Issue 1, Pages 9–11, 2003.
Response: As noted above, we
meets all the criteria and should be 7 A. Geisler FH, Blumenthal SL, Guyer Rd, et al., acknowledge that the CHARITÉTM may
approved for new technology add-on ‘‘Neurological complications of lumbar artificial have potential benefit for certain
payments. disc replacement and comparison of clinical results carefully selected Medicare
with those related to lumbar arthrodesis in the beneficiaries. However, we do not
Response: There have been a number literature: Results of a multicenter, prospective,
of clinical studies conducted on the randomized investigational device exemption study believe that one patient’s experience is
CHARITÉTM (some of the studies of Charité intervertebral disc’’, Journal of sufficient to show the substantial
referenced below were also submitted Neurosurgery (Spine 2) Volume 1 Number 2, Pages clinical improvement criterion has been
143–154, 2004. met. Further, while the patient’s
by the applicant). One study showed 8 Van Ooij, Oner, ‘‘Complications of Artificial
unsatisfactory long term results. Three Disc Replacement.’’, Verbout Journal of Spinal
experience indicates that there may be
Disorders and Techniques, Vol. 16 No. 4, p. 369– short-term benefits from receiving
383, 2003. treatment with CHARITÉTM, we remain
concerned that the data supplied by the criterion. Nevertheless, we did evaluate According to the manufacturer, the case-
applicant did not demonstrate whether to make a DRG change for weighted cost threshold for these DRGs
substantial clinical improvement long CHARITÉTM outside of the context of is $49,817. Based on this analysis, the
term, despite the product being the new technology process. We are manufacturer maintained that the
available on the European market since providing a full analysis of this issue in technology meets our cost threshold.
1987. We are also concerned about the section II.B.6.d. of the preamble to this The manufacturer argued that the
degree of controversy surrounding the final rule. GORE TAG represents a substantial
device within the orthopedic and spine clinical improvement over existing
d. Endovascular Graft Repair of the technology, primarily by avoiding the
surgery community. Therefore, we are
Thoracic Aorta traditional open aneurysm repair
denying this application for new
technology add-on payments because Endovascular stent-grafting of the procedure with its associated high
we did not find enough evidence that descending thoracic aorta (TA) provides morbidity and mortality. The applicant
the product meets the substantial a less invasive alternative to the argued that a descending thoracic aorta
clinical improvement criterion. traditional open surgical approach aneurysm is a potentially life
Comment: One commenter noted that required for the management of threatening condition that currently
CMS did not acknowledge that section descending thoracic aortic aneurysms. requires a major operative procedure for
1886(d)(5)(K) of the Act states: W. L. Gore & Associates, Inc. submitted its treatment. The mortality and
‘‘Before establishing any add-on an application for consideration of its complication rates associated with this
payment * * * with respect to a new Endovascular Graft Repair of the surgery are very high, and the surgery is
technology, the Secretary shall seek to Thoracic Aorta (GORE TAG) for new frequently performed under urgent or
identify one or more diagnosis-related technology add-on payments for FY emergent conditions. The applicant
groups associated with such technology, 2006. The GORE TAG device is a noted that such complications can
based on similar clinical or anatomical tubular stent-graft mounted on a increase the length of the hospital stay
characteristics and the cost of the catheter-based delivery system, and it and can include neurological damage,
technology.’’ replaces the synthetic graft normally paralysis, renal failure, pulmonary
The commenter explained that, in the sutured in place during open surgery. emboli, hemorrhage, and sepsis. The
proposed rule, CMS solicited comment The device is identified using ICD–9– average time for patients undergoing
on whether to reassign ICD–9–CM code CM procedure code 39.79 (Other surgical repair to return to normal
84.65 and on the new technology endovascular repair (of aneurysm) of activity is 3 to 4 months, but can be
application for the CHARITÉTM. The other vessels). The applicant has significantly longer.
commenter added that, instead of requested a unique ICD–9–CM In comparison, the applicant argued
considering these as two distinct issues, procedure code. (We refer readers to that endovascular stent-grafting done
CMS should consider a DRG change Tables 6A through 6H in the Addendum with the GORE TAG thoracic
within the new technology application to this final rule for information endoprosthesis is minimally invasive.
as mandated by the statute. regarding ICD–9–CM codes.) The manufacturer noted that patients
Another commenter indicated that the At the time of the initial application, treated with the endovascular technique
purpose of the new technology add-on the FDA had not yet approved this experience far less aneurysm-related
program is to provide a cost-based technology for general use. mortality and morbidity, compared to
bridge to compensate hospitals for Subsequently, however, we were those patients that receive the open
additional costs related to new notified that FDA approval was granted procedure, resulting in reduced overall
technology. Consistent with CMS’ on March 23, 2005. Therefore, GORE length-of-stay, less intensive care unit
position not to consider DRG changes TAG meets the newness criterion. days and less operative complications.
until sufficient data became available in Although we discussed some of the data We received the following public
MedPAR to support it, the commenter submitted with the application for new comments, in accordance with section
believed it would be premature to technology add-on payments, we were 503(b)(2) of Pub. L. 108–173, regarding
reassign spinal disc prostheses to DRGs unable to include a detailed analysis of this application for add-on payments
497 and 498 until further data become cost data and substantial clinical prior to publication of the FY 2006 IPPS
publicly available. The commenter improvement data in the FY 2006 IPPS proposed rule.
added that DRGs 497 and 498 are well proposed rule because FDA approval Comment: Several commenters
established and any changes to these occurred too late for us to conduct a expressed support for approval of new
DRGs, such as including cases of disc complete analysis. technology add-on payments for the
prosthesis in these DRGs without more The applicant submitted cost GORE TAG device. These commenters
complete data could result in an threshold information for the GORE noted that the data presented to the FDA
inappropriate reduction to the weight of TAG device. According to the advisory panel for consideration for
these DRGs. manufacturer, cases using the GORE FDA approval of the device clearly
Response: We agree with the TAG device would fall into DRGs 110 demonstrate the safety and efficacy of
comments regarding section and 111 (Major Cardiovascular the GORE TAG device. They also noted
1886(d)(5)(K) of the Act. If a product Procedures With and Without CC, that nearly 200 patients have been
meets all of the criteria for Medicare to respectively). The applicant identified treated with the endografts, with a
pay for a product as a new technology, 185 cases in the FY 2003 MedPAR using highly significant difference in both
there is a clear preference expressed in procedure code 39.79 (Other postoperative mortality and a reduction
the statute for us to assign the endovascular repair (of aneurysm) of in the incidence of spinal cord ischemic
technology to a DRG based on similar other vessels) and primary diagnosis complications, with some commenters
clinical or anatomical characteristics codes 441.2 (Thoracic aneurysm, noting the trial results, which showed a
and costs. However, as stated above, we without mention of rupture), 441.1 reduction in the rate of paraplegia from
are denying new technology add on (Thoracic aneurysm, ruptured), or 14 percent to 3 percent, compared to
payments for CHARITÉTM because we 441.01 (Dissection of aorta, thoracic). open surgery. The commenters also
could not establish that it meets the The case-weighted standardized charge stressed the rigorous nature of the open
substantial clinical improvement for 177 of these cases was $60,905. surgery, which requires a left lateral
thoracotomy, resulting in significant determined that the manufacturer has should code for the device using the
morbidity. The commenters further demonstrated that this device meets the newly created ICD–9–CM procedure
argued that, since many of the patients cost threshold for the DRGs to which code 39.73 (Endovascular implantation
with degenerative aneurysm of the these cases will be assigned. However, of graft in thoracic aorta). The cost of a
thoracic aorta are elderly or present we note that we would expect there to single device is $12,798. Because the
with significant comorbidities, or both, be significantly fewer hospital resources average patient receives 1.8
it is ‘‘a common circumstance in clinical required to care for a patient undergoing endovascular prostheses, we estimate
practice to deny repair to such patients the endovascular procedure compared the cost of the device to be $21,198 per
because of the magnitude of the to an open thoracotomy. Thus we are patient. Therefore, beginning October 1,
conventional open surgery.’’ Other concerned that the cost of cases using 2005, cases that include code 39.73 will
commenters stated that the 5-year this device is unnecessarily high. We be eligible to receive new technology
mortality in all patients diagnosed with will continue to monitor the data add-on payments up to $10,599, or half
thoracic aortic aneurysm is as high as 80 associated with the endovascular repair the cost of the device.
percent in some groups of patients. of a thoracic aortic aneurysm in the Comment: In the proposed rule, we
Therefore, the commenters argued, the future to obtain further information stated that ‘‘we would extend new
GORE TAG device for thoracic aortic about this issue. technology payments to any
aneurysm satisfies the criteria for Comment: Several commenters substantially similar technology that
substantial clinical improvement. encouraged CMS to approve the GORE also receives FDA approval prior to
Response: We appreciate the TAG device for new technology add-on publication of the FY 2006 final rule.’’
commenters’ input on this criterion. In payment approval. These commenters Commenters argued that, CMS should
the FY 2006 proposed rule, we indicated that this device is a significant not require, FDA approval to be granted
indicated that we would consider these advance in the treatment of thoracic to substantially similar devices prior to
comments regarding the substantial aortic aneurysms, particularly for the publication of the final rule for CMS
clinical improvement criterion in the elderly, frail patients who are not to extend new technology payments to
final rule if we determined that the candidates for the open procedure to these products.
technology meets the other two criteria. correct life-threatening aneurysms. They Response: We agree with the
Comment: A representative of another added that physicians pointed to the commenters. Any substantially similar
device manufacturer stated at the town mortality and comorbidity rates device that is FDA-approved after the
hall meeting that the manufacturer has associated with the open procedure, publication of the final rule that uses
a similar product awaiting FDA stating ‘‘even in centers of excellence, the same ICD–9–CM procedure code as
approval. the risk of either mortality or paraplegia GORE TAG and falls into the same
Response: In the proposed rule, we complicating surgery runs up to the 10 DRGs as those approved for new
responded that as we discussed in the percent range.’’ technology add-on payments should
new technology final rule (66 FR Response: We appreciate the also receive the new technology add-on
46915), an approval of a new technology commenters’ input on the substantial payment associated with this
for special payment should extend to all clinical improvement criterion, and we technology in FY 2006. The discussion
technologies that are substantially have determined that the GORE TAG of this issue in the preamble to the
similar. Otherwise, our payment policy device meets the substantial clinical proposed rule was intended to
would bestow an advantage to the first improvement criterion. In our view, the communicate that we would extend
applicant to receive approval for a GORE TAG device meets a number of new technology payments to any
particular new technology. In this case, the standards that we use to evaluate substantially similar product that is
we will determine whether the GORE whether a new technology is a assigned to the same ICD–9–CM code, as
TAG device qualifies for new substantial clinical improvement. For long as the applicant’s product received
technology add-on payments in this instance, GORE TAG offers a treatment FDA approval prior to the final rule. For
final rule. In the event that this option for patients with thoracic aortic the reason stated above, we have
technology satisfies all the criteria, as aneurysms that are not candidates for changed our position on this issue and
we indicated in the FY 2006 IPPS open surgery. Prior to endovascular will extend add-on payment to any
proposed rule, we would extend new treatment with this device, there were substantially similar products that are
technology payments to any no treatment options available for assigned to the same ICD–9–CM code
substantially similar technology that patients who were not candidates for and that receive FDA approval either
also receives FDA approval prior to open repair of a thoracic aortic before or during FY 2006.
publication of the FY 2006 final rule. In aneurysm. We also believe that, relative
to the open repair procedure, e. Restore Rechargeable Implantable
the FY 2006 IPPS proposed rule, we
endovascular aneurysm repair improves Neurostimulator
solicited comments regarding this
technology in light of its recent FDA clinical outcomes through lower Medtronic Neurological submitted an
approval, particularly with regard to the mortality and complication rates, application for new technology add-on
cost threshold and the substantial reduced overall length-of-stay, less payments for its Restore Rechargeable
clinical improvement criteria. intensive care unit days and less Implantable Neurostimulator. The
During the 60-day comment period for operative complications. For the reasons Restore Rechargeable Implantable
the FY 2006 IPPS proposed rule, we stated above, we find that the GORE Neurostimulator is designed to deliver
received the following comments: TAG device meets the substantial electrical stimulation to the spinal cord
Comment: The applicant submitted an clinical improvement criterion. for treatment of chronic, intractable
additional validation sample of cases to As indicated earlier, GORE TAG pain.
confirm the costs associated with this meets both the newness and cost Neurostimulation is designed to
technology. In this sample, charges for criteria. Therefore, in this final rule, we deliver electrical stimulation to the
the device ranged from approximately are approving the GORE TAG device for spinal cord to block the sensation of
$7,000.00 to $11,000.00 per device. new technology add-on payment for FY pain. The current technology standard
Response: We have reviewed the 2006. These cases generally are in DRGs for neurostimulators utilizes internal
evidence presented above and have 110 and 111. Cases involving the device sealed batteries as the power source to
generate the electrical current. These add-on amount of $10,568 if the product proposed rule, we indicated that we
internal batteries have finite lives, and were to be approved for new technology were making no decision concerning the
require replacement when their power payments. Restore application. We indicated that
has been completely discharged. We note that we reviewed a we would make a formal determination
According to the manufacturer, the technology for add-on payments for FY if FDA approval occurs in sufficient
Restore Rechargeable Implantable 2003 called RenewTM Radio Frequency time for full consideration in this final
Neurostimulator ‘‘represents the next Spinal Cord Stimulation (SCS) Therapy, FY 2006 rule. However, we noted that
generation of neurostimulator made by Advanced Neuromodulation we had reservations about whether this
technology, allowing the physician to Systems (ANS). In the FY 2003 final technology is new for purposes of the
set the voltage parameters in such a way rule, we discussed and subsequently new technology add-on payments
that fully meets the patient’s denied an application for new because of its similarity to other
requirements to achieve adequate pain technology add-on payment for products that are also used to treat the
relief without fear of premature RenewTM SCS because ‘‘RenewTM SCS same conditions. Although we
depletion of the battery.’’ The applicant was introduced in July 1999 as a device recognized the benefits of a more easily
stated that the expected life of the for the treatment of chronic intractable rechargeable neurostimulator system,
Restore rechargeable battery is 9 years, pain of the trunk and limbs’’ and could we believed that the Restore device
compared to an average life of 3 years no longer be considered a new product might not be sufficiently different from
for conventional neurostimulator (67 FR 50019). We also noted, ‘‘[t]his predecessor devices to meet the
batteries. The applicant stated that this system only requires one surgical newness criterion for the new
represents a significant clinical placement and does not require technology add-on payment. As we
improvement because patients can use additional surgeries to replace batteries discussed above, similar products have
any power settings that are necessary to as do other internal SCS systems.’’ been on the market since 1999.
achieve pain relief with less concern for The applicant also stated in its Therefore, these technologies are
battery depletion and subsequent application for Restore that cases already represented in the DRG weights
battery replacement. where it is used will be identified by and are not considered new for the
At the time of the FY 2006 proposed ICD–9–CM procedure code 03.93 purposes of the new technology add-on
rule, this device had not yet received (Insertion or replacement of spinal payment provision. We received no
approval for use by the FDA; however, neurostimulators), and this code was public comments regarding this
another manufacturer had received also used to identify the predecessor application for add-on payments prior
approval for a similar device. technology in order to perform the cost to the publication of the FY 2006 IPPS
(Advanced Bionics’ Precision threshold analysis. As we discussed in proposed rule. In the proposed rule, we
Rechargeable Neurostimulator was the FY 2003 final rule (67 FR 50019), solicited comments on this application
approved by the FDA on April 27, the RenewTM SCS is identified by the for add-on payments, specifically
2004.) same ICD–9–CM procedure code. As regarding how the Restore device may
Medtronic Neurological also provided discussed in the proposed rule, the or may not be significantly different
data to determine whether the Restore applicant applied for and was assigned from previous devices. We also sought
Rechargeable Implantable a new ICD–9–CM code for rechargeable comments on whether the product
Neurostimulator meets the cost neurostimulator pulse generator. (We meets the cost and significant
criterion. Medtronic Neurological stated refer readers to Tables 6A through 6H in improvement criteria.
that the cases involving use of the the Addendum to this final rule for During the 60-day comment period for
device would primarily fall into DRGs information regarding ICD–9–CM the proposed rule, we received the
499, 500, 531 and 532, which have a codes.) Because the RenewTM SCS and following comments:
case-weighted threshold of $24,090. The Restore technologies appear similar, Comment: Several commenters
manufacturer stated that the anticipated we asked Medtronic to provide supported the application for the
average standardized charge per case information that would demonstrate rechargeable implantable
involving the Restore technology is how the products were substantially neurostimulator for add-on payment.
$59,265. The manufacturer derived this different. The applicant noted that the Commenters noted that there is a large
estimate by identifying cases in the FY RenewTM SCS, while programmable and difference between the radio frequency
2003 MedPAR that reported procedure rechargeable, is not a good option for (RF) devices and the rechargeable
code 03.93 (Insertion or replacement of those patients who have high energy implantable neurostimulators. They
spinal nerostimulators). The requirements because of chronic argued that there is little relief with the
manufacturer then added the total cost intractable pain that will result in more RF systems, because once the
of the Restore Rechargeable battery wear and subsequent surgery to transmitter/power source is removed,
Implantable Neurostimulator to the replace the device. Both systems rely on the therapy immediately ends. Further,
average standardized charges for those rechargeable batteries, and in the case of commenters argued that due to these
cases. Of the applicable charges for the RenewTM SCS the energy is transmitted restrictions and the difficulty of
Restore Rechargeable Implantable through the skin from a radiofrequency ensuring patient compliance with this
Neurostimulator, only the components source for the purpose of recharging. device, the pain relief the RF system is
that the applicant identified as new Medtronic contends that the Restore intended to provide is not possible. As
would be eligible for new technology device is superior to the RenewTM such, the commenters argued that the
add-on payments. Medtronic device because RenewTM requires an rechargeable implantable device is a
Neurological submitted information that external component that uses a skin much better option for many patients
distinguished the old and new adhesive that is uncomfortable and with high power needs than previously
components of the device and submitted inconvenient (causes skin irritation, is available neurostimulators.
data indicating that the neurostimulator affected by moisture that will come from Commenters argued that the new,
itself is $17,995 and the patient bathing, sweating, swimming, etc.), rechargeable, implantable
recharger, antenna, and belt are $3,140. leading to patient noncompliance. neurostimulators meet the substantial
Thus, the total cost for new components Because FDA approval had not yet clinical improvement criterion by
would be $21,135, with a maximum been received for this device, in the eliminating surgeries to replace the
batteries, reducing the infection rate devices that use of RF as the recharging yet reflected within the DRG weights,
associated with greater frequency of source are significant. The applicant has we consider the Safe Cross to meet the
replacement surgeries, and providing demonstrated that there will not be the newness criterion.
more treatment options for those same patient compliance issues with its We note that the applicant submitted
patients that require high energy product. Because of the elimination of an application for a distinctive ICD–9–
stimulation. In addition, commenters the need for serial battery replacement CM code. The applicant noted in its
noted the clinical improvement surgeries and in light of the information application that the device is currently
associated with the ability to use two provided by the manufacturer and coded with ICD–9–CM procedure codes
16-electrode leads instead of the 8- commenters further clarifying the 36.09 (Other removal of coronary artery
channel leads that are used in older distinctions and improvements of the obstruction) and 39.50 (Angioplasty or
neurostimulators. They pointed out that, Restore technology when compared to atherectomy of other noncoronary
by using leads with more electrodes, the other devices, we believe that the device vessels).
physician can place the leads so that is a substantial clinical improvement As we stated in last year’s final rule,
more coverage is provided to the spinal over prior technologies. section 1886(d)(5)(K)(i) of the Act
nerves, and the physician is provided an As stated in the proposed rule, we requires that the Secretary establish a
option to reprogram the neurostimulator had previously determined that mechanism to recognize the costs of
without further invasive surgery if a Restore in combination with the other new medical services or technologies
lead migrates after the unit is installed. devices that already received FDA under the payment system established
Further, commenters argued that, by approval in 2004 and 2005, meets the under subsection (d) of section 1886,
paying the higher up-front expenses newness and cost threshold criteria. which establishes the system for paying
associated with these technologies, CMS Therefore, we are approving new for the operating costs of inpatient
will ultimately save money on reduced technology add-on payments for hospital services. The system of
surgical and physician encounters, rechargeable, implantable payment for capital costs is established
while improving the care that Medicare neurostimulators for FY 2006. Cases under section 1886(g) of the Act, which
beneficiaries receive. Finally, the involving these devices will be makes no mention of any add-on
manufacturer submitted an updated identified by the presence of newly payments for a new medical service or
price for the Restore rechargeable created ICD–9–CM code 86.98 (Insertion technology. Therefore, it is not
implantable neurostimulator that or replacement of dual array appropriate to include capital costs in
reflects a decrease in total costs for the rechargeable neurostimulator pulse the add-on payments for a new medical
new components associated with the generator). These cases are generally service or technology, and these costs
device. Based on this change, the included in the following DRGs: 7, 8, should not be considered in evaluating
manufacturer calculated the new 499, 500, 531, or 532. In the proposed whether a technology meets the cost
rule, we stated that the maximum add- criterion. As a result, we consider only
maximum add-on payment amount to
on payment for the new components of the Safe Cross crossing wire, ground
be $9,320 if the application is approved.
the device would be $10,568, or half of pad, and accessories to be operating
Response: We appreciate these $21,135. The applicant reported a equipment that is relevant to the
commenters’ input regarding this reduction in the price to $18,640 after evaluation of the cost criterion.
device. While the comments were publication of the proposed rule, The applicant submitted the following
submitted in support of a finding that making the maximum add-on payment two analyses on the cost criterion. The
this device meets the substantial clinical for the device $9,320. Therefore, we are first analysis contained 27 actual cases
improvement criterion, they have also finalizing a maximum add-on payment from two hospitals. Of these 27 cases,
convinced us that the device is of $9,320 for cases that involve this 25.1 percent of the cases were reported
significantly different from predecessor technology. in DRGs 24 (Seizure and Headache Age
devices. Therefore, we are reversing our >17 With CC), 107 (Coronary Bypass
preliminary determination that the f. Safe-Cross(r) Radio Frequency Total With Cardiac Catheterization), 125
Restore Rechargeable Implantable Occlusion Crossing System (Safe- (Circulatory Disorders Except AMI,
Neurostimulator is likely not new, and Cross) With Cardiac Catheterization and
we have determined that it can be Intraluminal Therapeutics submitted Without Complex Diagnosis), 518
considered new for the purposes of the an application for the Safe Cross Radio (Percutaneous Cardiovascular Procedure
new technology add-on payment for this Frequency (RF) Total Occlusion Without Coronary Artery Stent or AMI),
reason. The manufacturer also provided Crossing System. This device performs and 526 (Percutaneous Cardiovascular
data from its device registry the function of a guidewire during Procedure With Drug-Eluting Stent With
demonstrating that nearly 34 percent of percutaneous transluminal angioplasty AMI); and 74.9 percent were reported in
patients aged 65 and older, who receive of chronic total occlusions of peripheral DRG 527 (Percutaneous Cardiovascular
non-rechargeable devices, require a and coronary arteries. Using fiberoptic Procedure With Drug-Eluting Stent
replacement surgery within the first 10 guidance and radiofrequency ablation, it Without AMI). This resulted in a case-
years of implantation. In addition, of is able to cross lesions where a standard weighted threshold of $37,304 and a
those patients that require replacement guidewire is unsuccessful. On case-weighted average standardized
surgeries, more than half of those November 21, 2003, the FDA approved charge of $40,705. (We have updated the
patients have high energy needs that the Safe Cross for use in iliac and case weighted threshold and case
deplete the battery within the first 3 superficial femoral arteries. In January weighted average standardized charge
years. By avoiding the need for a battery 2004, the FDA approved the Safe Cross from the proposed rule due to an
replacement surgery, we believe these for coronary arteries. The device was inadvertent clerical error in reporting
data demonstrate that this device is a also approved by the FDA for all native these figures in the proposed rule.)
substantial clinical improvement for a peripheral arteries except carotids in Because the case-weighted average
large proportion of the patients who August 2004. Because the device is standardized charge is greater than the
receive implantable neurostimulators. In within the statutory timeframe of 2 to 3 case-weighted threshold, the applicant
addition, we agree that the patient years for all approved uses and data maintained that the Safe Cross meets
compliance issues with the predecessor regarding the cost of this device are not the cost criterion.
The applicant also submitted cases OPPS. The IPPS regulations provide that the Safe Cross for pass-through
from the FY 2003 MedPAR. The technology may be approved for add-on payments for the OPPS on the basis that
applicant found a total of 1,274,535 payments when it ‘‘represents an the technology did not meet the
cases that could be eligible for the Safe advance in medical technology that substantial clinical improvement
Cross using diagnosis codes 411 substantially improves, relative to criterion. In particular, we found that
through 411.89 (Other acute and technologies previously available, the studies failed to show long-term or
subacute forms of ischemic heart diagnosis or treatment of Medicare intermediate-term results, and the
disease) or 414 through 414.19 (Other beneficiaries’’ (66 FR 46912). Under the device had a relatively low rate of
forms of chronic ischemic heart disease) OPPS, the standard for approval of new successfully opening occlusions. Since
in combination with any of the devices is ‘‘a substantial improvement that initial determination, the applicant
following procedure codes: 36.01 in medical benefits for Medicare has requested reconsideration for pass-
(Single vessel percutaneous beneficiaries compared to the benefits through payments under the IPPS.
transluminal coronary angioplasty obtained by devices in previously However, on the basis of the original
(PTCA) or coronary atherectomy established (that is, existing or findings under the OPPS, we do not
without mention of thrombolytic agent), previously existing) categories or other now believe that the technology can
36.02 (Single vessel PTCA or coronary available treatments’’ (67 FR 66782). qualify for new technology add-on
atherectomy with mention of Furthermore, the OPPS and IPPS payments under the IPPS. Therefore, in
thrombolytic agent), 36.05 (Multiple employ identical language (for IPPS, see the FY 2006 IPPS proposed rule, we
vessel PTCA or coronary atherectomy 66 FR 46914, and for OPPS, see 67 FR proposed to deny new technology add-
performed during the same operation 66782) to explain and elaborate on the on payment for FY 2006 for Safe Cross
with or without mention of kinds of considerations that are taken on the grounds that it does not appear
thrombolytic agent), 36.06 (Insertion of into account in determining whether a to be a substantial clinical improvement
nondrug-eluting coronary artery new technology represents substantial over existing technologies. We sought
stent(s)), 36.07 (Insertion of drug-eluting improvement. In both systems, we further information on whether this
coronary artery stent(s)) and 36.09 employ the following kinds of device meets the substantial clinical
(Other removal of coronary artery considerations in evaluating particular improvement criterion, and indicated
obstruction). A total of 59.40 percent of requests for special payment for new that we would consider any further
these cases fell into DRG 517 technology: information prior to making our final
(Percutaneous Cardiovascular Procedure • The device offers a treatment option determination in this final rule.
With Nondrug-Eluting Stent Without for a patient population unresponsive We received no public comments
AMI), 16.4 percent of cases into DRG to, or ineligible for, currently available regarding this application for add-on
516 (Percutaneous Cardiovascular treatments. payments prior to the publication of the
Procedure With AMI), and 16.2 percent • The device offers the ability to FY 2006 IPPS proposed rule. During the
of cases into DRG 527, while the rest of diagnose a medical condition in a 60-day comment period on the FY 2006
the cases fell into the remaining DRGs patient population where that medical IPPS proposed rule, we received the
124, 518, and 526. The average case- condition is currently undetectable or following comment:
weighted standardized charge per case offers the ability to diagnose a medical Comment: One commenter expressed
was $40,318. This amount included an condition earlier in a patient population support for the Safe Cross, explaining
extra $6,000 for the charges related to than allowed by currently available that the increased chance of crossing a
the Safe Cross. The case-weighed methods. There must also be evidence CTO enables the placement of drug-
threshold across the DRGs mentioned that use of the device to make a eluting stents and represents a
above was $35,955. Similar to the diagnosis affects the management of the substantial clinical improvement for
analysis above, because the case- patient. treating the most challenging clinical
weighted average standardized charge is • Use of the device significantly subgroup with these conditions. Using
greater than the case-weighted improves clinical outcomes for a patient the device also raises the cost per case
threshold, the applicant maintained that population as compared to currently and, therefore, the commenter
the Safe Cross meets the cost criterion. available treatments. Some examples of recommended that CMS pay new
The applicant maintained that the outcomes that are frequently evaluated technology add-on payments for this
device meets the substantial clinical in studies of medical devices are the device.
improvement criterion. The applicant following: Response: In a letter dated June 3,
explained that many traditional —Reduced mortality rate with use of the 2003 to the applicant, CMS denied pass-
guidewires fail to cross a total arterial device. through payments under the OPPS for
occlusion due to difficulty in navigating —Reduced rate of device-related the Safe Cross because it did not
the vessel and to the fibrotic nature of complications. demonstrate a substantial clinical
the obstructing plaque. By using —Decreased rate of subsequent improvement. The letter explained that
fiberoptic guidance and radiofrequency diagnostic or therapeutic the company has not yet provided
ablation, the Safe Cross succeeds interventions (for example, due to intermediate to long-term results
where standard guidewires fail. The reduced rate of recurrence of the regarding reocclusion of previously
applicant further maintained that in disease process). occluded vessels after angioplasty with
clinical trials where traditional —Decreased number of future substantially improved patient
guidewires failed, the Safe Cross hospitalizations or physician visits. outcomes, which could demonstrate
succeeded in 54 percent of cases of —More rapid beneficial resolution of that the Safe Cross technology leads to
coronary artery chronic total occlusions the disease process treatment because significant clinical improvement for
(CTOs), and in 76 percent of cases of of the use of the device. patients in comparison with other
peripheral artery CTOs. —Decreased pain, bleeding, or other available treatments. Given the similar
However, in the FY 2006 IPPS quantifiable symptom. criteria for making pass-through
proposed rule, we noted that we use —Reduced recovery time. payments under the OPPS and new
similar standards to evaluate substantial In a letter to the applicant dated technology add-on payments under the
clinical improvement in the IPPS and October 25, 2004, we denied approval of IPPS, a finding that Safe Cross does not
meet the OPPS criteria means that, in cost of the device in the MedPAR data. This commenter suggested that it may
the absence of relevant new Because the device became available on be inappropriate to recognize only one
information, it cannot qualify for new the market in April 2003, charges of these new hip replacement products
technology add-on payments under the reflecting the cost of the device may for new technology add-on payments.
IPPS. Therefore, we are finalizing our have been included in the data used to Response: We appreciate the
proposal to deny new technology add- calculate the DRG weights in FY 2005 commenter’s input on this criterion. In
on payments for the Safe Cross in FY and the final DRG weights for FY 2006. the proposed rule, we indicated that we
2006 because it does not meet the Therefore, the technology may no longer would consider these comments
substantial clinical improvement be considered new for the purposes of regarding the substantial clinical
criterion. new technology add-on payments. For improvement criterion. However, based
this reason, in the FY 2006 IPPS on the observations provided at the
g. Trident Ceramic Acetabular System town hall meeting, we noted that we are
proposed rule, we proposed to deny
Stryker Orthopaedics submitted an add-on payments for the Trident considering alternative methods of
application for new technology add-on Ceramic Acetabular System for FY 2006. recognizing technological improvements
payments for the Trident Ceramic The applicant submitted cost in this area other than approving only
Acetabular System. This system is used threshold information for the Trident one of these new technologies for add-
to replace the ‘‘ball and socket’’ joint of Ceramic Acetabular System, stating that on payments. For example, as discussed
a hip when a total hip replacement is cases using the system would be in section II.B.6.a. of the preamble to the
performed for patients suffering from included in DRG 209 (Major Joint and proposed rule, we proposed to split
arthritis or related conditions. The Limb Reattachment Procedures of Lower DRG 209 to create a new DRG for
applicant stated that, unlike Extremity). The manufacturer indicated revisions of hip and knee replacements.
conventional hip replacement systems, that there is not an ICD–9–CM code We would leave all other replacements
the Trident system utilizes alumina specific to ceramic hip arthroplasty, but and attachment procedures in a
ceramic-on-ceramic bearing surfaces it is currently reported using code 81.51 separate, new DRG. We also stated that
rather than metal-on-plastic or metal-on- (Total hip replacement). Of the we would review these DRGs based on
metal. Alumina ceramic is the hardest applicable charges for the Trident new procedure codes that will provide
material next to diamond. The Trident Ceramic Acetabular System, only the more detailed data on the specific
System is a patented design that components that the applicant nature of the revision procedures
captures the ceramic insert in a titanium identified as new would be eligible for performed. In addition, we are creating
sleeve. This design increases the new technology add-on payments. The new procedure codes that will identify
strength of the ceramic insert by 50 estimated cost of the new portions of the the type of bearing surface of a hip
percent over other designs. The device, according to the information replacement. As we obtain data from
manufacturer stated that the alumina provided in the application, is $6,009. these new codes, we stated that we
ceramic bearing of the device is a The charge threshold for DRG 209 is would consider additional DRG
substantial clinical improvement $34,195. The data submitted by Stryker revisions to better capture the various
because it is extremely hard and scratch Orthopaedics showed an average types of joint procedures. We also stated
resistant, has a low coefficient of standardized charge, assuming a 28 that we may consider a future
friction and excellent wear resistance, percent implant markup, of $34,230. restructuring of the joint replacement
has improved lubrication over metal or Regarding the issue of substantial and revision DRGs that would better
polyethylene, has no potential for metal clinical improvement, we recognize that capture the higher costs of products that
ion release, and has less alumina the Trident Ceramic Acetabular offer greater durability, extended life,
particle debris. The manufacturer also System represents an incremental and improved outcomes. In doing so, of
stated that fewer hip revisions are advance in prosthetic hip technology. course, we may need to create
needed when this product is used (2.7 However, we also recognize that there additional, more precise ICD–9–CM
percent of ceramic versus 7.5 percent for are a number of other new prostheses codes. In the FY 2006 IPPS proposed
polyethylene). Stryker stated that the available that utilize a variety of bearing rule, we sought comments on this issue,
ceramic implant also causes less surface materials that also offer and generally on whether the Trident
osteolysis (or bone loss from particulate increased longevity and decreased wear. Ceramic Acetabular System meets the
debris). Due to these improvements over For this reason, we do not believe that criteria to qualify for new technology
traditional hip implants, the the Trident system has demonstrated add-on payments and received the
manufacturer stated the Trident itself to be a clearly superior new following comments during the 60-day
Ceramic Acetabular System has technology. comment period.
demonstrated significantly lower wear We received the following public During the 60-day comment period on
versus the conventional plastic/metal comments, in accordance with section the FY 2006 proposed rule, we received
system in the laboratory; therefore, it is 503(b)(2) of Pub. L. 108–173, regarding the following comments:
anticipated that these improved wear this application for add-on payments Comment: Several commenters
characteristics will extend the life of the prior to publication of the FY 2006 IPPS supported new technology add-on
implant. proposed rule. payments for the Trident ceramic on
In addition, we note that the Trident Comment: One commenter noted that ceramic hip. Many of these comments
Ceramic Acetabular System received clinical outcomes for the Trident reiterated the comment from the device
FDA approval in February 3, 2003. Ceramic Acetabular System are not a manufacturer, disagreeing with our
However, this product was not available significant clinical improvement over assertion that the technology represents
on the market until April 2003. The similar devices on the market. A only an incremental improvement over
period that technologies are eligible to member of the orthopedic community other technologies. The commenters
receive new technology add-on payment noted at the new technology town hall emphasized that the Trident Ceramic
is no less than 2 years but not more than meeting that this system is not the only Acetabular System had been evaluated
3 years from the point the product new product that promises significantly in an extensive prospective,
comes on the market. At this point, we improved results because of randomized, controlled clinical study,
begin to collect charges reflecting the enhancements to materials and design. and that the FDA Panel reviewing the
study commended it for its design, entire fiscal year, rather than 2004, two new ICD–9–CM procedure
statistical report, and patient followup. terminating payments part way through codes were created to code intracranial
Therefore, the commenters argued, the the year. Commenters urged us to angioplasty and intracranial stenting
product had shown clinical superiority reconsider whether this technology procedures: Procedure codes 00.62
where other devices and improved meets the newness criterion because it (Percutaneous angioplasty or
designs had not shown clinical will not be 3 years old until more than atherectomy of intracranial vessels) and
superiority to the metal on polyethelene 6 months into FY 2006. 00.65 (Percutaneous insertion of
hip implants. The commenter also cited Response: We believe the commenters intracranial vascular stents).
a post-market study of a subset of the make a good point about application of On January 9, 2004, the FDA
original study patients that the newness criteria to the Trident designated the WingspanTM as a
demonstrates continued good patient product. The commenters are correct Humanitarian Use Designation (HUD).
outcomes at a mean of 5.2 years that we have generally followed a The manufacturer has also applied for
followup, as presented at the 2005 guideline that uses a 6-month window Humanitarian Device Exemption (HDE)
American Academy of Orthopedic before and after the start of the fiscal status and expects approval from the
Surgeons Annual Meeting. year to determine whether to extend the FDA in July 2005. It is important to note
Response: The Trident Ceramic add-on payment for an additional year. that currently CMS has a noncoverage
Acetabular System is used to replace the In general, we extend add-on payments policy for percutaneous transluminal
‘‘ball and socket’’ joint of a hip when a for an additional year if the 3 year angioplasty to treat lesions of
total hip replacement is performed for anniversary date of the product’s entry intracranial vessels. The applicant is
patients suffering from arthritis or on the market occurs in the latter half working closely with CMS to review
related conditions. Prosthetic hip joints of the fiscal year. this decision upon FDA approval.
have been used to treat these conditions In the case of the Trident ceramic Because the device is neither FDA-
for many years. The Trident Ceramic acetabular system, the device was not approved nor Medicare-covered, we did
Acetabular System differs from its available on the market until April, not believe it was appropriate to present
predecessor prosthetic hips only in the 2003. Thus, the product will not have our full analysis on whether the
materials that are used in the joint. been available on the market for 3 years technology meets the individual criteria
Thus, the Trident Ceramic Acetabular until the second half of FY 2006. Thus, for the new technology add-on payment
System uses the same or a similar under policy, the Trident ceramic in the proposed rule. However, we note
mechanism of action to achieve a acetabular system could potentially that the applicant did submit the
therapeutic outcome (that is, it replaces qualify as new for FY 2006. However, following information below on the cost
the joint to address pain and related the device is very similar to existing criterion and substantial clinical
conditions for patients suffering from products, only differing in the improvement criterion.
arthritis or related conditions). Further, composite material used in The manufacturer submitted data
we note that the cases using the manufacturing. It is also used in the from MedPAR and non-MedPAR
Trident Ceramic Acetabular System same DRGs as these other similar databases. The non-MedPAR data was
will go into new DRGs 544 or 545 technologies, and we question whether from the 2003 patient discharge data
(Major Joint Replacement, Revision of it would be appropriate to deem this from California’s Office of Statewide
Hip or Knee Replacement), the same technology new and substantially Health Planning and Development
DRGs as the patients that receive the different from previous hip prosthetics. database for hospitals in California and
older prosthetic hip replacements. Thus, as noted above, we continue to from the 2003 patient data from
Therefore, because the Trident product find that the device does not meet our Florida’s Agency for Health Care
appears to offer only an incremental substantial clinical improvement Administration for hospitals in Florida.
advance in the treatment of patients criterion. Therefore, in this final rule, The applicant identified cases that had
requiring a total hip replacement, we we are finalizing our decision to deny a diagnosis code of 437.0 (Cerebral
find that it does not meet the substantial new technology add-on payments for atherosclerosis), 437.1 (Other
clinical improvement criterion. We also this device for FY 2006. generalized ischemic cerebrovascular
note that in this final rule, as proposed, disease) or 437.9 (Unspecified) or any
h. WingspanTM Stent System With
CMS is splitting DRG 209 into two diagnosis code that begins with the
GatewayTM PTA Balloon Catheter
separate DRGs (544 and 545) in order to prefix of 434 (Occlusion of cerebral
better reflect the higher costs of revising Boston Scientific submitted an arteries) in combination with procedure
hip and knee replacements. application for the WingspanTM Stent code 39.50 (Angioplasty or atherectomy
Comment: Several commenters System with GatewayTM PTA Balloon of noncoronary vessel) or procedure
objected to our interpretation of the Catheter for new technology add-on code 39.90 (Insertion of nondrug-
period of new with regard to this payments. The device is designed for eluting, noncoronary artery stents). The
technology. Several commenters noted the treatment of patients with applicant used procedure codes 39.50
that there appeared to be inconsistency intracranial atherosclerotic disease who and 39.90 because procedure codes
in the method CMS has used to suffer from recurrent stroke despite 00.62 and 00.65 were not available until
determine the period of ‘‘newness’’ for medical management. The device FY 2005. The applicant found cases in
each technology, noting in particular consists of the following: A self- DRG 5 (Extracranial Vascular
that both the CRT–D device and expanding nitinol stent, a multilumen Procedures) (which previously existed
INFUSE bone graft for spinal fusion over the wire delivery catheter, and a under the Medicare IPPS DRG system
received new technology add-on Gateway PTA Balloon Catheter. The prior to a DRG split) and in DRGs 533
payment beyond the 2–3 year period device is used to treat stenoses that (Extracranial Procedure with CC) and
that the devices could be considered occur in the intracranial vessels. Prior to 534 (Extracranial Procedure Without
new. As noted in the proposed rule, stent placement, the Gateway PTA CC). Even though DRG 5 was split into
commenters argued that, by CMS’ own Balloon is inflated to dilate the target DRGs 533 and 534 in FY 2003, some
rationale, payment beyond this period lesion, and then the stent is deployed hospitals continued to use DRG 5 for
was designed to provide payment across the lesion to restore and maintain non-Medicare cases. The applicant
predictability and consistency for the luminal patency. Effective October 1, found 22 cases that had an intracranial
PTA with a stent. The average III. Changes to the Hospital Wage Index hospitals participating in the Medicare
(nonstandardized) charge per case was program, in order to construct an
A. Background
$78,363. occupational mix adjustment to the
Section 1886(d)(3)(E) of the Act wage index. A discussion of the
The applicant also submitted data requires that, as part of the methodology occupational mix adjustment that we
from the FY 2002 and FY 2003 MedPAR for determining prospective payments to are applying beginning October 1, 2005
files. Using the latest data from the FY hospitals, the Secretary must adjust the (the FY 2006 wage index) appears under
2003 MedPAR and the same standardized amounts ‘‘for area section III.C. of this preamble.
combination of diagnosis and procedure differences in hospital wage levels by a
codes mentioned above to identify cases factor (established by the Secretary) B. Core-Based Statistical Areas Used for
of intracranial PTA with stenting, the reflecting the relative hospital wage the Proposed Hospital Wage Index
applicant found 116 cases in DRG 533 level in the geographic area of the The wage index is calculated and
and 20 cases in DRG 534. The case- hospital compared to the national assigned to hospitals on the basis of the
weighted average standardized charge average hospital wage level.’’ In labor market area in which the hospital
per case was $51,173. The average case- accordance with the broad discretion is located. In accordance with the broad
weighted threshold was $25,394. Based conferred under the Act, we currently discretion under section 1886(d)(3)(E) of
on this analysis, the applicant define hospital labor market areas based the Act, beginning with FY 2005, we
maintained that the technology meets on the definitions of statistical areas define hospital labor market areas based
the cost criteria since the average case- established by the Office of Management on the Core-Based Statistical Areas
weighted standardized charge per case and Budget (OMB). A discussion of the (CBSAs) established by OMB and
is greater than the average case- FY 2006 hospital wage index based on announced in December 2003 (69 FR
the statistical areas, including OMB’s 49027). OMB defines a CBSA, beginning
weighted threshold.
revised definitions of Metropolitan in 2003, as ‘‘a geographic entity
The applicant also maintained that Areas, appears under section III.B. of associated with at least one core of
the technology meets the substantial this preamble. 10,000 or more population, plus
clinical improvement criterion. Beginning October 1, 1993, section adjacent territory that has a high degree
Currently, there is no available surgical 1886(d)(3)(E) of the Act requires that we of social and economic integration with
or medical treatment for recurrent stroke update the wage index annually. the core as measured by commuting
that occurs despite optimal medical Furthermore, this section provides that ties.’’ The standards designate and
management. The WingspanTM is the the Secretary base the update on a define two categories of CBSAs:
first commercially available PTA/stent survey of wages and wage-related costs Metropolitan Statistical Areas (MSAs)
system designed specifically for the of short-term, acute care hospitals. The and Micropolitan Statistical Areas (65
intracranial vasculature. However, survey should measure the earnings and FR 82235).
because the WingspanTM does not have paid hours of employment by According to OMB, MSAs are based
FDA approval or Medicare coverage, as occupational category, and must on urbanized areas of 50,000 or more
exclude the wages and wage-related population, and Micropolitan Statistical
stated above, in the FY 2006 IPPS
costs incurred in furnishing skilled Areas (referred to in this discussion as
proposed rule, we proposed to deny
nursing services. This provision also Micropolitan Areas) are based on urban
add-on payment for this new requires us to make any updates or clusters with a population of at least
technology. adjustments to the wage index in a 10,000 but less than 50,000. Counties
We received no public comments manner that ensures that aggregate that do not fall within CBSAs are
regarding this application for add-on payments to hospitals are not affected deemed ‘‘Outside CBSAs.’’ In the past,
payments prior to the publication of the by the change in the wage index. The OMB defined MSAs around areas with
FY 2006 IPPS proposed rule. adjustment for FY 2006 is discussed in a minimum core population of 50,000,
During the 60-day comment period for section II.B. of the Addendum to this and smaller areas were ‘‘Outside
the FY 2006 IPPS proposed rule, we final rule. MSAs.’’
As discussed below in section III.H. of The general concept of the CBSAs is
received the following comment: this preamble, we also take into account that of an area containing a recognized
Comment: One commenter, the the geographic reclassification of population nucleus and adjacent
applicant, commented that the hospitals in accordance with sections communities that have a high degree of
WingspanTM represents a substantial 1886(d)(8)(B) and 1886(d)(10) of the Act integration with that nucleus. The
clinical improvement over what is when calculating the wage index. Under purpose of the standards is to provide
currently available to treat patients with section 1886(d)(8)(D) of the Act, the nationally consistent definitions for
intracranial atherosclerotic disease, and Secretary is required to adjust the collecting, tabulating, and publishing
who suffer from recurring stroke and standardized amounts so as to ensure Federal statistics for a set of geographic
recommended that, upon FDA approval that aggregate payments under the IPPS areas. CBSAs include adjacent counties
of the WingspanTM, CMS determine the after implementation of the provisions that have a minimum of 25 percent
most appropriate payment for this new of sections 1886(d)(8)(B) and (C) and commuting to the central counties of the
therapy. 1886(d)(10) of the Act are equal to the area. (This is an increase over the
aggregate prospective payments that minimum commuting threshold of 15
Response: We thank the commenter would have been made absent these percent for outlying counties applied in
for its comments and upon FDA provisions. The budget neutrality the previous MSA definition.)
approval we encourage the applicant to adjustment for FY 2006 is discussed in The new CBSAs established by OMB
reapply for new technology add-on section II.B. of the Addendum to this comprised MSAs and the new
payments. However, because the final rule. Micropolitan Areas based on Census
WingspanTM does not have FDA Section 1886(d)(3)(E) of the Act also 2000 data. (A copy of the announcement
approval or Medicare coverage, we are provides for the collection of data every may be obtained at the following
finalizing our proposal to deny add-on 3 years on the occupational mix of Internet address: http://
payment for this new technology. employees for short-term, acute care www.whitehouse.gov/omb/bulletins/
fy04/b04–03.html.) The definitions MGCRB, both during this transition reasonable and appropriate to adopt the
recognize 49 new MSAs and 565 new period as well as in subsequent years. new designations for FY 2006.
Micropolitan Areas, and extensively These hospitals will be considered rural Comment: One commenter noted that,
revised the composition of many of the for reclassification purposes. while CMS provided urban hospitals
existing MSAs. In addition, in the FY 2005 IPPS final that became rural under the new
The new area designations resulted in rule (69 FR 49032 and 49033), we definitions hold harmless protection for
a higher wage index for some areas and provided a 1-year transition blend for 3 years, urban hospitals that remained
lower wage index for others. Further, hospitals that, due solely to the changes in MSAs that experienced large wage
some hospitals that were previously in the labor market definitions, index reductions did not receive that
classified as urban are now in rural experienced a decrease in their FY 2005 same protection. The commenter stated
areas. Given the significant payment wage index compared to the wage index that, although all hospitals that
impacts upon some hospitals because of they would have received using the experienced a decrease in their wage
these changes, we provided a transition labor market areas included in index from the effects of the labor
period to the new labor market areas in calculating their FY 2004 wage index. market area changes received a 1-year
the FY 2005 IPPS final rule (69 FR Hospitals that experienced a decrease in blended transition, this transition
49027 through 49034). As part of that their wage index as a result of adoption expires on September 30, 2005. The
transition, we allowed urban hospitals of the new labor market area changes commenter urged CMS to provide hold
that became rural under the new received a wage index based on 50 harmless protection to all hospitals that
definitions to maintain their assignment percent of the CBSA labor market area experienced a wage index decrease of
to the Metropolitan Statistical Area definitions and 50 percent of the wage more than 10 percent as a result of the
(MSA) where they were previously index that the provider would have new labor market areas, regardless of
located for the 3-year period of FY 2005, received under the FY 2004 MSA whether the hospital remained urban or
FY 2006, and FY 2007. Specifically, boundaries (in both cases using the FY rural.
these hospitals were assigned the wage 2001 wage data). This blend applied to Response: We refer readers to the FY
index of the urban area to which they any provider experiencing a decrease 2005 IPPS final rule for a full discussion
previously belonged. (For purposes of due to adoption of the new definitions, of our rationale for limiting hold
wage index computation, the wage data including providers who were harmless protection to a particular
of these hospitals remained assigned to reclassifying under MGCRB group of hospitals (69 FR 49032).
the statewide rural area in which they requirements, section 1886(d)(8)(B) of Comment: A few commenters
are located.) The hospitals receiving this the Act, or section 508 of Pub. L. 108– addressed the use of Micropolitan Areas
transition will not be considered urban 173. In the FY 2005 IPPS final rule (69 as geographic areas. They stated that
hospitals; rather they will maintain their FR 49027 through 49033), we described because CMS assigns Micropolitan
status as rural hospitals. Thus, the the determination of this blend in detail. Areas to the statewide rural area for
hospital would not be eligible, for We noted that this blend does not purposes of the IPPS, several hospitals,
example, for a large urban add-on prevent a decrease in wage index due to by virtue of now being in a Micropolitan
payment under the capital PPS. In other any reason other than adoption of county, are reclassified as rural despite
words, it is the wage index, but not the CBSAs, nor does it apply to hospitals their previous designation as an urban
urban or rural status, of these hospitals that benefited from a higher wage index hospital. They noted that, although CMS
that is being affected by this transition. due to the new labor market definitions. provided a 3-year transition period to
The higher wage indices that these Consistent with the FY 2005 IPPS help alleviate the decreased wage index
hospitals are receiving are also being final rule, beginning in FY 2006, we are payments for hospitals that were
taken into consideration in determining providing that hospitals receive 100 previously classified as urban and are
whether they qualify for the out- percent of their wage index based upon now in rural areas based on the new
commuting adjustment discussed in the new CBSA configurations. definitions, this transition did not
section III.I. of this preamble and the Specifically, we have determined for ameliorate any reductions in DSH
amount of any adjustment. each hospital a new wage index for FY payments, because the transition did not
FY 2006 will be the second year of 2006 employing wage index data from affect a hospital’s urban/rural status.
this transition period. We will continue FY 2002 hospital cost reports and using They emphasized that, while urban
to assign the wage index for the urban the CBSA labor market definitions. hospitals of 100 or more beds have no
area in which the hospital was Comment: Commenters asked CMS to cap on DSH payments, rural hospitals of
previously located through FY 2007. In defer 100 percent adoption of the new all sizes are capped at 12 percent for
order to ensure this provision remains labor market area definitions to allow DSH payments. Commenters offered
budget neutral, we will continue to hospitals more time to adjust to the various recommendations about how to
adjust the standardized amount by a significant reimbursement impact. Most protect these hospitals from the changes
transition budget neutrality factor to commenters urged CMS to maintain the in the labor market area definitions.
account for these hospitals. Doing so is current 50 percent CBSA/50 percent Most commenters advocated allowing
consistent with the requirement of MSA blend. One commenter proposed counties that are reclassified as
section 1886(d)(3)(E) of the Act that any using a 75 percent CBSA/25 percent Micropolitan Areas despite their
‘‘adjustments or updates [to the MSA blend. previous urban designation to be
adjustment for different area wage Response: We have decided not to grandfathered into their previously
levels] * * * shall be made in a manner provide for a longer transition because urban MSA. Other commenters
that assures that aggregate payments we have already, in effect, provided 1 recommended that CMS provide an
* * * are not greater or less than those year at a higher wage index for hospitals exception to these hospitals under
that would have been made in the year by delaying full implementation of the section 1886(d)(5)(I)(i) of the Act.
without such adjustment.’’ new Census designations. Given that the Further, commenters suggested that
Beginning in FY 2008, these hospitals new designations are based on the most CMS adopt OMB’s new standards for
will receive their statewide rural wage recent Census data, whereas the prior use in defining labor market areas, but
index, although they will be eligible to labor market areas are based on 1990 lower the commuting threshold used by
apply for reclassification by the Census data, we believe it is both OMB to define CBSAs.
Response: We disagree with the FY 2005 IPPS final rule for our adoption same CMS Wage Index Occupational
commenters that hospitals that changed of the new Census designations as well Mix Survey and Bureau of Labor
status from urban to rural received no as the treatment of Micropolitan areas as Statistics (BLS) data that we used for the
amelioration with respect to DSH. As rural (69 FR 49027). FY 2005 wage index, with two
stated in the FY 2005 IPPS final rule (69 C. Occupational Mix Adjustment to FY exceptions. The CMS survey requires
FR 49033), the provisions of § 412.102 2006 Index hospitals to report the number of total
provide special protections for hospitals paid hours for directly hired and
against abrupt reductions in DSH As stated earlier, section 1886(d)(3)(E) contract employees in occupations that
payments resulting from transitions of the Act provides for the collection of
provide the following services: Nursing,
from urban to rural status. Specifically, data every 3 years on the occupational
physical therapy, occupational therapy,
as described in § 412.102, in the first mix of employees for each short-term,
acute care hospital participating in the respiratory therapy, medical and
year after a hospital loses urban status, clinical laboratory, dietary, and
the hospital will receive an additional Medicare program, in order to construct
an occupational mix adjustment to the pharmacy. These services each include
payment that equals two-thirds of the several standard occupational
wage index, for application beginning
difference between the urban classifications (SOCs), as defined by the
October 1, 2004 (the FY 2005 wage
disproportionate share payments BLS’ Occupational Employment
index). The purpose of the occupational
applicable to the hospital before its Statistics (OES) survey. For the FY 2006
mix adjustment is to control for the
redesignation from urban to rural and wage index, we used revised survey
effect of hospitals’ employment choices
the rural disproportionate share data for 20 hospitals that took advantage
on the wage index. For example,
payments applicable to its redesignation hospitals may choose to employ of the opportunity we afforded hospitals
from urban to rural. In the second year different combinations of registered to submit changes to their occupational
after the hospital loses urban status, the nurses, licensed practical nurses, mix data during the FY 2006 wage index
hospital will receive an additional nursing aides, and medical assistants for data collection process (see discussion
payment that equals one-third of the the purpose of providing nursing care to of wage data corrections process under
difference between the urban their patients. The varying labor costs section III.J. of this preamble). We also
disproportionate share payments associated with these choices reflect excluded survey data for hospitals that
applicable to the hospital before its hospital management decisions rather became designated as CAHs since the
redesignation from urban to rural and than geographic differences in the costs original survey data were collected and
the rural disproportionate share of labor. hospitals for which there are no
payments applicable to its redesignation
1. Development of Data for the corresponding cost report data for the
from urban to rural. Because hospitals
Occupational Mix Adjustment FY 2006 wage index. The FY 2006 wage
are already receiving adequate relief
index includes occupational mix data
with respect to DSH payments, we do In the FY 2005 IPPS final rule (69 FR
not believe it is necessary to address the from 3,541 out of 3,742 hospitals (94.6
49034), we discussed in detail the data
commenters’ recommendations we used to calculate the occupational percent response rate). The results of the
regarding grandfathering, exceptions, or mix adjustment to the FY 2005 wage occupational mix survey are included in
use of lower commuting thresholds. We index. For the final FY 2006 wage the chart below.
refer readers to the explanation in the index, as proposed, we are using the BILLING CODE 4120–01–P
ER12AU05.000</GPH>
BILLING CODE 4120–01–C hospitals should receive a special is determined by multiplying the
Comment: Two commenters noted reward for completing and submitting percentage of the general service
that the ‘‘Medicare Occupational Mix the occupational mix survey. Rather, a category (from Step 1) by the national
Survey Results’’ table in the FY 2006 hospital should deem the submission of average hourly rate for that SOC from
proposed rule (70 FR 23369) did not occupational mix data as a necessary the 2001 BLS OES survey, which was
include data pertaining to medical and part of its responsibility to provide used in calculating the occupational
clinical laboratory services, all other complete and accurate data for the wage mix adjustment for the FY 2005 wage
occupations, and total hospital index. We also note that implementing index. The 2001 OES survey is BLS’
employees. The commenters requested an occupational mix adjustment so that latest available hospital-specific survey.
that CMS publish the complete table in it applies to reporting hospitals only (See Chart 4 in the FY 2005 IPPS final
the final rule. when it is beneficial to such hospitals rule, 69 FR 49038.) Repeat this
Response: We apologize for any would defeat the purpose of the calculation for each of the 19 SOCs.
inconveniences caused by the misprint occupational mix adjustment.
of the table in the proposed rule. The Step 3—For each hospital, the
above table includes the complete set of 2. Calculation of the FY 2006 hospital’s adjusted average hourly rate
occupational mix survey results for the Occupational Mix Adjustment Factor for a general service category is
final FY 2006 wage index. and the FY 2006 Occupational Mix computed by summing the weighted
Comment: As a mechanism to achieve Adjusted Wage Index hourly rate for each SOC within the
a higher response rate, one commenter general category. Repeat this calculation
For the final FY 2006 wage index, we
recommended that CMS reward used the same methodology that we for each of the seven general service
hospitals that submit occupational mix used to calculate the occupational mix categories.
survey data. The commenter suggested adjustment to the FY 2005 wage index Step 4—For each hospital, the
that, for hospitals that submit (69 FR 49042). We used the following occupational mix adjustment factor for
occupational mix data, CMS should steps for calculating the FY 2006 a general service category is calculated
apply a higher percentage of the occupational mix adjustment factor and by dividing the national adjusted
occupational mix adjustment if the the occupational mix adjusted wage average hourly rate for the category by
adjustment results in a positive impact, index: the hospital’s adjusted average hourly
and a lower percentage if the adjustment Step 1—For each hospital, the rate for the category. (The national
results in a negative impact. percentage of the general service adjusted average hourly rate is
Response: Although the commenter’s category attributable to an SOC is computed in the same manner as Steps
suggestion pertaining to a procedural determined by dividing the SOC hours 1 through 3, using instead, the total SOC
mechanism by which CMS conducts the by the general service category’s total and general service category hours for
occupational mix survey is not a subject hours. Repeat this calculation for each all hospitals in the occupational mix
of the final policies included in this of the 19 SOCs. survey database.) Repeat this calculation
final rule, we note that we disagree with Step 2—For each hospital, the for each of the seven general service
ER12AU05.001</GPH>
the suggestion. We do not believe that weighted average hourly rate for an SOC categories. If the hospital’s adjusted rate
is less than the national adjusted rate Step 9—To compute the occupational collections, we would revise the
(indicating the hospital employs a less mix adjusted wage index, divide each occupational mix survey to allow
costly mix of employees within the area’s occupational mix adjusted hospitals to provide both salaries and
category), the occupational mix average hourly wage (Step 7) by the hours data for each of the employment
adjustment factor will be greater than national occupational mix adjusted categories that are included on the
1.0000. If the hospital’s adjusted rate is average hourly wage (Step 8). survey. We also indicated that we
greater than the national adjusted rate, Step 10—To compute the Puerto Rico would assess whether future
the occupational mix adjustment factor specific occupational mix adjusted wage occupational mix surveys should be
will be less than 1.0000. index, follow Steps 1 through 9 above. based on the calendar year or if the data
Step 5—For each hospital, the The Puerto Rico occupational mix should be collected on a fiscal year basis
occupational mix adjusted salaries and adjusted average hourly wage for FY as part of the Medicare cost report. (One
wage-related costs for a general service 2006 is $12.7985. logistical problem is that cost report
category are calculated by multiplying An example of the occupational mix data are collected yearly, but
the hospital’s total salaries and wage- adjustment was included in the FY 2005 occupational mix survey data are
related costs (from Step 5 of the IPPS final rule (69 FR 49043). collected only every 3 years.) We are
unadjusted wage index calculation in For the FY 2005 final wage index, we currently reviewing options for revising
section III.F. of this preamble) by the used the unadjusted wage data for the occupational mix survey and
percentage of the hospital’s total hospitals that did not submit improving the data collection process.
workers attributable to the general occupational mix survey data. For
Comment: Several commenters
service category and by the general calculation purposes, this equates to
provided recommendations for the
service category’s occupational mix applying the national SOC mix to the
design and release of a revised
adjustment factor (from Step 4 above). wage data for these hospitals, because
occupational mix survey.
Repeat this calculation for each of the hospitals having the same mix as the
Nation would have an occupational mix Response: We plan to release a
seven general service categories. The
adjustment factor equaling 1.0000. In revised occupational mix survey in an
remaining portion of the hospital’s total
the FY 2005 IPPS final rule (69 FR upcoming Federal Register notice. We
salaries and wage-related costs that is
49035), we noted that we would revisit will address the design and data
attributable to all other employees of the
this matter with subsequent collections collection issues, including the
hospital is not adjusted for occupational
of the occupational mix data. Because commenters’ recommendations, as part
mix.
Step 6—For each hospital, the total we are using essentially the same survey of that notice.
occupational mix adjusted salaries and data for the FY 2006 occupational mix In our continuing efforts to meet the
wage-related costs for a hospital are adjustment that we used for FY 2005, information needs of the public, we
calculated by summing the occupational with the only exceptions as stated in provided via the Internet three
mix adjusted salaries and wage-related section III.C.1. of this preamble, we are additional public use files for the
costs for the seven general service treating the wage data for hospitals that proposed occupational mix adjusted
categories (from Step 5) and the did not respond to the survey in this wage index concurrently with the
unadjusted portion of the hospital’s same manner for the FY 2006 wage publication of the FY 2006 IPPS
salaries and wage-related costs for all index. proposed rule: (1) A file including each
other employees. To compute a In implementing an occupational mix hospital’s unadjusted and adjusted
hospital’s occupational mix adjusted adjusted wage index based on the above average hourly wage (FY 2006 Proposed
average hourly wage, divide the calculation, the wage index values for Rule Occupational Mix Adjusted and
hospital’s total occupational mix 14 rural areas (29.8 percent) and 206 Unadjusted Average Hourly Wage by
adjusted salaries and wage-related costs urban areas (53.4 percent) would Provider); (2) a file including each
by the hospital’s total hours (from Step decrease as a result of the adjustment. CBSA’s adjusted and unadjusted
4 of the unadjusted wage index Seven (7) rural areas (14.9 percent) and average hourly wage (FY 2006 Proposed
calculation in section III.F. of this 111 urban areas (28.8 percent) would Rule Occupational Mix Adjusted and
preamble). experience a decrease of 1 percent or Unadjusted Average Hourly Wage and
Step 7—To compute the occupational greater in their wage index values. The Pre-Reclassified Wage Index by CBSA);
mix adjusted average hourly wage for an largest negative impact for a rural area and (3) a file including each hospital’s
urban or rural area, sum the total would be 1.9 percent and for an urban occupational mix adjustment factors by
occupational mix adjusted salaries and area, 4.2 percent. Meanwhile, 32 rural occupational category (Provider
wage-related costs for all hospitals in areas (68.1 percent) and 179 urban areas Occupational Mix Adjustment Factors
the area, then sum the total hours for all (46.4 percent) would experience an for Each Occupational Category). We
hospitals in the area. Next, divide the increase in their wage index values. also plan to post these files via the
area’s occupational mix adjusted Although these results show that rural Internet with future applications of the
salaries and wage-related costs by the hospitals would gain the most from an occupational mix adjustment.
area’s hours. occupational mix adjustment to the D. Worksheet S–3 Wage Data for the FY
Step 8—To compute the national wage index, their gains may not be as 2006 Wage Index Update
occupational mix adjusted average great as might have been expected.
hourly wage, sum the total occupational Further, it might not have been The FY 2006 wage index values
mix adjusted salaries and wage-related anticipated that almost one-third of (effective for hospital discharges
costs for all hospitals in the Nation, then rural hospitals would actually fare occurring on or after October 1, 2005
sum the total hours for all hospitals in worse under the adjustment. Overall, a and before October 1, 2006) in section
the Nation. Next, divide the national fully implemented occupational mix VI. of the Addendum to this final rule
occupational mix adjusted salaries and adjusted wage index would have a are based on the data collected from the
wage-related costs by the national redistributive effect on Medicare Medicare cost reports submitted by
hours. The national occupational mix payments to hospitals. hospitals for cost reporting periods
adjusted average hourly wage for FY In the FY 2005 IPPS proposed rule, beginning in FY 2002 (the FY 2005 wage
2006 is $28.0272. we indicated that, for future data index was based on FY 2001 wage data).
The FY 2006 wage index includes the and for the development of reasonable longstanding requirement that, for
following categories of data associated deferred compensation plan costs for purposes of program payment, providers
with costs paid under the IPPS (as well purposes of the wage index. must timely liquidate their liabilities.
as outpatient costs): With the FY 2007 wage index, GAAP does not specify a time
∑ Salaries and hours from short-term, hospitals and fiscal intermediaries must requirement for recognizing accrued
acute care hospitals (including paid ensure that pension, post-retirement costs.
lunch hours and hours associated with health benefits, and other deferred In 2003, we updated the cost report
military leave and jury duty). compensation plan costs for the wage instructions in section 3605.2 of the
∑ Home office costs and hours. index are developed according to the PRM, Part II, to also clarify the
∑ Certain contract labor costs and above terms. September 1, 1994 instructions for the
hours (which includes direct patient Comment: A few commenters wage index. At the instructions for
care, certain top management, addressed our discussion regarding the wage-related costs, lines 13 through 20,
pharmacy, laboratory, and nonteaching treatment of pension, post-retirement we noted that, ‘‘Although hospitals
physician Part A services). health benefits, and other deferred must use GAAP in developing wage-
∑ Wage-related costs, including compensation costs for purposes of the related costs, the amount reported for
pensions and other deferred wage index. Two commenters expressed wage index purposes must meet the
compensation costs. concern that the instructions are a reasonable cost provisions of Medicare.’’
The September 1, 1994 Federal significant change from our original The clarification was to ensure that a
Register (59 FR 45356) included a list of instructions published September 1, hospital includes in the wage index
core wage-related costs that are 1994. The commenters asserted that only those pension and other deferred
included in the wage index, and CMS provided no rationale for moving compensation plan costs that meet the
discussed criteria for including other away from using GAAP for developing timely liquidation requirements for
wage-related costs. In that discussion, these costs for the wage index, and Medicare reasonable cost principles.
we instructed hospitals to use generally requested an additional opportunity for When CMS issued the September 1,
accepted accounting principles (GAAPs) public comment. One commenter 1994 instructions, CMS did not
in developing wage-related costs for the suggested that using GAAP provides a anticipate nor intend for hospitals to
wage index for cost reporting periods more consistent methodology for include costs in the wage index that
beginning on or after October 1, 1994. capturing these costs than Medicare have not been funded and may never be
We discussed our rationale that ‘‘the reasonable cost principles. A fourth funded. Including unfunded deferred
application of GAAPs for purposes of commenter requested a more specific compensation costs in the wage index
compiling data on wage-related costs description of the treatment of pension, can significantly misrepresent an area’s
used to construct the wage index will post-retirement health benefits, and average hourly wage, especially if the
more accurately reflect relative labor other deferred compensation costs if plan is never funded. In a May 4, 2005
costs, because certain wage-related costs there are other ‘‘related Medicare Early Alert to CMS’s Administrator, the
(such as pension costs), as recorded program instructions’’ as we stated OIG stated that ‘‘While some hospitals
under GAAPs, tend to be more static above. include millions of dollars in unfunded
from year to year.’’ Response: For cost reporting periods pension and other postretirement
Since publication of the September 1, beginning prior to October 1, 1994, benefit costs in the annual wage data
1994 rule, we have periodically received hospitals were required to include in shown on their Medicare cost reports,
inquiries for more specific guidance on the wage index only the amount of others include only funded amounts. As
developing wage-related costs for the actual payments that the hospital made a result, the wage indexes for the
wage index. In response, we have to retirees in the reporting year. For hospitals that include unfunded
provided clarifications in the IPPS rules periods beginning on or after October 1, amounts are inflated, which leads to an
(for example, health insurance costs (66 1994, CMS instructed hospitals to use inadequate distribution of Medicare
FR 39859)) and in the cost report GAAPs, an accrual method of payments among hospitals.’’ In
instructions (Provider Reimbursement accounting, for developing pension, addition, the OIG warned that ‘‘* * *
Manual (PRM), Part II, Section 3605.2). deferred compensation, and other wage- the hospitals’ inclusion of costs related
Due to recent questions and concerns related costs for wage index purposes. to unfunded liabilities could
we received regarding inconsistent All other wage costs on Worksheet S–3 compromise the reliability of the wage
reporting and overreporting of pension must reflect costs that are actually data that CMS uses to develop the
and other deferred compensation plan expended by the hospital during the market basket * * *. Thus, the
costs, as a result of an ongoing Office of cost reporting period. We believed then inclusion of costs related to unfunded
Inspector General review, we are and continue to believe that the use of liabilities in hospitals’ wage data could
clarifying in this final rule that hospitals accrual accounting allows hospitals to produce an inaccurate market basket
must comply with the requirements in be more inconsistent in their reporting index for use in updating payments to
42 CFR 413.100, the PRM, Part I, of wage-related costs from year to year hospitals.’’
sections 2140, 2141, and 2142, and so that the wage index could be more Regarding the comment requesting a
related Medicare program instructions static. specific description of the treatment of
for developing pension and other Section 413.24 of the regulations also pension, post-retirement health benefits,
deferred compensation plan costs as provides for the accrual basis of and other deferred compensation costs
wage-related costs for the wage index. accounting for developing costs under if there are other ‘‘related Medicare
The Medicare instructions for pension Medicare’s cost finding principles. program instructions,’’ we included this
costs and other deferred compensation However, a major difference between phrase to set forth that hospitals must
costs combine GAAPs, Medicare GAAP and Medicare principles for also comply with any future
payment principles, and Department of recognizable pension and other deferred instructions related to these costs that
Labor and Internal Revenue Service compensation plan costs is an issue of may be initially issued through
requirements. We believe that the funding. In § 413.100 (and as discussed rulemaking or a one-time notice before
Medicare instructions allow for both in 60 FR 33126, June 27, 2005), we being included in the above PRM
consistent reporting among hospitals clarified and codified CMS’ sections.
We believe that our discussion in the other providers that are paid under a wage data for a base year that could be
proposed rule was sufficient notification Medicare prospective payment system, impacted by Pub. L. 108–173 changes
for this policy clarification. Therefore, such as SNFs, HHAs, and LTCHs. for CAHs.
we do not agree that CMS should MedPAC recommended that CMS Data collected for the IPPS wage
provide another comment period for begin collecting wage data from CAHs index are also currently used to
this matter. In addition, we believe that this year. calculate wage indices applicable to
hospitals and intermediaries should be Response: In the FY 2004 final rule other providers, such as SNFs, home
able to ensure that pension and other (68 FR 45397), we provided a complete health agencies, and hospices. In
deferred compensation costs are discussion, rationale, and analysis of addition, they are used for prospective
developed according to the above terms our policy for excluding CAHs from the payments to rehabilitation, psychiatric,
by the FY 2007 wage index, as hospitals wage index. In that rule, we stated that and long-term care hospitals, and for
have been required, since cost reporting CAHs are not paid under the IPPS, and, hospital outpatient services. We note
periods beginning during FY 1995, to like other non-IPPS providers such as that in the IPPS rules, we do not address
complete Form 339, a reconciliation SNFs, HHAs, LTCHs, and children’s comments pertaining to the wage
worksheet between GAAP and Medicare hospitals, we have always excluded indices for non-PPS providers. Such
principles. non-IPPS providers from the wage index comments should be made in response
Consistent with the wage index calculation. We also stated that, due to to separate proposed rules for those
methodology for FY 2005, the wage their remote location and more limited providers.
index for FY 2006 also excludes the services, CAHs ‘‘are unique compared to In the FY 2005 IPPS final rule, we
direct and overhead salaries and hours other short-term acute care hospitals.’’ stated that a commenter had asked CMS
for services not subject to IPPS payment, Using data collected from cost reporting to designate provider-based clinics as
such as SNF services, home health periods beginning during FY 2000, we IPPS-excluded areas in order to remove
services, costs related to GME (teaching further noted that, in most labor market the costs from the wage index (69 FR
physicians and residents) and certified areas with hospitals that converted to 49049). The commenter noted that
registered nurse anesthetists (CRNAs), CAH status some time after FY 2000, the provider-based clinics are like physician
and other subprovider components that average hourly wage for CAHs was private offices, which are excluded from
are not paid under the IPPS. The FY significantly lower than the average the wage index calculation, and that
2006 wage index also excludes the hourly wage for other short-term services provided in the provider-based
salaries, hours, and wage-related costs hospitals in the area. As a result, with clinics are paid for not through the
of hospital-based rural health clinics the FY 2004 wage index, we began IPPS, but rather under the hospital
(RHCs), and Federally qualified health excluding the data for any CAH, even if outpatient PPS. In response to the
centers (FQHCs) because Medicare pays it was an IPPS provider during the wage comment, we stated that we were not
for these costs outside of the IPPS (68 index base year. prepared to grant the commenter’s
FR 45395). In addition, salaries, hours We agree with MedPAC that CAHs request without first studying the issue,
and wage-related costs of CAHs are have recently become more similar in and that we would explore the matter of
excluded from the wage index, for the composition, services, and proximity to salaries related to provider-based clinics
reasons explained in the FY 2004 IPPS other rural hospitals, largely due to the in a future rule.
final rule (68 FR 45397). Pub. L. 108–173 (MMA). Section 405 of Regulations at 42 CFR 413.65 describe
Comment: Two commenters Pub. L. 108–173 allows for more the criteria and procedures for
recommended that CAHs be included in hospitals to now qualify and more determining whether a facility or
the wage index. One commenter seamlessly convert to CAH status. organization is provider-based.
suggested that CMS should exclude the However, because Pub. L. 108–173 was Historically, under the Medicare
wage data for a CAH only if it is enacted in calendar year 2003, it would program, some providers, referred to as
designated a CAH during the base year not affect the FY 2002 base year for the ‘‘main providers,’’ have functioned as
for the wage index calculation. MedPAC FY 2006 IPPS wage index. In addition, single entities while owning and
suggested that CMS should include the our analysis of the FY 2006 wage index operating multiple provider-based
wage data for all CAHs, even if the shows that rural areas are not harmed by departments, locations, and facilities
hospital is a CAH in the base year that the exclusion of CAHs. For FY 2006, we that are treated as part of the main
is used for calculating the wage index. removed the wage data for 162 hospitals provider for Medicare purposes. Section
In addition, MedPAC stated the in 39 rural areas because they became 413.65(a)(2) defines various types of
following: CAHs after they filed their FY 2002 cost provider-based facilities, including
∑ The wage index should ideally reports as IPPS hospitals. In all 39 rural ‘‘department of a provider.’’ A
reflect the data for all providers that are areas, the average hourly wages for FY ‘‘department of a provider’’ means a
similar in services and occupations to 2006 increased over those for FY 2005. facility or organization that is either
hospitals receiving payment under For 76.9 percent of the rural areas, the created by, or acquired by, a main
Medicare’s IPPS and OPPS. CAHs are average hourly wage increase is 5 provider for the purposes of furnishing
similar to other small rural hospitals percent or greater. health care services of the same type as
and in many cases are located close Therefore, we continue to believe that those furnished by the main provider
enough to IPPS hospitals to compete for it is prudent policy to remove the data under the name, ownership, and
the same workers. from CAHs from the wage index. As financial and administrative control of
∑ About 500 hospitals converted to such, we have excluded from the FY the main provider * * * a department
CAH status over the past 3 years. Since 2006 wage index in this final rule the of a provider may not itself be qualified
CAHs now dominate the rural areas for wages and hours for all hospitals that to participate in Medicare as a provider
some states, the data for CAHs may are currently designated as a CAH, even under § 489.2 * * * the term
become critical for an accurate if the hospital was paid under the IPPS ‘department of a provider’ does not
representation of rural area wage levels. during FY 2002, the cost reporting include an RHC or * * * an FQHC.’’
It is important to note that this period used in calculating the FY 2006 Thus, if a facility offers services that are
representation affects payment for not wage index. We will reconsider our similar to those provided in a
only the IPPS hospitals but also for policy when we can collect and analyze freestanding physician’s office, and the
facility meets the criteria to become argued that CMS should exclude index except for the fact that these
provider-based under § 413.65, the ‘‘hospital-owned provider-based entities are not paid under the IPPS.
facility would be considered a physician practices’’ from the wage Rather, wage data from RHCs and
‘‘department of a provider.’’ More index because, similar to RHCs and FQHCs are also not included in the
specifically, the hospital would FQHCs, the services provided by these wage index because, although they may
integrate the facility into the main facilities are also not paid for under the be provider-based, these entities are
provider’s outpatient department, since IPPS. The commenters alluded to the providers in their own right and may, by
the facility offers health care services of OIG 2004 Red Book (October 22, 2004), themselves, qualify to participate in
the same type as those furnished by the which proposed that CMS should Medicare as a provider under § 489.2.
main provider. In addition, because a eliminate provider-based designations As a general rule, we do not include the
physician’s office would not receive its for ‘‘hospital-owned physician wage data of facilities that are providers
own provider agreement or receive a practices,’’ since hospitals treat these in their own right in the IPPS wage
Medicare provider number under facilities as provider-based without index. Thus, the commenters are also
§ 489.2 unlike an FQHC or an RHC, it CMS’ approval. The commenters incorrect that ‘‘hospital-owned
cannot be considered a ‘‘provider-based questioned whether it would be ‘‘more provider-based physician practices’’
entity,’’ rather it would be considered a accurate and practical’’ to exclude all may, by themselves, be qualified to
department of a provider. (We note that ‘‘hospital-owned provider-based participate in Medicare as a provider
a provider-based RHC or FQHC may, by physician practices’’ from the wage under § 489.2 of the regulations, and
itself, be qualified to participate in index, in light of the OIG’s proposal. therefore, by definition, are not
Medicare as a provider under § 489.2 Lastly, the commenters asserted that ‘‘departments of a provider.’’ We note
and, thus, would be classified not as a CMS’ statement that the salaries and that § 489.2 does not list ‘‘hospital-
‘‘department of a provider’’ but as a wages of hospital employees working in owned provider-based physician
‘‘provider-based entity,’’ as defined at the outpatient areas of the hospital have practice’’ as one of the facilities that
§ 413.65(a)(2).) This provider-based historically been included in the wage may participate in Medicare as a
facility, or provider-based clinic, as the index since those employees often work provider. Further, while § 489.2 does list
commenter referred to it, would be both in the inpatient and outpatient ‘‘clinics’’ as a type of facility that can
reported on the main provider’s areas of the hospital, is inaccurate with participate in Medicare as a provider,
Medicare cost report as an outpatient respect to ‘‘hospital-owned provider- § 489.2(c) specifies that only clinics that
service cost center, on Worksheet A, based physician practices’’ because the furnish outpatient physical therapy and
line 60. With the exception of RHC and facilities do not provide services to IPPS speech pathology services may qualify
FQHC salaries that have been excluded areas of the hospital. as providers. Therefore, if a hospital
from the wage index beginning with FY Response: In the FY 2006 IPPS wishes that a physician practice be
2004 (68 FR 45395), the salaries proposed rule (70 FR 23371), we considered provider-based, the
attributable to employees working in discussed whether to include the costs physician practice, by definition, must
these outpatient service cost centers, of provider-based clinics in the wage be categorized as part of hospital
including emergency departments, are index because we stated in a response outpatient departments. As such, the
included in the main provider’s total to a comment in the FY 2005 IPPS final services provided in these provider-
salaries on Worksheet S–3, Part II, line rule (69 FR 49049) that we would based clinics are paid for by Medicare
1, and accordingly, are included in the explore the matter in a future rule. under the OPPS. Accordingly, it is
wage index calculation. We have Thus, we considered the issue and appropriate that the salaries and hours
historically included the salaries and concluded that it is appropriate to attributable to the provider-based clinics
wages of hospital employees working in include the salaries and hours of are included in the IPPS wage index.
the outpatient departments in the employees working in provider-based In response to the commenters’
calculation of the hospital wage index clinics in the wage index calculation. speculation as to whether it would be
since these employees often work in We came to this conclusion because ‘‘more accurate and practical’’ to
both the IPPS and in the outpatient provider-based clinics cannot qualify by exclude all ‘‘hospital-owned provider-
areas of the hospital. Consistent with themselves to participate in Medicare as based physician practices’’ from the
this longstanding treatment of a provider under § 489.2 of the wage index, in light of the OIG’s
outpatient salary costs in the wage regulations and are, therefore, proposal in the OIG 2004 Red Book
index calculation, we believe it is categorized as ‘‘departments of a (October 22, 2004), we believe the
appropriate to continue to include the provider’’ under the provider-based commenter is confusing the policies
salaries and wages of employees regulations at § 413.65. Accordingly, regarding (a) who should be considered
working in outpatient departments, they would be reported as part of the provider-based and (b) whether salaries
including provider-based clinics, in the main provider’s outpatient department and hours associated with provider-
wage index calculation. on line 60 of Worksheet C of the based clinics should be included in the
Comment: Two commenters objected Medicare cost report. In making this wage index. These are two different
to our clarification of historical policy conclusion, we distinguished provider- policy matters. On the first policy, we
that the salaries of employees working based clinics that are part of the hospital agree that firm oversight and consistent
in provider-based clinics should outpatient department and included in audit procedures for determining and
continue to be included in the wage the IPPS wage index from ‘‘provider- monitoring provider-based status are
index calculation. The commenters based entities’’ (such as SNFs, RHCs, necessary, since our existing payment
referred to these facilities as ‘‘hospital- and FQHCs) that are excluded from the systems provide for more generous
owned provider-based physician IPPS wage index because, under the payment to hospital outpatient
practices’’ that may be qualified to regulations at § 413.65, they participate departments than similar freestanding
participate in Medicare as providers in Medicare under their own provider facilities. However, the proposed rule
under § 489.2 of the regulations, and agreements. Commenters are incorrect discussed the second matter, not the
therefore, by definition, are not when they asserted that RHCs and first. The purpose of the discussion in
‘‘departments of a provider.’’ They FQHCs would be included in the wage the proposed rule was not to debate
whether physician practices should ever specific examples of cases where wage with incomplete or inaccurate data
be considered for provider-based status. index data is developed inconsistently, resulting in zero or negative, or
Certainly, we agree that freestanding or where intermediaries are interpreting otherwise aberrant, average hourly
physician offices, or facilities that have wage index policies inconsistently. wages. As a result, the final FY 2006
been denied provider-based status by Response: We are equally concerned wage index is calculated based on FY
the CMS Regional Office, should not be about consistent interpretation and 2002 wage data from 3,742 hospitals.
included in the wage index. Rather, the application of wage index policies by In constructing the FY 2006 wage
purpose of the discussion in the both intermediaries and hospitals, as the index, we include the wage data for
proposed rule was to clarify our wage index is a relative measure of area facilities that were IPPS hospitals in FY
longstanding policy that as long as a wage differences. Throughout the years, 2002, even for those facilities that have
hospital reports, and the CMS Regional we have revised and refined our policy since terminated their participation in
Office approves, that a facility which statements and cost reporting the program as hospitals, as long as
might formerly have been a freestanding instructions in order to achieve more those data do not fail any of our edits
physician office is provider-based, the accurate reporting of wage and hours for reasonableness. We believe that
proper categorization of such a facility data among hospitals and including the wage data for these
is as an outpatient department and the intermediaries. In addition, we seek to hospitals is, in general, appropriate to
wages and hours attributable to that close any loopholes in our policies that reflect the economic conditions in the
outpatient department are included in may result in varied applications among various labor market areas during the
the IPPS wage index. Thus, we believe hospitals. Our work to ensure accuracy relevant past period. However, we
the commenters’ reference to the OIG and consistency in the wage index is a exclude the wage data for CAHs (as
Red Book is misplaced. continuous effort. We encourage discussed in 68 FR 45397). The wage
Further, the commenters’ provide no hospitals and intermediaries to bring to index in this final rule excludes
support for their assertion that workers our attention any instances of perceived hospitals that are designated as CAHs by
in ‘‘hospital-owned provider-based inconsistencies. Also, we remind February 1, 2005, the date of the latest
physician practices’’ do not provide hospitals that the wage data correction available Medicare CAH listing at the
services to IPPS areas of the hospital. process is another mechanism that is time we released the proposed wage
We have not seen any evidence available for hospitals that require CMS’ index public use file (PUF) on February
suggesting that the employees working intervention to settle disputes with 25, 2005.
in provider-based clinics work intermediaries over wage index policy Comment: Two commenters
exclusively there, or in other outpatient interpretations (see section III.J. of this expressed concern that the wage data for
areas of the hospital. Furthermore, we preamble). two CAHs would not be removed from
believe it would be extremely the final FY 2006 wage index. The
E. Verification of Worksheet S–3 Wage commenters explained that the effective
complicated and unnecessary to attempt
Data date for conversion to CAH status for
to distinguish between the salaries and
hours of employees that work in the The wage data for the proposed FY both providers was in December 2004,
various outpatient areas of hospitals, for 2006 wage index were obtained from but because of the timing of the
purposes of computing the IPPS wage Worksheet S–3, Parts II and III of the FY notification of the CAH status, the
index. Hospitals often maintain 2002 Medicare cost reports. Instructions providers’ wage data was included in
provider-based facilities since the for completing the Worksheet S–3, Parts the February 25, 2005 PUF, and in
Medicare payment for services provided II and III are in the Provider Tables 2 and 4A that accompanied
in a hospital (provider-based) setting is Reimbursement Manual, Part I, sections publication of the proposed rule. The
typically more than the payment would 3605.2 and 3605.3. The data file used to commenters noted that, although CMS
be for the same service provided in a construct the wage index includes FY subsequently removed these providers’
freestanding setting. Hospitals should 2002 data as of June 30, 2005. As in past wage data from the May 6, 2005 PUF,
not be permitted to treat these facilities years, we performed an intensive review their wage data continued to be
as part of the hospital for one purpose, of the wage data, mostly through the use included in the revised Table 2 that was
and separate from the hospital for of edits designed to identify aberrant posted June 1, 2005 on the CMS Web
purposes of the wage index. If hospitals data. site. The commenters asked for
wish to exclude certain facilities from We asked our fiscal intermediaries to assurance that the wage data for these
the wage index, they have the option to revise or verify data elements that two CAHs would not be included in the
do so by converting them to resulted in specific edit failures. While final FY 2006 wage index.
freestanding facilities. Therefore, as most of the edit failures were resolved, Response: As stated in the FY 2004
stated in the FY 2006 proposed rule, we did remove the wage data of some IPPS final rule (68 FR 45398), we
consistent with our longstanding policy, hospitals from the final FY 2006 wage exclude providers from the wage index
we continue to believe that it is index. For the final FY 2006 wage index that were designated as CAHs by 7 or
appropriate to include the salaries and in this final rule, we removed the data more days prior to the posting of the
hours of employees working in the for 235 hospitals from our database: 201 preliminary PUF. This year, since the
outpatient departments, including hospitals became CAHs between preliminary PUF was posted on
provider-based clinics, in the wage February 20, 2004, the cutoff date for February 25, 2005, we excluded
index calculation. exclusion of CAHs from the FY 2005 providers that were designated as CAHs
Comment: Two commenters wage index, and February 18, 2005, this by February 18, 2005. These hospitals
expressed concern that the data used in year’s cutoff date for the exclusion of were both designated as CAHs prior to
calculating the wage index are CAHS from the FY 2006 wage index, February 18, 2005, and should not be
developed inconsistently across the and 27 hospitals were low Medicare included in the FY 2006 wage index
Nation. One of the commenters stressed utilization hospitals or failed edits that calculations. The commenters are
the need for consistent interpretation could not be corrected because the correct that, initially, we did not receive
and application of all wage index hospitals terminated the program or notification of the providers’ CAH status
policies by all fiscal intermediaries. The changed ownership. In addition, we in time to remove their wage data from
commenters did not provide any removed the wage data for 7 hospitals the February 25, 2005 PUF. We did not
include their wage data in the May 6, the Part B salaries reported on Lines 3, total salaries (plus wage-related costs)
2005 PUF. However, these hospitals 5 and 5.01, home office salaries reported and hours derived in Steps 2 and 3.
continued to be included in the updated on Line 7, and excluded salaries Step 5—For each hospital, we
Table 2 posted on the CMS Web site on reported on Lines 8 and 8.01 (that is, adjusted the total salaries plus wage-
June 1, 2005 because these revisions to direct salaries attributable to SNF related costs to a common period to
the wage data were based on the services, home health services, and determine total adjusted salaries plus
February 25, 2005 PUF. However, the other subprovider components not wage-related costs. To make the wage
data for these two CAHs are not subject to the IPPS). We also subtracted adjustment, we estimated the percentage
included in the FY 2006 final wage from Line 1 the salaries for which no change in the employment cost index
index calculations. We note that these hours were reported. To determine total (ECI) for compensation for each 30-day
two providers will continue to appear salaries plus wage-related costs, we increment from October 14, 2001
on Table 2 published along with the FY added to the net hospital salaries the through April 15, 2003 for private
2006 final rule because, although no costs of contract labor for direct patient industry hospital workers from the
average hourly wage will be listed next care, certain top management, Bureau of Labor Statistics’
to these providers for FY 2006, they did pharmacy, laboratory, and nonteaching Compensation and Working Conditions.
have wage data that contributed to the physician Part A services (Lines 9 and We use the ECI because it reflects the
wage index for their CBSA in FY 2004 10), home office salaries and wage- price increase associated with total
and FY 2005. related costs reported by the hospital on compensation (salaries plus fringes)
F. Computation of the FY 2006 Lines 11 and 12, and nonexcluded area rather than just the increase in salaries.
Unadjusted Wage Index wage-related costs (Lines 13, 14, and In addition, the ECI includes managers
18). as well as other hospital workers. This
The method used to compute the FY We note that contract labor and home methodology to compute the monthly
2006 wage index without an update factors uses actual quarterly ECI
office salaries for which no
occupational mix adjustment follows: data and assures that the update factors
corresponding hours are reported were
Step 1—As noted above, we based the match the actual quarterly and annual
FY 2006 wage index on wage data not included. In addition, wage-related
costs for nonteaching physician Part A percent changes. The factors used to
reported on the FY 2002 Medicare cost adjust the hospital’s data were based on
reports. We gathered data from each of employees (Line 18) are excluded if no
corresponding salaries are reported for the midpoint of the cost reporting
the non-Federal, short-term, acute care period, as indicated below.
hospitals for which data were reported those employees on Line 4.
on the Worksheet S–3, Parts II and III of Step 3—Hours—With the exception of
wage-related costs, for which there are MIDPOINT OF COST REPORTING
the Medicare cost report for the
hospital’s cost reporting period no associated hours, we computed total PERIOD
beginning on or after October 1, 2001 hours using the same methods as
described for salaries in Step 2. Adjust-
and before October 1, 2002. In addition, After Before ment
we included data from some hospitals Step 4—For each hospital reporting factor
that had cost reporting periods both total overhead salaries and total
beginning before October 2001 and overhead hours greater than zero, we 10/14/2001 ............ 11/15/2001 1.06469
reported a cost reporting period then allocated overhead costs to areas of 11/14/2001 ............ 12/15/2001 1.06007
the hospital excluded from the wage 12/14/2001 ............ 1/15/2002 1.05566
covering all of FY 2002. These data were 01/14/2002 ............ 02/15/2002 1.05139
included because no other data from index calculation. First, we determined
02/14/2002 ............ 03/15/2002 1.04725
these hospitals would be available for the ratio of excluded area hours (sum of 03/14/2002 ............ 04/15/2002 1.04317
the cost reporting period described Lines 8 and 8.01 of Worksheet S–3, Part 04/14/2002 ............ 05/15/2002 1.03907
above, and because particular labor II) to revised total hours (Line 1 minus 05/14/2002 ............ 06/15/2002 1.03496
market areas might be affected due to the sum of Part II, Lines 2, 3, 4.01, 5, 06/14/2002 ............ 07/15/2002 1.03083
the omission of these hospitals. 5.01, 6, 6.01, 7, and Part III, Line 13 of 07/14/2002 ............ 08/15/2002 1.02672
However, we generally describe these Worksheet S–3). We then computed the 08/14/2002 ............ 09/15/2002 1.02261
wage data as FY 2002 data. We note amounts of overhead salaries and hours 09/14/2002 ............ 10/15/2002 1.01860
to be allocated to excluded areas by 10/14/2002 ............ 11/15/2002 1.01478
that, if a hospital had more than one 11/14/2002 ............ 12/15/2002 1.01116
cost reporting period beginning during multiplying the above ratio by the total 12/14/2002 ............ 01/15/2003 1.00757
FY 2002 (for example, a hospital had overhead salaries and hours reported on 01/14/2003 ............ 02/15/2003 1.00385
two short cost reporting periods Line 13 of Worksheet S–3, Part III. Next, 02/14/2003 ............ 03/15/2003 1.00000
beginning on or after October 1, 2001 we computed the amounts of overhead 03/14/2003 ............ 04/15/2003 0.99613
and before October 1, 2002), we wage-related costs to be allocated to
included wage data from only one of the excluded areas using three steps: (1) We For example, the midpoint of a cost
cost reporting periods, the longer, in the determined the ratio of overhead hours reporting period beginning January 1,
wage index calculation. If there was (Part III, Line 13) to revised hours (Line 2002 and ending December 31, 2002 is
more than one cost reporting period and 1 minus the sum of Lines 2, 3, 4.01, 5, June 30, 2002. An adjustment factor of
the periods were equal in length, we 5.01, 6, 6.01, 7, 8, and 8.01); (2) we 1.03083 would be applied to the wages
included the wage data from the later computed overhead wage-related costs of a hospital with such a cost reporting
period in the wage index calculation. by multiplying the overhead hours ratio period. In addition, for the data for any
Step 2—Salaries—The method used to by wage-related costs reported on Part cost reporting period that began in FY
compute a hospital’s average hourly II, Lines 13, 14, and 18; and (3) we 2002 and covered a period of less than
wage excludes certain costs that are not multiplied the computed overhead 360 days or more than 370 days, we
paid under the IPPS. In calculating a wage-related costs by the above annualized the data to reflect a 1-year
hospital’s average salaries plus wage- excluded area hours ratio. Finally, we cost report. Dividing the data by the
related costs, we subtracted from Line 1 subtracted the computed overhead number of days in the cost report and
(total salaries) the GME and CRNA costs salaries, wage-related costs, and hours then multiplying the results by 365
reported on Lines 2, 4.01, 6, and 6.01, associated with excluded areas from the accomplishes annualization.
Step 6—Each hospital was assigned to payments are not greater or less than reclassification within 30 days of the
its appropriate urban or rural labor those that would have been made in the publication of the final rule.
market area before any reclassifications year if this section did not apply. For FY Response: We have carefully
under section 1886(d)(8)(B), section 2006, this change affects 174 hospitals considered the comments we received
1886(d)(8)(E), or section 1886(d)(10) of in 63 urban areas. The areas affected by regarding the proposed change in the FY
the Act. Within each urban or rural this provision are identified by a 2006 IPPS proposed rule to the
labor market area, we added the total footnote in Table 4A in the Addendum methodology for removing overhead
adjusted salaries plus wage-related costs of this final rule. wage-related costs attributable to areas
obtained in Step 5 for all hospitals in Comment: Numerous commenters of the hospital excluded from the IPPS.
that area to determine the total adjusted were concerned with the proposed Overall, commenters seemed to be more
salaries plus wage-related costs for the change in step 4 of the wage index concerned that the proposed rule did
labor market area. calculation in the FY 2006 IPPS not contain a detailed discussion of the
Step 7—We divided the total adjusted proposed rule (70 FR 23373). In order to modification, rather than disagreeing in
salaries plus wage-related costs obtained allocate overhead wage-related costs to principle with our modification.
under both methods in Step 6 by the areas of a hospital that are excluded Therefore, we are adopting our proposal
sum of the corresponding total hours from the IPPS, CMS uses three steps: (1) without modifications because we
(from Step 4) for all hospitals in each Determine the ratio of overhead hours to believe the proposal most accurately
labor market area to determine an revised (that is, allowable) hours; (2) calculates the overhead wage-related
average hourly wage for the area. compute overhead wage-related costs by costs that are attributable to excluded
Step 8—We added the total adjusted multiplying the overhead hours ratio areas. Historically, the wage index used
salaries plus wage-related costs obtained from Step 1 by wage-related costs; and to adjust a hospital’s payment under the
in Step 5 for all hospitals in the nation (3) multiply the overhead wage-related IPPS has only reflected costs of services
and then divided the sum by the costs from Step 2 by the excluded hours that are provided in areas of the hospital
national sum of total hours from Step 4 ratio (see Step 4 for more detail). The that are covered under the IPPS. That is,
to arrive at a national average hourly commenters noted that, for FY 2006, the because certain areas of a hospital are
wage. Using the data as described above, calculation of the overhead hours ratio specifically excluded from the IPPS,
the national average hourly wage is in Step 1 will be modified to subtract such as hospital-based SNFs, or distinct
$28.0011. hours attributable to excluded areas part rehabilitation and psychiatric units,
Step 9—For each urban or rural labor (from line 8 for SNFs and line 8.01 for the proportion of the salaries paid to
market area, we calculated the hospital excluded areas of Worksheet S–3, Part II and the hours worked by employees in
wage index value by dividing the area of the Medicare cost report). The areas of the hospital excluded from the
average hourly wage obtained in Step 7 commenters observed that this change IPPS are identified and removed from
by the national average hourly wage results in a higher overhead hours ratio, the hospital’s total salaries and hours.
computed in Step 8. which, in turn, results in a greater The remaining allowable salaries and
Step 10—Following the process set amount of overhead cost being allocated hours are used to compute the hospital’s
forth above, we developed a separate to excluded areas. The commenters average hourly wage, which, in turn, is
Puerto Rico-specific wage index for believed that, because more costs are used to calculate the wage index for the
purposes of adjusting the Puerto Rico being allocated to excluded areas, a labor market area in which the hospital
standardized amounts. (The national hospital’s average hourly wage would is located.
Puerto Rico standardized amount is decrease as a result of the proposal. One In addition to removing salaries and
adjusted by a wage index calculated for commenter added that the proposed hours that are directly attributable to
all Puerto Rico labor market areas based methodology is flawed, but did not employees working in excluded areas,
on the national average hourly wage as indicate why. Other commenters stated for each hospital reporting both total
described above.) We added the total that the excluded area overhead hours overhead salaries and total overhead
adjusted salaries plus wage-related costs ratio computed with CMS’ proposed hours greater than zero, we also remove
(as calculated in Step 5) for all hospitals methodology is ‘‘dramatically high’’ and any overhead (administrative and
in Puerto Rico and divided the sum by does not accurately reflect the hospital’s general) costs and hours attributable to
the total hours for Puerto Rico (as overhead costs attributable to its excluded areas by allocating overhead
calculated in Step 4) to arrive at an employee benefit amounts, but they did costs and hours between the IPPS areas
overall average hourly wage of $12.8063 not offer an explanation or an of the hospital and the areas of the
for Puerto Rico. For each labor market alternative for accurately identifying hospital excluded from the IPPS. We do
area in Puerto Rico, we calculated the excluded overhead costs. this by determining the ‘‘excluded rate’’
Puerto Rico-specific wage index value In general, the commenters, including for each hospital, which is the ratio of
by dividing the area average hourly the national hospital association, were excluded area hours to total hours (see
wage (as calculated in Step 7) by the concerned that the proposed rule did Step 4 of the wage index calculation).
overall Puerto Rico average hourly not discuss the impact of the change, The ‘‘excluded rate’’ reflects the
wage. and did not include a lengthy percentage of hours worked by hospital
Step 11—Section 4410 of Pub. L. 105– discussion of the changes. These employees in areas of the hospital
33 provides that, for discharges on or commenters believed that CMS should excluded from the IPPS. For example,
after October 1, 1997, the area wage postpone the change until a lengthy an ‘‘excluded rate’’ of 0.15 means that
index applicable to any hospital that is discussion of the proposal can be approximately 15 percent of total
located in an urban area of a State may included in a future proposed rule. The employee hours was spent in excluded
not be less than the area wage index commenters further recommended that, areas (and therefore, about 85 percent of
applicable to hospitals located in rural because the change in the wage index the employees’ time worked was spent
areas in that State. (For all-urban States, calculation caused confusion among in the IPPS areas of the hospital). We
we established an imputed floor (69 FR hospitals as to the correct average then determine the amount of overhead
49109). Furthermore, this wage index hourly wages, hospitals should be given salaries and hours to be allocated to the
floor is to be implemented in such a an opportunity to withdraw or reinstate excluded areas by taking the ‘‘excluded
manner as to ensure that aggregate IPPS their requests for geographic rate’’ and multiplying it by the
hospital’s total salaries and hours under the IPPS, and therefore, have a display on April 24, 2005. The tables
attributable to overhead. high percentage of employee hours included with the FY 2006 proposed
Next, because wage-related costs are related to the excluded areas), this issue rule also showed the average hourly
separate from salaries, we perform a is more significant. For example, in the wages and the wage indices resulting
similar calculation to determine the case of one hospital with an ‘‘excluded from the proposed modification.
percentage of wage-related costs rate’’ of 96 percent, under the FY 2005 Finally, clearly the fact that a hospital
attributable to overhead that should be calculation, we identified (and association and other commenters
allocated to the excluded areas of the removed) only 40 percent of the provided comments on the proposal
hospital. We do this by computing the overhead wage-related costs as being demonstrates that hospitals had actual
‘‘overhead rate,’’ which is the attributable to excluded areas, whereas notice of the change. Some commenters
percentage of allowable (that is, does under the FY 2006 calculation, 93 even computed the effect of the change
not include excluded area) overhead percent of the hospital’s overhead wage- on the calculation of their wage indices
hours to total hours. The ‘‘overhead related costs has been identified as for FY 2006. In addition, even if some
rate’’ is multiplied by total wage-related being attributable to excluded areas, and hospitals might object that they did not
costs to determine the amount of wage- therefore, are being removed for the FY understand the change included in the
related cost attributable to overhead. 2006 wage index. Clearly, in the case of FY 2006 proposed rule, we believe that
Finally, the amount of wage-related this hospital which predominantly the detailed steps used in calculating
costs attributable to overhead is provides services that are excluded from the wage index are interpretive rules
multiplied by the ‘‘excluded rate’’ to the IPPS, it is logical that the vast that are not subject to the notice and
determine the amount of overhead majority of its overhead costs are comment rulemaking procedures of the
wage-related costs that are associated attributable to excluded areas of the Administrative Procedure Act. Clearly,
with excluded areas, and, therefore, hospital as well, and, therefore, these we do not include each of the detailed
should be subtracted from the total overhead costs should be removed from steps and lines from the cost report in
allowable wages used in the wage index. the hospital’s average hourly wage used our regulations at § 412.64(h), the
Obviously, the larger the ‘‘overhead to determine the IPPS wage index. section of the regulations requiring CMS
rate,’’ the greater the amount of Accordingly, in order to correct the to adjust the ‘‘proportion of the Federal
overhead wage-related costs to be discrepancy between the numerator and rate for inpatient operating costs that are
allocated across the hospital, and the the denominator in the overhead rate attributable to wages and labor-related
greater the excluded area, the greater the calculation, and to correct the costs for area differences in hospital
amount of overhead wage-related cost understatement of the excluded wage levels by a [wage index] factor.’’
that is identified as being associated overhead wage-related costs, we believe For these reasons, we believe that we
with excluded areas and that should be that it is more appropriate to determine have provided sufficient notice of the
subtracted from allowable wages. the amount of overhead wage-related change in the ‘‘overhead rate’’
Through FY 2005, in determining the costs associated with excluded areas calculation.
‘‘overhead rate,’’ we divided the that should be excluded from the wage
allowable overhead hours by the index based on the ratio of allowable Commenters are correct that some
hospital’s total hours, including hours costs to allowable hours (that is, only hospitals that wish to reclassify for FY
attributable to excluded areas, even hours related to IPPS areas of the 2007 could also be affected by decreased
though the latter hours are excluded hospital). Specifically, we are not average hourly wages. However, we
from the wage index. Last year, after including the hours associated with have analyzed our data, and have found
publication of the FY 2005 IPPS final excluded areas in the denominator of that the impact of the change is limited.
rule, we became aware of the mismatch the ‘‘overhead rate’’ calculation. While Specifically, approximately 42 hospitals
between the numerator and the hospitals with small excluded areas in 11 labor market areas are receiving a
denominator in the ‘‘overhead rate’’ relative to their IPPS areas should be decrease of 1.0 to 5.5 percent in their FY
calculation. Specifically, because the minimally affected by the removal of the 2006 wage index as a result of this
numerator in the ‘‘overhead rate’’ excluded area hours from the change in the calculation. These labor
calculation does not include excluded calculation, this change will serve to market areas are primarily in the New
area overhead hours, and the lower the average hourly wages of England and East North Central census
denominator in the ‘‘overhead rate’’ hospitals with relatively large excluded regions. In addition, 10 rural hospitals
calculation does include the hours areas, more closely aligning them with and 18 urban hospitals are experiencing
attributable to excluded areas, this costs allowed under the IPPS. a decrease in their average hourly wages
results in an understatement of the We believe that, despite the absence of between 10 percent and 45 percent.
amount of wage-related costs of a lengthy discussion of the policy in However, the ‘‘excluded rates’’ for these
attributable to overhead that should be the proposed rule, the change in the hospitals range between 74 percent up
allocated to the excluded areas. That is, overhead wage-related cost allocation to and including 100 percent. While we
because we had not completely removed noted in the FY 2006 IPPS proposed note that CMS did provide a 30-day
the amount of wage-related cost rule (70 FR 23373) provided hospitals period after publication of the FY 2005
attributable to excluded areas from the with adequate notice of the change. IPPS final rule (69 FR 49066) allowing
denominator, the ‘‘overhead rate’’ was Hospitals are sufficiently sophisticated hospitals to reconsider their geographic
lower than it should be. A lower to understand the implications of a reclassification decisions, we provided
‘‘overhead rate’’ has the unintended proposal to exclude certain lines on the this opportunity because of the number
effect of artificially raising a hospital’s cost report from its calculations. In of changes between the proposed and
average hourly wage because a lower addition, the Average Hourly Wage final rules and the apparent confusion
amount of overhead attributable to Calculator, which included the revised regarding application of the section 505
excluded areas is removed from total overhead wage-related cost allocation, out-migration adjustment. We do not
allowable salaries. To the extent that a has been available on our Web site: believe a similar extension is warranted
hospital has a higher ‘‘excluded rate’’ http://www.cms.hhs.gov/providers/ in this case. Further, we do not agree
(that is, they provide a significant hipps/ippswage.asp since shortly after that a 30-day window after publication
amount of services that are not covered the proposed rule went on public of the final rule is necessary in order to
allow cancellations or reinstatements of in the survey. We noted that some States in exercising the Secretary’s authority to
reclassifications. The FY 2006 proposed had recently established floors on the establish the factor that adjusts for wage
rule change was clearly reflected in the minimum level of registered nurse differences. For example, in the FY 2005
wage index tables accompanying the staffing in hospitals in order to maintain final rule, we implemented new
proposed rule. Thus, hospitals were licensure. In addition, in some rural mapping boundaries for assigning
well aware of their proposed average areas, we believed that hospitals might hospitals to the geographic labor market
hourly wages and proposed wage be accounting for shortages of areas used for calculating the wage
indices for FY 2006. Hospitals could physicians by hiring more registered index. For hospitals that were harmed
review these wage tables, find the nurses. (A complete discussion of the by the new geographic boundaries, we
proposed average hourly wage and wage FY 2005 wage index adjustment factor used a blended rate based on 50 percent
index listed for the hospital and wage can be found in section III.G. of the FY of the wage index that would apply
area, and on the basis of such 2005 IPPS final rule (69 FR 49052).) using the new geographic boundaries
information, determine whether they In the FY 2005 final rule, we noted effective for FY 2005 and 50 percent of
wished to withdraw or retain a certain that while the statute required us to the wage index that would apply using
reclassification. Because of such notice, collect occupational mix data every 3 the old geographic boundaries that were
there is no need to provide a subsequent years, the statute does not specify how effective during FY 2004 (69 FR 49033).
30-day period for withdrawal or the occupational mix adjustment is to be Similarly, beginning with FY 2000, we
reinstatement. Further, we note that constructed or applied. We are began phasing out costs related to GME
hospitals could use the Average Hourly clarifying in this final rule that the and CRNAs from the wage index (64 FR
Wage Calculator on the CMS Web site October 1, 2004 deadline for 41505). Thus, for example, the FY 2001
to determine exactly how the revised implementing an occupational mix wage index was based on a blend of 60
methodology affected the wage index. adjustment is not codified in section percent of an average hourly wage
For the reasons stated above, we are 1886(d)(3)(E) of the Act, which requires including these costs, and 40 percent of
finalizing our proposed decision to only a collection and measurement of an average hourly wage excluding these
remove the excluded area hours on lines occupational mix data, but rather stems costs (65 FR 47071).
8 and 8.01 from the overhead wage- from the effective date provisions in As we proposed in the FY 2006 IPPS
related cost allocation. section 304(c) of the Medicare, proposed rule, for FY 2006, we are again
Medicaid and SCHIP Benefits adjusting 10 percent of the wage index
G. Computation of the FY 2006 Blended Improvement and Protection Act of factor for the occupational mix. In
Wage Index 2000, Pub. L. 106–554 (BIPA). Although computing the occupational mix
For the final FY 2005 wage index, we we believe that applying the adjustment for the final FY 2006 wage
used a blend of the occupational mix occupational mix to 10 percent of the index, we used the occupational mix
adjusted wage index and the unadjusted wage index factor fully implements the survey data that we collected for the FY
wage index. Specifically, we adjusted 10 occupational mix adjustment, we also 2005 wage index, replacing the survey
percent of the FY 2005 wage index interpret BIPA as requiring only that we data for 20 hospitals that submitted
adjustment factor by a factor reflecting begin applying an adjustment by revised data, and excluding the survey
occupational mix. Given that 2003–2004 October 1, 2004. BIPA required the data for hospitals with no corresponding
was the first time for the administration Secretary to complete, ‘‘by not later than Worksheet S–3 wage data for FY 2006
of the occupational mix survey, September 30, 2003, for application wage index. While we considered
hospitals had a short timeframe for beginning October 1, 2004,’’ both the adjusting 100 percent of the wage index
collecting their occupational mix survey collection of occupational mix data and by the occupational mix, we did not
data and documentation, the wage data the measurement of such data. (BIPA, believe it was appropriate to use first-
were not in all cases from a 1-year section 304(c)(3).) Thus, even if year survey data to make such a large
period, and there was no baseline data adjusting 10 percent of the wage index adjustment. As hospitals gain additional
for purposes of developing a desk for occupational mix were not (as we experience with the occupational mix
review program, we found it prudent believe it to be) considered to be full survey, and as we develop more
not to adjust the entire wage index implementation of the BIPA effective information upon which to audit the
factor by the occupational mix. date, we certainly began our application data we receive, we expect to increase
However, we did find the data of the adjustment as of October 1, 2004. the portion of the wage index that is
sufficiently reliable for applying an In addition, section 1886(d)(3)(E) of adjusted.
adjustment to 10 percent of the wage the Act provides broad authority for us As we did in the proposed rule, we
index. We found the data reliable to establish the factor we use to adjust also acknowledge the finding of the
because hospitals were given an hospital costs to take into account area District Court opinion in Bellevue
opportunity to review their survey data differences in wage levels. The statute is Hospital Center v. Leavitt, No. 04–8639
and submit changes in the Spring of clear that the wage index factor is to be (S.D.N.Y, March 2005). Given that the
2004, hospitals were already familiar ‘‘established by the Secretary.’’ The Government has appealed the
with the BLS OES survey categories, occupational mix is only one part of this occupational mix portion of that
hospitals were required to be able to wage index factor, which, for the most decision, we believe it is appropriate to
provide documentation that could be part, is calculated on the basis of continue with our policy of adopting the
used by fiscal intermediaries to verify average hourly wage data submitted by policy we believe to be most prudent for
survey data, and the results of our all hospitals in the United States. In occupational mix.
survey were consistent with the findings exercising the Secretary’s broad With 10 percent of the FY 2006 wage
of the 2001 BLS OES survey, especially discretion to establish the factor that index adjusted for occupational mix, the
for nursing and physical therapy adjusts for geographic wage differences, national average hourly wage is
categories. In addition, we noted that we in FY 2005 we adjusted 10 percent of $28.0037 and the Puerto Rico specific
were moving cautiously with such factor to account for occupational average hourly wage is $12.8055. The
implementing the occupational mix mix. wage index values for 13 rural areas
adjustment in recognition of changing Indeed, we have often used (27.7 percent) and 201 urban areas (52.1
trends in hiring nurses, the largest group percentage figures or blended amounts percent) would decrease as a result of
the adjustment. These decreases would to 10 percent of the wage index. The wage index values for FY 2006
be minimal; the largest negative impact Moreover, we believe that by (except those for hospitals receiving
for a rural area would be 0.18 percent implementing the wage index in this wage index adjustments under section
and for an urban area, 0.43 percent. manner, we are carrying out the 505 of Pub. L. 108–173) are shown in
Conversely, 31 rural areas (66.0 percent) Congressional requirement to begin Tables 4A, 4B, 4C, and 4F in the
and 176 urban areas (45.6 percent) applying an occupational mix to the Addendum to this final rule.
would benefit from this adjustment, wage index by October 1, 2004. Tables 3A and 3B in the Addendum
with 1 urban area increasing 2.2 percent We do not agree with commenters to this final rule list the 3-year average
and 1 rural area increasing 0.37 percent. that stated that the correction of data hourly wage for each labor market area
As there are no significant differences permitted for FY 2006 is sufficient to before the redesignation of hospitals,
between the FY 2005 and the FY 2006 allow for a 100 percent adjustment in based on FYs 2004, 2005, 2006 cost
occupational mix survey data and FY 2006. While hospitals were reporting periods. Table 3A lists these
results, we believe it is appropriate to permitted to correct their data for FY data for urban areas and Table 3B lists
again apply the occupational mix to 10 2006, only 20 out of the 3,541 hospitals these data for rural areas. In addition,
percent of the final FY 2006 wage index. did so. Further, the fact that hospitals Table 2 in the Addendum to this final
(See Appendix A to this final rule for were permitted to submit corrected data rule includes the adjusted average
further analysis of the impact of the does not alleviate concerns that (a) the hourly wage for each hospital from the
occupational mix adjustment on the data continued to be derived from the FY 2000 and FY 2001 cost reporting
final FY 2006 wage index.) first year of an occupational mix survey; periods, as well as the FY 2002 period
Comment: Most commenters or (b) that CMS had no historical used to calculate the FY 2006 wage
supported our proposal to adjust only baseline data for developing a robust index. The 3-year averages are
10 percent of the FY 2006 wage index audit program for such data. Given such calculated by dividing the sum of the
for occupational mix. However, one concerns, we also believe it would be dollars (adjusted to a common reporting
commenter requested CMS to neither equitable nor appropriate to period using the method described
implement the occupational mix adjust 100 percent of the wage index previously) across all 3 years, by the
adjustment in a way that ensures that when the occupational mix benefits sum of the hours. If a hospital is missing
the adjustment does not negatively hospitals, but 10 percent of the wage data for any of the previous years, its
impact his hospital and other similar index when it does not. Instead, we average hourly wage for the 3-year
hospitals, providing no further continue to believe that the proposed, period is calculated based on the data
elaboration for his suggestion, while two more moderate occupational mix available during that period.
other commenters opposed applying adjustment is the most equitable and The wage index values in Tables 4A,
any occupational mix adjustment at all appropriate approach. As such, the FY 4B, 4C, and 4F and the average hourly
until CMS performs a new survey. In 2006 wage index in this final rule is a wages in Tables 2, 3A, and 3B in the
contrast, a few commenters representing blend of 10 percent of a wage index Addendum to this final rule include the
hospitals that would benefit from a 100 adjusted for occupational mix and 90 occupational mix adjustment.
percent occupational mix adjustment to percent of an unadjusted wage index.
the wage index recommended the policy Comment: One commenter expressed Other Public Comments
that would most behoove them (that is, concern regarding CMS’ statement in Comment: One commenter stated that
a full implementation of the adjustment the proposed rule that ‘‘hospitals might an ongoing concern is that the hospital
for the FY 2006 wage index). These be accounting for shortages of wage index is applied to many provider
commenters supported their proposal by physicians by hiring more registered types for which wage data are excluded
noting that: (1) For FY 2006, hospitals nurses’’ (70 FR 23375). The commenter from the wage index calculation. The
were given an opportunity to revise or suggested that the statement is commenter recommended that CMS
correct data originally submitted; (2) unsupported and implies a ‘‘practice of separate wage indices for SNFs, IRFs,
occupational mix data from FY 2005 downgrading care, especially since it and IPFs by modifying the way the wage
were consistent with registered nurse uses ’registered nurses’, not even nurse index data are reported on the Medicare
and licensed practical nurse data from practitioners.’’ The commenter cost report.
a AHA annual survey of hospitals; and requested that we delete the statement Response: We appreciate the
(3) Congress intended for 100 percent of from the final rule. comment, but note that the subject-
the wage index to be adjusted for Response: We did not intend to imply
matter of this final rule is the IPPS
occupational mix beginning October 1, that hospitals that have increased their
system and not the PPSs governing non-
2004. reliance on registered nurses provide
IPPS entities such as SNFs, IRFs, and
Response: We do not agree with the downgraded care. Nursing schools and
nursing associations acknowledge a IPFs. Therefore, we are not responding
commenters recommending elimination
significant increase in the number of to this comment at this time. We suggest
of the occupational mix adjustment. As
registered nurses who are pursuing or that the commenter raise his or her
we stated in the proposed rule, given
have achieved advanced practice concerns as part of the rulemaking
the FY 2005 and FY 2006 wage indices
degrees as nurse practitioners, clinical process for updating the respective
were based on the first year of survey
nurse specialists, nurse midwives, and facility’s PPS.
data, as well as other stated
considerations (see 70 FR 23375), we certified registered nurse anesthetists. H. Revisions to the Wage Index Based
found survey results sufficiently robust Our statement merely acknowledged on Hospital Redesignation
to support an adjustment to 10 percent that hiring advanced practice registered
of the wage index, but did not believe nurses helps to mitigate problems with 1. General
it prudent to adjust the entire wage physician shortages by increasing the Under section 1886(d)(10) of the Act,
index by occupational mix. We refer number of staff who are available to the Medicare Geographic Classification
readers to the proposed rule for a full provide primary care, and that such Review Board (MGCRB) considers
discussion of our rationale. We continue hiring practices may have contributed to applications by hospitals for geographic
to believe that the data are sufficient to the higher than expected occupational reclassification for purposes of payment
support applying the occupational mix mix reported by many rural hospitals. under the IPPS. Hospitals must apply to
the MGCRB to reclassify by September would have on the wage index value for been redesignated to another area
1 of the year preceding the year during the area to which they have been continue to have their wage index
which reclassification is sought. redesignated. These requirements for values calculated as if no redesignation
Generally, hospitals must be proximate determining the wage index values for had occurred (otherwise, redesignated
to the labor market area to which they redesignated hospitals is applicable rural hospitals are excluded from the
are seeking reclassification and must both to the hospitals located in rural calculation of the rural wage index).
demonstrate characteristics similar to counties deemed urban under section • The wage index value for a
hospitals located in that area. The 1886(d)(8)(B) of the Act and hospitals redesignated rural hospital cannot be
MGCRB issues its decisions by the end that were reclassified as a result of the reduced below the wage index value for
of February for reclassifications that MGCRB decisions under section the rural areas of the State in which the
become effective for the following fiscal 1886(d)(10) of the Act. Therefore, as hospital is located.
year (beginning October 1). The provided in section 1886(d)(8)(C) of the 3. Application of Hold Harmless
regulations applicable to Act,9 the wage index values were Protection for Certain Urban Hospitals
reclassifications by the MGCRB are determined by considering the Redesignated as Rural
located in §§ 412.230 through 412.280. following:
Section 1886(d)(10)(D)(v) of the Act • If including the wage data for the Section 401(a) of Pub. L. 106–113 (the
provides that, beginning with FY 2001, redesignated hospitals would reduce the Balanced Budget Refinement Act of
a MGCRB decision on a hospital wage index value for the area to which 1999) amended section 1886(d)(8) of the
reclassification for purposes of the wage the hospitals are redesignated by 1 Act by adding paragraph (E). Section
index is effective for 3 fiscal years, percentage point or less, the area wage 401(a) created a mechanism that permits
unless the hospital elects to terminate index value determined exclusive of the an urban hospital to apply to the
the reclassification. Section wage data for the redesignated hospitals Secretary to be treated, for purposes of
1886(d)(10)(D)(vi) of the Act provides applies to the redesignated hospitals. subsection (d), as being located in the
that the MGCRB must use the 3 most • If including the wage data for the rural area of the State in which the
recent years’ average hourly wage data redesignated hospitals reduces the wage hospital is located. A hospital that is
in evaluating a hospital’s index value for the area to which the granted redesignation under section
reclassification application for FY 2003 hospitals are redesignated by more than 1886(d)(8)(E) of the Act, as added by
and any succeeding fiscal year. 1 percentage point, the area wage index section 401 of Pub. L. 106–113, is
Section 304(b) of Pub. L. 106–554 determined inclusive of the wage data therefore treated as a rural hospital for
provides that the Secretary must for the redesignated hospitals (the all purposes of payment under the
establish a mechanism under which a combined wage index value) applies to Medicare IPPS, including the
statewide entity may apply to have all the redesignated hospitals. standardized amount, wage index, and
of the geographic areas in the State • If including the wage data for the disproportionate share calculations as of
treated as a single geographic area for redesignated hospitals increases the the effective date of the redesignation.
purposes of computing and applying a wage index value for the urban area to Under current policy, as a result of an
single wage index, for reclassifications which the hospitals are redesignated, approved redesignation of an urban
beginning in FY 2003. The both the area and the redesignated hospital as a rural hospital, the wage
implementing regulations for this hospitals receive the combined wage index data are excluded from the wage
provision are located at § 412.235. index value. Otherwise, the hospitals index calculation for the area where the
Section 1886(d)(8)(B) of the Act located in the urban area receive a wage urban hospital is geographically located
requires the Secretary to treat a hospital index excluding the wage data of and included in the rural hospital wage
located in a rural county adjacent to one hospitals redesignated into the area. index calculation.
or more urban areas as being located in Last year, we became aware of an
• The wage data for a reclassified
the MSA to which the greatest number instance where the approved
urban hospital is included in both the
of workers in the county commute, if redesignation of an urban hospital as
wage index calculation of the area to
the rural county would otherwise be rural under section 1886(d)(8)(E) of the
which the hospital is reclassified
considered part of an urban area under Act resulted in the hospital’s data
(subject to the rules described above)
the standards for designating MSAs and having an adverse impact on the rural
and the wage index calculation of the
if the commuting rates used in wage index. We received a public
urban area where the hospital is
determining outlying counties were comment noting that specific ‘‘hold
physically located.
determined on the basis of the aggregate harmless’’ provisions apply to
• Rural areas whose wage index
number of resident workers who reclassifications that occur under
values would be reduced by excluding
commute to (and, if applicable under section 1886(d)(8)(B) and section
the wage data for hospitals that have
the standards, from) the central county 1886(d)(10) of the Act. That is, if a
or counties of all contiguous MSAs. In 9 Although section 1886(d)(8)(C)(iv)(I) of the Act hospital is granted geographic
light of the new CBSA definitions and also provides that the wage index for an urban area reclassification under section
the Census 2000 data that we may not decrease as a result of redesignated 1886(d)(8)(B) or section 1886(d)(10) of
hospitals if the urban area wage index is already the Act, there are certain rules that
implemented for FY 2005 (69 FR below the wage index for rural areas in the State
49027), we undertook to identify those in which the urban area is located, the provision
apply when the inclusion of the
counties meeting these criteria. The was effectively made moot by section 4410 of Pub. hospital’s data results in a reduction of
eligible counties are identified under L. 105–33, which provides that the area wage index the reclassification area’s wage index,
applicable to any hospital that is located in an and these rules are slightly different for
section III.H.5. of this preamble. urban area of a State may not be less than the area
wage index applicable to hospitals located in rural
urban areas versus rural areas. These
2. Effects of Reclassification rules are more fully described in the FY
areas in that State. For all-urban States, CMS
Section 1886(d)(8)(C) of the Act established an imputed floor (69 FR 49109). Also, 2005 IPPS final rule (69 FR 49053).
provides that the application of the section 1886(d)(8)(C)(iv)(II) of the Act provides that Generally stated, these rules prevent a
an urban area’s wage index may not decrease as a
wage index to redesignated hospitals is result of redesignated hospitals if the urban area is
rural area from being adversely affected
dependent on the hypothetical impact located in a State that is composed of a single urban as a result of reclassification. That is, if
that the wage data from these hospitals area. excluding the reclassifying hospitals’
wage data would decrease the wage extend hold harmless protection to index application after the MGCRB has
index of the rural area, the reclassifying urban hospitals that are redesignated as issued its decision, but prior to the
hospitals are included in the rural area’s rural under section 401. above date, it may later cancel its
wage index. Otherwise, the reclassifying We are including in the Addendum to withdrawal in a subsequent year and
hospitals are excluded. For hospitals this final rule Table 9C, which shows request the MGCRB to reinstate its wage
reclassifying out of urban areas, the hospitals redesignated under section index reclassification for the remaining
rules provide that the wage data for the 1886(d)(8)(E) of the Act. fiscal year(s) of the 3-year period
reclassified urban hospital are included 4. FY 2006 MGCRB Reclassifications (§ 412.273(b)(2)(i)). The request to
in the wage index calculation of the cancel a prior withdrawal must be in
urban area where the hospital is The MGCRB’s review of FY 2006 writing to the MGCRB no later than the
physically located. reclassification requests resulted in 299 deadline for submitting reclassification
The commenter recommended that hospitals approved for wage index applications for the following fiscal year
we revise our regulations and apply reclassifications for FY 2006. Because (§ 412.273(d)). For further information
similar hold harmless provisions and MGCRB wage index reclassifications are about withdrawing, terminating, or
treat hospitals redesignated under effective for 3 years, hospitals canceling a previous withdrawal or
section 1886(d)(8)(E) of the Act in the reclassified during FY 2004 or FY 2005 termination of a 3-year reclassification
same manner as reclassifications under are eligible to continue to be reclassified for wage index purposes, we refer the
section 1886(d)(8)(B) and section based on prior reclassifications to reader to § 412.273, as well as the
1886(d)(10) of the Act. In our continued current MSAs during FY 2006. There August 1, 2002, IPPS final rule (67 FR
effort to promote consistency, equity were 395 hospitals reclassified for wage 50065) and the August 1, 2001 IPPS
and to simplify our rules with respect to index for FY 2005, and 94 hospitals final rule (66 FR 39887).
how we construct the wage indexes of reclassified for wage index in FY 2004. Changes to the wage index that result
rural and urban areas, we are persuaded Some of the hospitals that reclassified in from withdrawals of requests for
that there is a need to modify our policy FY 2004 and FY 2005 have elected not reclassification, wage index corrections,
when hospital redesignations occur to continue their reclassifications in FY appeals, and the Administrator’s review
under section 1886(d)(8)(E) of the Act. 2006 because, under the new labor process have been incorporated into the
Therefore, for the FY 2006 wage index, market area definitions, they are now wage index values published in this
in the FY 2006 IPPS proposed rule, we physically located in the areas to which final rule. These changes may affect not
proposed to apply the hold harmless they previously reclassified. Of all of the only the wage index value for specific
rule that currently applies when rural hospitals approved for reclassification geographic areas, but also the wage
hospitals are reclassifying out of the for FY 2004, FY 2005, and FY 2006, 631 index value redesignated hospitals
rural area (from rural to urban) to hospitals are in a reclassification status receive; that is, whether they receive the
situations where hospitals are for FY 2006. wage index that includes the data for
reclassifying into the rural area (from Prior to FY 2004, hospitals had been both the hospitals already in the area
urban to rural under section able to apply to be reclassified for and the redesignated hospitals. Further,
1886(d)(8)(E) of the Act). Thus, the rule purposes of either the wage index or the the wage index value for the area from
would be that the wage data of the standardized amount. Section 401 of which the hospitals are redesignated
urban hospital reclassifying into the Pub. L. 108–173 established that all may be affected.
rural area are included in the rural hospitals will be paid on the basis of the Applications for FY 2007
area’s wage index, if including the large urban standardized amount, reclassifications are due to the MGCRB
urban hospital’s data increase the wage beginning with FY 2004. Consequently, by September 1, 2005. We note that this
index of the rural area. Otherwise, the all hospitals are paid on the basis of the is also the deadline for canceling a
wage data are excluded. Similarly, we same standardized amount, which made previous wage index reclassification
proposed to apply to these cases the rule such reclassifications moot. Although withdrawal or termination under
that currently applies when urban there could still be some benefit in § 412.273(d). Applications and other
hospitals reclassify under the MGCRB terms of payments for some hospitals information about MGCRB
process. Thus, the wage data for an under the DSH payment adjustment for reclassifications may be obtained,
urban hospital reclassifying under operating IPPS, section 402 of Pub. L. beginning in Mid-July 2005, via the
section 1886(d)(8)((E) of the Act are 108–173 equalized DSH payment CMS Internet Web site at: http://
always included in the wage index of adjustments for rural and urban cms.hhs.gov/providers/prrb/
the urban area where the hospital is hospitals, with the exception that the mgcinfo.asp, or by calling the MGCRB at
located, and can also be included in the rural DSH adjustment is capped at 12 (410) 786–1174. The mailing address of
wage index of the rural area to which it percent (except that RRCs have no cap). the MGCRB is: 2520 Lord Baltimore
is reclassifying (if doing so increases the (A detailed discussion of this Drive, Suite L, Baltimore, MD 21244–
rural area’s wage index). In the FY 2006 application appears in section IV.I. of 2670.
IPPS proposed rule, we stated that we the preamble of the FY 2005 IPPS final
rule (69 FR 49085). 5. FY 2006 Redesignations Under
believe this proposal provides
Under § 412.273, hospitals that have Section 1886(d)(8)(B) of the Act
uniformity in the way geographic areas
are treated under all types of been reclassified by the MGCRB are Beginning October 1, 1988, section
reclassifications. In addition, we further permitted to withdraw their 1886(d)(8)(B) of the Act required us to
stated that our proposal promotes applications within 45 days of the treat a hospital located in a rural county
predictability by alleviating fluctuations publication of a proposed rule. The adjacent to one or more urban areas as
in the wage indexes due to a section 401 request for withdrawal of an application being located in the MSA if certain
redesignation. for reclassification or termination of an criteria were met. Prior to FY 2005, the
No commenters objected to extending existing 3-year reclassification that rule was that a rural county adjacent to
hold harmless protection to urban would be effective in FY 2005 must be one or more urban areas would be
hospitals that are redesignated as rural received by the MGCRB within 45 days treated as being located in the MSA to
under section 401. Therefore, in this of the publication of the proposed rule. which the greatest number of workers in
final rule, we are finalizing the policy to If a hospital elects to withdraw its wage the county commute, if the rural county
would otherwise be considered part of Chart 6 incorrectly listed the examples in which hospitals with
an urban area under the standards redesignation CBSAs for Monroe, PA special designations, such as rural
published in the Federal Register on and Walworth, WI. This error was made referral centers, SCHs, MDHs, and
January 3, 1980 (45 FR 956) for only in the chart and not in the CAHs, where their status is dependent
designating MSAs (and NECMAs), and application of the rules; that is, we on being located in a rural area, lost
if the commuting rates used in correctly applied the rules to the correct their special designation when they
determining outlying counties (or, for rural counties qualifying to be urban for were reclassified to an urban area under
New England, similar recognized areas) FY 2005. section 1886(d)(8)(B) of the Act.
were determined on the basis of the In addition, we discovered that, in the
FY 2005 IPPS final rule, we had Response: We considered this
aggregate number of resident workers
erroneously printed the names of the comment and are responding to it only
who commute to (and, if applicable
entire Metropolitan Statistical Areas insofar as it relates to section 1886(d)
under the standards, from) the central
county or counties of all contiguous rather than the Metropolitan Division hospitals, such as rural referral centers,
MSAs (or NECMAs). Hospitals that met names. Because we recognized SCHs, and MDHs, located in Lugar
the criteria using the January 3, 1980 Metropolitan Divisions as MSAs in the counties. We refer readers to the section
version of these OMB standards were FY 2005 IPPS final rule (69 FR 49029), on CAHs in this final rule for
deemed urban for purposes of the we should have printed the division information on how CMS treats CAHs in
standardized amounts and for purposes names for the following counties: Lugar counties. The statute specifically
of assigning the wage data index. Henry, FL; Starke, IN; Henderson, TX; states that ‘‘(f)or purposes of this
On June 6, 2003, OMB announced the Fannin, TX; and Island, WA. subsection, the Secretary shall treat a
new CBSAs based on Census 2000 data. The chart below contains the hospital located in a rural county
For FY 2005, we used OMB’s 2000 corrected listing of the rural counties adjacent to one or more urban areas as
CBSA standards and the Census 2000 designated as urban under section being located in (a) urban metropolitan
data to identify counties qualifying for 1886(d)(8)(B) of the Act that we are statistical area * * *.’’ Therefore, all
redesignation under section using for FY 2006. For discharges section 1886(d) hospitals located in
1886(d)(8)(B) for the purpose of occurring on or after October 1, 2005, Lugar counties are deemed urban and
assigning the wage index to the urban hospitals located in the first column of such classification cannot be waived,
area. We presented this listing, effective this chart will be redesignated for except if a hospital is eligible for an out-
for discharges occurring on or after purposes of using the wage index of the migration adjustment. In order for a
October 1, 2004 (FY 2005), in Chart 6 of urban area listed in the second column. section 1886(d) hospital to retain its
the FY 2005 final rule (69 FR 49057). Comment: Several commenters urged special designation when the area in
However, Chart 6 in the FY 2005 final CMS to permit hospitals located in which it is located is redesignated from
rule contained a printing error in which counties redesignated under section rural to urban, a hospital must apply for
we misidentified the redesignation areas 1886(d)(8)(B) of the Act to waive or reclassification under § 412.103(a). We
for two counties that qualified for reject the redesignation if the encourage a hospital seeking
redesignation under section redesignation proves to be detrimental reclassification under this section to
1886(d)(8)(B) of the Act. The list of rural or otherwise undesirable to the submit a complete application in
counties qualifying to be urban in that qualifying hospital. They cited writing to its CMS Regional Office.
RURAL COUNTIES REDESIGNATED AS URBAN UNDER SECTION 1886(d)(8)(B) OF THE ACT

[Based on CBSAs and Census 2000 Data]
Rural county CBSA
Cherokee, AL ..................................................................................................................... Rome, GA.

Macon, AL .......................................................................................................................... Auburn-Opelika, AL.
Talladega, AL ..................................................................................................................... Anniston-Oxford, AL.
Hot Springs, AR ................................................................................................................. Hot Springs, AR.
Windham, CT ..................................................................................................................... Hartford-West Hartford-East Hartford, CT.
Bradford, FL ....................................................................................................................... Gainesville, FL.
Flagler, FL .......................................................................................................................... Deltona-Daytona Beach-Ormond Beach, FL.
Hendry, FL ......................................................................................................................... West Palm Beach-Boca Raton-Boynton, FL.
Levy, FL ............................................................................................................................. Gainesville, FL.
Walton, FL ......................................................................................................................... Fort Walton Beach-Crestview-Destin, FL.
Banks, GA .......................................................................................................................... Gainesville, GA.
Chattooga, GA ................................................................................................................... Chattanooga, TN-GA.
Jackson, GA ...................................................................................................................... Atlanta-Sandy Springs-Marietta, GA.
Lumpkin, GA ...................................................................................................................... Atlanta-Sandy Springs-Marietta, GA.
Morgan, GA ....................................................................................................................... Atlanta-Sandy Springs-Marietta, GA.
Peach, GA ......................................................................................................................... Macon, GA.
Polk, GA ............................................................................................................................. Atlanta-Sandy Springs-Marietta, GA.
Talbot, GA .......................................................................................................................... Columbus, GA-AL.
Bingham, ID ....................................................................................................................... Idaho Falls, ID.
Christian, IL ........................................................................................................................ Springfield, IL.
DeWitt, IL ........................................................................................................................... Bloomington-Normal, IL.
Iroquois, IL ......................................................................................................................... Kankakee-Bradley, IL.
Logan, IL ............................................................................................................................ Springfield, IL.
Mason, IL ........................................................................................................................... Peoria, IL.
Ogle, IL .............................................................................................................................. Rockford, IL.
Clinton, IN .......................................................................................................................... Lafayette, IN.
Henry, IN ............................................................................................................................ Indianapolis, IN.
Spencer, IN ........................................................................................................................ Evansville, IN-KY.
RURAL COUNTIES REDESIGNATED AS URBAN UNDER SECTION 1886(d)(8)(B) OF THE ACT—Continued

[Based on CBSAs and Census 2000 Data]
Rural county CBSA
Starke, IN ........................................................................................................................... Gary, IN.

Warren, IN ......................................................................................................................... Lafayette, IN.
Boone, IA ........................................................................................................................... Ames, IA.
Buchanan, IA ..................................................................................................................... Waterloo-Cedar Falls, IA.
Cedar, IA ............................................................................................................................ Iowa City, IA.
Allen, KY ............................................................................................................................ Bowling Green, KY.
Assumption Parish, LA ...................................................................................................... Baton Rouge, LA.
St. James Parish, LA ......................................................................................................... Baton Rouge, LA.
Allegan, MI ......................................................................................................................... Holland-Grand Haven, MI.
Montcalm, MI ..................................................................................................................... Grand Rapids-Wyoming, MI.
Oceana, MI ........................................................................................................................ Muskegon-Norton Shores, MI.
Shiawassee, MI ................................................................................................................. Lansing-East Lansing, MI.
Tuscola, MI ........................................................................................................................ Saginaw-Saginaw Township North, MI.
Fillmore, MN ...................................................................................................................... Rochester, MN.
Dade, MO .......................................................................................................................... Springfield, MO.
Pearl River, MS ................................................................................................................. Gulfport-Biloxi, MS.
Caswell, NC ....................................................................................................................... Burlington, NC.
Granville, NC ..................................................................................................................... Durham, NC.
Harnett, NC ........................................................................................................................ Raleigh-Cary, NC.
Lincoln, NC ........................................................................................................................ Charlotte-Gastonia-Concord, NC-SC.
Polk, NC ............................................................................................................................. Spartanburg, NC.
Los Alamos, NM ................................................................................................................ Santa Fe, NM.
Lyon, NV ............................................................................................................................ Carson City, NV.
Cayuga, NY ....................................................................................................................... Syracuse, NY.
Columbia, NY ..................................................................................................................... Albany-Schenectady-Troy, NY.
Genesee, NY ..................................................................................................................... Rochester, NY.
Greene, NY ........................................................................................................................ Albany-Schenectady-Troy, NY.
Schuyler, NY ...................................................................................................................... Ithaca, NY.
Sullivan, NY ....................................................................................................................... Poughkeepsie-Newburgh-Middletown, NY.
Wyoming, NY ..................................................................................................................... Buffalo-Niagara Falls, NY.
Ashtabula, OH ................................................................................................................... Cleveland-Elyria-Mentor, OH.
Champaign, OH ................................................................................................................. Springfield, OH.
Columbiana, OH ................................................................................................................ Youngstown-Warren-Boardman, OH-PA.
Cotton, OK ......................................................................................................................... Lawton, OK.
Linn, OR ............................................................................................................................. Corvallis, OR.
Adams, PA ......................................................................................................................... York-Hanover, PA.
Clinton, PA ......................................................................................................................... Williamsport, PA.
Greene, PA ........................................................................................................................ Pittsburgh, PA.
Monroe, PA ........................................................................................................................ Allentown-Bethlehem-Easton, PA-NJ.
Schuylkill, PA ..................................................................................................................... Reading, PA.
Susquehanna, PA .............................................................................................................. Binghamton, NY.
Clarendon, SC ................................................................................................................... Sumter, SC.
Lee, SC .............................................................................................................................. Sumter, SC.
Oconee, SC ....................................................................................................................... Greenville, SC.
Union, SC .......................................................................................................................... Spartanburg, SC.
Meigs, TN .......................................................................................................................... Cleveland, TN.
Bosque, TX ........................................................................................................................ Waco, TX.
Falls, TX ............................................................................................................................. Waco, TX.
Fannin, TX ......................................................................................................................... Dallas-Plano-Irving, TX.
Grimes, TX ......................................................................................................................... College Station-Bryan, TX.
Harrison, TX ....................................................................................................................... Longview, TX.
Henderson, TX ................................................................................................................... Dallas-Plano-Irving, TX.
Milam, TX ........................................................................................................................... Austin-Round Rock, TX.
Van Zandt, TX ................................................................................................................... Dallas-Plano-Irving, TX.
Willacy, TX ......................................................................................................................... Brownsville-Harlingen, TX.
Buckingham, VA ................................................................................................................ Charlottesville, VA.
Floyd, VA ........................................................................................................................... Blacksburg-Christiansburg-Radford, VA.
Middlesex, VA .................................................................................................................... Virginia Beach-Norfolk-Newport News, VA.
Page, VA ............................................................................................................................ Harrisonburg, VA.
Shenandoah, VA ................................................................................................................ Winchester, VA-WV.
Island, WA ......................................................................................................................... Seattle-Bellevue-Everett, WA.
Mason, WA ........................................................................................................................ Olympia, WA.
Wahkiakum, WA ................................................................................................................ Longview, WA.
Jackson, WV ...................................................................................................................... Charleston, WV.
Roane, WV ........................................................................................................................ Charleston, WV.
Green, WI .......................................................................................................................... Madison, WI.
Green Lake, WI ................................................................................................................. Fond du Lac, WI.
Jefferson, WI ...................................................................................................................... Milwaukee-Waukesha-West Allis, WI.
Walworth, WI ..................................................................................................................... Milwaukee-Waukesha-West Allis, WI.
As in the past, hospitals redesignated be subject to the regulation cited above. following procedural rules will apply
under section 1886(d)(8)(B) of the Act Thus, in applying for a 3-year MGCRB for section 508 hospitals that wish to
are also eligible to be reclassified to a reclassification beginning in FY 2007, reclassify for the second half of FY
different area by the MGCRB. Affected hospitals that are already reclassified to 2007:
hospitals were permitted to compare the the same area under section 508 should For section 508 hospitals applying for
reclassified wage index for the labor indicate in their MGCRB reclassification individual reclassification under 42 CFR
market area in Table 4C in the requests that if they receive the MGCRB 412.230—
Addendum of the May 4, 2005 proposed reclassification, they will forfeit the (1) Hospitals must apply for
rule into which they have been section 508 reclassification for the first reclassification through the MGCRB by
reclassified by the MGCRB to the wage 6 months of FY 2007. the September 1, 2005 deadline.
index for the area to which they are Comment: Many commenters (2) Section 508 hospitals that are
redesignated under section expressed concern regarding the timing approved by the MGCRB for
1886(d)(8)(B) of the Act. Hospitals were overlaps between section 508 of Pub. L. reclassification will have 45 days from
provided the opportunity to withdraw 108–173 and the FY 2007 the date the FY 2007 IPPS proposed rule
from an MGCRB reclassification within reclassifications. The commenters is published to cancel their section
45 days of the publication of the FY pointed out that section 508 of Pub. L. 1886(d)(10) reclassifications for either
2006 IPPS proposed rule (May 4, 2005). 108–173 required the Secretary to the first 6 months of FY 2007 or for the
develop a one-time special entire fiscal year. Hospitals should note
6. Reclassifications Under Section 508 reclassification procedure that allowed that if they fail to cancel their section
of Pub. L. 108–173 hospitals meeting specified criteria to be 1886(d)(10) reclassification by the
Under section 508 of Pub. L. 108–173, reclassified from April 1, 2004, through deadline, they will not receive their
a qualifying hospital could appeal the March 31, 2007. They further stated that section 508 wage adjustment in FY
wage index classification otherwise some hospitals that qualified for 2007. To further clarify—
applicable to the hospital and apply for reclassification under section 508 may • Hospitals that cancel their section
reclassification to another area of the qualify for geographic reclassification 1886(d)(10) reclassification for the first
State in which the hospital is located under one of the opportunities available 6 months receive their section 508
(or, at the discretion of the Secretary, to under the regulations in 42 CFR part reclassifications for October 2006
an area within a contiguous State). We 412, subpart L. Because pending through March 2007 and their section
implemented this process through reclassifications will expire in the 1886(d)(10) reclassifications for April
notices published in the Federal middle of a Federal fiscal year, the through September 2007.
Register on January 6, 2004 (69 FR 661) commenters requested that CMS clarify • Hospitals that cancel their section
and February 13, 2004 (69 FR 7340). when the hospitals should apply for 1886(d)(10) reclassification for the
Such reclassifications are applicable to reclassification under an opportunity entire year will receive their section 508
discharges occurring during the 3-year under subpart L. Commenters stated reclassification for October 2006
period beginning April 1, 2004 and that, unless CMS establishes an through March 2007 and their home
ending March 31, 2007. Under section accommodation for section 508 area wage index for April through
508(b), reclassifications under this hospitals, hospitals will be confronted September 2007.
process do not affect the wage index with a difficult dilemma: Forfeiting 6 • Hospitals that do not cancel their
computation for any area or for any months of section 508 reclassification to section 1886(d)(10) reclassifications will
other hospital and cannot be effected in be able to reclassify for FY 2007; or receive their section 1886(d)(10)
a budget neutral manner. postponing reclassification until FY reclassification, not their section 508
Comment: Some commenters 2008 and being without reclassification reclassification, for the entire fiscal year.
indicated that hospitals currently for the 6 months between April 1 and Hospital groups that include a section
receiving a section 508 reclassification September 30, 2007. The commenters 508 hospital would also be permitted to
are eligible to reclassify to that same believed that both of these options submit section 1886(d)(10)
area under the standard reclassification would carry significant financial reclassification applications by the
process as a result of the new labor consequences for hospitals. The September 1, 2005 deadline. However,
market definitions that we adopted for commenters urged CMS to implement a in order for a group reclassification to be
FY 2005. The commenters pointed out solution that does not require hospitals approved, either of the following
that the governing regulations indicate to make such a difficult choice, and conditions would need to be met:
that ‘‘if a hospital is already reclassified would provide them with the full (1) The section 508 hospital that is
to a given geographic area for wage benefits of the section 508 part of the group must waive its section
index purposes for a 3-year period, and reclassification. 508 reclassification for the first half of
submits an application to the same area Response: We appreciate the FY 2007. This is necessary because the
for either the second or third year of the commenters’ suggestions and their regulations at §§ 412.232 and 412.234
3-year period, that application will not interest in this matter. Under state that all hospitals in a county must
be approved.’’ These commenters 1886(d)(10)(D)(v) of the Act, CMS has apply for reclassification as a group. The
expressed concern that the MGCRB will the authority to ‘‘establish procedures’’ hospitals either agree to receive the
deny these hospitals reclassification for under which a hospital may elect to same reclassification or they fail to
FY 2007 if there is no change in the terminate a reclassification before the qualify as a group. The Administrator
regulations to address this issue. end of a 3-year period. Based on upheld this policy in an MGCRB appeal
Response: We appreciate the comments and on a careful review of the for FY 2006.
commenters’ interest in this matter. statute, we have decided to exercise this (2) Each member of the group agrees
Hospitals that indicate in their MGCRB authority to establish a procedural rule in writing, at the time the application is
applications that they agree to waive for section 508 hospitals to retain their submitted September 1, 2005, that they
their section 508 reclassification for the section 508 reclassification through its cancel the group reclassification if
first 6 months of FY 2007 if they are expiration on March 31, 2007 and granted for the first 6 months of FY
granted a 3-year reclassification under reclassify under a subpart L opportunity 2007. The section 1886(d)(10)
the traditional MGCRB process will not for the second half of FY 2007. The reclassification will be effective only
April through September 2007. Under section 1886(d)(3)(E) or section These adjustments are effective for each
this scenario, the section 508 hospital 1886(d)(8)(D) of the Act. county for a period of 3 fiscal years.
receives its section 508 reclassification Comment: One commenter proposed Hospitals that received the adjustment
from October 2006 through March 2007 that CMS allow hospitals that reclassify in FY 2005 will be eligible to retain that
and the remainder of the group receives and receive a diluted wage index to same adjustment for FY 2006 and FY
the home wage index for that time receive the out-migration adjustment 2007. For hospitals in newly qualified
period. For April through September provided it does not exceed the actual counties, adjustments to the wage index
2007, the section 508 hospital and the wage index for the area to which they are effective for 3 years, beginning with
remainder of the group receive the are reclassified. discharges occurring on or after October
group reclassification. The group will Response: The statute specifically 1, 2005.
have the opportunity to cancel the April states that hospitals that receive an out- As previously noted, hospitals
through September 2007 group migration adjustment are ineligible for receiving the wage index adjustment
reclassification within 45 days of reclassification under section 1886(d)(8) under section 1886(d)(13)(F) of the Act
publication of the proposed rule. or section 1886(d)(10) of the Act. are not eligible for reclassification under
We would apply a similar rule for Hospitals located in counties that sections 1886(d)(8) or (d)(10) of the Act,
purposes of the out-migration qualify for the wage index adjustment or under section 508 of Pub. L. 108–173,
adjustment. The statute states that a will receive an increase in the wage unless they waive such out-migration
hospital cannot receive an out-migration index that is equal to the average of the adjustment. As announced in the FY
adjustment if it is simultaneously differences between the wage indices of 2005 final rule as well as the proposed
reclassified under section 1886(d)(10) of the labor market area(s) with higher rule for FY 2006, hospitals redesignated
the Act. Therefore, hospitals that are not wage indices and the wage index of the under section 1886(d)(8) of the Act or
reclassified during any part of FY 2007 resident county, weighted by the overall reclassified under section 1886(d)(10) of
will, by default, receive an out- percentage of hospital workers residing the Act or under section 508 of Pub. L.
migration adjustment during that time in the qualifying county who are 108–173 were deemed to have chosen to
period. employed in any labor market area with retain their redesignation or
a higher wage index. We have employed reclassification, unless they explicitly
We show the reclassifications
the prereclassified wage indices in notified CMS that they elected to
effective under the one-time appeal
making these calculations. receive the out-migration adjustment
process in Table 9B in the Addendum Hospitals located in the qualifying instead within 45 days from the
to this final rule. counties identified in Table 4J in the publication of the FY 2006 IPPS
I. FY 2006 Wage Index Adjustment Addendum to this final rule that have proposed rule (May 4, 2005). Under
Based on Commuting Patterns of not already reclassified through section § 412.273, hospitals that have been
Hospital Employees 1886(d)(10) of the Act, redesignated reclassified by the MGCRB were
through section 1886(d)(8) of the Act, permitted to terminate existing 3-year
In accordance with the broad received a section 508 reclassification, reclassifications within 45 days of the
discretion under section 1886(d)(13) of or requested to waive the application of May 4, 2005 proposed rule. Hospitals
the Act, as added by section 505 of Pub. the out-migration adjustment will that are eligible to receive the out-
L. 108–173, beginning with FY 2005, we receive the wage index adjustment migration wage index adjustment and
established a process to make listed in the table for FY 2006. We used that withdraw their application for
adjustments to the hospital wage index the same formula described in the FY reclassification automatically receive
based on commuting patterns of 2005 final rule (69 FR 49064) to the wage index adjustment listed in
hospital employees. The process, calculate the out-migration adjustment. Table 4J in the Addendum to this final
outlined in the FY 2005 IPPS final rule This adjustment was calculated as rule. Requests for withdrawal of an
(69 FR 49061), provides for an increase follows: application for reclassification or
in the wage index for hospitals located Step 1. Subtract the wage index for termination of an existing 3-year
in certain counties that have a relatively the qualifying county from the wage reclassification will be effective in FY
high percentage of hospital employees index for the higher wage area(s). 2006 and had to have been received by
who reside in the county but work in a Step 2. Divide the number of hospital the MGCRB within 45 days of the
different county (or counties) with a employees residing in the qualifying publication of the FY 2006 IPPS
higher wage index. Such adjustments to county who are employed in such proposed rule. Requests to waive
the wage index are effective for 3 years, higher wage index area by the total section 1886(d)(8) redesignations for FY
unless a hospital requests to waive the number of hospital employees residing 2006 had to have been received by CMS
application of the adjustment. A county in the qualifying county who are within 45 days of the publication of the
will not lose its status as a qualifying employed in any higher wage index FY 2006 IPPS proposed rule. In
county due to wage index changes area. Multiply this result by the result addition, hospitals that wished to retain
during the 3-year period, and counties obtaining in Step 1. their redesignation/reclassification
will receive the same wage index Step 3. Sum the products resulting under section 1886(d)(8), section
increase for those 3 years. However, a from Step 2 (if the qualifying county has 1886(d)(10), or section 508 (instead of
county that qualifies in any given year workers commuting to more than one receiving the out-migration adjustment)
may no longer qualify after the 3-year higher wage area). for FY 2006 did not need to submit a
period, or it may qualify but receive a Step 4. Multiply the result from Step formal request to CMS; they
different adjustment to the wage index 3 by the percentage of hospital automatically retain their redesignation/
level. Hospitals that receive this employees who are residing in the reclassification status for FY 2006.
adjustment to their wage index are not qualifying county and who are Comment: Commenters expressed
eligible for reclassification under employed in any higher wage index opposition to and support of CMS’
section 1886(d)(8) or section 1886(d)(10) area. interpretation of the law that hospitals
of the Act. Adjustments under this The adjustments calculated for will receive the same out-migration
provision are not subject to the IPPS qualifying hospitals are listed in Table adjustment in each of the 3 years of
budget neutrality requirements under 4J in the Addendum to this final rule. eligibility for the adjustment. One
commenter recommended that CMS Response: First, we note that deadline and of all other possible
maintain its policy to keep the out- cancellation and reinstatement rules for deadlines and requirements, including
migration adjustment unchanged to geographic reclassifications are the requirement to review and verify
minimize uncertainties and instability procedural rules that are not subject to their data as posted on the preliminary
in Medicare reimbursement to hospitals. notice and comment rulemaking. wage index data file on the Internet,
Other commenters recommended that Second, we note that it has been our through the October 6, 2004
CMS revise its policy so that the out- longstanding policy that our procedural memorandum referenced above.
migration adjustment will be rules on withdrawals or terminations of In the October 6, 2004 memorandum,
recalculated each year based on updated reclassifications require such we also specified that a hospital could
wage data and the new wage indices. terminations and withdrawals be made only request revisions to the
Response: We appreciate the within 45 days of the proposed rule occupational mix data for the reporting
comments we received regarding this (§ 412.273). However, FY 2005 was an period that the hospital used in its
issue. The governing statute specifically exceptional circumstance due to the original FY 2005 wage index
states that the wage index increase extensive changes to the wage index as occupational mix survey. That is, a
‘‘shall be effective for a period of 3 fiscal a result of our adoption of the new labor hospital that submitted occupational
years.’’ We have interpreted this to market areas. We noted that this was a mix data for the 12-month reporting
mean that the adjustment shall be limited circumstance, and we did not period could not switch to submitting
identical for 3 years. If we were to expect to extend the withdrawal date data for the 4-week reporting period and
recalculate the out-migration adjustment beyond 45 days after the proposed rule vice versa. Further, a hospital could not
each year based on updated wage data in future years. We do not believe the submit an occupational mix survey for
as suggested, counties could potentially exceptional circumstance that existed the periods beginning before January 1,
be deemed ineligible for the wage index for FY 2005 exists for FY 2006, given 2003, or after January 11, 2004. In
adjustment if the average hourly wage the changes to the labor market areas addition, a hospital that did not submit
for all hospitals in the labor market area have been adopted. Therefore, we are an occupational mix survey for the FY
exceeded the average hourly wages for continuing with our longstanding policy 2005 wage index was not permitted to
all hospitals in the county. Therefore, that terminations of reclassifications are submit a survey for the FY 2006 wage
we have elected to maintain our policy required to be made within 45 days of index.
to keep the out-migration adjustment the proposed rule. As we have The fiscal intermediaries notified the
associated with a particular county explained in previous preamble hospitals by mid-February 2005 of any
unchanged. discussions (see, for example, 56 FR changes to the wage index data as a
Comment: One commenter requested 43241, August 30, 1991), the 45-day result of the desk reviews and the
that we clarify the removal of several deadline provides a reasonable time to resolution of the hospitals’ late
providers from Table 4J between the take withdrawals or terminations into November 2004 change requests. The
May 4, 2005 Federal Register account in developing the final wage fiscal intermediaries also submitted the
publication and the revised table posted index and prospective payment rates. revised data to CMS by mid-February
on the CMS Web site on June 1, 2005. 2005. CMS published the proposed
Response: There were some errors for J. Requests for Wage Index Data wage index public use files that
CBSAs and imputed rural floors and Corrections included hospitals’ revised wage data
these errors had an effect on the out- In the FY 2005 IPPS final rule (68 FR on February 25, 2005. In a
migration calculations shown in Table 27194), we revised the process and memorandum also dated February 25,
4J of the proposed rule. We posted the timetable for application for 2005, we instructed fiscal
corrected adjustments on the CMS Web development of the wage index, intermediaries to notify all hospitals
site on June 1, 2005. Hospitals were also beginning with the FY 2005 wage index. regarding the availability of the
notified of the corrected out-migration The preliminary and unaudited proposed wage index public use files
adjustments via the Listserv and a Worksheet S–3 wage data and and the criteria and process for
Hospital Open Door Forum on June 2, occupational mix survey files were requesting corrections and revisions to
2005. made available on October 8, 2004 the wage index data. Hospitals had until
Comment: Commenters requested that through the Internet on the CMS Web March 14, 2005 to submit requests to the
CMS make available the hospital site at: http://cms.hhs.gov/providers/ fiscal intermediaries for reconsideration
commuting data used to compute the hipps/ippswage.asp. In a memorandum of adjustments made by the fiscal
out-migration adjustment. dated October 6, 2004, we instructed all intermediaries as a result of the desk
Response: We plan to make the data Medicare fiscal intermediaries to inform review, and to correct errors due to
used for determining the qualifying the IPPS hospitals they service of the CMS’s or the fiscal intermediary’s
counties and the out-migration availability of the wage index data files mishandling of the wage index data.
adjustment available after the and the process and timeframe for Hospitals were also required to submit
publication of this final rule on the CMS requesting revisions (including the sufficient documentation to support
Web site at: http://www.cms.gov. specific deadlines listed below). We also their requests.
Comment: Commenters requested that instructed the fiscal intermediaries to After reviewing requested changes
CMS implement a policy similar to the advise hospitals that these data are also submitted by hospitals, fiscal
policy established for FY 2005 that made available directly through their intermediaries transmitted any
allows hospitals to withdraw or representative hospital organizations. additional revisions resulting from the
reinstate their geographic applications If a hospital wished to request a hospitals’ reconsideration requests by
within 30 days of the date that the final change to its data as shown in the April 15, 2005. The deadline for a
rule is published. Several commenters October 8, 2004 wage and occupational hospital to request CMS intervention in
believed there is still a likelihood that mix data files, the hospital was to cases where the hospital disagreed with
revisions made between the proposed submit corrections along with complete, the fiscal intermediary’s policy
and final rules may affect a hospital’s detailed supporting documentation to interpretations was April 22, 2005.
choice of whether to accept the out- its fiscal intermediary by November 29, Hospitals were also instructed to
migration or a reclassification. 2004. Hospitals were notified of this examine Table 2 in the Addendum to
the proposed rule. Table 2 of the intermediaries (that is, by June 10, 2005) by the June deadline for making
proposed rule contained each hospital’s have been incorporated into the final corrections to the wage data for the
adjusted average hourly wage used to wage index of this final rule and are following fiscal year’s wage index. This
construct the wage index values for the effective October 1, 2005. provision is not available to a hospital
past 3 years, including the FY 2002 data We created the processes described seeking to revise another hospital’s data
used to construct the FY 2006 wage above to resolve all substantive wage that may be affecting the requesting
index. We noted that the hospital index data correction disputes before we hospital’s wage index for the labor
average hourly wages shown in Table 2 finalize the wage and occupational mix market area. As indicated earlier, since
only reflected changes made to a data for the FY 2006 payment rates. CMS makes the wage data available to
hospital’s data and transmitted to CMS Accordingly, hospitals that did not meet a hospital on the CMS Web site prior to
by February 23, 2005. the procedural deadlines set forth above publishing both the proposed and final
The final wage data public use file will not be afforded a later opportunity IPPS rules, and the fiscal intermediaries
was released in early May 2005 to to submit wage index data corrections or notify hospitals directly of any wage
hospital associations and the public on to dispute the fiscal intermediary’s data changes after completing their desk
the Internet at http:/www.cms.hhs.gov/ decision with respect to requested reviews, we do not expect that midyear
providers/hipps/ippswage.asp. The May changes. Specifically, our policy is that corrections would be necessary.
2005 public use file was made available hospitals that do not meet the However, under our current policy, if
solely for the limited purpose of procedural deadlines set forth above the correction of a data error changes
identifying any potential errors made by will not be permitted to challenge later, the wage index value for an area, the
CMS or the fiscal intermediary in the before the Provider Reimbursement revised wage index value will be
entry of the final wage data that result Review Board, the failure of CMS to effective prospectively from the date the
from the correction process described make a requested data revision. (See correction is made.
above (revisions submitted to CMS by W.A. Foote Memorial Hospital v.
In the FY 2006 IPPS proposed rule,
the fiscal intermediaries by April 15, Shalala, No. 99–CV–75202–DT (E.D.
we proposed to revise § 412.64(k)(2) to
2005). If, after reviewing the May 2005 Mich. 2001) and Palisades General
specify that a change to the wage index
final file, a hospital believed that its Hospital v. Thompson, No. 99–1230
can be made retroactive to the beginning
wage data were incorrect due to a fiscal (D.D.C. 2003.) We refer the reader also
of the Federal fiscal year only when: (1)
intermediary or CMS error in the entry to the FY 2000 final rule (64 FR 41513)
The fiscal intermediary or CMS made an
or tabulation of the final wage data, it for a discussion of the parameters for
was provided the opportunity to send a appealing to the PRRB for wage index error in tabulating data used for the
letter to both its fiscal intermediary and data corrections. wage index calculation; (2) the hospital
CMS that outlined why the hospital Again, we believe the wage index data knew about the error and requested that
believed an error exists and to provide correction process described above the fiscal intermediary and CMS correct
all supporting information, including provides hospitals with sufficient the error using the established process
relevant dates (for example, when it first opportunity to bring errors in their wage and within the established schedule for
became aware of the error). These index data to the fiscal intermediaries’ requesting corrections to the wage data,
requests had to be received by CMS and attention. Moreover, because hospitals before the beginning of the fiscal year
the fiscal intermediaries by no later than had access to the final wage index data for the applicable IPPS update (that is,
June 10, 2005. The fiscal intermediary by early May 2005, they had the by the June 10, 2005 deadline for the FY
reviewed requests upon receipt and opportunity to detect any data entry or 2006 wage index); and (3) CMS agreed
contacted CMS immediately to discuss tabulation errors made by the fiscal that the fiscal intermediary or CMS
its findings. intermediary or CMS before the made an error in tabulating the
After the release of the May 2005 development and publication of the hospital’s wage data and the wage index
wage index data file, changes to the final FY 2006 wage index in this final should be corrected. We proposed this
hospital wage data were only made in rule, and the implementation of the FY change because there may be instances
those very limited situations involving 2006 wage index on October 1, 2005. If in which a hospital identifies an error
an error by the fiscal intermediary or hospitals availed themselves of the in its wage data and submits a
CMS that the hospital could not have opportunities afforded to provide and correction request using all appropriate
known about before its review of the make corrections to the wage data, the procedures and by the June deadline,
final wage index data file. Specifically, wage index implemented on October 1 CMS agrees that the fiscal intermediary
neither the intermediary nor CMS should be accurate. Nevertheless, in the or CMS caused the error in the
accepted the following types of requests: event that errors are identified by hospital’s wage data and that the wage
• Requests for wage data corrections hospitals and brought to our attention index must be corrected, but CMS fails
that were submitted too late to be after June 10, 2005, we retain the right to publish or implement the corrected
included in the data transmitted to CMS to make midyear changes to the wage wage index value by the beginning of
by fiscal intermediaries on or before index under very limited circumstances. the Federal fiscal year. We made this
April 15, 2005. Specifically, in accordance with proposed revision to § 412.64(k)(2)
• Requests for correction of errors § 412.64(k)(1) of our existing because we believe that it is appropriate
that were not, but could have been, regulations, we make midyear and fair. We also believe that, unlike a
identified during the hospital’s review corrections to the wage index for an area generalized retroactive policy, the
of the February 25, 2005 wage index only if a hospital can show that: (1) the situations where this will occur will be
data file. fiscal intermediary or CMS made an minimal, thus minimizing the
• Requests to revisit factual error in tabulating its data; and (2) the administrative burden associated with
determinations or policy interpretations requesting hospital could not have such retroactive corrections. In those
made by the fiscal intermediary or CMS known about the error or did not have circumstances where a hospital requests
during the wage index data correction an opportunity to correct the error, a correction to its wage data before CMS
process. before the beginning of the fiscal year. calculates the final wage index (that is,
Verified corrections to the wage index For purposes of this provision, ‘‘before by the June deadline), and CMS
received timely by CMS and the fiscal the beginning of the fiscal year’’ means acknowledges that the error in the
hospital’s wage data caused by CMS’s or (that is, by October 1, 2004), but CMS wage index and intended to pay the
the fiscal intermediary’s mishandling of was unable to publish the correction by hospital at the corrected wage index
the data, we believe that the hospital the beginning of the fiscal year. effective October 1, 2004.
should not be penalized by our delay in On December 30, 2004, we published Comment: Two commenters urged
publishing or implementing the in the Federal Register a correction CMS to retroactively apply the policy
correction. As with our current policy, notice to the FY 2005 IPPS final rule that we are finalizing in this final rule
we indicated that the proposed that included the corrected wage data to extend hold harmless protections to
provision would not be available to a for four hospitals that meet all of the urban hospitals that are redesignated as
hospital seeking to revise another three above stated criteria (69 FR rural under section 401 to the FY 2005
hospital’s data. In addition, the 78526). These corrections were effective IPPS wage index.
provision could not be used to correct January 1, 2005. As noted, our current Response: Retroactive wage
prior years’ wage data; it could only be regulations allow only for a prospective corrections are intended to correct
used for the current Federal fiscal year. correction to the hospitals’ area wage errors made in a previous year. In this
In other situations, we continue to index values. However, we believe that, case, we made a change to the
believe that it is appropriate to make in the limited circumstance mentioned regulations prospectively. Because the
prospective corrections to the wage above, a retroactive correction to the FY regulation change is unrelated to errors
index in those circumstances where a 2005 wage index is appropriate and that were not corrected, we do not
hospital could not have known about or meets the condition of section 903(a)(1) believe a retroactive wage index
did not have the opportunity to correct of Pub. L. 108–173 that ‘‘failure to apply correction is warranted.
the fiscal intermediary’s or CMS’s error the change retroactively would be Comment: One commenter, a group of
before the beginning of the fiscal year contrary to the public interest.’’ hospitals within a single CBSA,
(that is, by the June deadline). Comment: Several commenters believed that the proposed retroactive
We are making this change to supported CMS’ proposal to correct the wage index corrections should be
§ 412.64(k)(2) effective on October 1, FY 2005 wage index retroactive to
expanded to include geographic
2005, that is, beginning with the FY October 1, 2004, using the authority
classification errors. The commenter
2006 wage index. We note that, as with provided under section 903(a)(1) of Pub.
indicated that CMS made an error in
prospective changes to the wage index, L. 108–173 on a one-time only basis for
tabulating the FY 2005 wage index data
the final retroactive correction will be the limited circumstance where a
for the CBSA when it incorrectly
made irrespective of whether the change hospital meets the first two criteria
categorized one provider as belonging to
increases or decreases a hospital’s specified in the proposal. However, the
another CBSA. The commenter added
payment rate. In addition, we note that commenters requested that CMS amend
that the geographic classification error
the policy of retroactive adjustment will the proposed policy to delete the third
had the effect of lowering the wage
still apply in those instances where a criterion that CMS must have agreed
before October 1 that the fiscal index of the CBSA and inflating the
judicial decision reverses a CMS denial
intermediary or CMS made an error in wage index for the other CBSA. The
of a hospital’s wage data revision
tabulating the hospital’s wage data. The commenter indicated that CMS was
request.
In addition, in the FY 2006 IPPS commenters were concerned that if CMS given notice of the error prior to October
proposed rule, we proposed to correct could not notify hospitals before 1, 2004, but the correction was changed
the FY 2005 wage index retroactively October 1 that the wage data would be prospectively effective January 1, 2005,
(that is, from October 1, 2004) on a one- corrected, the hospital would not be rather than retrospectively.
time only basis for a limited eligible for the retroactive correction to Response: We agree that both
circumstance using the authority the FY 2005 wage index. geographic classification and
provided under section 903(a)(1) of Pub. Response: We believe it is important reclassification technical errors should
L. 108–173. This provision authorizes to retain the requirement that CMS must be corrected retroactive to the beginning
the Secretary to make retroactive have notified the hospital before of the fiscal year and that the special
changes to items and services if failure October 1 that an error was made in rule for FY 2005 should apply if the
to apply such changes would be calculating the wage index for an area circumstances are the same as those that
contrary to the public interest. However, for the correction to be made we are applying to the wage index. This
as indicated, our current regulations at retroactively to October 1. The October would apply in cases where the wage
§ 412.64(k)(1) allow only for a 1 date is relevant because it is the first index of an area has been miscalculated
prospective correction to the hospitals’ day of the new fiscal year. Once the because of the improper assignment of
area wage index values. We proposed to fiscal year begins, we believe it is a particular hospital to a labor market
correct the FY 2005 wage index important to only make changes to the area.
retroactively in the limited wage index prospectively, as has been Beginning with FY 2006, a hospital
circumstance where a hospital meets all CMS’ longstanding policy as stated in could receive a retroactive adjustment to
of the following criteria: (1) The fiscal the FY 1984 IPPS final rule (49 FR 258, its wage index for a geographic
intermediary or CMS made an error in January 3, 1984), unless it is clear that classification or reclassification error if
tabulating a hospital’s FY 2005 wage CMS determined that either it or the the circumstances included in
index data; (2) the hospital informed the fiscal intermediary made an error prior § 412.64(k)(2) exist. Generally stated, the
fiscal intermediary or CMS, or both, to the beginning of the fiscal year and following circumstances must be
about the error, following the intended to pay hospitals using a present.
established schedule and process for different wage index. With respect to For classification/reclassification
requesting corrections to its FY 2005 the specific requirements for making FY errors made during the proposed rule:
wage index data; and (3) CMS agreed 2005 wage index corrections retroactive (1) CMS made a technical error in
before October 1 that the fiscal to October 1, 2004, we will accept assigning the hospital to a geographic
intermediary or CMS made an error in letters, e-mails, and other written labor market area. (The error made must
tabulating the hospital’s wage data and evidence from hospitals demonstrating be truly technical in nature and could
the wage index should be corrected by that, prior to October 1, 2004, CMS not include any disputes about policy or
the beginning of the Federal fiscal year agreed that an error was made to the cases where a hospital disagrees with
the MGCRB or CMS’ reclassification mail during the comment period on the purchase in order to furnish inpatient
decisions.) proposed rule and using the procedures care. We first used the market basket to
(2) The hospital notifies CMS of the for submitting formal comments; adjust hospital cost limits by an amount
technical error using the formal (3) The error was not corrected in the that reflected the average increase in the
comment process and during the tables accompanying the FY 2005 final prices of the goods and services used to
comment period on the proposed rule. rule (69 FR 49690); and provide hospital inpatient care. This
(This period is different from the period (4) The hospital notified CMS of the approach linked the increase in the cost
for requesting wage index corrections, error via written correspondence or e- limits to the efficient utilization of
as wage index data are posted on the mail following the publication of the resources.
CMS Web site and must follow a certain final rule, CMS agreed prior to October Since the inception of the IPPS, the
schedule set by CMS—for example, for 1, 2004, that an error was made, CMS projected change in the hospital market
FY 2006, tabulation errors were required agreed that the error should be corrected basket has been the integral component
to have been identified by June 10, by the beginning of the Federal fiscal of the update factor by which the
2005.) year (that is, by October 1, 2004), but prospective payment rates are updated
(3) The error was not corrected in the CMS was unable to publish the every year. An explanation of the
final rule. correction by the beginning of such hospital market basket used to develop
(4) The hospital again notifies CMS of fiscal year. the prospective payment rates was
the geographic assignment error, via For geographic assignment errors published in the Federal Register on
written correspondence or e-mail made for the first time during the FY September 1, 1983 (48 FR 39764). We
following the publication of the final 2005 final rule: also refer the reader to the August 1,
rule, and CMS agrees prior to October 1 (1) CMS made a technical error in the 2002 Federal Register (67 FR 50032) in
that an error was made. tables of the FY 2005 final rule (69 FR which we discussed the previous
For classification/reclassification 49690) in assigning a hospital to a rebasing of the hospital input price
errors made for the first time during the geographic labor market area; and index.
final rule: (2) The hospital notified CMS of the The hospital market basket is a fixed
(1) CMS made a technical error in the error via written correspondence or e- weight, Laspeyres-type price index that
final rule in assigning the hospital to a mail following the publication of the is constructed in three steps. First, a
geographic labor market area; and final rule, CMS agreed prior to October base period is selected (in this final rule,
(2) The hospital notifies CMS of the 1, 2004, that an error was made, CMS FY 2002) and total base period
error via written correspondence or e- agreed that the error should be corrected expenditures are estimated for a set of
mail, following the publication of the by the beginning of the Federal fiscal mutually exclusive and exhaustive
final rule, and CMS agrees prior to year (that is, by October 1, 2004), but spending categories based upon type of
October 1 that an error was made. CMS was unable to publish the expenditure. Then the proportion of
In addition, we also agree that correction by the beginning of such total operating costs that each category
geographic classification or fiscal year. represents is determined. These
reclassification errors that resulted in an proportions are called cost or
incorrect wage index for FY 2005 IV. Rebasing and Revision of the expenditure weights. Second, each
should also be corrected retroactively Hospital Market Baskets expenditure category is matched to an
(that is, from October 1, 2004) on a one- A. Background appropriate price or wage variable,
time only basis for a limited referred to as a price proxy. In nearly
circumstance using the authority Effective for cost reporting periods every instance, these price proxies are
provided under section 903(a)(1) of Pub. beginning on or after July 1, 1979, we price levels derived from publicly
L. 108–173. This provision authorizes developed and adopted a hospital input available statistical series that are
the Secretary to make retroactive price index (that is, the hospital market published on a consistent schedule,
changes to items and services if failure basket for operating costs). Although preferably at least on a quarterly basis.
to apply such changes would be ‘‘market basket’’ technically describes Finally, the expenditure weight for
contrary to the public interest. Again, the mix of goods and services used to each cost category is multiplied by the
we believe it would not be in the public produce hospital care, this term is also level of its respective price proxy. The
interest for us to pay hospitals using an commonly used to denote the input sum of these products (that is, the
incorrect wage index when the price index (that is, cost category expenditure weights multiplied by their
geographic classification/reclassification weights and price proxies combined) price levels) for all cost categories yields
error was brought to our attention and derived from that market basket. the composite index level of the market
we agreed prior to the beginning of FY Accordingly, the term ‘‘market basket’’ basket in a given period. Repeating this
2005 that the error should be corrected. as used in this document refers to the step for other periods produces a series
For FY 2005, we will make corrections hospital input price index. of market basket levels over time.
to the wage index for geographic The terms ‘‘rebasing’’ and ‘‘revising,’’ Dividing an index level for a given
classification errors retroactive to while often used interchangeably, period by an index level for an earlier
October 1, 2004 in the following actually denote different activities. period produces a rate of growth in the
circumstances: ‘‘Rebasing’’ means moving the base year input price index over that time period.
For classification/reclassification for the structure of costs of an input The market basket is described as a
errors made during the FY 2005 IPPS price index (for example, in this final fixed-weight index because it describes
proposed rule: rule, we are shifting the base year cost the change in price over time of the
(1) CMS made a technical error in the structure for the IPPS hospital index same mix of goods and services
tables of the FY 2005 proposed rule (69 from FY 1997 to FY 2002). ‘‘Revising’’ purchased to provide hospital services
FR 28752, May 18, 2004) in assigning a means changing data sources, or price in a base period. The effects on total
hospital to a geographic labor market proxies, used in the input price index. expenditures resulting from changes in
area; The percentage change in the market the quantity or mix of goods and
(2) The hospital notified CMS of the basket reflects the average change in the services (intensity) purchased
error, via written correspondence or e- price of goods and services hospitals subsequent to the base period are not
measured. For example, shifting a (hospital inputs) to furnish inpatient hospital market basket cost weights is
traditionally inpatient type of care to an care between base periods. We last the FY 2002 Medicare cost reports.
outpatient setting might affect the rebased the hospital market basket cost These cost reports are from IPPS
volume of inpatient goods and services weights effective for FY 2003 (67 FR hospitals only. They do not reflect data
purchased by the hospital, but would 50032, August 1, 2002), with FY 1997 from hospitals excluded from the IPPS
not be factored into the price change data used as the base period for the or CAHs. The IPPS cost reports yield
measured by a fixed weight hospital construction of the market basket cost seven major expenditure or cost
market basket. In this manner, the weights. categories: wages and salaries, employee
market basket measures only the pure benefits, contract labor,
price change. Only when the index is B. Rebasing and Revising the Hospital
Market Basket pharmaceuticals, professional liability
rebased using a more recent base period
insurance (malpractice), blood and
would the quantity and intensity effects 1. Development of Cost Categories and
be captured in the cost weights. blood products, and a residual ‘‘all
Weights
Therefore, we rebase the market basket other.’’
a. Medicare Cost Reports
periodically so the cost weights reflect
changes in the mix of goods and The major source of expenditure data
services that hospitals purchase for developing the rebased and revised
CHART 1.—MAJOR COST CATEGORIES FOUND IN MEDICARE COST REPORTS

FY 1997- FY 2002-
Major cost categories based market based market
basket basket
Wages and salaries ................................................................................................................................................. 48.965 45.590

Employee benefits ................................................................................................................................................... 10.597 11.189
Contract labor .......................................................................................................................................................... 2.094 3.214
Professional Liability Insurance (Malpractice) ......................................................................................................... 0.840 1.589
Pharmaceuticals ...................................................................................................................................................... 5.416 5.855
Blood and blood products ........................................................................................................................................ 0.875 1.082
All other .................................................................................................................................................................... 31.213 31.481
b. Other Data Sources I–O is an update of the 1992 I–O tables, appropriate wage and price proxies to
while the 1997 Benchmark I–O is an reflect the rate-of-price change for each
In addition to the Medicare cost
entirely new set of numbers derived expenditure category. With the
reports, other sources of data used in
from the 1997 Economic Census. The exception of the Professional Liability
developing the market basket weights
2002 Benchmark Input-Output tables proxy, all the indicators are based on
are the Benchmark Input-Output Tables
are not yet available. Therefore, as we Bureau of Labor Statistics (BLS) data
(I–Os) created by the Bureau of
proposed in the FY 2006 IPPS proposed and are grouped into one of the
Economic Analysis, U.S. Department of rule, we use the 1997 Benchmark I–O following BLS categories:
Commerce, and the Business Expenses data in the FY 2002-based market
Survey developed by the Bureau of the • Producer Price Indexes—Producer
basket, to be effective for FY 2006. Price Indexes (PPIs) measure price
Census, U.S. Department of Commerce, Instead of using the less detailed, less
from its Economic Census. changes for goods sold in other than
accurate Annual I–O data, we aged the retail markets. PPIs are preferable price
New data for these sources are 1997 Benchmark I–O data forward to FY
scheduled for publication every 5 years, proxies for goods that hospitals
2002. The methodology we used to age purchase as inputs in producing their
but may take up to 7 years after the the data involves applying the annual
reference year. Only an Annual I–O is outputs because the PPIs would better
price changes from the price proxies to reflect the prices faced by hospitals. For
produced each year, but the Annual I– the appropriate cost categories. We
O contains less industry detail than example, we use a special PPI for
repeat this practice for each year. prescription drugs, rather than the
does the Benchmark I–O. When we The ‘‘all other’’ cost category is
rebased the market basket using FY Consumer Price Index (CPI) for
further divided into other hospital
1997 data in the FY 2003 IPPS final prescription drugs because hospitals
expenditure category shares using the
rule, the 1997 Benchmark I–O was not generally purchase drugs directly from
1997 Benchmark Input-Output tables.
yet available. Therefore, we did not the wholesaler. The PPIs that we use
Therefore, the ‘‘all other’’ cost category
incorporate data from that source into measure price change at the final stage
expenditure shares are proportional to
the FY 1997-based market basket (67 FR of production.
their relationship to ‘‘all other’’ totals in
50033). However, we did use a the I–O tables. For instance, if the cost • Consumer Price Indexes—
secondary source, the 1997 Annual for telephone services were to represent Consumer Price Indexes (CPIs) measure
Input-Output tables. The third source of 10 percent of the sum of the ‘‘all other’’ change in the prices of final goods and
data, the 1997 Business Expenditure I–O (see below) hospital expenditures, services bought by the typical
Survey (now known as the Business then telephone services would represent consumer. Because they may not
Expenses Survey) was used to develop 10 percent of the market basket’s ‘‘all represent the price faced by a producer,
weights for the utilities and telephone other’’ cost category. we used CPIs only if an appropriate PPI
services categories. was not available, or if the expenditures
The 1997 Benchmark I–O data are a 2. PPS—Selection of Price Proxies were more similar to those of retail
much more comprehensive and After computing the FY 2002 cost consumers in general rather than
complete set of data than the 1997 weights for the rebased hospital market purchases at the wholesale level. For
Annual I–O estimates. The 1997 Annual basket, it was necessary to select example, the CPI for food purchased
away from home is used as a proxy for We evaluated the price proxies using applied. The CPIs, PPIs, and ECIs
contracted food services. the criteria of reliability, timeliness, selected meet these criteria.
• Employment Cost Indexes— availability, and relevance. Reliability Chart 2 sets forth the complete market
Employment Cost Indexes (ECIs) indicates that the index is based on basket including cost categories,
measure the rate of change in employee valid statistical methods and has low
weights, and price proxies. For
wage rates and employer costs for sampling variability. Timeliness implies
employee benefits per hour worked. comparison purposes, the
that the proxy is published regularly, at
These indexes are fixed-weight indexes least once a quarter. Availability means corresponding FY 1997-based market
and strictly measure the change in wage that the proxy is publicly available. basket is listed as well. A summary
rates and employee benefits per hour. Finally, relevance means that the proxy outlining the choice of the various
Appropriately, they are not affected by is applicable and representative of the proxies follows the chart.
shifts in employment mix. cost category weight to which it is
CHART 2.—FY 2002-BASED PPS HOSPITAL MARKET BASKET COST CATEGORIES, WEIGHTS, AND PROXIES WITH FY
1997-BASED MARKET BASKET USED FOR COMPARISON
Rebased FY
FY 1997-Based 2002-based
Expense categories hospital market Rebased FY 2002-based hospital market basket price proxies
hospital market
basket weights basket weights
1. Compensation ........................................ 61.656 59.993

A. Wages and Salaries* ..................... 50.686 48.171 ECI—Wages and Salaries, Civilian Hospital Workers.
B. Employee Benefits* ........................ 10.970 11.822 ECI—Benefits, Civilian Hospital Workers.
2. Professional Fees* ................................. 5.401 5.510 ECI—Compensation for Professional, Specialty & Technical
Workers.
3. Utilities ................................................... 1.353 1.251
A. Fuel, Oil, and Gasoline .................. 0.284 0.206 PPI Refined Petroleum Products.
B. Electricity ........................................ 0.833 0.669 PPI Commercial Electric Power.
C. Water and Sewerage ..................... 0.236 0.376 CPI–U Water & Sewerage Maintenance.
4. Professional Liability Insurance ............. 0.840 1.589 CMS Professional Liability Insurance Premium Index.
5. All Other ................................................. 30.749 31.657
A. All Other Products .......................... 19.537 20.336
(1) Pharmaceuticals ..................... 5.416 5.855 PPI Prescription Drugs.
(2) Direct Purchase Food ............ 1.370 1.664 PPI Processed Foods & Feeds.
(3) Contract Service Food ........... 1.274 1.180 CPI–U Food Away From Home.
(4) Chemicals .............................. 2.604 2.096 PPI Industrial Chemicals.
(5) Blood and Blood Products** .. 0.875
(6) Medical Instruments ............... 2.192 1.932 PPI Medical Instruments & Equipment.
(7) Photographic Supplies ........... 0.204 0.183 PPI Photographic Supplies.
(8) Rubber and Plastics ............... 1.668 2.004 PPI Rubber & Plastic Products.
(9) Paper Products ...................... 1.355 1.905 PPI Converted Paper & Paperboard Products.
(10) Apparel ................................. 0.583 0.394 PPI Apparel.
(11) Machinery and Equipment ... 1.040 0.565 PPI Machinery & Equipment.
(12) Miscellaneous Products** .... 0.956 2.558 PPI Finished Goods less Food and Energy.
B. All Other Services .......................... 11.212 11.321
(1) Telephone Services ............... 0.398 0.458 CPI–U Telephone Services.
(2) Postage .................................. 0.857 1.300 CPI–U Postage.
(3) All Other: Labor Intensive* ..... 5.438 4.228 ECI—Compensation for Private Service Occupations.
(4) All Other: Non-Labor Inten- 4.519 5.335 CPI–U All Items.
sive.
Total .................................................... 100.000 100.000

* Labor-Related.
** Blood and blood products, previously a separate cost category, is now contained within Miscellaneous Products in the FY 2002-based mar-
ket basket. See discussion in section IV.B.2.r., miscellaneous products, as well as comment and response on blood and blood products that fol-
low this section.
a. Wages and Salaries benefits for civilian hospital workers. d. Fuel, Oil, and Gasoline
This is the same proxy that was used in
For measuring the price growth of the FY 1997-based market basket. The percentage change in the price of
wages in the FY 2002-based market gas fuels as measured by the PPI
basket, as we proposed, we used the ECI c. Nonmedical Professional Fees (Commodity Code #0552) is applied to
for wages and salaries for civilian The ECI for compensation for this component. The same proxy was
hospital workers as the proxy for wages professional and technical workers in used in the FY 1997-based market
in the hospital market basket. This same private industry is applied to this basket.
proxy was used for the FY 1997-based category because it includes e. Electricity
market basket. occupations such as management and
b. Employee Benefits consulting, legal, accounting and The percentage change in the price of
engineering services. The same proxy commercial electric power as measured
The FY 2002-based hospital market was used in the FY 1997-based market by the PPI (Commodity Code #0542) is
basket uses the ECI for employee basket. applied to this component. The same
proxy was used in the FY 1997-based proxy was used in the FY 1997-based as measured by the PPI (Commodity
market basket. market basket. Code #SOP3500) is applied to this
component. Using this index removes
f. Water and Sewerage k. Chemicals
the double-counting of food and energy
The percentage change in the price of The percentage change in the price of prices, which are already captured
water and sewerage maintenance as industrial chemical products as elsewhere in the market basket. The
measured by the CPI for all urban measured by the PPI (Commodity Code same proxy was used in the FY 1997-
consumers (CPI Code # #061) is applied to this component. based market basket. The weight for this
CUUR0000SEHG01) is applied to this While the chemicals hospitals purchase cost category is higher than in the FY
component. The same proxy was used include industrial as well as other types 1997-based market basket because the
in the FY 1997-based market basket. of chemicals, the industrial chemicals weight for blood and blood products
component constitutes the largest (1.082) is added to it. In the FY 1997-
g. Professional Liability Insurance
proportion by far. Thus, we believe that based market basket, we included a
The FY 2002-based index uses the Commodity Code #061 is the separate cost category for blood and
percentage change in the hospital appropriate proxy. The same proxy was blood products, using the BLS PPI
professional liability insurance (PLI) used in the FY 1997-based market (Commodity Code #063711) for blood
premiums as estimated by the CMS basket. and derivatives as a price proxy. A
Hospital Professional Liability Index, review of recent trends in the PPI for
which we use as a proxy in the l. Medical Instruments
blood and derivatives suggests that its
Medicare Economic Index (68 FR The percentage change in the price of movements may not be consistent with
63244), for the proxy of this category. medical and surgical instruments as the trends in blood costs faced by
Similar to the Physicians Professional measured by the PPI (Commodity Code hospitals. While this proxy did not
Liability Index, we attempt to collect #1562) is applied to this component. match exactly with the product
commercial insurance premiums for a The same proxy was used in the FY hospitals are buying, its trend over time
fixed level of coverage, holding 1997-based market basket. appears to be reflective of the historical
nonprice factors constant (such as a price changes of blood purchased by
change in the level of coverage). In the m. Photographic Supplies
hospitals. However, an apparent
FY 1997-based market basket, the same The percentage change in the price of divergence over recent periods led us to
price proxy was used. photographic supplies as measured by reevaluate whether the PPI for blood
We continue to research options for the PPI (Commodity Code #1542) is and derivatives was an appropriate
improving our proxy for professional applied to this component. The same measure of the changing price of blood.
liability insurance. This research proxy was used in the FY 1997-based We ran test market baskets classifying
includes exploring various options for market basket. blood in three separate cost categories:
expanding our current survey, including blood and blood products, contained
n. Rubber and Plastics
the identification of another entity that within chemicals as was done for the FY
would be willing to work with us to The percentage change in the price of 1992-based market basket, and within
collect more complete and rubber and plastic products as measured miscellaneous products. These
comprehensive data. We are also by the PPI (Commodity Code #07) is categories use as proxies the following
exploring other options such as third applied to this component. The same PPIs: the PPI for blood and blood
party or industry data that might assist proxy was used in the FY 1997-based derivatives, the PPI for chemicals, and
us in creating a more precise measure of market basket. the PPI for finished goods less food and
PLI premiums. We have not yet o. Paper Products energy, respectively. Of these three
identified a preferred option. Therefore, market baskets, the market basket with
we did not make any changes to the The percentage change in the price of
blood in miscellaneous products and its
proxy in this rule. converted paper and paperboard
associated proxy, the PPI for finished
products as measured by the PPI
h. Pharmaceuticals goods less food and energy, moved very
(Commodity Code #0915) is used. The
similar to the market basket with blood
The percentage change in the price of same proxy was used in the FY 1997-
as a separate category. In addition, the
prescription drugs as measured by the based market basket.
impact on the overall market basket by
PPI (PPI Code #PPI32541DRX) is used as
p. Apparel using different proxies for blood was
a proxy for this category. This is a
The percentage change in the price of negligible, mostly due to the relatively
special index produced by BLS and is
apparel as measured by the PPI small weight for blood in the market
the same proxy used in the FY 1997-
(Commodity Code #381) is applied to basket. Therefore, we chose the PPI for
based market basket.
this component. The same proxy was finished goods less food and energy for
i. Food: Direct Purchases used in the FY 1997-based market the blood proxy because we believe it
The percentage change in the price of basket. will best be able to proxy price changes
processed foods and feeds as measured (not quantities or required tests)
q. Machinery and Equipment associated with blood purchased by
by the PPI (Commodity Code #02) is
applied to this component. The same The percentage change in the price of hospitals. We will continue to evaluate
proxy was used in the FY 1997-based machinery and equipment as measured this proxy for its appropriateness and
market basket. by the PPI (Commodity Code #11) is will explore the development of
applied to this component. The same alternative price indexes to proxy the
j. Food: Contract Services proxy was used in the FY 1997-based price changes associated with this cost.
The percentage change in the price of market basket. Comment: Some commenters
food purchased away from home as questioned the CMS proposal to remove
measured by the CPI for all urban r. Miscellaneous Products blood and blood products as a separate
consumers (CPI Code #CUUR0000SEFV) The percentage change in the price of cost category and add its weight to the
is applied to this component. The same all finished goods less food and energy miscellaneous products cost category of
the hospital market basket. A few whether the BLS’ PPI for Blood and Products. We considered placing blood
commenters supported this move only Organ Banks (NAICS 621991), which is and blood products in the ‘‘other
as a temporary measure until a more still in development, may be an products’’ subcategory because blood is
appropriate blood and blood products appropriate price proxy that could be a product purchased by hospitals. From
PPI can be developed by the BLS. proposed for blood and blood products. 2001 to 2003 the percent changes in the
Response: We studied different cost The alternative cost categories we price proxies for these respective cost
categories that might be used until we considered were Blood and Blood categories were:
have had the opportunity to evaluate Products, Chemicals, and Miscellaneous
CHART 3.—ANNUAL GROWTH RATES FOR THREE POSSIBLE PRICE PROXIES

Cost category Proxy 2001–2002 2002–2003
Chemicals ..................................................................... Industrial Chemicals ..................................................... ¥0.9 11.3

Blood ............................................................................. Blood and Derivatives .................................................. ¥7.2 ¥11.4
Miscellaneous Products ................................................ Finished Goods less Food and Energy ........................ 0.1 0.2
In discussions with the blood banking appropriate price proxies for the change market baskets were identical, except
industry we were presented data that in blood prices (67 FR 50035). We that the blood weight was in its own
the cost of blood had been increasing believed the PPI for finished goods less cost category, in chemicals, or in
over the 2001–2003 period. In addition, food and energy was an appropriate miscellaneous products, respectively.
an analysis of Medicare Cost Report data proxy because it has a more stable As shown in Chart 4, the annual
indicated that the cost weight for blood measure than the others considered, and increases in the market baskets were
was increasing had increased from 1.023 had not exhibited negative price similar, regardless of which cost
in 2001 to 1.082 in 2002. Neither of movements in recent periods and category contained the market basket
these data sources supported the trends currently serves as a proxy for all weight for blood and blood products.
in the PPI for blood and derivatives over product costs that are small or without
Therefore, even if blood and blood
a specific price proxy.
this period. In addition, we had We ran test market baskets using the products were its own cost category, it
previously determined that the PPI for most recent forecast (2005q2, with would have little effect on the market
Industrial Chemicals was not an history through 2005q1). The three basket update factor.
CHART 4.—MARKET BASKET INCREASE WITH BLOOD AND BLOOD PRODUCTS LOCATED IN:
Blood and Miscellaneous
Chemicals
blood products products
2000 ............................................................................................................................................. 3.2 3.3 3.2

2001 ............................................................................................................................................. 4.2 4.2 4.1
2002 ............................................................................................................................................. 3.7 3.6 3.7
2003 ............................................................................................................................................. 3.9 4.2 4.0
2004 ............................................................................................................................................. 3.9 4.0 3.9
Average: 2000–2004 ................................................................................................................... 3.8 4.0 3.8
We are adopting the PPI for finished # CUUR0000SEED) is applied to this used in the FY 1997-based market
goods less food and energy as the price component. The same proxy was used basket.
proxy for blood and blood products in the FY 1997-based market basket.
v. All Other Services: Nonlabor
because our analysis shows that this t. Postage Intensive
price proxy most accurately reflects
changes in costs of blood products. We The percentage change in the price of The percentage change in the all-
note that the BLS is developing a postage as measured by the CPI for all items component of the CPI for all urban
Producer Price Index for Blood and urban consumers (CPI Code #
consumers (CPI Code # CUUR0000SA0)
Organ Banks. We look forward to CUUR0000SEEC01) is applied to this
is applied to this component. The same
evaluating this index when it is ready component. The same proxy was used
proxy was used in the FY 1997-based
in the FY 1997-based market basket.
for use. market basket.
u. All Other Services: Labor Intensive For further discussion of the
s. Telephone
The percentage change in the ECI for rationales for choosing many of the
The percentage change in the price of compensation paid to service workers specific price proxies, we refer the
telephone services as measured by the employed in private industry is applied reader to the August 1, 2002 final rule
CPI for all urban consumers (CPI Code to this component. The same proxy was (67 FR 50037).
CHART 5.—FY 1997-BASED AND FY 2002-BASED PROSPECTIVE PAYMENT HOSPITAL OPERATING INDEX PERCENT
CHANGE, FY 2000 THROUGH FY 2008
Rebased FY FY 1997-
2002-based
Fiscal year (FY) based market
hospital mar- basket
ket basket
Historical data:
FY 2000 ............................................................................................................................................................ 3.2 3.3
FY 2001 ............................................................................................................................................................ 4.1 4.3
FY 2002 ............................................................................................................................................................ 3.7 3.8
FY 2003 ............................................................................................................................................................ 4.0 3.9
FY 2004 ............................................................................................................................................................ 3.9 3.9
Average FYs 2000–2004 .................................................................................................................................. 3.8 3.8
Forecast:
FY 2005 ............................................................................................................................................................ 4.2 4.2
FY 2006 ............................................................................................................................................................ 3.7 3.7
FY 2007 ............................................................................................................................................................ 3.1 3.2
FY 2008 ............................................................................................................................................................ 2.9 3.0
Average FYs 2005–2008 .................................................................................................................................. 3.5 3.5
Source: Global Insight, Inc. 2nd Qtr 2005, @USMACRO/CNTL0605 @CISSIM/TL0505.SIM
Prior to the publication of the FY proxies using models that take into energy costs, which, in a global
2006 IPPS proposed rule, we had been account national and global economic economy, have an indirect effect on
actively working with our forecasting trends. wages and other costs as well as a direct
firm, Global Insight, Inc. (GII), to Over the last several years, dramatic effect on utility prices. With our input
improve the forecasting accuracy of the fluctuations in the price of certain costs and consultation, GII recently evaluated
market baskets. GII is a nationally have made it difficult to forecast price and modified their forecasting models to
recognized economic and financial proxy inflation. This uncertainty has help improve their accuracy. Using
forecasting firm that contracts with CMS resulted in market basket forecast error these improved forecasting models, GII
to forecast the components of the market greater than 0.25 percentage points in calculated updated inflation factors for
baskets. Among other services GII FY 2001, FY 2003, and FY 2004. The
the major cost categories in Chart 6.
provides to CMS, GII calculates driving force behind much of this
projected inflation factors for price uncertainty has been the instability of
CHART 6.—COMPARISON OF THE 4 QUARTER MOVING AVERAGE PERCENT CHANGES FOR SEVERAL COST CATEGORY
WEIGHTS BETWEEN THE FY 2006 IPPS PROPOSED AND FINAL RULES
GII 2004q4 GII 2005q2
FY 2002- forecast of FY forecast of FY
Expense category based cost 2006 2006
weights (Proposed (Final Rule)
Rule)
Total—PPS02 .............................................................................................................................. 100.000 3.2 3.7

Compensation ....................................................................................................................... 59.993 3.5 3.9
Utilities .................................................................................................................................. 1.251 0.8 3.6
Professional Fees ................................................................................................................. 5.510 3.6 4.3
Professional liability insurance ............................................................................................. 1.589 8.4 7.8
All Other ................................................................................................................................ 31.657 2.4 3.0
All Other Products ................................................................................................................ 20.336 2.3 3.2
All Other Services ................................................................................................................. 11.321 2.4 2.6
In the FY 2006 IPPS proposed rule, projection methodology in order to Response: We have summarized our
we forecasted a market basket update of ensure equitable payments. calculation of the market basket update
3.2 percent. Based on our updated Response: We recognize the in Chart 6 above.
forecasting model, we are forecasting a importance of a reliable forecasting 3. Labor-Related Share
market basket update of 3.7 percent for methodology. As discussed above, we
FY 2006. Under section 1886(d)(3)(E) of the
have worked with our forecasting firm, Act, the Secretary estimates from time to
Comment: Several commenters GII, to modify and improve GII’s time the proportion of payments that are
requested that CMS review and revise forecasting models to help improve their labor-related. ‘‘The Secretary shall
the methodology used to determine the accuracy. The final FY 2006 update of adjust the proportion (as estimated by
projected FY 2006 market basket. They 3.7 percent reflects these modifications. the Secretary from time to time) of
are concerned that the previously Comment: Several commenters hospitals’ costs which are attributable to
proposed FY 2006 update of 3.2 percent requested that CMS make the wages and wage-related costs of the
is a dramatic underestimation. They calculation of the projected FY 2006 DRG prospective payment rates * * *.’’
emphasized the importance of a reliable available to the public. We refer to the proportion of hospitals’
costs that are attributable to wages and
wage-related costs as the ‘‘labor-related 1886(d)(9)(C)(iv) of the Act to provide related portions of the Puerto Rico-
share.’’ that the Secretary must employ 62 specific standardized amount listed in
The labor-related share is used to percent as the labor-related share unless Table 1C of the Addendum to the
determine the proportion of the national this employment ‘‘would result in lower proposed rule reflected the current FY
PPS base payment rate to which the area payments than would otherwise be 2005 labor-related share for Puerto Rico
wage index is applied. As we proposed made.’’ of 71.3 percent. We solicited comments
in the FY 2006 IPPS proposed rule, we Comment: One commenter suggested on our proposal to update the labor-
are continuing to use our current that we decrease the labor-related share related share for Puerto Rico.
methodology of defining the labor- from 62 percent to 50 percent for those After publication of the proposed
related share as the national average hospitals with wage indices under 1.0. rule, we calculated an updated labor-
proportion of operating costs that are Response: As stated above, the 62 related share of 58.7 percent for Puerto
attributable to wages and salaries, fringe percent labor-related share provision Rico and posted it on the CMS Web site
benefits, professional fees, contract was established by section 403 of Pub. at http://www.cms.hhs.gov/providers/
labor, and labor intensive services. L. 108–173. This provision was hipps. We did not receive any public
Therefore, we calculate the labor-related mandated by Congress and, therefore, comments on the proposed updated
share by adding the relative weights for CMS has no authority to modify it. labor-share for Puerto Rico.
these operating cost categories. We As we proposed, we also are updating Accordingly, we are adopting an
continue to believe, as we have stated in the labor-related share for Puerto Rico. updated Puerto Rico labor-related share
the past, that these operating cost Consistent with our methodology for of 58.7 percent, which is reflected in the
categories likely are related to, are determining the national labor-related Table 1C of the Addendum of this final
influenced by, or vary with the local share, we add the Puerto Rico-specific rule.
markets. Our definition of the labor- relative weights for wages and salaries, Unlike the 1997 Annual I–O which
related share therefore continues to be fringe benefits, and contract labor. was based on Standard Industrial Codes
consistent with section 1886(d)(3) of the Because there are no Puerto Rico- (SIC), the 1997 Benchmark I–O is
Act. As we proposed, we are removing specific relative weights for professional categorized using the North American
postage costs from the FY 2002-based fees and labor intensive services, we use Industrial Classification System
labor-related share. the national weights. In the proposed (NAICS). This change required us to
Using the cost category weights that rule, we observed that, rather than using classify all cost categories under NAICS,
we determined in section IV.B. of this a Puerto Rico-specific labor-related including a reevaluation of labor-related
preamble, we calculated a labor-related share, another option would be to apply costs on the NAICS definitions. Chart 7
share of 69.731 percent, using the FY the national labor-related share to the compares the FY 1992-based labor-
2002-based PPS market basket. Puerto Rico-specific rate. In the related share, the current measure, with
Accordingly, in this final rule, we are proposed rule, we also noted that we the FY 2002-based labor-related share.
implementing a labor-related share of were still reviewing our data and had When we rebased the market basket to
69.7 percent for discharges occurring on not yet calculated the updated Puerto reflect FY 1997 data, we did not change
or after October 1, 2005. We note that Rico-specific labor-related share the labor-related share (67 FR 50041).
section 403 of Pub. L. 108–173 amended percentage. Therefore, in the proposed Therefore, the FY 1992-based labor-
sections 1886(d)(3)(E) and rule, the labor-related and nonlabor- related share is the current measure.
CHART 7.—LABOR-RELATED SHARE: FY 1992-BASED AND FY 2002-BASED

FY 1992- FY 2002-
Cost category Difference
based weight based weight
Wages and salaries ..................................................................................................................... 50.244 48.171 ¥2.073

Fringe benefits ............................................................................................................................. 11.146 11.822 0.676
Nonmedical professional fees ..................................................................................................... 2.127 5.510 3.383
Postal services* ........................................................................................................................... 0.272 ........................ ¥0.272
Other labor-intensive services** .................................................................................................. 7.277 4.228 ¥3.049
Total labor-related ................................................................................................................ 71.066 69.731 ¥1.335
Total nonlabor-related ................................................................................................... 28.934 30.269 1.335

*No longer considered to be labor-related.
**Other labor-intensive services includes landscaping services, services to buildings, detective and protective services, repair services, laundry
services, advertising, auto parking and repairs, physical fitness facilities, and other government enterprises.
Although we are continuing to urban and rural hospitals, using edited FY 1997 hospital data, found that
calculate the labor-related share by regression analysis to determine the the compensation share of costs for
adding the relative weights of the labor- proportion of costs influenced by the hospitals in rural areas was higher on
related operating cost categories, we area wage index, and exploring average than the compensation share for
continue to evaluate alternative alternative methodologies to determine hospitals in urban areas. We also
methodologies. In the May 9, 2002 whether all or only a portion of researched whether only a proportion of
Federal Register (67 FR 31447), we professional fees and nonlabor intensive the costs in professional fees and labor-
discussed our research on the services should be considered labor- intensive services should be considered
methodology for the labor-related share. related. labor-related, not the entire cost
This research involved analyzing the Our original analysis, which appeared categories. However, there was not
compensation share (the sum of wages in the May 9, 2002 Federal Register (67 sufficient information available to make
and salaries and benefits) separately for FR 31447) and which focused mainly on this determination.
Our finding that the average loosened the edits, we found higher Register) with the independent
compensation share of costs for rural wage index coefficients and still a worse variables being the compensation per
hospitals was higher than the average fit. Second, we added additional FTE, the ratio of interns and residents
compensation for urban hospitals was variables to the regression equation to per bed (as proxy for IME status), the
validated consistently through our attempt to explain some of the variation occupancy rate, the number of hospital
regression analysis. Regression analysis that was not being captured. We found beds, a dummy variable that equals one
is a statistical technique that determines the best fit occurred when the following if the hospital is privately owned and is
the relationship between a dependent variables were added: the occupancy zero otherwise, a dummy variable that
variable and one or more independent rate, the number of hospital beds, a equals one if the hospital is government-
variables. We tried several regression dummy variable that equals one if the controlled and is zero otherwise, the
specifications in an effort to determine hospital is privately owned and zero Medicare length of stay, the number of
the proportion of costs that are otherwise, a dummy variable that equals FTEs per bed, the age of fixed assets,
influenced by the area wage index. one if the hospital is government- and a dummy variable that equals one
Furthermore, MedPAC raised the controlled and zero otherwise, the if the hospital is located in a
possibility that regression may be an Medicare length of stay, the number of metropolitan area with a population of
alternative to the current market basket FTEs per bed, and the age of fixed 1 million or more. This is a similar
methodology. In our initial regression assets. The result of this specification model to the one described in the May
specification (in log form), Medicare was a wage index coefficient of 0.620 9, 2002 Federal Register (67 FR 31447)
operating cost per Medicare discharge (adjusted R-squared = 68.7), with the as having the best fit, with two notable
was the dependent variable and the regression on rural hospitals having a exceptions. First, the area wage index is
independent variables were the area coefficient of 0.772 (adjusted R-squared replaced by compensation per FTE,
wage index, the case-mix index, the = 45.0) and the regression on urban where compensation is the sum of
ratio of residents per bed (as proxy for hospitals having a coefficient of 0.474 hospital wages and salaries, contract
IME status), and a dummy variable that (adjusted R-squared = 60.9). Neither of labor costs, and benefits. The area wage
equaled one if the hospital was located these alternatives seemed to help the index is a payment variable computed
in a metropolitan area with a population underlying difficulties with the by averaging wages across all hospitals
of 1 million or more. (A dummy variable regression analysis. within each MSA, whereas
represents the presence or absence of a Subsequent to the work described compensation per FTE differs from one
particular characteristic.) This above, we have undertaken the research hospital to the next. Second, the case-
regression produced a coefficient for all necessary to reevaluate the current mix index is no longer included as a
hospitals for the area wage index of assumptions used in determining the regressor because it is correlated with
0.638 (which is equivalent to the labor labor-related share. We ran regressions other independent variables in the
share and can be interpreted as an applying the previous specifications to regression. In other words, the other
elasticity because of the log more recent data (FY 2001 and FY independent variables are capturing part
specification) with an adjusted R- 2002), and, as described below, we ran of the effect of the case-mix index. We
squared of 64.3. (Adjusted R-squared is regressions using alternative made these two specification changes in
a measure of how well the regression specifications. In the FY 2006 IPPS an attempt to only use cost variables to
model fits the data.) While, on the proposed rule, we solicited comments explain the variation in Medicare
on this research and any information
surface, this appeared to be a reasonable operating costs per discharge. We
that is available to help determine the
result, this same specification for urban believe this is appropriate in order to
most appropriate measure.
hospitals had a coefficient of 0.532 The first step in our regression
compare to the results we are getting
(adjusted R-squared = 53.2) and a analysis to determine the proportion of from the market basket methodology,
coefficient of 0.709 (adjusted R-squared hospitals’ costs that varied with labor- which is based solely on cost data. As
= 36.4) for rural hospitals. This related costs was to edit the data, which we will show below, the use of payment
highlighted some apparent problems had significant outliers in some of the variables on the right-hand side of the
with the specification because the variables we used in the regressions. We equation appears to be producing less
overall regression results appeared to be originally began with an edit that reasonable results when cost data are
masking underlying problems. It did not excluded the top and bottom 5 percent used.
seem reasonable that urban hospitals of reports based on average Medicare The revised specification for FY 2002
would have a labor share below their cost per discharge and number of produced a coefficient for all hospitals
actual compensation share or that the discharges. We also used edits to for compensation per FTE of 0.673
discrepancy between urban and rural exclude reports that did not meet basic (which is roughly equivalent to the
hospitals would be this large. When we criteria for use, such as having costs labor share and can be interpreted as an
standardized the Medicare operating greater than zero for total, operating, elasticity because of the log
cost per Medicare discharge for case- and capital for the overall facility and specification) with an adjusted R-
mix, the fit, as measured by adjusted R- just the Medicare proportion. We also squared of 63.7. The coefficient result
squared, fell dramatically and the used an edit that required that the for FY 2001 is 64.5, with an adjusted R-
urban/rural discrepancy became even hospital occupancy rate, length of stay, squared of 65.2. (For comparison, a
larger. number of beds, FTEs, and overall and separate regression for FY 2002 with the
Based on this initial result, we tried Medicare discharges be greater than log area wage index and log case-mix
two modifications to the FY 1997 zero. Finally, we excluded reports with index included in the set of regressors
regressions to correct for the underlying occupancy rates greater than one. displays a log area wage index
problems. First, we edited the data Our regression specification (in log coefficient of 75.6 (adjusted R-squared =
differently to determine whether a few form) was Medicare operating cost per 67.7).) For FY 2001, the coefficient for
reports were causing the inconsistent Medicare discharge as the dependent the log area wage index is 72.3 (adjusted
results. We found when we tightened variable (the same dependent variable R-squared = 67.9). On the surface, these
the edits, the wage index coefficient was we used in the regression analysis seem to be reasonable results. However,
lower and the fit was worse. When we described in the May 9, 2002 Federal a closer look reveals some problems. In
FY 2001, the coefficient for urban stated in the past, we believe that items is the best method presently available to
hospitals was 59.6 (adjusted R-squared should not be excluded from the labor- appropriately capture the changing cost
= 57.3), and the coefficient for rural related share merely because they could structures hospitals have faced over the
hospitals was 61.3 (adjusted R-squared be purchased nationally (68 FR 45467). last ten year period (1992 to 2002).
= 50.6). On the other hand, in FY 2002, We do plan to expand our efforts in this Therefore, we are establishing the labor
the coefficient for urban hospitals area to determine whether it would be share at 69.7 percent.
increased to 69.2 (adjusted R-squared = appropriate in the future to modify our In addition, we are implementing this
55.9), and the coefficient for rural methodology for calculating the labor- revised and rebased labor share in a
hospitals decreased to 58.2 (adjusted R- related share. In the FY 2006 IPPS budget neutral manner, but consistent
squared = 46.0). The results for FY 2001 proposed rule, we solicited data or with section 1886(d)(3)(E) of the Act, we
seem reasonable, but not when studies that would be helpful in this are not taking into account the
compared with the results for FY 2002. analysis. However, we indicated that we additional payments that will be made
Furthermore, for FY 2002 the were unsure if we would be able to as a result of hospitals with a wage
compensation share of costs for finish this analysis in time for inclusion index less than or equal to 1.0 being
hospitals in rural areas was higher on in this FY 2006 IPPS final rule. paid using a labor-related share lower
average than the compensation share for Comment: Several commenters than the labor-related share of hospitals
hospitals in urban areas. Rural areas had objected to our proposal to change the with a wage index greater than 1.0.
an average compensation share of 63.3 labor-related share to 69.7 percent and Section 1886(d)(3)(E) of the Act directs
percent, while urban areas had a share requested that CMS maintain a labor- us to determine a labor related share
of 60.5 percent. This compares to a related share of 71.1 percent. The that reflects the ‘‘proportion * * * of
share of 61.2 percent for all hospitals. commenters provided similar reasons hospitals’’ costs which are attributable
Due to these problems, we do not for rejecting this provision of the to wages and wage-related costs.’’ In
believe the regression analysis is proposed rule. Generally, the addition, section 1886(d)(3)(E) of the
producing sound enough evidence at commenters were concerned that the Act requires that we implement the
this point for us to make the decision to new lower labor share would negatively wage index adjustment in a budget
change from the current method for impact urban hospitals and several neutral manner. However, section 403 of
calculating the labor-related share. We commenters stated that CMS should Pub. L. 108–173, which sets the labor-
continue to analyze these data and work postpone changing the labor share until related share at 62 percent for hospitals
on alternative specifications, including the agency has finished researching they with a wage index less than or equal to
working with MedPAC, who in the past are finished researching different labor- 1.0, also provides that the Secretary
have done similar analysis in their related share methodologies. In shall calculate the budget neutrality
studies of payment adequacy. In the FY addition, commenters noted that the adjustment for the wage index as if the
2006 IPPS proposed rule, we solicited budget neutral manner in which CMS Pub. L. 108–173 had not been enacted.
comments on this approach, given the proposed to implement this labor share Therefore, for purposes of the budget
difficulties we have encountered. change would increase the standardized neutrality adjustment, section 403 of
We also continue to look into ways to amount for all hospitals. They believed Pub. L. 108–173 prohibits us from
refine our market basket approach to this is unfair as the increased amount taking into account the additional
more accurately account for the would provide an additional benefit to payments that will be made as a result
proportion of costs influenced by the rural hospitals that are already of hospitals with a wage index less than
local labor market. Specifically, we are advantaged by many provisions of Pub. or equal to 1.0 being paid using a labor-
looking at the professional fees and L. 108–173, including section 403 related share of 62 percent. While we
labor-intensive cost categories to which sets the labor share at 62 percent recognize that this does have the effect
determine if only a proportion of the for hospitals with a wage index less of increasing the standardized amount
costs in these categories should be than or equal to 1.0. applicable to all hospitals, the statute
considered labor-related, not the entire Response: Section 404 of Pub. L. 108– requires this implementation
cost category. Professional fees include 173 requires the Secretary to update the methodology.
management and consulting fees, legal weights used in the IPPS operating and As mentioned previously in the
services, accounting services, and capital market baskets, including the proposed rule, we proposed to continue
engineering services. Labor-intensive labor-related share, to reflect the most to calculate the labor-related share by
services are mostly building services, current available data. Therefore, we are adding the relative weights of the
but also include other maintenance and directed by statute to update the labor operating cost categories that are related
repair services. share and cannot maintain the labor to, influenced by, or vary with the local
We conducted preliminary research share at the outdated percentage of 71.1. labor markets. These categories include
into whether the various types of Since the FY 2003 IPPS final rule was wages and salaries, fringe benefits,
professional fees are more or less likely issued, CMS has continued to evaluate professional fees, contract labor and
to be purchased locally. Through alternative labor-related share labor-intensive services. Using this
contact with a handful of hospitals in methodologies. Given this research, we methodology, we calculated a labor-
only two States, we asked for the believe our existing methodology of related share of 69.731, which we are
percentages of their advertising, legal, calculating the labor-related share is the using for FY 2006.
and management and consulting most appropriate methodology at this Comment: One commenter requested
services that they purchased locally, time. Our alternative methodologies did that CMS continue to include postage in
regionally, or nationally. The results not produce the sound evidence needed the labor-related share.
were quite consistent across all of the to justify changing our existing Response: We do not believe that we
hospitals, indicating most advertising methodology. Specifically, our should continue to include postage
and legal services are purchased locally regression results were inconsistent and costs in the labor-related share as
or regionally and nearly all management highlighted underlying data problems postage fees are set at nationally
and consulting services are purchased that were not evident in our market uniform rates and are not affected by
nationally. Although the results of our basket labor-related share methodology. local purchasing power of hospitals.
research are instructive, as we have We are confident that our current model The cost of postage is primarily
influenced by weight of the package and Comment: Several commenters the 1997 Bureau of Economic Analysis’
the distance the package is traveling suggested that we include professional Annual I–O Tables. As stated in the FY
(National Zone Chart Program Technical liability insurance (PLI) in the labor- 2003 IPPS final rule (67 FR 50034), if
Guide 2003–2004, http:// related share since these costs are CMS had used the Annual I–O Tables to
www.ribbs.usps.gov/files/Zone_Charts/ included in the wage index. The calculate the FY 1992 nonmedical
ZCTECHNICAL_GUIDE.PDF, page 2). commenters also claimed that professional fees component, the
For example, the cost of mailing a professional liability insurance costs are proportion would have been similar to
package from Boston, MA to Baltimore, wage related. the FY 1997 share. The FY 2002
MD (approximately 450 miles) is the Response: The wage index includes, nonmedical professional fees cost
same price as mailing a package from as a fringe benefit cost, PLI for those category is based on 1997-Benchmark I–
Long Beach, NC to Baltimore, MD policies that list actual names or O data trended forward using the ECI for
(approximately 450 miles) (http:// specific titles of covered employees (59 Compensation for Private Service
postcalc.usps.gov/). FR 45358). The benefit cost weight in Occupations.
Comment: One commenter argued the market basket, included in the labor- The decline in the other labor
that geographical differences in costs of related share, is also based on the same intensive cost category from 1997 to
goods and services such as food, energy, wage index benefit data. Therefore, the 2002 is a result of hospitals purchasing
telephone services, pharmaceuticals, labor-related share includes these PLI patterns and substituting the 1997
and supplies are attributable to local costs. General PLI coverage maintained Benchmark I–O data for the 1997
differences in wages and hence should by hospitals is not recognized as a wage- Annual I–O data. The 1997 Benchmark
be included in the labor-related share. related cost for purposes of the wage I–O data are a much more
Response: We believe that the index or labor-related share. comprehensive and complete set of data
Although general PLI costs do vary by than the 1997 Annual I–O estimates.
commenter may have misunderstood a
geographic region, they are not labor- The 1997 Annual I–O is an update of
statement in the notice of proposed
intensive inputs. The variance in the 1992 I–O tables, while the 1997
rulemaking. Previously, we stated that
general PLI costs is primarily influenced Benchmark I–O is an entirely new set of
our current methodology is to define the
by state legislation and risk level, not by numbers derived from the 1997
labor-related share as the national
local wage rates. In fact, areas with high Economic Census. The 1997-Benchmark
average proportion of operating costs wage indices may have low relative PLI
that are related to, influenced by, or I–O is also based on the 1997 North
costs. For example, the malpractice American Industrial Classification
vary with local labor markets. As we geographic price indices, used in the
have stated in previous rules and System while the 1997 Annual I–O is
Medicare physician payment system, for based on the 1987 Standard Industrial
clarified in this final rule, it is more San Francisco, Los Angeles, and Boston
accurate to say that we define the labor- Classification System.
regions are below 1, while their hospital CMS has maintained a relatively
related share as the national average wage indices for comparable areas are
proportion of operating costs that are consistent methodology for calculating
much greater than 1. the hospital market basket cost weights.
attributable to wages and salaries, fringe Comment: Several commenters
benefits, professional fees, contract However, the methodology is
requested that CMS explain why the
labor, and labor intensive services. periodically modified to include more
labor-related share is fluctuating
These costs are included in the labor- comprehensive data sources and/or
between FYs 1992, 1997, and 2002-
related share because they are labor price proxies. These methodological
based market baskets. They stated these
intensive, and therefore, are ‘‘hospitals’’ changes, as well as their impacts, are
changes raise questions about the (1)
costs that are attributable to wages and published in the Federal Register. In
veracity of the data, (2) the change in
wage-related costs.’’ As was stated most instances, the modifications have
base cost data, (3) effect of proxy
previously, we believe that, with the a small effect on the total market basket
changes on the trending, (4) consistency
exclusion of postage, the costs included update.
of CMS’ methodology, and (5) other
in the labor-related share are, in fact, Finally, approximately 85 percent of
factors. They specifically requested that
related to, influenced by, or vary with the labor-related shares (FY 1992, FY
CMS explain in more detail the change
local labor markets. However, hospital 1997, and FY 2002) are based on
in the other labor-intensive services cost
costs are not necessarily ‘‘attributable to Medicare Cost Report data submitted by
weight.
wages and wage-related costs ‘‘merely Response: In addition to the official hospitals.
because they may be related to, may be market basket weights published in the C. Separate Market Basket for Hospitals
influenced by, or may vary with local Federal Register, CMS also analyzed the and Hospital Units Excluded From the
labor markets. Therefore, it would be weights based on different trimming IPPS
incorrect to say that all costs that are methodologies and on a matched
related to, influenced by, or vary with sample of hospitals over time. These 1. Hospitals Paid Based on Their
the local labor market must be included weights exhibited the same trends as Reasonable Costs
in the labor-related share merely our published weights. Specifically, the On August 7, 2001, we published a
because they are related to, influenced compensation cost weight, the largest final rule in the Federal Register (66 FR
by, or vary with the local labor market. component in the labor-related share, 41316) establishing the PPS for IRFs,
We include only labor-intensive from 1997 to 2002 steadily declined in effective for cost reporting periods
inputs in the labor-related share (55 FR all instances. beginning on or after January 1, 2002.
36046). Although the costs of goods and The decline in the nonmedical On August 30, 2002, we published a
services such as food, pharmaceuticals, professional fees from 1992 to 1997 final rule in the Federal Register (67 FR
energy, telephone services, and supplies reflects hospital purchasing patterns’ 55954) establishing the PPS for LTCHs,
may vary by geographic area, these and a change in the data source used to effective for cost reporting periods
items are not labor-intensive inputs. derive this weight. The FY 1992-based beginning on or after October 1, 2002.
Thus, we disagree with the commenter’s market basket used the American On November 15, 2004, we published a
argument that these items should be Hospital Association Survey data while final rule in the Federal Register (69 FR
included in the labor-related share. the FY 1997-based market basket used 66922) establishing the PPS for the IPFs,
effective for cost reporting periods hospitals and because these hospitals feature of the PPSs for IRFs, LTCHs, and
beginning on or after January 1, 2005. provide limited Medicare cost report IPFs. As indicated in the proposed rule,
Prior to being paid under a PPS, IRFs, data, in the FY 2006 IPPS proposed rule, we do not believe that it makes sense to
LTCHs, and IPFs were reimbursed we did not propose to create a separate propose to create an entirely new
solely under the reasonable cost-based market basket specifically for these methodology for creating the market
system under § 413.40 of the hospitals. Under the broad authority in basket index which updates the
regulations, which impose rate-of- sections 1886(b)(3)(A) and (B), ‘‘reasonable cost’’ portion of a blend
increase limits. Children’s and cancer 1886(b)(3)(E), and 1871 of the Act, we methodology since the ‘‘reasonable cost
hospitals and religious nonmedical proposed to use the FY 2002 IPPS portion’’ will last at most for 1 or 3
health care institutions (RNHCIs) are operating market basket percentage additional years (1 year for LTCHs paid
still reimbursed solely under the increase to update the target amounts under a blend methodology since some
reasonable cost-based system, subject to for children’s and cancer hospitals and LTCHs only have 1 year remaining in
the rate-of-increase limits. Under these the market basket for RNHCIs under their transition, and 3 years for IPFs
limits, an annual target amount § 403.752(a) of the regulations. This since existing IPFs paid under a blend
(expressed in terms of the inpatient proposal reflected our belief that it is methodology only have 3 years
operating cost per discharge) is set for best to use an index that most closely remaining under a blend methodology).
each hospital based on the hospital’s represents the cost structure of However, the same cannot be said for
own historical cost experience trended children’s and cancer hospitals and the adjusted Federal payment amount.
forward by the applicable rate-of- RNHCIs. The FY 2002 cost weights for In the case of the IRF PPS, all IRFs are
increase percentages. To the extent an wages and salaries, professional paid at 100 percent of the adjusted
LTCH or IPF receives a blend of liability, and ‘‘all other’’ for children’s Federal payment amount and will
reasonable cost-based payment and the and cancer hospitals are noticeably continue to be paid based on 100
Federal prospective payment rate closer to those in the IPPS operating percent of this amount under current
amount, the reasonable cost portion of market basket than those in the law. In the LTCH PPS, most LTCHs (98
the payment is also subject to the excluded hospital market basket, which percent) are already paid at 100 percent
applicable rate-of-increase percentage. is based on the cost structure of IRFs, of the adjusted Federal payment
Section 1886(b)(3)(B) (ii) of the Act sets LTCHs, IPFs, and children’s and cancer amount. In the case of the few LTCHs
the percentage increase of the limits, hospitals and RNHCIs. Therefore, as that are paid under a blend
which in certain years was based upon proposed, for this final rule we are using methodology for cost reporting periods
the market basket percentage increase. the IPPS operating market basket to beginning on or after October 1, 2006,
Beginning in FY 2003 and subsequent update the target amounts for children’s payment will be based entirely on the
years, the applicable rate-of-increase is and cancer hospitals and the market adjusted Federal prospective payment
the market basket increase. The market basket for RNHCIs under § 403.752(a) of rate. In the case of IPFs, new IPFs (as
basket currently (and historically) used the regulations. However, when we defined in § 412.426(c)) will be paid at
is the excluded hospital operating compare the weights for LTCHs and 100 percent of the adjusted Federal
market basket, representing the cost IPFs to the weights for IPPS hospitals, prospective payment rate (the Federal
structure of rehabilitation, long-term we did not find them comparable. per diem payment amount), while all
care, psychiatric, children’s, and cancer Therefore, we did not believe it was others will continue to transition to 100
hospitals (FY 2003 final rule, 67 FR appropriate to use the IPPS market percent of the Federal per diem
50042). payment amount. In any event, even
basket for LTCHs and IPFs to update the
In the FY 2006 IPPS proposed rule, those transitioning will be at 100
portion of their payment that is based
we indicated that because IRFs, LTCHs, percent of the adjusted Federal
and some IPFs are now paid under a on reasonable cost.
prospective payment rate in 3 years.
PPS, we were considering developing a For similar reasons, we indicated in Comment: One commenter supported
separate market basket for these the proposed rule that we are CMS evaluation of a potential new
hospitals that contains both operating considering at some other date market basket for LTCHs and other post-
and capital costs. (The IPF PPS was proposing a separate market basket to acute care providers. However, they
implemented recently for cost reporting update the adjusted Federal payment cautioned CMS to look at the distinct
periods beginning on or after January 1, amount for IRFs, LTCHs, and IPFs. We attributes and price inputs of various
2005; therefore, all IPFs will soon be expect that these changes would be providers, claiming the price inputs of
paid under the IPF PPS.) We indicated proposed in separate proposed rules for LTCHs are linked more closely to those
that we would publish any proposal to each of these three hospital types. We of acute care hospitals than other types
use a revised separate market basket for envision that these changes should of providers. They also recommended
each of these types of hospitals when apply to the adjusted Federal payment that CMS use FY 2002 hospital data to
we propose the next update of their rate, and not the portion of the payment calculate the excluded hospital with
respective PPS rates. Children’s and that is based on a facility-specific (or capital market basket in the 2007 LTCH
cancer hospitals are two of the reasonable cost) payment to the extent rate year payment update.
remaining three types of hospitals such a hospital or unit is paid under a Response: In the RY 2007 LTCH
excluded from the IPPS that are still blend methodology. In other words, to proposed rule, we plan to propose a
being paid based solely on their the extent any of these hospitals are new market basket for updating the
reasonable costs, subject to target paid under a blend methodology LTCH prospective payments which may
amounts. (RNHCIs, the third type of whereby a percentage of the payment is be based on 2002 data. The proposed
IPPS-excluded entity still subject to based on reasonable cost principles, we methodology used to create this market
target amounts, are reimbursed under would not propose to make changes to basket will be described in detail and is
§ 403.752(a) of the regulations.) Because the existing methodology for developing likely going to be similar to the market
there are a small number of children’s the market basket for the reasonable cost basket described in the IRF FY 2006
and cancer hospitals and RNHCIs, portion of the payment because this proposed rule. We will also present any
which receive in total less than 1 portion of the payment is being phased additional analysis we have conducted
percent of all Medicare payments to out, if it is not already a nonexistent on the differing cost structures of LTCHs
and other types of providers. This hospital market basket until new market Chart 8 compares the limited data
proposed rule will be subject to baskets are implemented for IRFs, IPFs, available on median salary, median
comments. and LTCHs. pharmaceutical, and median
Comment: Several commenters Response: Due to the small number of professional liability insurance (PLI)
disagreed with CMS proposal to use the children’s and cancer hospitals and cost weights (as a percent of operating
FY 2002 IPPS operating market basket to costs) for cancer and children’s
RNCHIs (less than 80 in 2002) and
update the target amounts for children’s hospitals and RNCHTs; IPPS hospitals;
limited reporting, we believe we are
and cancer hospitals. One commenter and IRFs, LTCHs, and IPFs. As
recommended CMS implement a unable to create a representative market indicated, the cost structure for cancer
separate market basket for cancer basket for those hospitals still being and children’s hospitals and RNCHIs is
hospitals that would recognize the paid based solely on their reasonable more like the cost structure for IPPS
actual cost increases experienced by costs, subject to target amounts. hospitals than that for IRFs, LTCHs, and
these institutions. The commenters Therefore, we proposed to use the FY IPFs. Because both the excluded and
contended that the existing excluded 2002 IPPS operating market basket IPPS market baskets use the same price
market basket falls short of reflecting the percentage increase to update the target proxies, a difference in update would be
annual cost increases actually amounts for children’s and cancer due to the base cost structure. Therefore,
experienced by cancer hospitals. They hospitals and the market basket for by choosing a market basket that most
have determined this shortfall to be RNHCIs under § 403.752(a) of the closely represents the cost structures of
specific cost weights and relative price regulations because this market basket cancer and children’s hospitals and
proxies of pharmaceuticals and most closely represented the cost RNCHIs, we are reflecting the annual
compensation. Another commenter structure of children’s and cancer cost increases experienced by these
recommended using the excluded hospitals and RNHCIs. hospitals.
CHART 8.—COMPARISON OF 2002 MEDIAN COST WEIGHTS FROM THE MEDICARE COST REPORTS
Cancer
and chil- IRFs,
IPPS
dren’s hos- LTCHs,
hospitals
pitals and and IPFs
RNCHIs
Salary Cost Weight ........................................................................................................................................ 49.486 46.278 55.263

(Number of providers) .................................................................................................................................... (68) (3889) (591)
Pharmaceutical Cost Weight ......................................................................................................................... 6.053 5.453 4.992
(Number of providers) .................................................................................................................................... (56) (3891) (585)
PLI Cost Weight ............................................................................................................................................. 1.050 1.099 0.922
(Number of Providers) ................................................................................................................................... (75) (2341) (279)
1 Costswere included if they were greater than zero and less than operating costs.
2 Salarycost weights exclude contract labor costs.
3 The cost weights presented here are medians, which is different than the market basket cost weights which are means (they are calculated
by dividing total expenditures for all hospitals by total operating costs for all hospitals).
We will continue to monitor the cost basket, the index we proposed to use to proposal to use the proposed FY 2002
structures of children’s and cancer update the target amounts for children’s IPPS operating market basket to update
hospitals and RNHCIs to ensure the and cancer hospitals, and RNHCIs, with the target amounts for children’s and
IPPS hospital market basket adequately a FY 2002-based excluded hospital cancer hospitals reimbursed under
reflects these hospitals purchasing market basket that is based on the sections 1886(b)(3)(A) and (b)(3)(E) of
patterns. We do not believe it is current methodology (that is, based on the Act and the market basket for
necessary to postpone the the cost structure of IRFs, LTCHs, IPFs, RNHCIs under § 403.752(a) of the
implementation of the IPPS market and children’s and cancer hospitals). regulations. The forecasts are based on
basket to update the target limits for Although the percent change in the IPPS the GII 2nd quarter, 2005 forecast with
children’s and cancer hospitals and
operating market basket is typically historical data through the 1st quarter of
RNCHIs until a new market basket has
lower than the percent change in the FY 2005, incorporating two more quarters
been implemented to update IRFs,
LTCHs, and IPFs payments. The latter 2002-based excluded hospital market of historical data than published in the
group of hospitals are, or soon will be, basket (see charts), we believe it is FY 2006 IPPS proposed rule. (As we
reimbursed under a PPS that will not important to use the market basket that indicated earlier, GII is a nationally
affect the reimbursement of children’s most closely reflects the cost structure recognized economic and financial
and cancer hospitals and RNCHIs. of children’s and cancer hospitals and forecasting firm that contracts with CMS
Chart 9 compares the updates for the RNCHIs. In the FY 2006 IPPS proposed to forecast the components of the market
FY 2002-based IPPS operating market rule, we invited comments on our baskets.)
CHART 9.—FY 2002-BASED IPPS AND FY 2002-BASED EXCLUDED HOSPITAL OPERATING INDEX PERCENT CHANGE, FYS
2000 THROUGH 2007
Rebased FY FY 2002-
2002-based based ex-
Fiscal year IPPS oper- cluded hospital
ating market market basket
basket
Historical Data:
FY 2000 ............................................................................................................................................................ 3.2 3.3
FY 2001 ............................................................................................................................................................ 4.1 4.3
FY 2002 ............................................................................................................................................................ 3.7 4.2
FY 2003 ............................................................................................................................................................ 4.0 4.1
FY 2004 ............................................................................................................................................................ 3.9 4.0
Average FYs 2000–2004 .......................................................................................................................... 3.8 4.0

Forecast:
FY 2005 ............................................................................................................................................................ 4.2 4.2
FY 2006 ............................................................................................................................................................ 3.7 3.8
FY 2007 ............................................................................................................................................................ 3.1 3.4
Average FYs 2005–2007 .......................................................................................................................... 3.7 3.8

Source: Global Insight, Inc, 2nd Qtr. 2005; @USMACRO/CONTROL0605 @CISSIM/TL0505.SIM.
2. Excluded Hospitals Paid Under a standard Federal rate. Effective for cost pharmaceutical, and median
Blend Methodology reporting periods beginning on or after professional liability insurance cost
As we discuss in greater detail in January 1, 2005, IPFs, as defined in weights for IPPS hospitals and IRFs,
Appendix B to this final rule, in the § 412.426(c), are paid under the IPF PPS LTCHs, and IPFs.
past, hospitals and hospital units under which they receive payment Comment: One commenter endorsed
excluded from the IPPS have been paid based on a prospectively determined the CMS proposal to rebase the
based on their reasonable costs, subject Federal per diem rate that is based on excluded hospital market basket, stating
to TEFRA limits. However, some of the sum of the average routine that rebasing the excluded hospital
these categories of excluded hospitals operating, ancillary, and capital costs market basket improves accuracy and
and hospital units are now paid under for each patient day of psychiatric care predictability of the LTCH PPS. The
their own PPSs. Specifically, existing in an IPF, adjusted for budget neutrality. commenter also hoped that the forecast
LTCHs and existing IPFs are or will be During a 3-year transition period, for the final rule for FY 2006 will be
transitioning from reasonable cost-based existing IPFs are paid based on a blend higher than the proposed rule’s forecast
payments (subject to the TEFRA limits) of the reasonable cost-based payments of 3.2 percent.
to prospective payments under their and the Federal prospective per diem Response: We agree that the market
respective PPSs. Under the respective base rate. For cost reporting periods baskets should be periodically rebased
transition period methodologies for the beginning on or after January 1, 2008, to ensure they adequately reflect the
LTCH PPS and the IPF PPS, which are existing IPFs are to be paid based on 100 purchasing patterns of hospitals and the
described below, payment is based, in percent of the Federal per diem rate. A price increases associated with
part, on a decreasing percentage of the ‘‘new’’ IPF, as defined in § 412.426(c), is providing hospital services. The 2002-
reasonable cost-based payment amount, paid based on 100 percent of the Federal based excluded hospital’s FY 2006
which is subject to the TEFRA limits per diem payment amount. Any LTCHs forecast was run on the GII second
and an increasing percentage of the or IPFs that receive a PPS payment that quarter forecast for 2005, with historical
Federal prospective payment rate. In includes a reasonable cost-based data through the first quarter of 2005,
general, LTCHs and IPFs whose PPS payment during its respective transition incorporating two more quarters of
payment is comprised in part of a period will have that portion of its historical data than published in the FY
reasonable cost-based payment will payment subject to the TEFRA limits. 2006 IPPS proposed rule. The forecast
have those reasonable cost-based Under the broad authority of sections for FY 2006 for the FY 2002-based
payment amounts limited by the 1886(b)(3)(A) and (b)(3)(B) of the Act, as excluded hospital market basket is 3.8
hospital’s TEFRA ceiling. was proposed, for LTCHs and IPFs that percent.
Effective for cost reporting periods are transitioning to the fully Federal 3. Development of Cost Categories and
beginning on or after October 1, 2002, prospective payment rate, we are using Weights for the FY 2002-Based
LTCHs are paid under the LTCH PPS, the rebased FY 2002-based excluded Excluded Hospital Market Basket
which was implemented with a 5-year hospital market basket to update the
transition period, transitioning existing reasonable cost-based portion of their a. Medicare Cost Reports
LTCHs to a payment based on the fully payments. The market basket update is In this final rule, as was proposed, the
Federal prospective payment rate described in detail below. We do not major source of expenditure data for
(August 30, 2002; 67 FR 55954). believe the IPPS operating market basket developing the rebased and revised
However, an existing LTCH may elect to should be used for the update to the excluded hospital market basket cost
be paid at 100 percent of the Federal reasonable cost-based portion of the weights is the FY 2002 Medicare cost
prospective rate at the start of any of its payments to LTCHs or IPFs because this reports. We chose FY 2002 as the base
cost reporting periods during the 5-year market basket does not reflect the cost year because we believe this is the most
transition period. A ‘‘new’’ LTCH is structure of LTCHs and IPFs. Chart 8 recent, relatively complete year (with a
paid based on 100 percent of the compares the median salary, median 90-percent reporting rate) of Medicare
cost report data. These cost reports are higher or lower) of the total facility a share of Medicare patient days relative
from rehabilitation, psychiatric, long- average length of stay for the hospital. to total patient days that was
term care, children’s, cancer, and We use a less stringent edit for Medicare approximately three times greater than
RNHCIs. They do not reflect data from length of stay for IPFs, requiring the for those hospitals excluded from our
IPPS hospitals or CAHs. These are the average length of stay to be within 30 or sample. Our goal is to measure cost
same hospitals included in the FY 1997- 50 percent (depending on the total shares that are reflective of case-mix and
based excluded hospital market basket, facility average length of stay) of the practice patterns associated with
except for RNHCIs. Due to insufficient total facility length of stay. This allows providing services to Medicare
Medicare cost report data for these us to increase our sample size by over beneficiaries.
excluded hospitals, their cost reports 150 reports and produce a cost weight
yield only four major expenditure or more consistent with the overall facility. As was proposed, cost weights for
cost categories: Wages and salaries, The edit we applied to IPFs when benefits, contract labor, and blood and
pharmaceuticals, professional liability developing the FY 1997-based excluded blood products were derived using the
insurance (malpractice), and a residual hospital market basket was based on the FY 2002-based IPPS market basket. This
‘‘all other.’’ best available data at the time. is necessary because these data are
Since the cost weights for the FY We believe that limiting our sample to poorly reported in the cost reports for
2002-based excluded hospital market hospitals with a Medicare average non-IPPS hospitals. For example, the
basket are based on facility costs, as we length of stay within a comparable range ratio of the benefit cost weight to the
proposed, in this final rule, we are using of the total facility average length of stay wages and salaries cost weight was
those cost reports for IRFs, LTCHs, and provides a more accurate reflection of applied to the excluded hospital wages
children’s, cancer, and RNHCIs whose the structure of costs for Medicare and salaries cost weight to derive a
Medicare average length of stay is treatments. Our method results in benefit cost weight for the excluded
within 15 percent (that is, 15 percent including in our data set hospitals with hospital market basket.
CHART 10.—MAJOR COST CATEGORIES FOUND IN EXCLUDED HOSPITAL MEDICARE COST REPORTS
FY 1997-based FY 2002-based
excluded hos- excluded hos-
Major cost categories pital market pital market
basket basket
Wages and salaries ............................................................................................................................................. 51.998 57.037

Professional Liability Insurance (Malpractice) ..................................................................................................... 0.805 1.504
Pharmaceuticals .................................................................................................................................................. 6.940 5.940
All other ................................................................................................................................................................ 40.257 35.519
b. Other Data Sources The 1997 Benchmark I–O data are a I–O (see below) hospital expenditures,
much more comprehensive and then telephone services would represent
In addition to the Medicare cost complete set of data than the 1997 10 percent of the market basket’s ‘‘all
reports, the other source of data used in Annual I–O estimates. The 1997 Annual other’’ cost category. The remaining
developing the excluded hospital I–O is an update of the 1992 I–O tables, detailed cost categories under the
market basket weights is the Benchmark while the 1997 Benchmark I–O is an residual ‘‘all other’’ cost category were
Input-Output Tables (I–Os) created by entirely new set of numbers derived derived using the 1997 Benchmark
the Bureau of Economic Analysis, U.S. from the 1997 Economic Census. The Input-Output Tables aged to FY 2002
Department of Commerce. 2002 Benchmark Input-Output tables using relative price changes.
New data for this source are are not yet available. Therefore, we used
4. FY 2002-Based Excluded Hospital
scheduled for publication every 5 years, the 1997 Benchmark I–O data in the FY
Market Basket—Selection of Price
but may take up to 7 years after the 2002-based excluded hospital market
Proxies
reference year. Only an Annual I–O is basket, to be effective for FY 2006.
Instead of using the less detailed, less After computing the FY 2002 cost
produced each year, but the Annual I– weights for the rebased excluded
accurate Annual I–O data, we aged the
O contains less industry detail than hospital market basket, it is necessary to
1997 Benchmark I–O data forward to FY
does the Benchmark I–O. When we select appropriate wage and price
2002. As was proposed, the
rebased the excluded hospital market proxies to reflect the rate-of-price
methodology we used to age the data for
basket using FY 1997 data in the FY this final rule involves applying the change for each expenditure category.
2003 IPPS final rule, the 1997 annual price changes from the price With the exception of the Professional
Benchmark I–O was not yet available. proxies to the appropriate cost Liability proxy, as was proposed, all the
Therefore, as was proposed, for this categories. We repeat this practice for indicators are based on Bureau of Labor
final rule, we did not incorporate data each year. Statistics (BLS) data and are grouped
from that source into the FY 1997-based The ‘‘all other’’ cost category is into one of the following BLS categories:
excluded hospital market basket (67 FR further divided into other hospital • Producer Price Indexes—Producer
50033). However, we did use a expenditure category shares using the Price Indexes (PPIs) measure price
secondary source, the 1997 Annual 1997 Benchmark Input-Output tables. changes for goods sold in other than
Input-Output tables. The third source of Therefore, the ‘‘all other’’ cost category retail markets. PPIs are preferable price
data, the 1997 Business Expenditure expenditure shares are proportional to proxies for goods that hospitals
Survey (now known as the Business their relationship to ‘‘all other’’ totals in purchase as inputs in producing their
Expenses Survey), was used to develop the I–O tables. For instance, if the cost outputs because the PPIs would better
weights for the utilities and telephone for telephone services were to represent reflect the prices faced by hospitals. For
services categories. 10 percent of the sum of the ‘‘all other’’ example, we use a special PPI for
prescription drugs, rather than the away from home is used as a proxy for regularly, at least once a quarter.
Consumer Price Index (CPI) for contracted food services. Availability means that the proxy is
prescription drugs because hospitals • Employment Cost Indexes— publicly available. Finally, relevance
generally purchase drugs directly from Employment Cost Indexes (ECIs) means that the proxy is applicable and
the wholesaler. The PPIs that we use measure the rate of change in employee representative of the cost category
measure price change at the final stage wage rates and employer costs for weight to which it is applied. The CPIs,
of production. employee benefits per hour worked. PPIs, and ECIs selected meet these
These indexes are fixed-weight indexes criteria and, therefore, we believe they
• Consumer Price Indexes— and strictly measure the change in wage continue to be the best measure of price
Consumer Price Indexes (CPIs) measure rates and employee benefits per hour. changes for the cost categories to which
change in the prices of final goods and Appropriately, they are not affected by they are applied.
services bought by the typical shifts in employment mix. We made no Chart 11 sets forth the complete FY
consumer. Because they may not changes to the proposed price proxies in 2002-based excluded hospital market
represent the price faced by a producer, this final rule. We evaluated the price basket including cost categories,
we used CPIs only if an appropriate PPI proxies using the criteria of reliability, weights, and price proxies. For
was not available, or if the expenditures timeliness, availability, and relevance. comparison purposes, the
were more similar to those of retail Reliability indicates that the index is corresponding FY 1997-based excluded
consumers in general rather than based on valid statistical methods and hospital market basket is listed as well.
purchases at the wholesale level. For has low sampling variability. Timeliness A summary outlining the choice of the
example, the CPI for food purchased implies that the proxy is published various proxies follows the charts.
CHART 11.—FY 2002-BASED EXCLUDED HOSPITAL MARKET BASKET COST CATEGORIES, WEIGHTS, AND PROXIES WITH
FY 1997-BASED EXCLUDED HOSPITAL MARKET BASKET USED FOR COMPARISON
FY 1997-based FY 2002-based
excluded hos- excluded hos- FY 2002-based excluded hospital market basket
Expense categories pital market pital market price proxies
basket weights basket weights
1. Compensation ......................................................... 63.251 71.035

C. Wages and Salaries* ...................................... 51.998 57.037 ECI—Wages and Salaries, Civilian Hospital Work-
ers.
D. Employee Benefits* ........................................ 11.253 13.998 ECI—Benefits, Civilian Hospital Workers.
2. Professional Fees* ................................................. 4.859 3.543 ECI—Compensation for Professional, Specialty &
Technical Workers.
3. Utilities .................................................................... 1.296 0.804
A. Fuel, Oil, and Gasoline ................................... 0.272 0.132 PPI Refined Petroleum Products.
B. Electricity ......................................................... 0.798 0.430 PPI Commercial Electric Power.
C. Water and Sewerage ...................................... 0.226 0.242 CPI–U Water & Sewerage Maintenance.
4. Professional Liability Insurance .............................. 0.805 1.504 CMS Professional Liability Insurance Premium
Index.
5. All Other .................................................................. 29.790 23.114
B. All Other Products ........................................... 19.680 15.836
(1) Pharmaceuticals .................................................... 6.940 5.940 PPI Prescription Drugs.
(2) Direct Purchase Food ........................................... 1.233 1.070 PPI Processed Foods & Feeds.
(3) Contract Service Food .......................................... 1.146 0.759 CPI–U Food Away From Home.
(4) Chemicals .............................................................. 2.343 1.347 PPI Industrial Chemicals.
(5) Blood and Blood Products** ................................. 0.821
(6) Medical Instruments .............................................. 1.972 1.242 PPI Medical Instruments & Equipment.
(7) Photographic Supplies .......................................... 0.184 0.118 PPI Photographic Supplies.
(8) Rubber and Plastics .............................................. 1.501 1.289 PPI Rubber & Plastic Products.
(9) Paper Products ..................................................... 1.219 1.225 PPI Converted Paper & Paperboard Products.
(10) Apparel ................................................................ 0.525 0.253 PPI Apparel.
(11) Machinery and Equipment .................................. 0.936 0.364 PPI Machinery & Equipment.
(12) Miscellaneous Products** ................................... 0.860 2.230 PPI Finished Goods less Food and Energy.
B. All Other Services ........................................... 10.110 7.279
(1) Telephone Services .............................................. 0.382 0.295 CPI–U Telephone Services.
(2) Postage ................................................................. 0.771 0.836 CPI–U Postage.
(3) All Other: Labor Intensive* .................................... 4.892 2.718 ECI-Compensation for Private Service Occupations.
(4) All Other: Non-Labor Intensive ............................. 4.065 3.430 CPI–U All Items.
Total ..................................................................... 100.000 100.000

* Labor-Related
** Blood and blood products, previously a separate cost category, is now contained within Miscellaneous Products in the FY 2002-based ex-
cluded hospital market basket.
a. Wages and Salaries hospital workers as the proxy for wages. b. Employee Benefits
This same proxy was used for the FY
For measuring the price growth of 1997-based excluded hospital market The FY 2002-based excluded hospital
wages in the FY 2002-based excluded basket. market basket uses the ECI for employee
hospital market basket, we used the ECI benefits for civilian hospital workers.
for wages and salaries for civilian This is the same proxy that was used in
the FY 1997-based excluded hospital yet identified a preferred option. o. Paper Products
market basket. Therefore, we are not making any The percentage change in the price of
changes to the proxy in this final rule. converted paper and paperboard
c. Nonmedical Professional Fees
h. Pharmaceuticals products as measured by the PPI
The ECI for compensation for (Commodity Code #0915) is used. The
professional and technical workers in The percentage change in the price of same proxy was used in the FY 1997-
private industry is applied to this prescription drugs as measured by the based excluded hospital market basket.
category because it includes PPI (PPI Code #PPI32541DRX) is used as
occupations such as management and a proxy for this category. This is a p. Apparel
consulting, legal, accounting and special index produced by BLS and is The percentage change in the price of
engineering services. The same proxy the same proxy used in the FY 1997- apparel as measured by the PPI
was used in the FY 1997-based based excluded hospital market basket. (Commodity Code #381) is applied to
excluded hospital market basket. this component. The same proxy was
i. Food: Direct Purchases
d. Fuel, Oil, and Gasoline used in the FY 1997-based excluded
The percentage change in the price of hospital market basket.
The percentage change in the price of processed foods and feeds as measured
gas fuels as measured by the PPI by the PPI (Commodity Code #02) is q. Machinery and Equipment
(Commodity Code #0552) is applied to applied to this component. The same The percentage change in the price of
this component. The same proxy was proxy was used in the FY 1997-based machinery and equipment as measured
used in the FY 1997-based excluded excluded hospital market basket. by the PPI (Commodity Code #11) is
hospital market basket. applied to this component. The same
j. Food: Contract Services
e. Electricity proxy was used in the FY 1997-based
The percentage change in the price of excluded hospital market basket.
The percentage change in the price of food purchased away from home as
commercial electric power as measured measured by the CPI for all urban r. Miscellaneous Products
by the PPI (Commodity Code #0542) is consumers (CPI Code #CUUR0000SEFV) The percentage change in the price of
applied to this component. The same is applied to this component. The same all finished goods less food and energy
proxy was used in the FY 1997-based proxy was used in the FY 1997-based as measured by the PPI (Commodity
excluded hospital market basket. excluded hospital market basket. Code #SOP3500) is applied to this
component. Using this index removes
f. Water and Sewerage k. Chemicals the double-counting of food and energy
The percentage change in the price of The percentage change in the price of prices, which are already captured
water and sewerage maintenance as industrial chemical products as elsewhere in the market basket. The
measured by the CPI for all urban measured by the PPI (Commodity Code same proxy was used in the FY 1997-
consumers (CPI Code #061) is applied to this component. based excluded hospital market basket.
#CUUR0000SEHG01) is applied to this While the chemicals hospitals purchase The weight for this cost category is
component. The same proxy was used include industrial as well as other types higher than in the FY 1997-based index
in the FY 1997-based excluded hospital of chemicals, the industrial chemicals because it also includes blood and blood
market basket. component constitutes the largest products. In the FY 1997-based
proportion by far. Thus, we believe that excluded hospital market basket, we
g. Professional Liability Insurance
Commodity Code #061 is the included a separate cost category for
The FY 2002-based excluded hospital appropriate proxy. The same proxy was blood and blood products, using the
market basket uses the percentage used in the FY 1997-based excluded BLS PPI (Commodity Code #063711) for
change in the hospital professional hospital market basket. blood and derivatives as a price proxy.
liability insurance (PLI) premiums as A review of recent trends in the PPI for
estimated by the CMS Hospital l. Medical Instruments blood and derivatives suggests that its
Professional Liability Index for the The percentage change in the price of movements may not be consistent with
proxy of this category. Similar to the medical and surgical instruments as the trends in blood costs faced by
Physicians Professional Liability Index, measured by the PPI (Commodity Code hospitals. While this proxy did not
we attempt to collect commercial #1562) is applied to this component. match exactly with the product
insurance premiums for a fixed level of The same proxy was used in the FY hospitals are buying, its trend over time
coverage, holding nonprice factors 1997-based excluded hospital market appears to be reflective of the historical
constant (such as a change in the level basket. price changes of blood purchased by
of coverage). In the FY 1997-based hospitals. However, an apparent
excluded hospital market basket, the m. Photographic Supplies divergence over recent periods led us to
same price proxy was used. The percentage change in the price of reevaluate whether the PPI for blood
We continue to research options for photographic supplies as measured by and derivatives was an appropriate
improving our proxy for professional the PPI (Commodity Code #1542) is measure of the changing price of blood.
liability insurance. This research applied to this component. The same We ran test market baskets classifying
includes exploring various options for proxy was used in the FY 1997-based blood in three separate cost categories:
expanding our current survey, including excluded hospital market basket. blood and blood products, contained
the identification of another entity that within chemicals as was done for the FY
would be willing to work with us to n. Rubber and Plastics 1992-based index, and within
collect more complete and The percentage change in the price of miscellaneous products. These
comprehensive data. We are also rubber and plastic products as measured categories use as proxies the following
exploring other options such as third by the PPI (Commodity Code #07) is PPIs: the PPI for blood and blood
party or industry data that might assist applied to this component. The same products, the PPI for chemicals, and the
us in creating a more precise measure of proxy was used in the FY 1997-based PPI for finished goods less food and
PLI premiums. At this time, we have not excluded hospital market basket. energy, respectively. These three market
baskets moved similarly. The impact on in the FY 2002-based excluded hospital v. All Other Services: Nonlabor
the overall market basket by using market basket. Intensive
different proxies for blood was s. Telephone
negligible, mostly due to the relatively The percentage change in the all-
small weight for blood in the market The percentage change in the price of items component of the CPI for all urban
basket. Therefore, we chose the PPI for telephone services as measured by the consumers (CPI Code #CUUR0000SA0)
CPI for all urban consumers (CPI Code is applied to this component. The same
finished goods less food and energy for
#CUUR0000SEED) is applied to this proxy was used in the FY 1997-based
the blood proxy because we believe it
component. The same proxy was used excluded hospital market basket.
will best be able to proxy price changes in the FY 1997-based excluded hospital
(not quantities or required tests) market basket. For further discussion of the rationale
associated with blood purchased by for choosing many of the specific price
hospitals. We will continue to evaluate t. Postage proxies, we refer the reader to the
this proxy for its appropriateness and The percentage change in the price of August 1, 2002 final rule (67 FR 50037).
will explore the development of postage as measured by the CPI for all Chart 12 compares the updates for the
alternative price indexes to proxy the urban consumers (CPI Code FY 2002-based excluded hospital
price changes associated with this cost. #CUUR0000SEEC01) is applied to this market basket (based on the cost
We received several comments on component. The same proxy was used structures of IRFs, LTCHs, IPFs,
in the FY 1997-based excluded hospital children’s and cancer hospitals, and
including blood and blood products
market basket. RNCHIs), the index we proposed to use
costs in miscellaneous products cost
weight. These comments were u. All Other Services: Labor Intensive to update the reasonable cost-based
addressed in section IV.B.1.b.2 of this The percentage change in the ECI for portion of IPF and LTCH payments and
final rule and are applicable to the FY compensation paid to service workers which we are adopting in this final rule,
2002-based excluded hospital market employed in private industry is applied with a FY 1997-based excluded hospital
basket as well because our rationale for to this component. The same proxy was market basket (based on the cost
how we treat blood and blood products used in the FY 1997-based excluded structure of IRFs, LTCHs, IPFs, and
in the IPPS market basket is the same as hospital market basket. children’s and cancer hospitals).
CHART 12.—FY 1997-BASED AND FY 2002-BASED EXCLUDED HOSPITAL OPERATING INDEX PERCENT CHANGE, FY 2000
THROUGH FY 2008
FY 2002- FY 1997-
based ex- based ex-
Fiscal Year (FY) cluded hospital cluded hospital
market basket market basket
Historical data:
FY 2000 ............................................................................................................................................................ 3.3 3.3
FY 2001 ............................................................................................................................................................ 4.3 4.3
FY 2002 ............................................................................................................................................................ 4.2 3.9
FY 2003 ............................................................................................................................................................ 4.1 4.0
FY 2004 ............................................................................................................................................................ 4.0 3.9
Average FYs 2000–2004 .......................................................................................................................... 4.0 3.9

Forecast:
FY 2005 ............................................................................................................................................................ 4.2 4.2
FY 2006 ............................................................................................................................................................ 3.8 3.8
FY 2007 ............................................................................................................................................................ 3.4 3.2
FY 2008 ............................................................................................................................................................ 3.2 3.0
Average FYs 2005–2008 .......................................................................................................................... 3.7 3.6

Source: Global Insight, Inc. 2nd Qtr 2005, @USMACRO/CNTL0605 @CISSIM/TL0505.SIM
D. Frequency of Updates of Weights in labor share, in such market basket to requirement, and sets forth a rebasing
IPPS Hospital Market Basket reflect the most current data available frequency that makes optimal use of
Section 404 of Pub. L. 108–173 more frequently than once every 5 years; available data.
(MMA) requires CMS to report in this and Our past practice has been to monitor
final rule the research that has been ‘‘(b) Incorporation of explanation in the appropriateness of the market basket
done to determine a new frequency for rulemaking. The Secretary shall include on a consistent basis in order to rebase
rebasing the hospital market basket. in the publication of the final rule for and revise the index when necessary.
Specifically, section 404 states: payment for inpatient hospitals services The decision to rebase and revise the
‘‘(a) More frequent updates in weights. under section 1886(d) of the Social index has been driven in large part by
After revising the weights used in the Security Act (42 U.S.C. 1395ww(d)) for the availability of the data necessary to
hospital market basket under section fiscal year 2006, an explanation of the produce a complete index. In the past,
1886(b)(3)(B)(iii) of the Social Security reasons for, and options considered, in we have supplemented the Medicare
Act (42 U.S.C. 1395ww(b)(3)(B)(iii)) to determining the frequency established cost report data that are available on an
reflect the most current data available, under subsection (a).’’ annual basis with Bureau of the Census
the Secretary shall establish a frequency This section of the final rule discusses hospital expense data that are typically
for revising such weights, including the the research we have done to fulfill this available only every 5 years (usually in
years ending in 2 and 7). Because of weights under various frequencies. We of Medicare cost report data. In
this, we have generally rebased the did this by developing market baskets developing the hospital market basket
index every 5 years. However, prior to that had base years for every year weights, we have used the Medicare
the requirement associated with section between 1997 and 2002, and then cost reports to determine the weights for
404 of Pub. L. 108–173, there was no analyzed how different the market six major cost categories (wages,
legislative requirement regarding the basket percent changes were over benefits, contract labor,
timing of rebasing the hospital market various periods. We used the results pharmaceuticals, professional liability,
basket nor was there a hard rule that we from these areas of research to assist in and blood and blood products). In FY
used in determining this frequency. our determination of a new rebasing 2002, these six categories accounted for
ProPAC, one of MedPAC’s predecessor frequency. Based on this analysis, as we 68.5 percent of the hospital market
organizations, submitted a report to the proposed in the FY 2006 IPPS proposed basket. Therefore, it is possible to
Secretary on April 1, 1985, that rule, we would rebase the hospital develop a new set of market basket
supported periodic rebasing at least market basket every 4 years. This would weights for these categories on an
every 5 years. mean the next rebasing would occur for annual basis, but with a substantial lag
The most recent rebasing of the the FY 2010 update. (for the FY 2006 update, we consider
hospital market basket was just 3 years As we have described in numerous the latest year of historical data to be FY
ago, for the FY 2003 update. Since its Federal Register documents over the 2002).
inception with the hospital PPS in FY past few decades, the hospital market
1984, the hospital market basket has basket weights are the compilation of The second source of data is the U.S.
been rebased several times (FY 1987 data from more than one data source. Department of Commerce, Bureau of
update, FY 1991 update, FY 1997 When we are discussing rebasing the Economic Analysis’ Benchmark Input-
update, FY 1998 update, and FY 2003 weights in the hospital market basket, Output (I–O) table. These data are
update). One of the reasons we believe there are two major data sources: (1) the published every 5 years with a more
it appropriate to rebase the index on a Medicare cost reports; and (2) expense significant lag than the Medicare cost
periodic basis is that rebasing (as surveys from the Bureau of the Census reports. For example, the 1997
opposed to revising, as explained in (the Economic Census is used to Benchmark I–O tables were not
section IV.A. of this preamble) tends to develop data for the Bureau of published until the beginning of 2003.
have only a minor impact on the actual Economic Analysis’ input-output We have sometimes used data from a
percentage increase applied to the PPS series). third data source, the Bureau of the
update. There are two major reasons for Each Medicare-participating hospital Census’ Business Expenses Survey
this: (1) The cost category weights tend submits a Medicare cost report to CMS (BES), which is also published every 5
to be relatively stable over shorter term on an annual basis. It takes roughly 2 years. The BES data are used as an input
periods (3 to 5 years); and (2) the update years before ‘‘nearly complete’’ into the I–O data, and thus are
is based on a forecast, which means the Medicare cost report data are available. published a few months prior to the
individual price series tend not to grow For example, approximately 90 percent release of the I–O. However, the BES
as differently as they have in some of FY 2002 Medicare cost report data contains only a fraction of the detail
historical periods. were available in October 2004 (only 50 contained in the I–O.
We focused our research in two major percent of FY 2003 data was available), Chart 13 below takes into
areas. First, we reviewed the frequency although only 20 percent of these consideration the expected availability
and availability of the data needed to reports were settled. We choose FY 2002 of these major data sources and
produce the market basket. Second, we as the base year because we believe this summarizes how they could be
analyzed the impact on the market is the most recent, relatively complete incorporated into the development of
basket of determining the market basket year (with a 90 percent reporting rate) future market basket weights.
CHART 13.—EXPECTED FUTURE DATA AVAILABILITY FOR MAJOR DATA SOURCES USED IN THE HOSPITAL MARKET BASKET
PPS FY Update ....................................................................................... FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011
Market Basket Base Year ........................................................................ FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007
Medicare Cost Report Data Available ..................................................... FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007
I–O Data Available ................................................................................... 1997 1997 1997 1997 1997 2002
BES Data Available ................................................................................. 1997 1997 1997 1997 1997 2002
Number of Years Data Must Be Aged ..................................................... 5 6 7 8 9 5
FPS FY Update ............................................................................................................ FY 2012 FY 2013 FY 2014 FY 2015 FY 2016

Market Basket Base Year ............................................................................................ FY 2008 FY 2009 FY 2010 FY 2011 FY 2012
Medicare Cost Report Data Available ......................................................................... FY 2008 FY 2009 FY 2010 FY 2011 FY 2012
I–O Data Available ....................................................................................................... 2002 2002 2002 2002 2007
BES Data Available ..................................................................................................... 2002 2002 2002 2002 2007
Number of Years Data Must Be Aged ......................................................................... 6 7 8 9 5
It would be necessary to age the I–O 1997 Benchmark I–O data for this final would recently be available. In order to
or BES data to the year for which cost rule. match the Medicare cost report data that
report data are available using the price As the table clearly indicates, the would be available at that time (FY 2007
changes between those periods. While most optimal rebasing frequency from a data), we would have to age the I–O data
not a preferred method in developing data availability standpoint is every 5 to FY 2007. However, this would be
the market basket weights, we have years. That is, if we were to next rebase aging the data only 5 years, whereas if
done this in the past when rebasing the for the FY 2011 update, we could use the rebasing frequency was determined
index. For instance, we have aged the the 2002 Benchmark I–O data that to be every 4 years, we would have to
age 1997 I–O data to FY 2006. While data as much as 9 years to use the same weights under various frequencies. We
aging data over 5 years is problematic year as the cost report data. did this by using the current historical
(there can be significant utilization and For a rebasing frequency of every 4 data that are available (both Medicare
intensity changes over that length years, our next rebasing would be for cost report and I–O) to develop market
period, as opposed to only one or two the FY 2010 update using FY 2006 baskets with base year weights for each
years), it would be significantly worse to Medicare cost report data and 1997 I–O year between FY 1997 and FY 2002. We
age data over an 8-year or 9-year period. data. This is also problematic because then analyzed how differently the
If we were on a 5-year rebasing the 1997 I–O data would need to be market baskets moved over various
frequency, for the FY 2016 update, we aged 9 years to match the cost report historical periods.
would use cost report data for FY 2012 data. The next two rebasings would be Approaching the analysis this way
and the newly available 2007 I–O data. for the FY 2014 update (using FY 2010 allowed us to develop six hypothetical
Again, the I–O data would have to be cost report data and 2002 I–O data) and market baskets with different base years
aged only 5 years to match the cost FY 2018 (using FY 2014 cost report data (FY 1997, FY 1998, FY 1999, FY 2000,
report data. and 2007 I–O data). Again, this FY 2001, and FY 2002). As we have
We systematically examined at the frequency would make optimal use of done when developing the official
implications of determining a rebasing the Medicare cost report data but would market baskets, we used Medicare cost
frequency of every 3 or 4 years. require aging of the I–O data between 7 report data where available. Thus, cost
Considering a frequency of 3 years first, and 9 years in order to match the cost report data were used to determine the
we would next rebase for the FY 2009 report data. weights for wages and salaries, benefits,
update using FY 2005 Medicare cost It is clear from this analysis that contract labor, pharmaceuticals, blood
report data and 1997 I–O data (the same neither the 3-year nor 4-year rebasing and blood products, and all other costs.
data currently being used in the FY frequencies optimize the timeliness of We used the 1997 Benchmark I–O data
2002-based market basket). This is the data relative to rebasing every 5 to fill out the remainder of the market
problematic because the 1997 I–O data years. In addition, when comparing the basket weights (note that this produces
would need to be aged 8 years to match 3-year and 4-year rebasing frequencies, a different index for FY 1997 than the
the cost report data. The next two no one method stands out as being official FY 1997-based hospital market
rebasings would be for the FY 2012 significantly improved over another. basket that used the Annual 1997 I–O
update (using FY 2008 cost report data Thus, this analysis does not lead us to data), aging the data to the appropriate
and 2002 I–O data) and FY 2015 (using draw any definitive conclusions as to a year to match the cost report data. This
FY 2011 cost report data and 2002 I–O rebasing frequency more appropriate means the FY 2002-based index used in
data). This means that while we are than every 5 years. this analysis matches the FY 2002-based
making optimal use of the Medicare cost Our second area of research in market basket we are using in this final
report data, we would be forced to use determining a new rebasing frequency rule. Chart 14 shows the weights from
the same I–O data in consecutive was to analyze the impact on the market these hypothetical market baskets:
rebasings and would have to age that basket of determining the market basket BILLING CODE 4120–01–P
BILLING CODE 4120–01–C the results of this analysis will show, consider the hypothetical FY 1997-
Note that the weights remain rebasing the market basket more based index to be the benchmark
relatively stable between periods. It is frequently than every 5 years is measure and the other indexes to
for this reason that we believe defining expected to have little impact on the indicate the impact of rebasing over
the market basket as a Laspeyres-type, overall percent change in the hospital various frequencies. The hypothetical
fixed-weight index is appropriate. market basket. FY 2000-based index would reflect the
Because the weights in the market impact of rebasing every 3 years, the
basket are generally for aggregated costs Using these hypothetical market
baskets, we can produce market basket hypothetical FY 2001-based index
(for example, wages and salaries for all
percent changes over historical periods would reflect the impact of rebasing
employees), there is not much volatility
in the weights between periods, to determine what is the impact of using every 4 years, and the hypothetical FY
various base periods. In our analysis, we 2002-based index would reflect the
ER12AU05.002</GPH>
especially over shorter time spans. As
impact of rebasing every 5 years. Chart 15 shows the results of these

comparisons.
CHART 15.—COMPARISON OF HYPOTHETICAL MARKET BASKETS, FY 1997 THROUGH FY 2002 BASE YEARS, PERCENT
CHANGES, FY 1998 THROUGH FY 2004
Percent Change in Hypothetical Market Baskets
Federal Fiscal Year FY 1997- FY 1998- FY 1999- FY 2000- FY 2001- FY 2002-
based based based based based based
1998 ......................................................... 2.7 2.6 2.6 2.6 2.6 2.6

1999 ......................................................... 2.7 2.5 2.5 2.5 2.5 2.5
2000 ......................................................... 3.2 3.3 3.3 3.3 3.3 3.2
2001 ......................................................... 4.2 4.2 4.2 4.2 4.2 4.1
2002 ......................................................... 3.8 3.8 3.8 3.7 3.7 3.7
2003 ......................................................... 3.9 4.0 4.0 4.0 4.0 4.0
2004 ......................................................... 3.9 3.8 3.9 3.8 3.9 3.9
Average: FY 1998–2004 ................... 3.5 3.5 3.5 3.4 3.5 3.4

Source: Global Insight, Inc, 2nd Qtr. 2005;@USMACRO/CNTL0605 @CISSIM/TL0505.SIM.
It is clear from this comparison that potentially limit the amount of time and repeal section 404 of Pub. L. 108–173
there is little difference between the resources we could devote to the market requiring the more frequent updating of
indexes, and, for some FYs, there would basket rebasing process. In addition, we the market basket. CMS’ analysis shows
be no difference in the market basket recognize that, in the future, we may be that updating the weights more
update factor if we had rebased the required to develop additional market frequently then every 5 years would
market basket more frequently. In baskets that would require frequent make only small differences in its
particular, there is no difference in the rebasing. market basket forecasts. In addition,
hypothetical indexes based between FY Given the number of market baskets some of the data used in developing the
2000 and FY 2002. This suggests that we are responsible for rebasing and market basket is only available every 5
setting the rebasing frequency to 3, 4, or revising, the regulatory process for each, years, thus a 4-year rebasing schedule
5 years will have little or no impact on and the availability of source data, we could make the market basket weights
the resulting market basket. As we believe that while it is not necessary, even more out of date due to the timing
found when analyzing data availability, rebasing and revising the hospital of these data sources. Therefore,
this portion of our research does not market baskets every 4 years is the most MedPAC concluded that updating the
suggest that rebasing the market basket appropriate frequency to meet the weights more often than once every 5
more frequently than every 5 years legislative requirement. years is unnecessary and potentially
results in an improved market basket or Comment: A few commenters stated counterproductive. Other commenters
that there is any noticeable difference there is no compelling reason to rebase also requested that CMS continue with
between rebasing every 3 or 4 years. the market basket for the FY 2006 a 5-year rebasing schedule.
Market basket rebasing is a 1-year to update. They requested that CMS begin Response: As described in this rule,
2-year long process that includes data its 4-year rebasing schedule, beginning we agree with the commenters that
processing, analytical work, with the FY 2007 update (4 years after rebasing the hospital market basket
methodology reevaluation, and the last rebasing of the hospital market more frequently than every 5 years is
regulatory process. After developing a for the FY 2003 update). unnecessary. However, section 404 of
rebased and revised market basket, there Response: Section 404(a) of Pub. L. Pub. L. 108–173 requires a shorter
are extensive internal review processes 108–173 directs the Secretary to frequency, which CMS has set at every
that a rule must undergo, both in establish a frequency for rebasing the 4 years.
proposed and final form. Once the market basket after updating the weights
used in the IPPS operating and capital E. Capital Input Price Index Section
proposed rule has been published, there
is a 60-day comment period set aside for market baskets to reflect the most The Capital Input Price Index (CIPI)
the public to respond to the proposed current available data. Section 404(b) of was originally described in the
rule. After comments are received, we the Pub. L. 108–173 provides that the September 1, 1992 Federal Register (57
then require adequate time to research Secretary shall include his explanation FR 40016). There have been subsequent
and reply to all comments submitted. of the reasons for the frequency of discussions of the CIPI presented in the
The last part of the regulatory process is market basket updates in the FY 2006 May 26, 1993 (58 FR 30448), September
the 60-day requirement that is, the final IPPS final rule. We believe that section 1, 1993 (58 FR 46490), May 27, 1994 (59
rule must be published 60 days before 404 of Pub. L. 108–173 requires that we FR 27876), September 1, 1994 (59 FR
the provisions of the rule can become rebase the market basket in the FY 2006 45517), June 2, 1995 (60 FR 29229),
effective. IPPS final rule because we are required September 1, 1995 (60 FR 45815), May
We would like to rebase all of our to establish a schedule for rebasing the 31, 1996 (61 FR 27466), and August 30,
indexes (PPS operating, PPS capital, market basket in the FY 2006 IPPS final 1996 (61 FR 46196) issues of the Federal
excluded hospital with capital, SNFs, rule, but may not establish the schedule Register. The August 1, 2002 (67 FR
HHAs, and Medicare Economic Index) until after we have rebased the market 50032) rule discussed the most recent
on a regular schedule. Therefore, if we basket to reflect the most current data revision and rebasing of the CIPI to a FY
were to choose a 3-year rebasing available. 1997 base year, which reflects the
schedule, we would have to rebase more Comment: MedPAC urged the capital cost structure facing hospitals in
than one index at a time. This may Secretary to propose legislation to that year.
In this final rule, we are revising and that the Medicare cost reports provided equipment and movable equipment was
rebasing the CIPI to a FY 2002 base year accurate data for all capital expenditure determined using the Medicare cost
to reflect the more recent structure of cost categories. We used the FY 2001 reports. This methodology was also
capital costs in hospitals. Unlike the Medicare cost reports for PPS hospitals, used to compute the FY 1997-based
PPS operating market basket, we do not aged to FY 2002, excluding expenses index.
have FY 2002 Medicare cost report data from hospital-based subproviders, to Total interest expense cost category is
available for the development of the determine weights for all three cost split between government/nonprofit and
capital cost weights, due to a change in categories: depreciation, interest, and profit interest. The FY 1997-based CIPI
the FY 2002 cost reporting other capital expenses. We compared allocated 85 percent of the total interest
requirements. Rather, we used hospital the weights determined from the cost weight to government/nonprofit
capital expenditure data for the capital Medicare cost reports to the 2002 interest, proxied by average yield on
cost categories of depreciation, interest, Bureau of the Census’ Business domestic municipal bonds, and 15
and other capital expenses for FY 2001 Expenses Survey and found the weights percent to for-profit interest, proxied by
and aged these data to a FY 2002 base to be similar to those developed from average yield on Moody’s Aaa bonds (67
year using the relevant vintage-weighted the Medicare cost reports. FR 50044). The methodology used to
price proxies. As with the FY 1997- Lease expenses are not broken out as derive this split is explained in the June
based index, we have developed two a separate cost category in the CIPI, but 2, 1995 issue of the Federal Register (60
sets of weights in order to calculate the are distributed among the cost FR 29233).
FY 2002-based CIPI. The first set of categories of depreciation, interest, and We derived the split using the relative
weights identifies the proportion of other, reflecting the assumption that the FY 2001 Medicare cost report data on
hospital capital expenditures underlying cost structure of leases is interest expenses for government/
attributable to each expenditure similar to capital costs in general. As nonprofit and profit hospitals. Based on
category, while the second set of was done in previous rebasings of the these data, we applied a 75/25 split
weights is a set of relative vintage CIPI, we assumed 10 percent of lease between government/nonprofit and
weights for depreciation and interest. expenses are overhead and assigned profit interest. We believe it is
The set of vintage weights is used to them to the other capital expenses cost important that this split reflects the
identify the proportion of capital category as overhead. The remaining latest relative cost structure of interest
expenditures within a cost category that lease expenses were distributed to the expenses. The split of 75/25 had little
is attributable to each year over the three cost categories based on the (less than 0.1 percent in any given year)
useful life of the capital assets in that proportion of depreciation, interest, and or no effect on the annual capital market
category. A more thorough discussion of other capital expenses to total capital basket percent change in both the
vintage weights is provided later in this costs, excluding lease expenses. historical and forecasted periods.
section. Depreciation contains two Chart 16 presents a comparison of the
Both sets of weights are developed subcategories: building and fixed FY 2002-based CIPI capital cost weights
using the best data sources available. In equipment and movable equipment. The and the FY 1997-based CIPI capital cost
reviewing source data, we determined split between building and fixed weights.
CHART 16.—COMPARISON OF FY 1997-BASED AND FY 2002-BASED CIPI COST CATEGORY WEIGHTS

FY 2002 FY 1997
Expense categories Price proxy
weights weights
Total ................................................. 100.00 100.00

Total depreciation ............................ 74.58 71.35
Building and fixed equipment depre- 36.23 34.22 Boeckh Institutional Construction Index—vintage weighted (23 years).
ciation.
Movable equipment depreciation ..... 38.35 37.13 PPI for machinery and equipment—vintage weighted (11 years).
Total interest .................................... 19.86 23.46
Government/nonprofit interest ......... 14.90 19.94 Average yield on domestic municipal bonds (Bond Buyer 20 bonds)—
vintage weighted (23 years).
For-profit interest ............................. 4.97 3.52 Average yield on Moody’s Aaa bonds—vintage weighted (23 years).
Other ................................................ 5.55 5.19 CPI–U—Residential Rent.
Because capital is acquired and paid vintage-weighted price changes actual capital investment process. By
for over time, capital expenses in any associated with depreciation and accounting for the vintage nature of
given year are determined by both past interest expense. capital, we are able to provide an
and present purchases of physical and Vintage weights are an integral part of accurate, stable annual measure of price
financial capital. The vintage-weighted the CIPI. Capital costs are inherently changes. Annual nonvintage price
CIPI is intended to capture the long- complicated and are determined by changes for capital are unstable due to
term consumption of capital, using complex capital purchasing decisions, the volatility of interest rate changes
vintage weights for depreciation over time, based on such factors as and, therefore, do not reflect the actual
(physical capital) and interest (financial interest rates and debt financing. In annual price changes for Medicare
capital). These vintage weights reflect addition, capital is depreciated over capital-related costs. CMS’ CIPI reflects
the proportion of capital purchases time instead of being consumed in the the underlying stability of the capital
attributable to each year of the expected same period it is purchased. The CIPI acquisition process and provides
life of building and fixed equipment, accurately reflects the annual price hospitals with the ability to plan for
movable equipment, and interest. We changes associated with capital costs, changes in capital payments.
used the vintage weights to compute and is a useful simplification of the
To calculate the vintage weights for the depreciation expenses into annual amount of the physical acquisition, net
depreciation and interest expenses, we amounts of building and fixed of price inflation. This real annual
needed a time series of capital equipment depreciation and movable purchase amount for movable
purchases for building and fixed equipment depreciation. Year-end asset equipment was calculated by deflating
equipment and movable equipment. We costs for building and fixed equipment the nominal annual purchase amount by
found no single source that provides the and movable equipment were the movable equipment price proxy, the
best time series of capital purchases by determined by multiplying the annual PPI for Machinery and Equipment.
hospitals for all of the above depreciation amounts by the expected Based on our determination that
components of capital purchases. The life calculations from the FY 2001 movable equipment has an expected life
early Medicare cost reports did not have Medicare cost reports. We then of 11 years, the vintage weights for
sufficient capital data to meet this need. calculated a time series back to 1963 of movable equipment represent the
While the AHA Panel Survey provided annual capital purchases by subtracting average expenditure for movable
a consistent database back to 1963, it the previous year asset costs from the equipment over an 11-year period. With
did not provide annual capital current year asset costs. From this real movable equipment purchase
purchases. The AHA Panel Survey capital purchase time series, we were estimates available back to 1963,
provided a time series of depreciation able to calculate the vintage weights for twenty-eight 11-year periods were
expenses through 1997 which could be building and fixed equipment and averaged to determine the average
used to infer capital purchases over movable equipment. Each of these sets vintage weights for movable equipment
time. From 1998 to 2001, hospital of vintage weights is explained in detail that are representative of average
depreciation expenses were calculated below. movable equipment purchase patterns
by multiplying the AHA Annual Survey For building and fixed equipment over time. Vintage weights for each 11-
total hospital expenses by the ratio of vintage weights, the real annual capital year period are calculated by dividing
depreciation to total hospital expenses purchase amounts for building and the real movable capital purchase
from the Medicare cost reports. fixed equipment derived from the AHA amount for any given year by the total
Beginning in 2001, the AHA Annual Panel Survey were used. The real amount of purchases in the 11-year
survey began collecting depreciation annual purchase amount was used to period. This calculation was done for
expenses. We expect to be able to use capture the actual amount of the each year in the 11-year period, and for
these data in future rebasings. physical acquisition, net of the effect of each of the twenty-eight 11-year
In order to estimate capital purchases price inflation. This real annual periods. We used the average of each
from AHA data on depreciation purchase amount for building and fixed year across the twenty-eight 11-year
expenses, the expected life for each cost equipment was produced by deflating periods to determine the average
category (building and fixed equipment, the nominal annual purchase amount by movable equipment vintage weights for
movable equipment, and interest) is the building and fixed equipment price the FY 2002-based CIPI.
needed to calculate vintage weights. We proxy, the Boeckh Institutional For interest vintage weights, the
used FY 2001 Medicare cost reports to Construction Index. Because building nominal annual capital purchase
determine the expected life of building and fixed equipment have an expected amounts for total equipment (building
and fixed equipment and movable life of 23 years, the vintage weights for and fixed, and movable) derived from
equipment. The expected life of any building and fixed equipment are the AHA Panel and Annual Surveys
piece of equipment can be determined deemed to represent the average were used. Nominal annual purchase
by dividing the value of the asset purchase pattern of building and fixed amounts were used to capture the value
(excluding fully depreciated assets) by equipment over 23-year periods. With of the debt instrument. Because we have
its current year depreciation amount. real building and fixed equipment determined that hospital debt
This calculation yields the estimated purchase estimates available back to instruments have an expected life of 23
useful life of an asset if depreciation 1963, we averaged sixteen 23-year years, the vintage weights for interest
were to continue at current year levels, periods to determine the average vintage are deemed to represent the average
assuming straight-line depreciation. weights for building and fixed purchase pattern of total equipment
From the FY 2001 cost reports, the equipment that are representative of over 23-year periods. With nominal total
expected life of building and fixed average building and fixed equipment equipment purchase estimates available
equipment was determined to be 23 purchase patterns over time. Vintage back to 1963, sixteen 23-year periods
years, and the expected life of movable weights for each 23-year period are were averaged to determine the average
equipment was determined to be 11 calculated by dividing the real building vintage weights for interest that are
years. The FY 1997-based CIPI showed and fixed capital purchase amount in representative of average capital
the same expected life for the two any given year by the total amount of purchase patterns over time. Vintage
categories of depreciation. purchases in the 23-year period. This weights for each 23-year period are
Between the publication of the FY calculation is done for each year in the calculated by dividing the nominal total
2006 IPPS proposed rule and this final 23-year period, and for each of the capital purchase amount for any given
rule, we conducted a further review of sixteen 23-year periods. We used the year by the total amount of purchases in
the methodology used to derive the average of each year across the sixteen the 23-year period. This calculation is
useful life of an asset. Based on this 23-year periods to determine the 2002 done for each year in the 23-year period
brief analysis into the capital cost average building and fixed equipment and for each of the sixteen 23-year
structures of hospitals, we are not vintage weights for the FY 2002-based periods. We used the average of each
changing the expected life of fixed and CIPI. year across the sixteen 23-year periods
moveable assets for the final rule. For movable equipment vintage to determine the average interest vintage
As proposed, we used the building weights, the real annual capital weights for the FY 2002-based CIPI. The
and fixed equipment and movable purchase amounts for movable vintage weights for the FY 1997 CIPI
equipment weights derived from FY equipment derived from the AHA Panel and the FY 2002 CIPI are presented in
2001 Medicare cost reports to separate Survey were used to capture the actual Chart 17.
CHART 17.—FY 1997 AND FY 2002 VINTAGE WEIGHTS FOR CAPITAL-RELATED PRICE PROXIES
Building and fixed equipment Movable equipment Interest
Year FY 1997 FY 2002 FY 1997 FY 2002 FY 1997 FY 2002
23 years 23 years 11 years 11 years 23 years 23 years
1 ............................................................... 0.018 0.021 0.063 0.065 0.007 0.010

2 ............................................................... 0.021 0.022 0.068 0.071 0.009 0.012
3 ............................................................... 0.023 0.025 0.074 0.077 0.011 0.014
4 ............................................................... 0.025 0.027 0.080 0.082 0.012 0.016
5 ............................................................... 0.026 0.029 0.085 0.086 0.014 0.019
6 ............................................................... 0.028 0.031 0.091 0.091 0.016 0.023
7 ............................................................... 0.030 0.033 0.096 0.095 0.019 0.026
8 ............................................................... 0.032 0.035 0.101 0.100 0.022 0.029
9 ............................................................... 0.035 0.038 0.108 0.106 0.026 0.033
10 ............................................................. 0.039 0.040 0.114 0.112 0.030 0.036
11 ............................................................. 0.042 0.042 0.119 0.117 0.035 0.039
12 ............................................................. 0.044 0.045 ........................ ........................ 0.039 0.043
13 ............................................................. 0.047 0.047 ........................ ........................ 0.045 0.048
14 ............................................................. 0.049 0.049 ........................ ........................ 0.049 0.053
15 ............................................................. 0.051 0.051 ........................ ........................ 0.053 0.056
16 ............................................................. 0.053 0.053 ........................ ........................ 0.059 0.059
17 ............................................................. 0.057 0.056 ........................ ........................ 0.065 0.062
18 ............................................................. 0.060 0.057 ........................ ........................ 0.072 0.064
19 ............................................................. 0.062 0.058 ........................ ........................ 0.077 0.066
20 ............................................................. 0.063 0.060 ........................ ........................ 0.081 0.070
21 ............................................................. 0.065 0.060 ........................ ........................ 0.085 0.071
22 ............................................................. 0.064 0.061 ........................ ........................ 0.087 0.074
23 ............................................................. 0.065 0.061 ........................ ........................ 0.090 0.076
Total .................................................. 1.000 1.000 1.000 1.000 1.000 1.000
After the capital cost category weights appropriate proxies for hospital capital category. There was no difference in the
were computed, it was necessary to costs that meet our selection criteria of two sets of index percent changes either
select appropriate price proxies to relevance, timeliness, availability, and historically or forecasted. The rationale
reflect the rate-of-increase for each reliability. We ran the FY 2002-based for selecting these price proxies is
expenditure category. Our price proxies index using the Moody’s Aaa bonds explained more fully in the August 30,
for the FY 2002-based CIPI are the same average yield and then using the 1996 final rule (61 FR 46196). The
as those used in the FY 1997-based CIPI. Moody’s Baa bonds average yield as proxies are presented in Chart 18.
We still believe these are the most proxy for the for-profit interest cost
CHART 18.—COMPARISON OF FY 1997-BASED AND FY 2002-BASED CAPITAL INPUT PRICE INDEX, PERCENT CHANGE, FY
1998 THROUGH FY 2007
CIPI, FY 1997- CIPI, FY 2002-
Federal fiscal year based based
1998 ......................................................................................................................................................................... 0.9 1.0

1999 ......................................................................................................................................................................... 0.9 0.9
2000 ......................................................................................................................................................................... 1.1 1.0
2001 ......................................................................................................................................................................... 0.9 0.9
2002 ......................................................................................................................................................................... 0.8 0.7
2003 ......................................................................................................................................................................... 0.6 0.5
2004 ......................................................................................................................................................................... 0.6 0.5
Forecast:
2005 .................................................................................................................................................................. 0.6 0.5
2006 .................................................................................................................................................................. 1.0 0.8
2007 .................................................................................................................................................................. 1.0 0.9
Average:
FYs 1998–2004 ................................................................................................................................................ 0.8 0.8
FYs 2005–2007 ................................................................................................................................................ 0.9 0.7
Source: Global Insight, Inc, 2nd Qtr. 2005; @USMACRO/CONTROL0605 @CISSIM/TL0505.
Global Insight, Inc. forecasts a 0.8 (building and fixed equipment, and 2006, as indicated in Chart 19.
percent increase in the FY 2002-based movable equipment) and a 3.3 percent Accordingly, for FY 2006, we have
CIPI for 2006, as shown in Chart 17. increase in other capital expense prices, adopted a 0.8 percent increase in the
This is the result of a 1.4 percent partially offset by a 2.3 percent decrease CIPI.
increase in projected depreciation prices in vintage-weighted interest rates in FY
CHART 19.—CMS CAPITAL INPUT PRICE INDEX PERCENT CHANGES, TOTAL AND COMPONENTS, FYS 1995 THROUGH
2007
Depreciation, Depreciation,
Total deprecia- building and
Fiscal Year Total movable Interest Other
tion fixed equip- equipment
ment
Weights FY 2002 ..................................... 1.000 0.7458 0.3623 0.3835 0.1986 0.0556
Vintage-Weighted Price Changes
1995 ......................................................... 1.7 2.7 4.0 1.6 ¥1.2 2.5

1996 ......................................................... 1.4 2.5 3.8 1.4 ¥1.8 2.6
1997 ......................................................... 1.3 2.3 3.7 1.2 ¥2.0 2.8
1998 ......................................................... 1.0 2.1 3.4 0.9 ¥2.6 3.2
1999 ......................................................... 0.9 1.9 3.2 0.7 ¥2.6 3.2
2000 ......................................................... 1.0 1.7 3.1 0.4 ¥1.7 3.4
2001 ......................................................... 0.9 1.5 3.0 0.2 ¥2.2 4.3
2002 ......................................................... 0.7 1.3 2.9 0.0 ¥2.4 4.3
2003 ......................................................... 0.5 1.3 2.8 ¥0.2 ¥3.0 3.1
2004 ......................................................... 0.5 1.3 2.8 ¥0.2 ¥3.3 2.7
Forecast:
2005 .................................................. 0.5 1.3 2.8 ¥0.1 ¥3.7 3.0
2006 .................................................. 0.8 1.4 2.7 0.0 ¥2.3 3.3
2007 .................................................. 0.9 1.3 2.6 0.0 ¥2.0 3.2
Rebasing the CIPI from FY 1997 to FY per diem rate for each day of the stay, all cases assigned to one of 10 DRGs
2002 decreased the percent change in not to exceed the full DRG payment that selected by the Secretary, if the
the FY 2006 forecast by 0.2 percentage would have been made if the patient individuals are discharged to one of the
point, from 1.0 to 0.8, as shown in Chart had been discharged without being following postacute care settings:
14. The difference is caused mostly by transferred. • A hospital or hospital unit that is
changes in the relationships between The per diem rate paid to a not a subsection 1886(d) hospital.
the cost category weights within transferring hospital is calculated by (Section 1886(d)(1)(B) of the Act
depreciation and interest. The fixed dividing the full DRG payment by the identifies the hospitals and hospital
depreciation cost weight relative to the geometric mean length of stay for the units that are excluded from the term
movable depreciation cost weight and DRG. Based on an analysis that showed ‘‘subsection (d) hospital’’ as psychiatric
the nonprofit/government interest cost that the first day of hospitalization is the hospitals and units, rehabilitation
weight relative to the for-profit interest most expensive (60 FR 45804), our hospitals and units, children’s hospitals,
cost weight are both less in the FY 2002- policy provides for payment that is long-term care hospitals, and cancer
based CIPI. The changes in these double the per diem amount for the first hospitals.)
relationships have a small effect on the day (§ 412.4(f)(1)). Transfer cases are • A SNF (as defined at section
FY 2002-based CIPI percent changes. also eligible for outlier payments. The 1819(a) of the Act).
However, when added together, they are outlier threshold for transfer cases is • Home health services provided by a
responsible for a negative two-tenths of equal to the fixed-loss outlier threshold home health agency, if the services
a percentage point difference between for nontransfer cases, divided by the relate to the condition or diagnosis for
the FY 2002-based CIPI and the FY geometric mean length of stay for the which the individual received inpatient
1997-based CIPI. DRG, multiplied by the length of stay for hospital services, and if the home health
We did not receive any public the case, plus one day. The purpose of services are provided within an
comments on the CIPI. the IPPS transfer payment policy is to appropriate period (as determined by
avoid providing an incentive for a the Secretary).
V. Other Decisions and Changes to the In the FY 1999 IPPS final rule (63 FR
hospital to transfer patients to another
IPPS for Operating Costs and GME 40975 through 40976), we specified that
hospital early in the patients’ stay in
Costs a patient discharged to home would be
order to minimize costs while still
A. Postacute Care Transfer Payment receiving the full DRG payment. The considered transferred to postacute care
Policy (§ 412.4) transfer policy adjusts the payments to if the patient received home health
approximate the reduced costs of services within 3 days after the date of
1. Background discharge. In addition, in the FY 1999
transfer cases.
Existing regulations at § 412.4(a) IPPS final rule, we did not include
define discharges under the IPPS as 2. Changes to DRGs Subject to the patients transferred to a swing-bed for
situations in which a patient is formally Postacute Care Transfer Policy skilled nursing care in the definition of
released from an acute care hospital or (§§ 412.4(c) and (d)) postacute care transfer cases (63 FR
dies in the hospital. Section 412.4(b) Section 1886(d)(5)(J) of the Act 40977).
defines transfers from one acute care provides that, effective for discharges on Section 1886(d)(5)(J) of the Act
hospital to another, and § 412.4(c) or after October 1, 1998, a ‘‘qualified directed the Secretary to select 10 DRGs
defines transfers to certain postacute discharge’’ from one of 10 DRGs based upon a high volume of discharges
care providers. Our policy provides that, selected by the Secretary to a postacute to postacute care and a disproportionate
in transfer situations, full payment is care provider would be treated as a use of postacute care services. As
made to the final discharging hospital transfer case. This section required the discussed in the FY 1999 IPPS final
and each transferring hospital is paid a Secretary to define and pay as transfers rule, these 10 DRGs were selected in
1998 based on the MedPAR data from DRGs qualified under the four criteria transfer policy, although one or more of
FY 1996. Using that information, we set forth in the IPPS final rule for FY the original criteria may no longer
identified and selected the first 20 DRGs 2004. We also analyzed the DRGs apply. Under the proposed alternate
that had the largest proportion of included under the policy for FY 2004 criteria, DRGs 430, 541, and 542 would
discharges to postacute care (and at least to determine if they still met the criteria have qualified for inclusion in the
14,000 such transfer cases). In order to to remain under the policy. In addition, postacute care transfer policy.
select 10 DRGs from the 20 DRGs on our we analyzed the special circumstances In the response to comments on our
list, we considered the volume and arising from a change to one of the DRGs FY 2005 proposal, we decided not to
percentage of discharges to postacute included under the policy in FY 2004. adopt the proposed alternate criteria for
care that occurred before the mean In the FY 2005 IPPS final rule (69 FR including DRGs under the postacute
length of stay and whether the 48942), we deleted DRG 483 care transfer policy in the FY 2005 IPPS
discharges occurring early in the stay (Tracheostomy With Mechanical final rule. Instead we adopted the policy
were more likely to receive postacute Ventilation 96+ Hours or Principal of simply grandfathering, for a period of
care. We identified 10 DRGs to be Diagnosis Except Face, Mouth, and 2 years, any cases that were previously
subject to the postacute care transfer Neck Diagnosis) and established the included within a DRG that has split,
rule starting in FY 1999. following new DRGs as replacements: when the split DRG qualified for
Section 1886(d)(5)(J)(iv) of the Act DRG 541 (Tracheostomy With inclusion in the postacute care transfer
authorizes the Secretary to expand the Mechanical Ventilation 96+ Hours or policy for both of the previous 2 years.
postacute care transfer policy for FY Principal Diagnosis Except Face, Mouth Under this policy, the cases that were
2001 or subsequent fiscal years to and Neck Diagnoses With Major O.R. previously assigned to DRG 483 and that
additional DRGs based on a high Procedure) and DRG 542 (Tracheostomy now fall into DRGs 541 and 542
volume of discharges to postacute care With Mechanical Ventilation 96+ Hours continue to be subject to the policy.
facilities and a disproportionate use of or Principal Diagnosis Except Face, Therefore, effective for discharges on or
postacute care services. In the FY 2004 Mouth and Neck Diagnoses Without after October 1, 2004, 30 DRGs,
IPPS final rule (68 FR 45412), we Major O.R. Procedure). Cases in the including new DRGs 541 and 542, are
expanded the postacute care transfer existing DRG 483 were assigned to the subject to the postacute care transfer
policy to include additional DRGs. We new DRGs 541 and 542 based on the policy. We indicated that we would
established the following criteria that a presence or absence of a major O.R. monitor the frequency with which these
DRG must meet, for both of the 2 most procedure, in addition to the cases are transferred to postacute care
recent years for which data are tracheostomy code that was previously settings and the percentage of these
available, in order to be included under required for assignment to DRG 483. cases that are short-stay transfer cases.
the postacute care transfer policy: Specifically, if the patient’s case Because we did not adopt the proposed
• At least 14,000 postacute care involves a major O.R. procedure (a alternate criteria for DRG inclusion in
transfer cases; procedure whose code is included on the postacute care transfer policy, DRG
• At least 10 percent of its postacute the list that is assigned to DRG 468 430 (Psychoses) did not meet the criteria
care transfers occurring before the (Extensive O.R. Procedure Unrelated to for inclusion and has not been subject
geometric mean length of stay; Principal Diagnosis), except for to the postacute care transfer policy for
• A geometric mean length of stay of tracheostomy codes 31.21 and 31.29), FY 2005. We also invited comments on
at least 3 days; and the case is assigned to the DRG 541. If how to treat the cases formerly included
• If a DRG is not already included in the patient does not have an additional in a split DRG after the grandfathering
the policy, a decline in its geometric major O.R. procedure (that is, if there is period.
mean length of stay during the most only a tracheostomy code assigned to We noted that some commenters also
recent 5-year period of at least 7 the case), the case is assigned to DRG suggested that, in place of the proposed
percent. 542. alternate criteria, we should adopt a
In the FY 2004 IPPS final rule, we Based on data analysis, we policy of permanently applying the
identified 21 new DRGs that met these determined that neither DRG 541 nor postacute care transfer policy to a DRG
criteria. We also determined that one DRG 542 would have enough cases to once it has initially qualified for
DRG from the original group of 10 DRGs meet the existing threshold of 14,000 inclusion in the policy. These
(DRG 263) no longer met the volume transfer cases for inclusion in the commenters noted that removing DRGs
criterion of 14,000 transfer cases. postacute care transfer policy. from the postacute care transfer policy
Therefore, we removed DRGs 263 and Nevertheless, we believed the cases that makes the payment system less stable
264 (DRG 264 is paired with DRG 263) would be incorporated into these two and results in inconsistent incentives
from the policy and expanded the DRGs remained appropriate candidates over time. They also argued that ‘‘a drop
postacute care transfer policy to include for application of the postacute care in the number of transfers to postacute
payments for transfer cases in the new transfer policy and that the subdivision care settings is to be expected after the
21 DRGs, effective October 1, 2003. As of DRG 483 should not change the transfer policy is applied to a DRG, but
a result, a total of 29 DRGs were subject original application of the postacute the frequency of transfers may well rise
to the postacute care transfer policy in care transfer policy to the cases once again if the DRG is removed from the
FY 2004. In the FY 2004 IPPS final rule, included in that DRG. Therefore, for FY policy.’’ We indicated that we would
we indicated that we would review and 2005, we proposed alternate criteria to consider adopting this general policy
update this list periodically to assess be applied in cases where DRGs do not once we had evaluated the experience
whether additional DRGs should be satisfy the existing criteria, for with the specific cases that are subject
added or existing DRGs should be discharges occurring on or after October to the grandfathering policy for FY 2005
removed (68 FR 45413). 1, 2004 (69 FR 28273 and 28374). The and FY 2006.
For FY 2005, we analyzed the proposed new criteria were designed to In the FY 2005 IPPS proposed rule,
available data from the FY 2003 address situations such as those posed we also called attention to the data
MedPAR file. For the 2 most recent by the split of DRG 483, where there concerning DRG 263, which was subject
years of available data (FY 2002 and FY remain substantial grounds for inclusion to the postacute care transfer policy
2003), we found that no additional of cases within the postacute care until FY 2004. We removed DRG 263
from the postacute care transfer policy under the policy in subsequent fiscal decline in length of stay to qualify to be
for FY 2004 because it did not have the years. The geometric mean length of added to the policy for FY 2005. We
minimum number of cases (14,000) stay for DRG 263 showed only a 6- indicated that we would continue to
transferred to postacute care (13,588 percent decrease since 1999. As a result, monitor the experience with DRG 263,
transfer cases in FY 2002, with more DRG 263 did not qualify to be included especially in light of the comment that
than 50 percent of transfer cases being in the policy for FY 2005 under the recommended a general policy of
short-stay transfers). The FY 2003 criteria that were applied in last year’s grandfathering cases that qualify under
MedPAR data show that there were final rule. DRG 263 would have the criteria for inclusion in the
15,602 transfer cases in the DRG in FY qualified under the volume threshold postacute care transfer policy.
2003, of which 46 percent were short- and percent of short-stay transfer cases
stay transfers. Because we removed the under the proposed new alternate The table below displays the 30 DRGs
DRG from the postacute care transfer criteria contained in the FY 2005 that are included in the postacute care
policy in FY 2004, it was required to proposed rule. However, it still would transfer policy, effective for discharges
meet all of the criteria to be included not have met the proposed required occurring on or after October 1, 2004.
DRG DRG Title
12 ........................... Degenerative Nervous System Disorders.

14 ........................... Intracranial Hemorrhage and Stroke with Infarction.
24 ........................... Seizure and Headache Age >17 With CC.
25 ........................... Seizure and Headache Age >17 Without CC.
88 ........................... Chronic Obstructive Pulmonary Disease.
89 ........................... Simple Pneumonia and Pleurisy Age > 17 With CC.
90 ........................... Simple Pneumonia and Pleurisy Age >17 Without CC.
113 ......................... Amputation for Circulatory System Disorders Except Upper Limb and Toe.
121 ......................... Circulatory Disorders With AMI and Major Complication, Discharged Alive.
122 ......................... Circulatory Disorders With AMI Without Major Complications Discharged Alive.
127 ......................... Heart Failure & Shock.
130 ......................... Peripheral Vascular Disorders With CC.
131 ......................... Peripheral Vascular Disorders Without CC.
209 ......................... Major Joint and Limb Reattachment Procedures of Lower Extremity.
210 ......................... Hip and Femur Procedures Except Major Joint Age >17 With CC.
211 ......................... Hip and Femur Procedures Except Major Joint Age >17 Without CC.
236 ......................... Fractures of Hip and Pelvis.
239 ......................... Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy.
277 ......................... Cellulitis Age >17 With CC.
278 ......................... Cellulitis Age >17 Without CC.
294 ......................... Diabetes Age>35.
296 ......................... Nutritional and Miscellaneous Metabolic Disorders Age >17 With CC.
297 ......................... Nutritional and Miscellaneous Metabolic Disorders Age >17 Without CC.
320 ......................... Kidney and Urinary Tract Infections Age >17 With CC.
321 ......................... Kidney and Urinary Tract Infections Age >17 Without CC.
395 ......................... Red Blood Cell Disorders Age >17.
429 ......................... Organic Disturbances and Mental Retardation.
468 ......................... Extensive O.R. Procedure Unrelated to Principal Diagnosis.
541 (formerly 483) Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses
With Major O.R. Procedure.
542 (formerly 483) Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses
Without Major O.R. Procedure.
For the FY 2006 IPPS proposed rule, geometric mean length of stay is in the DRG’s geometric mean length of
we conducted an extensive analysis of associated with an increase in the stay during the most recent 5-year
the FY 2003 and FY 2004 MedPAR data volume and proportion of total cases in period. It has come to our attention that
to monitor the effects of the postacute a DRG that are discharges to postacute not all DRGs that experience an increase
care transfer policy. We also conducted care. We analyzed these data as part of in postacute care utilization also
an overall assessment of the postacute determining whether to retain the experience a decrease in geometric
care transfer policy since its inception criteria that a DRG must have a decline mean length of stay. In fact, some DRGs
in FY 1999. Specifically, we examined in the geometric mean length of stay of with increases in postacute care
the relationship between rates of at least 7 percent in the previous 5-year utilization during the past several years
postacute care utilization and the period to be included under the have also experienced an increase in the
geometric mean length of stay and the postacute care transfer policy. geometric mean length of stay. The table
relationship between a high volume and Our current criteria for inclusion in below lists a number of DRGs that
a high proportion of postacute care the postacute care transfer policy experienced increases in postacute care
transfers within a DRG considering our include a requirement that, if a DRG is utilization and increases in the
experience under the current policy. We not already included in the policy, there geometric mean length of stay from FY
also examined whether a decline in the must be a decline of at least 7 percent 2002 through FY 2004:
Percent Percent
change in geo- change in
DRG DRG Title metric mean postacute care
length of stay utilization
1 .................. Craniotomy Age >17 With CC ....................................................................................................... 5.26 2.70

6 .................. Carpal Tunnel Release .................................................................................................................. 4.76 56.92
15 ................ Nonspecific CVA and Precerebral Occlusion Without Infarction ................................................... 30.00 27.75
40 ................ Extraocular Procedures Except Orbit Age >17 .............................................................................. 12.50 15.47
42 ................ Intraocular Procedures Except Retina, Iris, and Lens ................................................................... 12.75 6.71
51 ................ Salivary Gland Procedures Except Sioloadenectomy ................................................................... 5.56 20.00
55 ................ Miscellaneous Ear, Nose, Mouth, and Throat Procedures ............................................................ 11.11 22.22
113 .............. Amputation for Circulatory System disorders Except Upper Limb and Toe ................................. 2.04 21.25
118 .............. Cardiac Pacemaker Device Replacement ..................................................................................... 11.11 30.29
223 .............. Major Shoulder/Elbow Procedure or Other Upper Extremity Procedure With CC ........................ 4.76 36.17
317 .............. Admittance for Renal Dialysis ........................................................................................................ 20.00 80.84
319 .............. Kidney and Urinary Tract Neoplasms Without CC ........................................................................ 4.76 24.49
345 .............. Other Male Reproductive System O.R. Procedure Except for Malignancy .................................. 11.11 94.34
447 .............. Allergic Reactions Age >17 ............................................................................................................ 5.56 16.81
494 .............. Laparoscopic Cholecystectomy Without C.D.E. Without CC ........................................................ 5.26 26.39
Our current criteria also include a In addition, 39 of these 64 DRGs have within the postacute care transfer
requirement that a DRG have at least fewer than 50 short-stay transfer cases. policy. First, our analysis called into
14,000 total postacute care transfer cases Consistent with the statutory guidance, question the requirement that a DRG
in order to be included in the policy. we did not propose any change to how experience a decline in the geometric
We have examined the data on the we would apply the postacute care mean length of stay over the most recent
numbers of transfers and the percentage transfer payment policy to these DRGs 5-year period. Our findings that some
of postacute care transfer cases across because we believe that these DRGs do DRGs with increases in postacute care
DRGs. Among the 30 DRGs currently not have a high volume of discharges to utilization during the past several years
included within the postacute care postacute care facilities or involve a have also experienced increases in
transfer policy, we found that the disproportionate use of postacute care geometric mean length of stay indicated
percentage of postacute care transfer services. that this criterion is no longer effective
cases ranges from a low of 15 percent to Once we eliminated the DRGs cited to identify those DRGs that should be
a high of 76 percent. Among DRGs that above from consideration for the subject to the postacute care transfer
are not currently included within the postacute care transfer policy, we policy. In addition, our findings about
policy, many had a relatively high examined the characteristics of the the number of DRGs with relatively high
percentage of postacute care transfer remaining 231 DRGs. In the proposed volumes (at least 2,000 cases) and
cases in proportion to the total volume rule, we stated that 223 DRGs were relatively high proportions (at least 20
of cases for the DRG or a relatively high included in this analysis, but percent) of postacute care utilization
volume of discharges to postacute care subsequently posted a change to the suggested that we should revise the
facilities, or both. For this reason, we number of eligible DRGs on our Web requirement that a DRG have at least
reviewed the data for all DRGs before site. This change reflected that we had 14,000 total postacute care transfer cases
we proposed a change to the postacute inadvertently excluded 8 DRGs. Of these to be included within the postacute care
care transfer payment policy in the FY 231 DRGs, we found that these DRGs transfer policy.
2006 proposed rule. As part of this had three common characteristics: Our analysis did confirm that it is
review, we found that: • The DRG had at least 2,000 total appropriate to maintain the requirement
• Of 550 DRGs, 26 have been postacute care transfer cases. that a DRG must have a geometric mean
deactivated and 17 have no cases in the • At least 20 percent of all cases in length of stay of at least 3.0 days in
FY 2004 MedPAR files. We did not the DRG were discharged to postacute order to be included within the
propose any changes for these DRGs care settings. postacute care transfer policy. We
because application of the postacute • 10 percent of all discharges to believe that this policy should be
care transfer policy to them would have postacute care were prior to the retained because, under the transfer
no effect. geometric mean length of stay for the payment methodology, hospitals receive
• Of the remaining 507 DRGs, 220 DRG. the entire payment for cases in these
have geometric mean lengths of stay that Consistent with the statutory DRGs in the first 2 days of the stay.
are less than 3.0 days. Because the guidance giving the Secretary the Lowering the limit below 3.0 days
transfer payment policy provides 2 authority to make a DRG subject to the would, therefore, have no effect on
times the per diem rate for the first day postacute care transfer policy based on payment for DRGs with geometric mean
of care (due to the large proportion of a high volume of discharges to postacute lengths-of-stay in this range. For the
charges incurred on the first day of a care facilities and a disproportionate use reasons discussed in the FY 2004 IPPS
patient’s treatment), including these of postacute care services, in the FY proposed rule (68 FR 27199) and
DRGs in the transfer policy would be 2006 proposed rule, we indicated that because it is a common characteristic of
relatively meaningless as they would all we believed these DRGs have DRGs with a large number of cases
receive a full DRG payment. For this characteristics that make them discharged to postacute care, we also
reason, we did not propose any changes appropriate for inclusion in the indicated that we would retain the
to the postacute care transfer policy for postacute care transfer policy. We also criterion that at least 10 percent of all
these DRGs for FY 2006. indicated that we believed it is cases that are transferred to postacute
• Of the remaining 287 DRGs, 64 have appropriate to consider major revisions care should be short-stay cases where
fewer than 100 short-stay transfer cases. to the criteria for including a DRG the patient is transferred before the
geometric mean length of stay for the applying the policy to any DRG that Other commenters contended that the
DRG. We also continue to believe that meets the following criteria: policy creates a geographic bias against
both DRGs in a CC/non-CC pair should • The DRG has at least 2,000 regions that have access to greater
be subject to the postacute care transfer postacute care transfer cases; capital resources and postacute care
policy if one of the DRGs meets the • At least 20 percent of the cases in facilities and that traditionally have had
criteria for inclusion. By including both the DRG are discharged to postacute shorter lengths of stay for their patients
DRGs in a CC/non-CC pair, our policy care; than other regions of the country. Some
precludes an incentive for hospitals to • Out of the cases discharged to commenters argued that the provision
code cases in ways designed to avoid postacute care, at least 10 percent occur creates a perverse incentive for hospitals
triggering the application of the policy, before the geometric mean length of stay to keep their patients longer and to deny
for example, by excluding codes that for the DRG;. them the appropriate care in postacute
would identify a complicating or • The DRG has a geometric mean care facilities when it is needed.
comorbid condition in order to assign a length of stay of at least 3.0 days; Commenters continued to argue that
case to a non-CC DRG that is not subject • If the DRG is one of a paired set of this policy undermines the incentive for
to the policy. DRGs based on the presence or absence hospitals to reduce lengths of stay.
Therefore, for the FY 2006 IPPS of a comorbidity or complication, both Several commenters pointed to the
proposed rule, we considered paired DRGs are included if either one tremendous administrative burden
substantial revisions to the four criteria meets the first three criteria above. placed on hospitals with the expansion
that are currently used to determine As explained above, option 2 would of the policy, particularly with regard to
whether a DRG qualifies for inclusion in expand the application of the postacute transfers to HHAs. Other commenters
the postacute care transfer policy. The care transfer policy to 231 DRGs (rather noted the administrative burdens of
current criteria provide that, in order to than 223 DRGs as stated in the proposed time, resource utilization, and delay of
be included within the policy, a DRG rule) that have both a relatively high payments already associated with these
must have, for both of the 2 most recent volume and a relatively high proportion types of transfers and subsequent claims
years for which data are available: of postacute care utilization. We corrections and reprocessing with the
• At least 14,000 total postacute care existing 30 DRGs.
proposed this change to avoid applying
transfer cases;
• At least 10 percent of its postacute the postacute care transfer policy to Response: We do not agree that the
care transfers occurring before the DRGs with only a small number or postacute care transfer policy is
geometric mean length of stay; proportion of cases transferred to inappropriate or contrary to the
• A geometric mean length of stay of postacute care. We believe that the principles of prospective payment. The
at least 3 days; analysis that we conducted suggests that policy is fully consistent with the
• If a DRG is not already included in substantial revisions to the criteria for principles of prospective payment
the policy, a decline in its geometric including a DRG within the postacute because the operative averaging
mean length of stay during the most care transfer policy are warranted. principle in such systems assumes that
recent 5-year period of at least 7 Therefore, in the FY 2006 IPPS the full extent of care is consistently
percent; and proposed rule, we formally proposed provided in an acute care hospital. The
• If the DRG is one of a paired set of Option 2 as presented above. However, averaging principle would be
DRGs based on the presence or absence we invited comments on both of the undermined if the system did not
of a comorbidity or complication, both options and on the analysis that we had provide for adjustments in cases where
paired DRGs are included if either one presented. a large proportion of the patient’s care
meets the first three criteria above. Comment: Many commenters is provided by another entity. Thus, the
As we indicated in the FY 2006 IPPS expressed opposition to the postacute statute appropriately provides for
proposed rule, as a result of our care transfer policy in general. Some of treating discharges to postacute care
analysis, we considered two options for these commenters argued that the policy from certain DRGs as transfer cases. The
revising the current criteria. Option 1 is contrary to the premise of the DRG statute also gives the Secretary the
was to include all DRGs within the system, which is to pay the average of discretion to select appropriate DRGs to
postacute care transfer policy. This all cases in a DRG, regardless of cost and which this policy should be applied on
option has the advantage of providing length of stay. Some commenters also the basis of a high volume of discharges
consistent treatment of all DRGs. contended that the transfer policy is to postacute care and a disproportionate
However, as we discussed in the based on a false assumption of gaming use of post discharge services. Although
proposed rule and above in this final by providers, and that it punishes it is true that many postacute settings to
rule, our analysis tends to indicate that, providers for providing the appropriate which the policy applies are now
at a minimum, it may be appropriate to level of care in the most appropriate subject to a prospective payment
maintain the requirement that a DRG setting. Other commenters argued that methodology, this fact in no way
must have a geometric mean length of the rationale for the policy no longer undermines the appropriateness of a
stay of at least 3.0 days because, under exists because most of the providers of postacute transfer policy. Rather, such a
the transfer payment methodology, postacute care services in question have policy serves to ensure that Medicare
hospitals receive the entire payment for transitioned from cost-based does not make full payments under two
these DRGs in the first 2 days of the reimbursement to PPSs themselves different payment systems when a
stay. Therefore, lowering the limit (SNFs as of October 1, 1998; HHAs as patient’s full course of treatment is
below 3.0 days would have little or no of October 1, 2000; IRFs as of January divided between two facilities. It is just
effect on payment for DRGs with 1, 2002; LTCHs as of October 1, 2002; as inappropriate for Medicare to pay for
geometric mean lengths of stay in this and IPFs as of January 1, 2005). Further, the treatment of patients in these cases,
range. commenters noted that each of these at the full DRG amount at the IPPS
The second option that we considered postacute care payment systems have hospital and under either a per
in the FY 2006 IPPS proposed rule was admission criteria to ensure that discharge or per diem prospective
to expand the application of the patients are not discharged prematurely payment in the postacute care setting as
postacute care transfer policy by to a lower level of care. it is to pay the full DRG payment twice
when a patient is transferred from one the newly proposed criteria. One positively skewed. As a result, a
acute care hospital to another. commenter proposed that CMS establish relatively small number of DRGs with
Therefore, because the majority of short- thresholds at least one standard very high volume and rates of postacute
stay transfer cases receive the majority deviation above the average to care utilization have a disproportionate
of their care at postacute care facilities determine when DRGs meet a impact on the average or mean.
(except for those DRGs that we have disproportionate use of postacute care. Therefore, a better measure of central
identified as having high costs on the Another commenter noted that tendency in these cases is the median,
first day and that are paid under a thresholds of one standard deviation are or 50th percentile in the rankings of
special payment methodology), we employed elsewhere in Medicare policy. discharges and rates of postacute care
continue to believe that full payment to One commenter noted that, under the utilization from highest to lowest.
those facilities and reduced payment to original implementation of the policy, However, employing the median rather
acute facilities for these cases are the 10 DRGs that were included had a than the mean makes it impossible to
merited. Numerous studies of the postacute care utilization rate of at least employ the standard deviation in setting
postacute care transfer policy by 45.3 percent (not including pairs) and an appropriate threshold. In lieu of
MedPAC, the Office of Inspector when the policy was expanded to 30 using the mean and standard deviation
General, and other health-related DRGs, the lowest percentage of as suggested by the commenter, it is
entities continue to support the need for postacute care utilization (not including possible to select a percentile ranking in
the policy, and some studies have pairs) was 34.86. Therefore, this each array as an appropriate measure of
supported expansion of the policy to commenter contended that a reasonable ‘‘high volume’’ and ‘‘disproportionate
additional DRGs where appropriate. figure that might represent a use.’’ By definition, any volume of
Comment: Most commenters objected disproportionate use of postacute care discharges above the 50th percentile can
to the proposed alternate criteria for utilization would be no less than 34.0 be considered a high volume in the
DRGs to be included in the postacute percent. context of the ranking from highest to
Response: We do not agree that the lowest. Similarly, any rate of postacute
care transfer policy. Some commenters
proposed thresholds were inappropriate care utilization above the 50th
objected to our proposing changes in the
or without analytical support. In percentile can also be considered
qualifying criteria for the postacute care
particular, we do not agree that the disproportionate use of such services.
transfer policy for the third consecutive
threshold of 2,000 discharges to However, we agree with those
year. These commenters argued that postacute care falls short of the statutory
such frequent changes in policy gives commenters who recommended
standard that DRGs included within the thresholds based on standard deviations
the appearance of a contrived policy to policy must have a ‘‘high volume of
suit CMS’ desires and makes the above the mean, that it is appropriate to
discharges.’’ In analyzing the total establish levels somewhat above the
regulatory process unpredictable and number of discharges to postacute care
unfair. Many commenters asserted that measures of central tendency as
in each DRG, we found that the median thresholds for high volume and
there was little analytical support for DRG had approximately 1,600
changing the criteria, and in particular disproportionate use. Therefore, we
discharges to postacute care. Thus, our have determined that the 55th
that CMS had presented little analytical proposed criteria of 2,000 discharges to
support for the proposed thresholds of percentile is an appropriate level at
postacute care is well above the median which to establish these thresholds.
2,000 and 20 percent of cases DRG’s number of discharges to
transferred to postacute care. Some postacute care and can easily be argued In the course of examining the
commenters also contended that the to meet the statutory criteria of a ‘‘high relevant data, we also considered
proposed criteria appeared contrived to volume of discharges.’’ Nevertheless, in several alternatives to the ratio of
ensure that the proposal would meet response to the many comments on the postacute care discharges to total
specific budgetary goals. Many proposed new thresholds, we have discharges as the most appropriate
commenters expressed dismay that CMS reexamined the data concerning the measure of the rate of postacute care
would lower the limit so drastically volume and the proportions of utilization across DRGs. We came to the
from 14,000 postacute care transfer discharges to postacute care across conclusion that a more appropriate
cases to 2,000, a ‘‘dramatic drop of 86 DRGs. Our goal was to select thresholds measure of postacute care utilization is
percent.’’ Many commenters also that are appropriate to the purposes of the proportion of discharges to
believed that the proposed alternate the postacute care transfer policy and postacute care that occur prior to the
criteria did not meet the standards that clearly meet the statutory standards geometric mean length of stay for a
established in the statute. Specifically, cited by the commenters. DRG. We believe that the proportion of
these commenters indicated that the We began by considering the such short-stay discharges is a more
proposed threshold of 2,000 transfer suggestion of several commenters that it appropriate measure in this context than
cases does not constitute a ‘‘high might be appropriate to establish the overall proportion of discharges to
volume of discharges’’ under the statute. thresholds at levels of one standard postacute care because only these
Similarly, many commenters stated that deviation above the average to discharges are affected by the postacute
a threshold of 20 percent of postacute determine high volume and care transfer policy. Specifically, under
transfer cases does not constitute a disproportionate use of postacute care the formula employed to determine
‘‘disproportionate use of post-discharge services. As one commenter pointed payments for transfer cases, discharges
services.’’ These commenters argued out, we have used such a standard for that occur at or after the mean length of
that, by definition, disproportionate use similar purposes in other areas of the stay receive payments that equal the full
of postacute care should be well above Medicare program. However, our DRG payment. Furthermore, we believe
the norm. One commenter added that it examination of the DRG data indicated a focus on short-stay discharges to
‘‘is a statistical impossibility for half of that the average, or mean, is not the postacute care is more consistent with
the universe of DRGs to have most appropriate measure of central the statutory criteria of
‘disproportionate use of post-discharge tendency in these cases. The ‘‘disproportionate use of post-discharge
services.’ ’’ Some commenters suggested distributions of discharge volume and services.’’ These short-stay cases are
that CMS consider using alternatives to postacute care usage across DRGs are atypical in that they are discharged
before the geometric mean length of stay Response: The statute does not measure that uses short-stay transfer
and result in the majority of care being establish any requirement that we cases.
provided at postacute care facilities. consider declining length of stay as a Comment: Many commenters also did
Therefore, we examined the standard in selecting appropriate DRGs not support the criterion of including
percentile rankings of DRGs inVersion for inclusion under the postacute care paired DRGs in the policy, citing that
23.0 of the DRG Definitions Manual (FY transfer policy. We originally adopted most hospitals have switched to a
2006) in relation to the volume of such a standard because we found a coding system that interfaces with the
discharges to postacute care, and the relationship between declining lengths coder electronically, thereby reducing
ratio of short-stay discharges to of stay and increasing use of postacute the probability that a coder would
postacute care. We employed the March care services. As we discussed in the remove a CC code in order to change the
2005 update of FY 2004 MedPAR data, proposed rule, and again above, our payment for a case that was transferred
the most recent data available to us. We more recent analysis has called into to postacute care. Further, some
determined that the median number of question the basis for the requirement commenters noted that it might be
discharges to postacute care across all that a DRG experience a decline in the inappropriate to include paired DRGs in
DRGs was 1,619, and the 55th percentile geometric mean length of stay over the the special payment methodology, as
was 2,050. The median proportion of most recent 5-year period. Our finding the transfer payment for the first day for
short-stay discharges to postacute care that some DRGs with increases in many of the CC DRGs in the CC/non-CC
was 4.8 percent, and the 55th percentile postacute care utilization during the pair is typically higher than the full
was 5.5 percent. Therefore, in place of past several years have also experienced DRG payment for the non-CC pair. As a
the first two criteria that we proposed in increases in geometric mean length of result, these commenters contended that
the FY 2006 IPPS proposed rule, we are stay indicates that this criterion is no coders would not have any incentive to
establishing the following two criteria in longer effective to identify those DRGs exclude a CC from the hospital’s bill.
this final rule, effective October 1, 2005: that should be subject to the postacute Therefore, these commenters suggested
• The DRG has at least 2,050 care transfer policy. Therefore, we are that CMS consider adopting a policy
postacute care transfer cases; finalizing our proposal to discontinue that excludes ‘‘the non-CC of a paired
• At least 5.5 percent of the cases in DRG when the transfer weight of the CC
the current criterion for inclusion in the
the DRG are discharged to postacute DRG would be greater than the full DRG
policy that requires a DRG to experience
care prior to the geometric mean length payment of the non-CC DRG.’’ They
a decline of at least 7 percent over the
of stay for the DRG. noted that, by following this
In response to the comments last 5 years in the geometric mean
length of stay. recommendation, the policy would
suggesting that we provided little data agree with CMS’ rationale for the
or analytic support for our proposal, we Comment: Some commenters objected
inclusion of paired DRGs and also
provided detailed analysis of our to our current criterion that 10 percent
exclude those DRGs that do not meet the
findings on these issues in both the FY of the postacute care transfer cases
qualifying criteria.
2006 IPPS proposed rule and this final within a DRG must be short-stay cases Response: It has been our practice to
rule. The data underlying our analysis in order for the DRG to be included in include paired DRGs since the inception
are publicly available through the CMS the policy. Some of these commenters of the policy in 1998. This practice is in
Web site at: http://www.cms.hhs.gov/ argued that this would effectively mean compliance with § 412.4(d)(1)(iv) of the
data/order/default.asp. that up to 90 percent of all discharges regulations. While it is possible that
Comment: Many commenters also within a DRG are not short-stay technical advances have resulted in
objected to our proposal to eliminate the discharges, and therefore, these DRGs electronic systems and more automated
requirement that a DRG experience a would not meet the disproportionate coding, the selection of codes to include
decline in length of stay. These use requirement as provided in the on the bill remain within the
commenters contended that there was statute. responsibility and authority of the
no evidence provided that hospitals are Response: We do not agree with the hospital and its staff. Thus, we believe
changing their behavior, transferring commenters that inclusion of this the coder will have the ability to select
patients earlier, or taking advantage of criterion in the policy was whether to include or exclude a CC
the payment system. Another inappropriate. To the contrary, for the secondary diagnosis code on the
commenter argued that removal of the reasons we have discussed above and in hospital’s bill when a patient is
requirement that DRGs experience a previous rules, we believe that some transferred to postacute care. We
decline in length of stay was contrary to consideration of the proportion of short- include both DRGs from a paired-DRG
the intent of the statute. This stay discharges to postacute care—the combination because if we were to
commenter argued that the objective of discharges actually affected by the include only the more complex DRG
the policy was ‘‘to adjust inpatient PPS application of the policy—is an (that is, the ‘‘with CC’’ DRG from a
payments to account for reduced appropriate component of the criteria ‘‘with/without CC’’ DRG combination)
hospital lengths of stay due to a employed to determine the scope of the in the transfer policy, there might be an
discharge to another setting.’’ Therefore, policy. However, we have decided not incentive for hospitals not to include
the commenter argued, if the MedPAR to retain that specific criterion under the any code that would identify a
data demonstrates that postacute care revised policy that we are adopting in complicating or cormorbid condition. In
utilization for a DRG does not contribute this final rule. This criterion is our analysis of the included pairs in our
to a significant decrease in the unnecessary because we decided to data, we have not found support for the
geometric mean length of stay, the DRG adopt the criterion that at least 5.5 commenter’s assertion that, in some
should not be subject to the policy. In percent of cases in the DRG must be instances, the transfer adjusted payment
general, commenters recommend a discharged to postacute care prior to the for a ‘‘CC’’ DRG is greater than the full
different approach to further expansions geometric mean length of stay for the payment for the non-transfer adjusted
of the postacute care transfer policy that DRG. By including this criterion as a ‘‘without CC’’ DRG. In cases where a
they assert would more accurately measure of disproportionate use of ‘‘CC:’’ DRG is transferred after a one day
reflect the costs of patient care provided postacute care services, we believe that length of stay, the estimated transfer
in acute care hospitals. it becomes redundant to retain another adjusted payments for the ‘‘CC’’ DRGs
are less than the full payments for the care transfer policy. They argued that understand what the hospitals would
‘‘without CC’’ DRGs. As this could CMS should have proposed the criteria, accomplish because even though they
introduce improper coding incentives, accepted comment on the alternate would receive the full DRG payment,
we continue to believe our approach of criteria, and made appropriate changes they would also have costs associated
identifying either DRG from a paired- based on those comments before with retaining patients who would be
DRG combination individually for applying them to any additional DRGs. more appropriately discharged to
inclusion in the policy is appropriate. Instead, commenters contended that another setting in the hospital.
Comment: Some commenters argued CMS seemingly arbitrarily created the It is not clear to us why an analysis
that including a transfer-adjusted case alternate set of criteria and applied them of MedPAC’s recommendation that we
weight in the DRG relative weight to new DRGs in the same rule. adopt severity DRGs is relevant to the
calculation has the effect of maintaining Response: We are making the change postacute care transfer policy. To our
the DRG weight at an artificially high to our postacute care transfer policy knowledge, such a change to the DRG
level. Other commenters indicated that, through a notice and comment system would be intended to result in
in the absence of this adjustment, the rulemaking procedure before applying better recognition of severity levels in
lower costs of short-stay postacute care the new policy to any DRGs. The making DRG assignments, but would
transfers will be reflected in lower DRG implication in these comments that we not involve any direct consideration of
case weights, making a postacute care have already expanded the policy to whether a hospital provides the full
transfer payment policy unnecessary. additional DRGs is incorrect. We will be course of treatment to a patient. We are
Another commenter stated that the cost applying the revised postacute care unaware that a severity DRG system,
savings realized through shorter lengths transfer policy for discharges occurring such as the APR–DRGs, would use
of stay, including those from transfer on or after October 1, 2006, after having length of stay and early discharge to
cases, have already been considered and provided notice of our proposal to postacute care as a basis for making a
accounted for by Congress each year revise the policy in the proposed rule; DRG assignment. Nevertheless, we will
when it sets the market basket update. allowing for a 60-day public comment consider this issue as we study the
Response: We agree with the period; and making changes to the MedPAC recommendation.
commenters that a high proportion of policy in response to public comment. Comment: Commenters argued that
short-stay to total cases in DRGs that are Comment: Some commenters objected we should not further expand the
not subject to the postacute care transfer to the implication that early discharges postacute care transfer payment policy
policy will likely result in lower to postacute care are done for economic until a full analysis of last year’s
weights for these DRGs. However, we reasons instead of patient need. Other changes to the policy is completed.
believe these commenters actually commenters believed hospitals may According to the commenters, we
support our argument for expanding the keep patients in the hospital longer to should analyze whether the postacute
postacute care transfer policy to more avoid the reduced IPPS payment. These care transfer policy has led to
DRGs where there is disproportionate commenters indicated that the policy unnecessarily extended hospital stays in
use of postacute care services. While would increase, not reduce, Medicare order to avoid the adjustment and
including all cases in the relative weight spending to treat the same patients. affected quality of care. Commenters
calculation without any adjustment Other commenters encouraged CMS to also noted that studies show that the
would likely result in a lower DRG complete its analysis of the MedPAC majority of patients who use postacute
weight and payment for a short-stay recommendation to adopt severity DRGs care have longer (7.51 days), not shorter
transfer case, it would also result in before expanding the postacute care (4.93 days), hospital stays. These
lower payments for all of the remaining transfer policy. These commenters commenters argued that CMS should
cases in the DRG where the hospital argued that CMS should apply the focus its efforts on improving quality of
used more resources to care for the postacute care transfer policy to DRGs care, not on further expanding the
patient. To the extent that there is consistent with the goal of ‘‘aligning postacute care transfer provision.
disproportionate use of postacute care patient severity with payment.’’ These Response: In the FY 2005 IPPS final
services, hospitals would be commenters argued that, if severity rule (69 FR 49073), we established a
disadvantaged in the relative weight DRGs were implemented, there would policy for how to apply the criteria for
calculation and their payments when be no need for a postacute care transfer the postacute care transfer policy to
the patient is not discharged early if we policy because the system would cases that were previously assigned to a
were to make no adjustment for a recognize higher payment for more DRG that has split, when the split DRG
transfer case when setting the DRG resource intensive patients. qualified for inclusion in the postacute
relative weight. By reducing the impact Response: Our proposal to expand the care transfer policy. This policy was a
that short-stay cases have on the DRG postacute care transfer policy was not rather limited change to our postacute
relative weight, we believe our payment intended to imply that hospitals will care transfer policy that has little
will more accurately reflect all of the prematurely discharge patients early to bearing on the changes that we are
resources provided by a hospital during postacute care for financial reasons. making for FY 2006. Thus, we do not
a typical stay. Thus, the payment will Rather, our policy recognizes that believe further analysis of this change is
better reflect all of the costs a hospital hospitals expend fewer resources for necessary before undertaking the
expends for the stay when a full course patients who are discharged prior to the changes we are adopting in this final
of treatment is provided and our geometric mean length of stay and rule.
postacute care transfer policy will Medicare’s payment should be less. We We believe the point made by the
appropriately provide less payment for do note that some of the commenters commenter provides further grounds to
a transfer case in recognition of the themselves imply that hospitals will expand the postacute care transfer
lower cost of an abbreviated hospital react to the financial incentives of the policy. The policy only applies to
stay. revised postacute care transfer policy by patients that are discharged from the
Comment: Some commenters objected keeping patients in the hospital longer hospital at least one day before the
to the method by which CMS proposed to avoid payment reductions that will geometric mean length of stay. The
the change in the criteria for DRGs to occur if patients are discharged early to policy does not apply to the longer stay
qualify to be included in the postacute postacute care. If true, it is hard to patients that are, according to the
commenter, more resource intensive. The impact section in Appendix A of qualifying for the policy in one year,
Thus, we make a reduced payment only this final rule discusses our findings on deleted the next year, only to be
for those short-stay patients transferred the effects of adopting our final rule readded the following year. However,
to postacute care that are, following the policy. The DRG relative weights in over time, as treatment practices change
logic of the comment, less costly to the Tables 5 and 7 of the Addendum to this it is possible that some DRGs that
hospital. final rule also include the effect of currently qualify for the policy will no
Comment: Some commenters argued changing the postacute care transfer longer exhibit a disproportionate use of
that studies have shown that many rural policy. We note that we will follow postacute care. Similarly, there may be
areas now have the same types of procedures similar to those that are other DRGs that currently have a low
postacute care facilities as urban currently followed for treating cases rate of discharges to postacute care, but
hospitals and expanding the postacute identified as transfers in the DRG which will have very high rates in the
care transfer policy will harm rural recalibration process. That is, as future. For these reasons, we expect to
areas by reducing payments to rural described in the discussion of DRG periodically review the criteria that are
hospitals. Many commenters suggested recalibration in section II.C. of the used to make a DRG subject to the
that, if CMS is determined to make an preamble to this final rule, additional postacute transfer policy. At this time,
expansion to the policy without transfer cases will be counted as a we have not decided on how frequently
providing analysis supporting the fraction of a case based on the ratio of to perform this review but are
changes, any changes should be made in a hospital’s transfer payment under the considering undertaking this analysis
a budget neutral manner. Other per diem payment methodology to the every 5 years. We welcome public
commenters suggested that we should full DRG payment for nontransfer cases. comments on this issue.
implement the policy expansion over 3 In summary, after consideration of the Section 1886(d)(5)(J)(i) of the Act
years to lessen the financial impact in comments received, in this final rule, recognizes that, in some cases, a
the first year. Commenters also disputed we have revised the criteria that we substantial portion of the cost of care is
our savings estimates indicating that proposed for determining which DRGs incurred in the early days of the
once the effects of IME, disproportionate qualify for postacute care transfer inpatient stay. Similar to the policy for
share, capital and outlier payments are payments. The final policy, which we transfers between two acute care
taken into consideration, the total are incorporating into the regulations at hospitals, transferring hospitals receive
annual reduction would be closer to § 412.4, specifies that, effective October twice the per diem rate for the first day
$894 million. They argued that hospitals 1, 2005, we are making a DRG subject of treatment and the per diem rate for
can ill-afford this kind of reduction in to the postacute care transfer policy if, each following day of the stay before the
payments at a time when they are based on the Version 23.0 GROUPER transfer, up to the full DRG payment, for
(FY 2006), using data from FY 2004, the cases discharged to postacute care.
already experiencing nursing shortages,
DRG meets the following criteria: However, in the past, three of the DRGs
incurring losses for treating Medicare
• The DRG must have a geometric subject to the postacute care transfer
beneficiaries, and expecting tremendous mean length of stay of at least 3 days; policy have exhibited an even higher
increases in costs associated with the • The DRG must have at least 2,050 share of costs very early in the hospital
aging baby boom generation. postacute care transfer cases; stay in postacute care transfer
Commenters also indicated that the • At least 5.5 percent of the cases in situations. For these DRGs, hospitals
policy should not apply in situations the DRG are discharged to postacute receive 50 percent of the full DRG
where a patient is living in a SNF. In care prior to the geometric mean length payment plus the single per diem
these cases, the commenters argued that of stay for the DRG; and (rather than double the per diem) for the
an early discharge of the patient to a • If the DRG is one of a paired set of first day of the stay and 50 percent of
SNF is really a discharge to the patient’s DRGs based on the presence or absence the per diem for the remaining days of
home and the policy should not be of a comorbidity or complication, both the stay, up to the full DRG payment.
applied. paired DRGs are included if either one Comment: Commenters indicated
Response: We do not believe that the meets the three criteria above. there was not a clear explanation for
law permits us to distinguish between If a DRG meets the above criteria when a DRG would be subject to the
urban and rural areas when applying based on the Version 23.0 GROUPER special payment methodology. For
this policy. Furthermore, we do not and FY 2004 MedPAR data, we are example, commenters indicated that
believe there is a policy basis for such making the DRG subject to the postacute DRGs 107 (Coronary Bypass with
a distinction because the principle of care transfer policy. We will not revise PTCA), 108 (Coronary Bypass with
making lower payments to the acute the list of DRGs subject to the postacute Cardiac Catheterization) and 109
care hospital based on the majority of care transfer policy annually unless we (Coronary Bypass without PTCA or
care being provided in a postacute care are making a change to a specific DRG. Cardiac Catheterization) are all related,
setting would apply equally to urban Using the version of the Medicare but only DRG 109 is paid using the
and rural hospitals. The law does not GROUPER for the year when a new or special payment methodology. The
require or authorize us to make these revised DRG first becomes effective, we commenters argued that resource
changes over a transitional period or in will make the DRG subject to the utilization for all three of these surgical
a budget neutral manner as suggested by postacute care transfer policy if its total DRGs would be similar, and therefore,
the commenters. For this reason, we are number of discharges and proportion of all three DRGs should be paid using the
implementing the policy as we have short-stay discharges to postacute care special payment methodology.
described. We note that our savings exceed the 55th percentile for all DRGs. Response: To identify DRGs that are
estimates have been updated to reflect We are establishing this policy to subject to the special payment
the policies we are adopting in this final promote certainty and stability in the methodology, we compare the average
rule. With respect to a discharge to a postacute care transfer payment policy. charges for all cases with a length of
SNF, we note that section Annual reviews of the list of DRGs stay of 1 day to the average charges of
1886(d)(5)(J)(ii)(II) of the Act makes subject to the policy would likely lead all cases in a particular DRG. To qualify
clear that the postacute care transfer to great volatility in the payment for the alternative methodology, the
policy must apply in this situation. methodology with certain DRGs average charges of the 1-day discharge
cases must be at least 50 percent of the Medical Colleges, the Joint Commission a sense of predictability about public
average charges for all cases in the DRG. on Accreditation of Healthcare reporting expectations; (3) begin to
We only apply this methodology to Organizations (JCAHO), the National standardize data and data collection
those DRGs that have a mean length of Quality Forum, the American Medical mechanisms; and (4) foster hospital
stay that is greater than 4 days because Association, the Consumer-Purchaser quality improvement. Many hospitals
cases with a shorter average length of Disclosure Project, the American have participated in the National
stay will receive the full DRG payment Association of Retired Persons, the Voluntary Hospital Reporting Initiative
for the case on the second day of the American Federation of Labor-Congress (NVHRI), and are continuing to submit
stay regardless of the payment of Industrial Organizations, the Agency data to the QIO Clinical Warehouse for
methodology used. In addition, if a DRG for Healthcare Research and Quality, as that purpose.
in a paired set of DRGs based on the well as CMS, Quality Improvement Over the next several years, hospitals
presence or absence of a comorbidity or Organizations (QIOs), and others. are encouraged to take steps toward the
complication meets the criteria for being In July 2003, CMS began the National adoption of electronic medical records
included in the postacute care transfer Voluntary Hospital Reporting Initiative (EMRs) that will allow for reporting of
policy and qualifies for the special (NVHRI), now known as the Hospital clinical quality data from the electronic
payment methodology, we include both Quality Alliance (HQA): Improving Care record directly to a CMS data repository.
DRGs in the special payment through Information. Data from this CMS intends to begin working toward
methodology in order to eliminate any initiative have been used to populate a creating measures specifications and a
incentive to code incorrectly to receive professional Web site providing data to system or mechanism, or both, that will
a higher payment for a case. We have healthcare professionals. The Hospital accept the data directly without
identified those additional DRGs that Compare Web site has also been requiring the transfer of the raw data
are subject to the special payment developed to provide information into an XML file as is currently done.
methodology in Table 5 of the appropriate for Medicare beneficiaries. The Department is presently working
Addendum to this final rule. The consumer Web site is intended to cooperatively with other Federal
be an important tool for individuals to agencies in the development of Federal
B. Reporting of Hospital Quality Data health architecture data standards. CMS
use in making decisions about health
for Annual Hospital Payment Update encourages hospitals that are developing
care options. The information in this
(§ 412.64(d)(2)) systems to conform them to both
Web site assists beneficiaries by
1. Background providing comparison information for industry standards and, when
consumers who need to select a developed, the Federal health
Section 1886(b)(3)(B)(vii) of the Act, architecture data standards, and to
as added by section 501(b) of Pub. L. hospital. It also serves as a way to
encourage accountability of hospitals for ensure that the data necessary for
108–173 revised the mechanism used to quality measures are captured. Ideally,
update the standardized amount of the care they provide to patients.
The 10 measures that are employed in such systems will also provide point-of-
payment for inpatient hospital operating care decision support that enables high
costs. Specifically, the statute provides this voluntary initiative as of November
1, 2003, are: levels of performance on the measures.
for a reduction of 0.4 percentage points Hospitals using EMRs to produce data
to the update percentage increase (also • Heart Attack (Acute Myocardial
Infarction) on quality measures will be held to the
known as the market basket update) for same performance expectations as
Was aspirin given to the patient upon
each of FYs 2005 through 2007 for any hospitals not using EMRs. In the FY
arrival to the hospital?
‘‘subsection (d) hospital’’ that does not 2006 IPPS proposed rule, we indicated
Was aspirin prescribed when the
submit data on a set of 10 quality that we were exploring requirements
patient was discharged?
indicators established by the Secretary Was a beta-blocker given to the and other options to encourage the
as of November 1, 2003. The statute also patient upon arrival to the hospital? submission of electronically produced
provides that any reduction will apply Was a beta-blocker prescribed when data, and invited comments on such
only to the fiscal year involved, and will the patient was discharged? requirements and options.
not be taken into account in computing Was an ACE inhibitor given for the Comment: One commenter expressed
the applicable percentage increase for a patient with heart failure? support for the creation of a system to
subsequent fiscal year. This measure • Heart failure move information from electronic health
establishes an incentive for IPPS Did the patient get an assessment of records to a CMS data repository.
hospitals to submit data on the quality his or her heart function? Response: We agree, and this is one of
measures established by the Secretary. Was an ACE inhibitor given to the the reasons why we proposed the
We initially implemented section patient? question in the preamble of the Notice.
1886(b)(3)(B)(vii) of the Act in the FY • Pneumonia We appreciate this commenter’s support
2005 IPPS final rule (August 11, 2004, Was an antibiotic given to the patient and will strive to minimize data
69 FR 49078) in continuity with the in a timely way? burdens while improving hospital
Department’s Hospital Quality Initiative Had a patient received a quality by moving to an industry-
as described at the CMS Web site: pneumococcal vaccination? accepted system of electronic health
www.cms.hhs.gov/quality/hospitals. At Was the patient’s oxygen level records.
a press conference on December 12, assessed? Comment: One commenter supported
2002, the Secretary of the Department of These measures have been endorsed the use of a single national database of
Health and Human Services (HHS) by the National Quality Forum (NQF) quality measures that could be used by
announced a series of steps that HHS and are a subset of the same measures all stakeholders. However, this
and its collaborators were taking to currently collected for the JCAHO by its commenter believed that the business
promote public reporting of hospital accredited hospitals. The Secretary case for the investment in electronic
quality information. These collaborators chose these 10 quality measures in order medical records is not clear.
include the American Hospital to collect data to: (1) Provide useful and Response: CMS strives to minimize
Association, the Federation of American valid information about hospital quality data reporting burdens, while working
Hospitals, the Association of American to the public; (2) provide hospitals with with providers to improve hospital
quality. We will study and assess cost, whether the hospital uses a vendor for calendar year 2004 (October to
burden, and benefits of moving to an transmission of data. December 2004). Hospitals had 41⁄2
industry-accepted system of electronic • All participants must first register months from the end of the fourth
health records. with the QualityNet Exchange, quarter until the closing of the
Comment: Several commenters regardless of the method used for data warehouse (from December 31, 2004,
suggested that CMS should provide submission. If a hospital participated in until May 15, 2005) to make sure there
financial support and appropriate the voluntary reporting initiative, re- were no errors in the submitted data.
technical assistance to hospitals prior registration on QualityNet Exchange is The warehouse was closed at that time
to, or in conjunction with any unnecessary. However, the hospital in order to draw the validation sample
requirements for hospitals to implement must complete the ‘‘Reporting Hospital and to begin preparing the public file for
electronic medical records and submit Quality Data for Annual Payment the Hospital Compare public reporting
the data directly to the CMS data Update Notice of Participation’’ form. Web site. Data from fourth quarter 2004
warehouse. The commenter added that, All hospitals must send this form to discharges (October through December
eventually, using electronic medical their QIO. 2004) are the last quarter of data with
records to submit data would add • The hospital must collect data for a submission deadline (May 15, 2005)
additional burdens to the hospital, such all 10 measures and submit the data to preceding our deadline for certifying the
as cost and the need for additional the QIO Clinical Warehouse either using hospitals’ eligible to receive the full
resources. the CMS Abstraction & Reporting Tool update for FY 2006. As we required for
Response: We do not currently have (CART), the JCAHO Oryx Core Measures FY 2005, the data for each quarter must
the authority to pay for electronic data Performance Measurement System be submitted on time and pass all of the
submission. However, we do appreciate (PMS), or another third-party vendor edits and consistency checks required in
the challenges and work that lie ahead tool that has met the measurement the clinical warehouse. Hospitals that
to achieve the vision of using electronic specification requirements for data do not treat a condition or have very few
medical records to submit data. We will transmission to QualityNet Exchange. discharges will not be penalized, and
keep these issues in mind as we move The QIO Clinical Warehouse will will receive the full annual payment
forward pursuing electronic data submit the data to CMS on behalf of the update if they submit all the data on the
submission. hospitals. The submission will be done 10 measures.
This method of collecting data, if well through QualityNet Exchange, which is New hospitals should begin collecting
designed, should expedite the a secure site that voluntarily meets or and reporting data immediately and
submission of quality data. We found in exceeds all current Health Insurance complete the registration requirements
the Surgical Care Improvement Project Portability and Accountability Act for the RHQDAPU. New hospitals will
(SCIP) that hospitals with electronic (HIPAA) requirements, while be held to the same standard as
records were able to abstract SCIP data maintaining QIO confidentiality as established facilities when determining
in as little as 10 minutes. It may require required under the relevant regulations the expected number of discharges for
designing a report specifically for the and statutes. The information in the the calendar quarters covered for each
Medicare measures, but after that work Clinical Warehouse is considered QIO fiscal year. The full annual payment
is complete, we would expect no information and, therefore, is subject to updates will be based on the successful
increase in resources in hospitals with the stringent QIO confidentiality submission of data to CMS via the QIO
electronic records. At worst, hospitals regulations in 42 CFR Part 480. Clinical Warehouse by the established
with EMRs should only have the For the first year of the program, FY deadlines.
additional expense of printing the 2005, hospitals were required to begin For FY 2005, hospitals could have
patient record. After that is done, the the submission of data by July 1, 2004, withdrawn from RHQDAPU at any time
abstraction cost would be no greater under the provisions of section up to August 1, 2004. Hospitals
burden on the hospital. 1886(b)(3)(B)(vii)(II) of the Act, as added withdrawing from the program did not
by section 501(b) of Pub. L. 108–173. receive the full market basket update
2. Requirements for Hospital Reporting Because section 501(b) of Pub. L. 108– and, instead, received a reduction of 0.4
of Quality Data 173 granted a 30-day grace period for percentage points in their update. By
The procedures for participating in submission of data for purposes of the law, a hospital’s actions each year will
the Reporting Hospital Quality Data for FY 2005 update, hospitals were given not affect its update in a subsequent
the Annual Payment Update until August 1, 2004, to begin year. Therefore, a hospital must meet
(RHQDAPU) program created in submissions into the QIO Clinical the requirements for RHQDAPU each
accordance with section 501(b) of Pub. Warehouse. Hospitals were required to year the program is in effect to qualify
L. 108–173 can be found on the submit data for the first calendar quarter for the full update each year.
QualityNet Exchange at the Web site: of 2004. We received data from over 98 For the first year, FY 2005, there were
http://www.qnetexchange.org in the percent of the eligible hospitals. no chart-audit validation criteria in
‘‘Reporting Hospital Quality Data for We proposed in the FY 2006 IPPS place. Based upon our experience from
Annual Payment Update Reference proposed rule, and are adopting as final the FY 2005 submissions, and upon our
Checklist’’ section of the Web site. This policy in this rule, that, for FY 2006, requirement for reliable and valid data,
checklist also contains all of the forms hospitals must continuously submit the we proposed to place the following
to be completed by hospitals required 10 measures each quarter additional requirements on hospitals for
participating in the program. In order to according to the schedule found on the the data for the FY 2006 payment
participate in the hospital reporting Web site at http:// update. We are finalizing the proposed
initiative, hospitals must follow these www.qnetexchange.org. New facilities additional requirements in this rule.
steps: must submit the data using the same These requirements, as well as
• The hospital must identify a schedule, as dictated by the quarter they additional information on validation
QualityNet Exchange Administrator begin discharging patients. We expect requirements, are being placed on
who follows the registration process and that all hospitals will have submitted QualityNet Exchange.
submits the information through the data to the QIO Clinical Warehouse for • The hospital must pass our
QIO. This must be done regardless of discharges through the fourth quarter of validation requirement of a minimum of
80 percent reliability, based upon our reliability after the standard appeals validation determinations. Many
chart-audit validation process, for the process may ask that CMS accept the commenters stated that the current
third quarter data of calendar year 2004. fourth quarter of calendar year 2004 timeframe of 10 days is not sufficient
These data were due to the clinical validation results as a final attempt to time to decide to appeal the results.
warehouse by February 15, 2005. We present evidence of reliability. However, Commenters also asked CMS to specify
use appropriate confidence intervals as in order to process the fourth quarter if the 10-day time period is measured in
explained in the proposed rule to data in time to meet our internal calendar days or business days.
determine if a hospital has achieved an deadlines, these hospitals needed to Response: The 10 days are business
80-percent reliability. The use of submit the charts requested for days. This timeframe is designed to
confidence intervals allows us to reabstraction by no later than August 1, provide sufficient time for hospitals to
establish an appropriate range below the 2005, in order for us to guarantee gather relevant information. Hospital
80-percent reliability threshold that consideration of this information. will not need to produce more
demonstrates a sufficient level of Hospitals that make the early information in deciding whether or not
validity to allow the data to still be submission of these data and pass the to appeal the results of the abstraction.
considered valid. We estimate the 80-percent reliability minimum level Hospitals are required only to submit
percent reliability based upon a review will satisfy this requirement. In their request for appeal form within the
of five charts, and then calculate the reviewing the data for these hospitals, 10-day time period. We believe 10
upper 95 percent confidence limit for we plan to combine the 5 cases from the business days is sufficient time for a
that estimate. If this upper limit is above third quarter and the 5 cases from the hospital to decide whether or not it
the required 80 percent reliability, the fourth quarter into a single sample to wants the contractor to review its
hospital data are considered validated. determine whether the 80-percent original abstraction. However, it does
As proposed, we are using the design reliability level is met. This gives us the expedite the final determination and
specific estimate of the variance for the greatest accuracy when estimating the minimizes data lag for public reporting
confidence interval calculation, which, reliability level. The confidence interval and payment determination.
in this case, is a single stage cluster approach accounts for the variation in Comment: Four commenters
sample, with unequal cluster sizes. (For coding among the 5 charts pulled each requested that CMS allow more time for
reference, see Cochran, William G, quarter and for the entire year around the hospital to produce the medical
(1977) Sampling Techniques, John the overall hospital mean score (on all record and submit the record for the
Wiley & Sons, New York, chapter 3, individual data elements compared). validation review.
section 3.12.) The closer each case’s reliability score is Response: We believe the timeframe
We use a two-step process to to the hospital mean score, the tighter provides sufficient time for hospitals to
determine if a hospital is submitting the confidence interval established for gather the medical record and copy and
valid data. In the first step, we calculate that hospital. A hospital may code each forward it to the contractor. After the
the percent agreement for all of the chart equally inaccurately, achieve a warehouse closes for quarterly
variables submitted in all of the charts. tight confidence interval, and not pass submissions, a sample of five charts is
If a hospital falls below the 80 percent even though its overall score is just selected for validation. The CDAC
cutoff, we then restrict the comparison below the passing threshold (75 percent, requests the charts from the hospital.
to those variables associated with the 10 for example). A hospital with more Hospitals are provided 30 days, as
measures required under section 501(b) variation among charts will achieve a stated in the Hospital Validation Flow
of Pub. L. 108–173. We recalculate the broader confidence interval, which may Chart which can be found on QNet
percent agreement and the estimated 95 allow it to pass even though some charts Exchange Web site. Upon completion of
percent confidence interval and again score very low and others score very validation, the hospital receives a
compare to the 80 percent cutoff point. high. submission report that states whether
If a hospital passes under this restricted We believe we have adopted the most the five charts meet the validation
set of variables, the hospital is suitable statistical tests for the hospital criteria. If the hospital fails validation,
considered to be submitting valid data data we are trying to validate. However, the hospital is provided 10 business
for purposes of the RHQDAPU. in the FY 2006 IPPS proposed rule, we days to notify the QIO that it wishes to
Under the standard appeal process, all invited public comments on this and appeal the validation decision. This
hospitals are given the detailed results any other approaches. We expressed timeframe helps expedite the final
of the Clinical Data Abstraction Center particular interest in comments from determination and minimizes data lag
(CDAC) reabstraction along with their hospitals on the initial starting points for public reporting and payment
estimated percent reliability and the for the passing threshold, the determination.
upper bound of the 95 percent confidence interval established, and the Comment: Four commenters
confidence interval. If a hospital does sampling approach. Because we will be requested that CMS delay hospital
not meet the required 80 percent receiving data each quarter from reporting until we have aligned our
threshold, the hospital has 10 days to hospitals, our information on the definitions and abstraction guidelines
appeal these results to their QIO. The sampling methodology will improve with JCAHO.
QIO will review the appeal with the with each quarter’s submissions. We Response: The third quarter 2004
hospital and make a final determination have indicated that we will analyze this definitions and abstraction guidelines
on the appeal. If the QIO does not agree information to determine if any changes are better aligned to JCAHO than
with the hospital’s appeal, then the in our methodology are required. We previous quarters, and with these third
original results stand. The new results will make any necessary revisions to the quarter 2004 definitions and abstraction
will be provided to the hospital through sampling methodology and the guidelines, we believe we have made
the usual processes, and the validation statistical approach through manual great strides in the long-term alignment
described previously will be repeated. issuances and other guidance to process with JCAHO. Although CMS
This process is described in detail at the hospitals. and JCAHO will not be fully aligned
following Web site: http:// Comment: Several commenters with third quarter and fourth quarter
www.qnetexchange.org. Hospitals that requested that we provide additional discharges, validation results for these
fail to receive the required 80-percent time for the hospitals to appeal their periods are calculated from only those
aligned data elements. We anticipate reabstraction so that hospital staff may CMS will extend IV&V to all areas
full alignment with first quarter 2005 determine the types of errors and take involving the annual payment update.
discharges. appropriate action. In addition, a pre production check has
Comment: Many of the comments The five sampled charts usually yield been implemented and will be
requested requiring only submission of 100 data elements that are used to enhanced to review any output prior to
hospital reporting data in order to be determine the validation rate. This production release. Finally, CMS has a
eligible for the full annual payment sample of data elements is sufficient to QualityNet Help Desk that can assist
update, and separating the process of produce reliable validation rate providers with questions or concerns.
validation from eligibility for the market estimates. Analysis of previous quarters’ Comment: One commenter suggested
basket update. Commenters frequently submitted data indicates that the that CMS resolve all of the vendor
cited difficulties with the data clustering effect caused by the five chart upload issues prior to increasing the
infrastructure, specifically the sample boosts sampling variability by a reimbursement for pay-for-performance
communication of validation results to relatively small proportion. Despite this programs.
the hospital that was causing confusion increase in sampling variability, the Response: The hospital-to-vendor
for the hospitals. The commenters also sample still produces reliable validation relationship is external to CMS.
cited technical difficulties with data rate estimates. The relative sampling Therefore, hospitals are responsible for
submission to the warehouse. variability is largely determined by the selecting and ensuring that vendors
Response: A production problem number of data elements abstracted, submit valid data into the QIO clinical
occurred while releasing the first set of while incorporating the increased warehouse. CMS does not have
third quarter 2004 validation results. A variability caused by the number of contractual agreements with vendors.
CMS contractor had forwarded records. Analysis of previous quarters’ Communication with vendors is the
individual validation results with the submitted data indicates that the hospitals’ responsibility. CMS holds
wrong data to a small number of sampling variability is increased by a hospitals responsible for submitting
hospitals. The run was discontinued relatively small proportion. accurate data. Therefore, hospitals that
immediately upon discovery. All Comment: Seven commenters have a contractual agreement with a
hospitals involved were notified of the requested that we use a test process for vendor must collaborate with the
error and have verified the destruction our data submission and our validation vendor to ensure the data file is
of the files. In addition, hospitals also parameters. submitted accurately. When the data are
encountered abstraction and processing Response: We agree that there should uploaded to the QIO Clinical
issues in this process. CMS and its be a test process. In order to address this Warehouse, we encourage providers to
contractors readily resolved these issues concern, we encourage hospitals to access their Data Submission report. To
and there has not been a negative submit data continuously throughout access this report, log in to QNet
impact on hospitals or their patients. the quarter; thereby data submission Exchange and click on the QIO Clinical
Ninety-eight percent of the hospitals problems can be addressed and Warehouse Feedback Reports. The Data
that submitted data for the third quarter corrected early. Also, CMS, JCAHO, and Submission report will give the provider
of 2004 that are eligible for the market the Hospital Reporting QIOSC conduct a detailed summary of the cases that
basket update will receive the full National calls once a month with entered the clinical warehouse.
update based on validation results. The vendors to provide further assistance. Comment: Sixteen commenters
production problem did not contribute The calls give vendors the opportunity recommended that CMS state
to the 2 percent of the hospitals whose to ask questions and get timely feedback submission and validation parameters
data did not validate. We believe that it to make necessary changes to the data clearly and document them. They also
is important for the data in the clinical file prior to submission. recommended that CMS provide 120-
warehouse on which full payment is Hospitals have continued access to day notice prior to any changes to the
determined to be reliable and valid. view and change their own data in the parameters. The commenters added that
Comment: Three commenters stated warehouse up to the time the warehouse there should be less frequent changes to
that five charts per hospital for is closed. The hospitals can pull the the requirements.
validation is not a sufficient number to validation sample and begin preparing Response: CMS and its contractors
judge the quality of the care delivered the file used for public reporting on the strive to give providers sufficient time to
in the hospital. Hospital Compare Web site at http:// incorporate changes to submission and
Response: CMS factored cost, burden, www.HospitalCompare.hhs.gov. CMS validation parameters. However,
and precision of the validation results encourages hospitals to test their data processing and logistical issues
when deciding to implement the current submission processing during this time sometimes require more expedited
validation sampling methodology. The by submitting quality data into the QIO implementation of these changes,
goal of the chart audit validation clinical warehouse before the deadline because measure and policy changes
process is to ensure that the hospital is and reviewing their submission reports frequently occur. To address this issue,
abstracting and submitting accurate to ensure that all data were successfully CMS and JCAHO released an aligned
data. In order to calculate quality submitted into the warehouse. manual on January 1, 2005. This release
measures, which are used to determine The validation parameters for the occurred 108 days prior to
the standard of care, we need to have CART software are extensively tested implementation of any of the provisions
complete and accurate data. Errors of through internal quality assurance and in the manual. Since that time, CMS and
omission and transcription errors independent validation and verification. JCAHO have agreed to release
contribute to the overall errors in The CMS contractor uses an internal documents at a minimum of 120 days
calculating quality measures. We agree quality control process to verify that all prior to implementation. All manuals
that it is important to differentiate applications and data processes produce contain data file submission
between these errors in order to provide the results outlined in the requirements and programming formats
feedback to hospitals. The process we specifications. CMS provides further for each quarter.
have in place to provide this feedback quality assurance in some areas using an Comment: Eight commenters
gives each hospital the detailed Independent Validation & Verification requested that CMS be consistent when
abstraction results from the CDAC (IV&V) process by another contractor. releasing any communications related to
hospital reporting, and that there should payment should be delayed until data warehouse after submitting their data.
be one central point for all of these infrastructure and processes are Hospitals also have the opportunity to
communications. improved. appeal their validation results if their
Response: Hospitals are required to Response: We disagree with the validation rate is below 80 percent.
establish relationships with the Quality comments indicating that section 501(b) Therefore, hospitals are provided the
Improvement Organizations for their of Pub. L. 108–173 only requires the opportunity to appeal if it appears
States and, furthermore, must establish submission of data. The commenters validation was denied due to an
a formal relationship with the QIO stated that additional requirements were alignment issue. CMS and JCAHO
Clinical Data Warehouse and its Web not contemplated by Congress. continue to work collaboratively to
site, http://www.QNetexchange.org. All However, the validation process does accomplish full alignment across all of
policies and procedures concerning not contradict Pub. L. 108–173. Section the quality measures. We anticipate full
hospital reporting are communicated to 501 (b) also states the submission of the alignment with first quarter 2005
the hospital community through these data is to be in the ‘‘form and manner discharges.
two channels. CMS communicates specified by the Secretary’’. We believe Comment: One commenter suggested
information about hospital reporting that validation requirements fall under that there be better communication
directly to the QIOs through the QIO this broad authority. This requirement between the abstractors and providers.
Hospital Public Reporting contact for does not appear to be to stringent based Providers do not know appropriate
each State, using a formal system of on validation results showing 98 standards for abstraction.
memoranda (‘‘SDPS memos’’) which can percent of providers that submitted data Response: CMS contracts with the
be viewed at http://qionet.sdps.org. The for the third quarter 2004 are eligible for QIO in each State to provide technical
QIOs are then responsible for the full market basket update. While assistance and to work with providers
dissemination of the information to the hospitals did encounter abstraction and on the abstraction process. We believe
appropriate hospital staff in each State. processing issues, these problems were this State-level conduit provides local,
Responses to specific questions are immediately resolved. CMS’ policy on accurate, and accessible communication
addressed through the Quest system; validation requirements are very to providers about the abstraction
CMS monitors responses and lenient, and offer hospitals several
process. In addition to the QIO
clarifications that are published on opportunities to validate their data in
assistance, guidelines for abstraction
Quest. QIOs are expected to provide order to receive the full update.
Comment: Two commenters prior to discharges January 1, 2005 were
technical assistance, as well as provide
recommended using the first quarter available on the QNet Exchange Web
e-mail blasts to all hospitals on any
2005 as the first quarter in which the site under the CART Content link under
important topics and developments
validation process is used for Related Resources. These guidelines
pertinent to reporting hospitals.
calculating the full payment to occur in were in a downloadable PDF format.
Hospitals also receive direct
2007. These Topic Specific Resources were
communication or can seek assistance
Response: We appreciate the designed to assist abstractors in
from the QIO Clinical Data Warehouse,
by Internet (through QNet Exchange). comment and will incorporate this determining how a question should be
CMS and the JCAHO have formally comment into the decisionmaking answered. The abstractor should first
agreed to work together to maintain process for the FY 2007 payment refer to the specific notes and guidelines
common performance measures and to determination. It has been our intention under each data element. All of the
ensure that any communication to use continuous quarters of data, but allowable values for a given question
concerning these measures is CMS and JCAHO measures differed in were outlined, and notes and guidelines
coordinated and consistent. several substantial areas (pre-alignment) were often included which provided the
In addition to this formal system of prior to the third quarter 2004 calendar necessary direction for abstracting a
communication, hospitals can obtain year. Based largely on these differences data element. Beginning with discharges
information or seek answers to specific in measures, we chose to use validation January 1, 2005, the guidelines all
questions on the monthly Hospital Open results from third and fourth quarter abstractors use are published in the
Door Forum (see http:// 2004 calendar year discharges only Specifications Manual for National
www.cms.hhs.gov/opendoor/ using aligned measures to provide the Hospital Quality Measures. These
schedule.asp for schedule) on the highest possibility for validation for guidelines are available to all providers
hospital quality initiative. Hospitals can hospitals. The CMS and JCAHO in a PDF format and can be downloaded
also monitor CMS’s activities to measures were approximately 95 from the QNet Exchange Web site at
promote quality of care in hospitals by percent aligned for the third quarter https://qnetexchange.org/public/
checking http://www.cms.hhs.gov/ 2004 calendar year discharges. Our hdc.do?hdcPage=rltd-rsrcs. CMS also
quality/hospital/. This site includes validation results for this period were has an online questions and answers
information about CMS’s involvement calculated from only those aligned data database that provides a centralized and
in the Hospital Quality Alliance, a elements. standard solution for the management of
public-private partnership to promote Comment: Two commenters stated questions and answers submitted by the
hospital public reporting (see http:// that misalignment with the JCAHO user community. This database may be
www.hospitalcompare.hhs.gov). measures caused many issues with the accessed on the QNet Exchange Web
Comment: A few commenters initial submission of the 10 starter site mentioned above by selecting the
suggested that the only requirement to measures. ‘‘Resources’’ heading at https://
receive the full market basket update Response: As of July 1, 2004 qnetexchange.org/public/home.do. CMS
should be submission of data to the discharges, all data elements within the welcomes comments from the provider
warehouse. These commenters stated 10 starter set were aligned. CMS and its and QIO communities on additional
the intent of the law was to limit the contractors worked diligently to ensure ways to improve communication.
requirement to data submission, and not that alignment issues did not impact Comment: Seven commenters stated
require validation. In addition, there eligibility for receiving the market that the validation process should only
were comments that the validation basket update. All providers can review incorporate data associated with the 10
process is flawed and any link to their quality data in the clinical specified measures.
Response: Although hospitals are quality assurance. We consistently validation are used to calculate the
urged to submit more than the starter set achieve inter-rater reliability rates quality measures. The brief history of
of measures, hospitals submitting approaching 100 percent in the CDAC. hospital submission and validation
quality data will only be denied the full Comment: Two commenters stated indicates that hospitals are improving
market basket update in the validation that hospitals should not fail validation the element level rate of validation. We
process if the 10 specified measures do based on the parent element not expect this improvement to continue
not meet the 80 percent upper bound of validating, and therefore the child over time. As this rate increases, we
a 95 percent confidence interval. The element not validating. believe that the overall accuracy of the
current process allows CMS to Response: Parent/child relationships measures will also improve over time.
incorporate the reliability of both the 22 are defined in the analytic flows. The In the near future, CMS and its
HQA measures as a whole, and responses to the parent element, and contractors will assess the accuracy of
exclusively the 10 specific measures. possibly the child element, determine these hospital submitted measures,
Comment: Five commenters stated the measure category assignment. The relative to surveillance sample data
that we have to be careful not to response to this ‘‘parent’’ element also abstracted by CDAC. This process is
withhold the full update from hospitals determines whether the ‘‘child’’ necessary to eventually improve quality
due to errors on the part of abstractors questions are then answered or not. of care for patients.
or CMS. Validation follows this same Comment: One commenter stated that
Response: We agree that it is relationship. In validation, if the parent an additional component of variability
important not to withhold the full response causes a ‘‘stop abstraction,’’ that is attributable to CMS ratings
update from hospitals due to such then no further elements are answered. should be factored into the computation
errors. With this in mind, in the chart Only the elements answered (parent of the confidence interval for the
audit validation process, the CDAC only) are included in the validation agreement statistic.
reabstracts the medical records and score. If the parent response causes the Response: The validation rates are
compares it to the original abstraction child element(s) to be answered, then based on the reliability of hospital
submitted. The abstraction is compared both the parent and child elements are submitted data, relative to an
at the element level and a percent validated and count in the validation independent abstraction of the sampled
agreement is calculated. The chart audit score. For example, the parent is charts by the CDAC. The CDAC
validation process determines a Working Diagnosis of Pneumonia and abstraction is considered to be a gold
hospital’s reliability score. The score is the response is no, the measure category standard, relative to the hospital
the number on which an appeal is assignment is ‘‘B’’ (not in the measure abstracted data. We believe that the
based. If a provider does not meet the population), this record would not need percentage agreement between the
80-percent reliability threshold, it can to be processed through the individual hospital’s submitted elements and
appeal. Beginning with third quarter measure algorithms. In another CDAC-abstracted elements is a valid
2004 validation results, the final appeal example, the parent is Working estimator of a hospital’s submitted data.
decision will be made by the QIOs. This Diagnosis of Pneumonia and the Comment: One commenter requested
allows for an independent review and it response is ‘‘yes.’’ Per the algorithm, if that there be accommodation for
is designed to find coding errors on the the ‘‘child’’ element is Comfort exceptions to be included in the design
part of abstractors. In this process, the Measures Only and if the response is of measurement requirements.
QIO can either uphold or reverse the ‘‘no,’’ continue to the ‘‘child’’ element Response: The fundamental reason for
CDAC validation decision. The QIO Transfer From another ED and if that standardized reporting is to identify a
receives from the hospital the element response is no, continue to the next means for hospitals, consumers and
or elements that are to be evaluated ‘‘child’’ element Admission Source and others to compare hospital performance
during the appeal process, along with continue through the algorithm based using a common metric. The measures
the hospital rationale for the difference on the response to each ‘‘child’’ are defined to a very detailed level
between the hospital’s abstraction and question. (‘‘microspecifications’’), which include
the CDAC’s abstraction. The QIO has Comment: One commenter stated that flow diagrams that portray acceptable
available to it the hospital’s answer and the current validation process does not documentation. In the current
the CDAC decision when it reviews the match the intended outcome. The microspecifications of the measures, the
hospital rationale and a copy of the commenter believed that the intended ‘‘accommodation for exceptions’’ is
medical record sent to it by the CDAC. outcome is to validate that the publicly built into the measures through
The QIO then makes a final decision on reported numbers are accurate. The identification of exclusionary factors
the response to the element or elements. commenter indicated that, currently, it and excluded populations. Hospitals
This final decision is whether the is only an element by element and readers can view the technical
element(s) response will remain as the validation of data abstraction. descriptions of the measures in the
CDAC indicated or whether the QIO Response: The purpose of the Specifications Manual for National
will reverse the CDAC’s decision and validation of these data is to determine Hospital Quality Measures at http://
agree with the hospital’s response. QIOs the hospital’s ability to correctly qnetexchange.org/public/
are obligated to make appeal decisions abstract and report clinical data as hdc.do?hdcPage=rltd-rsrcs for the most
based on the data that was submitted to evidenced by the consistency between definitive description of the inclusion
the clinical warehouse from the what the hospital reports, and and exclusion criteria for each reported
hospitals. In addition, the abstraction reabstraction by the CDAC. Because measure.
guidelines are clear and straight these data are used for quality Comment: Three commenters
forward. The information requested by improvement, public reporting, and also requested that CMS clarify the
each question in the abstraction tool is for determining eligibility for the APU, validation process and clearly state the
either there, as stated, or it is not. We it is important for CMS to assess the parameters.
have devoted a great deal of resources reliability of this information. It is not Response: We appreciate the
to ensuring that the CDAC abstraction a validation of the quality of the care comment and will strive to clarify the
process is consistent and accurate exhibited by the measures. All of the existing documentation about the
through our training and internal elements used for determining data validation process on the QualityNet
Exchange internet site. CMS also • The CDAC will reabstract the chart measures. To protect the integrity of the
contracts with QIOs to work with using the CMS CART. The relevant data in the QIO Clinical Warehouse, we
hospitals in explaining the validation differences will be identified and the believe if a measure is submitted to the
process and its parameters. Since the CDAC will assign a reason code to each warehouse that data is subject to
publication of the proposed rule, we difference noted. validation.
have added additional information to • The results of the reabstraction will Comment: One commenter expressed
the Qnet exchange Web site explaining be stored in the QIO Clinical Warehouse concern over a lack of an independent
the application of the confidence and made available to the QIO to review process outside of the CDAC
interval to the overall validation results. provide feedback to each hospital. review system for a hospital’s appeal.
The data are being validated at several • Hospitals will receive educational Response: Beginning with third
levels. There are consistency and feedback including an overall reliability quarter 2004 validation results, the final
internal edit checks to ensure the rate and case details on each appeal decision will be made by the
integrity of the submitted data; there are abstraction. QIOs. This allows for an independent
external edit checks to verify • Based upon the CDAC review, since the QIOs and CDACs are
expectations about the volume of the reabstraction, the percent agreement at not connected with each other. In this
data received. Beginning with data for the element level will be calculated. process, the QIO can either uphold or
the fourth quarter of 2002 (October Hospitals that reach or exceed the 80 reverse the CDAC validation decision.
through December), there will be chart percent threshold will be considered to QIOs are obligated to make appeal
level audits to ensure the reliability of be supplying valid data for that quarter. decisions based on the data that was
the submitted data. • Measures for which there are found submitted to the clinical warehouse by
Web sites where additional to be significant errors may not be the hospital. The abstraction guidelines
information related to Hospital Data posted on the Web site. are clear and straight forward. The
Validation can be found: Comment: Two commenters requested information requested by each question
Quality Net Exchange: https:// that the optional elements validated by in the abstraction tool is either there, as
qnetexchange.org/public/hdc.do the CDAC not be included in stated, or it is not.
CMS Hospital Quality Initiative: determining validation and Comment: One commenter suggested
https://qnetexchange.org/public/hdc.do reimbursement. that CMS continue to improve
The purpose of patient level record Response: All of the elements used for communications with hospitals and
validation is to verify that the data determining data validation are used to vendors. We should also improve the
abstracted by the hospitals is consistent calculate the quality measures. It is the quality of the phone calls so that
and reproducible. CMS will identify the responsibility of each vendor (and participants can hear CMS and JCAHO
universe of abstracted data submitted by ultimately, of the hospital) to adhere to officials.
the hospital, draw a small, simple skip logic as defined in the CMS Response: We welcome suggestions
random sample, obtain access to the measures. For third quarter 2004, the on how to improve our processes and
identified charts, and have the CDAC ten CMS measures used for market communications. CMS and its
reabstract the clinical measures. The basket update were largely aligned with contractors currently conduct monthly
CDAC reabstractions will be compared JCAHO. CMS is currently working with calls with vendors, and separate
to the original hospital abstractions and the JCAHO to completely align monthly calls with QIOs. We also
the results shared with the QIO and the exclusion criteria and missing data encourage hospitals to participate in the
affected hospital. The hospitals will be treatment that covers skip logic with the quality section of the Hospital Open
deemed certified as submitting valid JCAHO. CMS policy is if a measure is Door Forums (ODF) that are held once
data based upon the percent agreement submitted to the warehouse, that data is a month. Information on these ODF can
between the hospital and CDAC subject to validation. For example, AMI be found at http://www.cms.hhs.gov/
abstractions. The QIO will be test measures are optional only in the opendoor/hospitals.asp. We will strive
responsible for making all final appeal sense that you had the choice of to improve the quality of these phone
decisions and for providing assistance whether to include those test measures calls. We recommend that callers press
to improve hospital abstractions. in your abstraction, or not to include the ‘‘mute’’ button to minimize outside
All data that has been successfully them in your abstraction. The noise during these calls.
submitted and is in the QIO Clinical Specifications for Calculating Hospital Comment: One commenter stated that
Warehouse is subject to the hospital Data Validation document that was data validation should be directed more
data validation process. An overview of updated June 21, 2005, on QNet at care, and not just at abstraction.
the processes that make up the entire Exchange states ‘‘The CDAC will Response: It is the hospitals’
hospital data validation process is abstract elements for all measures performance on the measures that
described below: (indicators) based on the measure sent reflect the quality of care a hospital
• For each calendar quarter, all in the original (hospital) xml file.’’ If the provides to patients with any of these
hospitals submitting abstracted data will indicator for T1a (LDL Cholesterol clinical conditions, not the abstraction
be identified. Assessment) is included, then the process itself. Validation of these data is
• For each hospital, all abstracted corresponding data elements should be to determine the hospitals’ ability to
charts will be enumerated. included. correctly abstract and report clinical
• A simple random sample of five Hospitals submitting quality data will data. All of the elements used for
charts per quarter will be identified be considered not eligible for full determining data validation are used to
from all hospitals with a minimum of market basket update in the validation calculate the quality measures. These
six discharges in the QIO Clinical process only if the ten specified quality measures are designed to
Warehouse. The sample is selected from measures do not meet the 80 percent estimate the quality of care.
all the cases submitted and is not topic- upper bound of a 95 percent confidence Comment: One commenter expressed
specific. interval. The current process allows concern over incorrect abstraction by
• The CMS CDAC will request the CMS to incorporate the reliability of the CDACs due to the fact that hospitals
paper medical records for each of the both the 22 HQA measures as a whole, keep charts differently. The commenter
sampled charts. and exclusively the 10 specific is concerned that this inconsistency is
resulting in an erroneously high rate of hospitals to collate all necessary professionals. CDAC abstractors must
non-validation. documents for the medical record. It is have at least 2 years of experience in
Response: It is every hospital’s important for the hospitals to submit all work involving hospital medical record
responsibility to abstract valid data and necessary documentation for validation review. Once hired, the abstractors
provide, upon request, a complete as part of the medical records upon the undergo a rigorous training program.
medical record for validation. The same request of the CDAC. The multiphase CDAC training program
abstraction guidelines are used by the Comment: One commenter stated that consists of knowledge transfer,
CDAC and the hospital. Therefore, the we should add outcome measures to the simulation, evaluation and feedback.
results of the abstraction should be the hospital reporting initiatives to align our Employees must demonstrate a high
same regardless of how the hospital efforts with those of private purchases level of proficiency before ‘‘graduating’’
maintains its records. It is every to financially reward high quality to live production abstraction. During
hospital’s responsibility to abstract valid providers for improving outcomes of production, inter-rater reliability and
data. The measures and exclusion care. data accuracy are monitored
criteria are created by expert panels of Response: We are engaged in a continuously through the CDAC quality
medical and technical professionals. number of activities to develop control process. We consistently achieve
The CDAC abstraction guidelines are meaningful, actionable measures of the inter-rater reliability rates approaching
designed to minimize these ambiguities outcomes of care, including various 100 percent in the CDAC. CMS and its
encountered by the CDAC abstractors. research and demonstration projects. In contractors monitor the performance of
Comment: One commenter suggested addition, CMS is participating in the the CDAC abstractions, and perform
the only validation criteria should be Hospital Quality Alliance (HQA), a quality assurance to ensure that their
submission of four consecutive quarters pubic-private collaboration to promote abstraction is of the highest quality.
of data, or 12 months’ worth of data. If public reporting on hospital quality. Comment: One commenter stated that
the hospital submits 4 consecutive The HQA is currently considering the there are many data elements that are
quarters of data, and the data passes the feasibility of adding outcome measures subject to interpretation.
warehouse edits, the hospital should be that would complement the current set Response: It is every hospital’s
given credit for the submission. of 20 process measures that are reported responsibility to abstract valid data. The
Response: It is CMS’ goal for FY 2007 publicly. However, there are no definite measures and exclusion criteria are
to use the four consecutive quarters’ plans to add outcome measures at this created by expert panels of medical and
validation results as the validation time. technical professionals. A Data
criteria. Comment: One commenter stated that Dictionary is posted for abstractors to
Comment: One commenter stated that hospitals should be able to appeal utilize in the abstraction of each
vendors working with the hospital mismatches even if their data reached element for the measures. As questions
should employ the same skip logic in the 80 percent validation mark. The are received, the data elements are
their software that is used by the CDAC. commenter added that all appeals reviewed to determine if additional
Response: The hospital-to-vendor should be reviewed by a clinician. clarification would improve the
relationship is external to CMS. Response: Hospitals are reviewed by reliability of the abstraction. Revisions
Therefore, hospitals are responsible for QIO staff. This staff is made up of health are made in conjunction with the
selecting and ensuring that vendors care professionals. We have determined JCAHO and released with each new
submit valid data into the QIO clinical that providers with a reliability score of version of the Specifications Manual.
warehouse. We suggest that hospitals 80 percent and above have met the chart Comment: One commenter suggested
exercise due diligence in selecting audit validation requirement and that we should automatically compute
vendors to abstract and submit quality therefore no appeal is necessary. The the match rate confidence interval for
data. It is the responsibility of each appeals process is designed to provide the entire submitted data set and for the
vendor (and ultimately, of the hospital) feedback to those hospitals that did not 10 starter measures only. We should
to adhere to skip logic as defined in the meet the 80 percent validation rate. then automatically assign the higher
CMS measures. Workload and other issues prevent CMS score to the hospital, even if both are
Comment: One commenter stated that from implementing this process for all passing rates.
hospitals should be able to submit providers. The goal is to have reliable Response: The sequential rate
documentation to us to prove that care data in the warehouse at the 80 percent calculation process is designed to
took place. This followup element level. provide hospitals with the opportunity
documentation should be accepted after Comment: One commenter to be eligible to receive the full market
the hospital validation results have been recommended that CMS describe the basket update. Hospitals are eligible if
published. credentials of the staff the agency uses the 95 percent upper bound of either CI
Response: The medical chart is the for chart abstraction, describe the rate is 80 percent or greater. CMS uses
basis of information for conducting training of those staff, and facilitate the this rate for the sole purpose of
CDAC abstractions. Using development of materials that hospitals determining payment eligibility.
supplementary information that differs could use to hire and train their own • The information collected by CMS
greatly by hospital would create greater personnel. The commenter also through this rule will be displayed for
ambiguity in the abstraction process. recommended that CMS should have public viewing on the Internet. Prior to
The abstraction guidelines are written to clinical staff study the inter-rater this display, hospitals are permitted to
use the medical chart to objectively reliability of its own abstractor’s preview their information as we have it
abstract the necessary information. determinations. recorded. In our previous experience, a
Hospitals are given 30 days to submit Response: The CDAC staff are number of hospitals requested that this
the medical records to the CDAC for professional abstractors specifically information not be displayed due to
validation abstractions. The request for trained to abstract these data as errors in the submitted data that were
the medical records happens described in the measures and not of the sort that could be detected by
approximately 5 months after the close validation criteria. The measures and the normal edit and consistency checks.
of the quarter that is being validated. We exclusion criteria are created by expert We acquiesced to these requests in the
believe this provide sufficient time for panels of medical and technical public interest and because of our own
desire to present correct data. However, level; it will only include a mismatch absence of other like hospitals (as
we still believe that the hospital bears reason and educational information if determined by the Secretary), or
the responsibility of submitting correct the elements are a true mismatch historical designation by the Secretary
data that can serve as valid and reliable affecting the numerator and as an essential access community
information. Therefore, in order to denominator calculation from the CDAC hospital, is the sole source of inpatient
receive the full market basket update for abstracted records. hospital services reasonably available to
IPPS, as we proposed, we are Comment: Three commenters Medicare beneficiaries. The regulations
establishing a requirement for 2 expressed support for the Hospital that set forth the criteria that a hospital
consecutive quarters of publishable Reporting initiative and the subsequent must meet to be classified as an SCH are
data. We published the first quarter of quality improvement that will result located in § 412.92 of the regulations.
calendar year 2004 data in November from this effort. Although SCHs and MDHs are paid
2004. The first two quarters of calendar Response: We agree and appreciate under a special payment methodology,
year 2004 data were published in March these commenters’ support. We will they are hospitals that are paid under
2005. Our plans are to publish the first strive to provide hospitals and the section 1886(d) of the Act. Like all IPPS
3 quarters of calendar 2004 in public with valid quality data for hospitals paid under section 1886(d) of
September 2005. For the FY 2006 quality improvement, as well as better the Act, SCHs and MDHs are paid for
update, we expect that all hospitals consumer information about hospital their discharges based on the DRG
receiving the full market basket update quality. weights calculated under section
for FY 2006 to have published data for Comment: One commenter expressed 1886(d)(4) of the Act.
all of the required 10 measures for both concern over access to individual Effective with hospital cost reporting
the March and September 2005 hospital data. The commenter noted that periods beginning on or after October 1,
publications. Allowances will be made employees of the hospital system may 2000, section 1886(d)(5)(D)(i) of the Act
for hospitals that do not treat a not have access to data necessary to do (as amended by section 6003(e) of Pub.
particular condition, and for new their jobs. L. 101–239) and section 1886(b)(3)(I) of
hospitals that have not had the Response: Privacy restrictions to the Act (as added by section 405 of Pub.
opportunity to provide the required patient-level data must be strictly L. 106–113 and further amended by
data. The fiscal intermediaries will enforced. It is each hospital’s section 213 of Pub. L. 106–554), provide
provide information on new hospitals to responsibility to ensure that only that SCHs are paid based on whichever
the QIO in the State in which the appropriate parties within their of the following rates yields the greatest
hospital has opened for operations as a management structure are able to access aggregate payment to the hospital for the
Medicare provider as soon as possible the quality data as well as make cost reporting period:
so that the QIO can enter the provider available the results of the quality data • The Federal rate applicable to the
information into its Program Resource for quality improvement activities as hospital;
System (PRS) and follow through with appropriate throughout the hospital. We • The updated hospital-specific rate
ensuring provider participation with the refer readers to the HIPAA regulations at based on FY 1982 costs per discharge;
requirements for quality data reporting 45 CFR Parts 160 and 164 or the • The updated hospital-specific rate
under this rule. individual institution’s Privacy or based on FY 1987 costs per discharge;
Comment: Two commenters HIPAA Specialist. We believe there or
expressed support for the validation of • The updated hospital-specific rate
should be no reason for an employee not
the hospital reporting data. based on FY 1996 costs per discharge.
to have the necessary data to do their For purposes of payment to SCHs for
Response: We appreciate the jobs.
commenters’ support. The Hospital which the FY 1996 hospital-specific rate
Comment: One commenter stated that yields the greatest aggregate payment,
Quality Data for Annual Payment the proposed rule change would add to
Update initiative has been an evolving payments for discharges during FYs
the significant adverse reimbursement 2001, 2002, and 2003 were based on a
process that we are dedicated to actions that are threatening the viability
improving. We want to acknowledge our blend of the FY 1996 hospital-specific
of hospitals that bear the brunt of caring rate and the greater of the Federal rate
appreciation to QIOs, hospitals and for the uninsured and underinsured.
stakeholders. We strive to provide or the updated FY 1982 or FY 1987
Response: All hospitals eligible for
hospitals and the public with valid hospital-specific rate. For discharges
Medicare reimbursement are
quality data for quality improvement, during FY 2004 and subsequent fiscal
responsible for keeping sufficient
and better consumer information about years, payments based on the FY 1996
records and documentation about the
hospital quality. hospital-specific rate are 100 percent of
quality of care. The purpose of this
Comment: Three commenters stated the updated FY 1996 hospital-specific
change is to help hospitals improve the
that the reports resulting from the rate.
quality of care that they provide to all For each cost reporting period, the
reporting do not provide clear
patients. fiscal intermediary determines which of
information to determine the numerator
and the denominator and percent of C. Sole Community Hospitals (SCHs) the payment options will yield the
agreement. and Medicare Dependent Hospitals highest rate of payment. Payments are
Response: Hospital Validation Reports (MDHs) (§§ 412.73, 412.75, 412.77, automatically made at the highest rate
are available on QualityNet Exchange. 412.92 and 412.108) using the best data available at the time
These reports have been modified with the fiscal intermediary makes the
third quarter 2004 validation results. 1. Background determination. However, it may not be
They now reflect all elements that count Under the IPPS, special payment possible for the fiscal intermediary to
toward the numerator and the protections are provided to a sole determine in advance precisely which
denominator and the percent of community hospital (SCH). Section of the rates will yield the highest
agreement. The Hospital Validation 1886(d)(5)(D)(iii) of the Act defines an payment by year’s end. In many
Case Detail report provides SCH as a hospital that, by reason of instances, it is not possible to forecast
administrative, demographic, and factors such as isolated location, the outlier payments, the amount of the
clinical information at the element weather conditions, travel conditions, DSH adjustment, or the IME adjustment,
all of which are applicable only to indicated that the normalization 1886(d) of the Act, we believe their DRG
payments based on the Federal rate. The adjustment does not achieve budget payments should be factored into the
fiscal intermediary makes a final neutrality with respect to aggregate DRG reclassification and recalibration
adjustment at the close of the cost payments to hospitals under section factor component of the budget
reporting period to determine precisely 1886(d) of the Act. In order to comply neutrality adjustment to ensure that
which of the payment rates would yield with the requirement of section recalibration does not affect total
the highest payment to the hospital. 1886(d)(4)(C)(iii) of the Act that the DRG payments to hospitals under section
If a hospital disagrees with the fiscal reclassification changes and 1886(d) of the Act. Therefore, we
intermediary’s determination regarding recalibration of the relative weights be continue to believe it is appropriate to
the final amount of program payment to budget neutral and the requirement of apply the DRG reclassification and
which it is entitled, it has the right to section 1886(d)(3)(E) of the Act that the recalibration factor component of the
appeal the fiscal intermediary’s decision updated wage index be implemented in budget neutrality adjustment to SCHs
in accordance with the procedures set a budget neutral manner, we compare and MDHs. Furthermore, consistent
forth in Subpart R of Part 405, which the estimated aggregate payments using with the requirement of section
concern provider payment the current year’s relative weights and 1886(d)(4)(C)(iii) of the Act that DRG
determinations and appeals. wage index factors to aggregate reclassification changes and
Under section 1886(d)(5)(G) of the payments using the prior year’s weights recalibration of relative weights be
Act, Medicare dependent hospitals and factors. Based on this comparison, budget neutral, we continue to believe
(MDHs) are paid based on the Federal we compute a budget neutrality it is appropriate to apply this
national rate or, if higher, the Federal adjustment factor. This budget adjustment without removing the
national rate plus 50 percent of the neutrality adjustment factor is then previous year’s adjustment factor.
difference between the Federal national applied to the standardized per In the FY 1991 IPPS proposed rule (55
rate and the updated hospital-specific discharge payment amount. Beginning FR 19466), we discussed the rationale
rate based on FY 1982 or FY 1987 costs in FY 1994, in applying the current behind our decision to apply the wage
per discharge, whichever is higher. year’s budget neutrality adjustment index portion of the budget neutrality
MDHs do not have the option to use factor to both the standard Federal rate adjustment factors to hospitals that are
their FY 1996 hospital-specific rate. The and hospital-specific rates, we do not paid under section 1886(d) of the Act
regulations that set forth the criteria that remove the prior years’ budget based on a hospital-specific rate. We
a hospital must meet to be classified as neutrality adjustment factors because described how, even though the wage
an MDH are located in § 412.108. estimated aggregate payments after the index is only applicable to those
2. Budget Neutrality Adjustment to changes in the DRG relative weights and hospitals that are paid based on the
Hospital Payments Based on Hospital- wage index factors must equal estimated Federal rate, the changes in wage index
Specific Rate aggregate payments prior to the changes. can cause changes in the payment basis
If we removed the prior year for some SCHs, and MDHs. That is,
Under section 1886(d)(4)(C)(i) of the adjustment, we would not satisfy this depending on the size of the increase in
Act, beginning in FY 1988 and for each condition. (58 FR 30269) their wage index values, some hospitals
fiscal year thereafter, the Secretary is We are bound by the Act to ensure that had been paid based on a hospital-
required to adjust the DRG that aggregate payments to hospitals specific rate could now be paid based
classifications and weighting factors under section 1886(d) of the Act are on the Federal rate when the wage
established under sections 1886(d)(4)(A) projected to neither increase nor index-adjusted Federal rate exceeds the
and (d)(4)(B) of the Act to reflect decrease as a result of the annual hospital-specific rate. In some instances,
changes in treatment patterns, updates to the DRG classifications and hospitals that had previously been paid
technology, and other factors that may weighting factors and for the updated based on the Federal rate may be paid
change the use of hospital resources. For wage indices. However, we have broad based on a hospital-specific rate if the
discharges beginning in FY 1991, authority under the statute to determine Federal rate is adjusted by a lower wage
section 1886(d)(4)(C)(iii) of the Act the method for implementing budget index and the hospital-specific rate now
requires the Secretary to ensure that neutrality. We have maintained since exceeds the Federal rate. These shifts in
adjustments to DRG classifications and 1991 that the budget neutrality the payment basis affect aggregate
weighting factors result in aggregate adjustment is applied, as described program payments and, therefore, are
DRG payments that are budget neutral above, to all hospitals paid under taken into account in the budget
(not greater or less than the aggregate section 1886(d) of the Act, including neutrality adjustment. In addition, we
payments without the adjustments). In those that are paid based on a hospital- maintained that because we apply the
addition, section 1886(d)(3)(E) of the specific rate. Thus, the budget neutrality adjustment to all hospitals paid based
Act requires the Secretary to update the factor applies to payments to SCHs and on the Federal rate under section
hospital wage index annually in a MDHs. 1886(d) of the Act, it would be fair to
manner that does not affect aggregate Hospitals that are paid under section apply it to hospitals that are paid under
payments to hospitals under section 1886(d) of the Act based on a hospital- section 1886(d) of the Act based on
1886(d) of the Act. specific rate are subject to the DRG hospital-specific rates. We believed that
As discussed in the FY 2001 IPPS reclassification and recalibration factor if we did not apply the budget neutrality
proposed rule (55 FR 19466), we component of the budget neutrality factor to hospitals paid based on their
normalize the proposed recalibrated adjustment because, as IPPS hospitals, hospital-specific rate, hospitals that are
DRG weights by an adjustment factor so they are paid based on DRGs. As paid on the Federal rate would be
that the average case weight after described above, changes in DRG subject to larger reductions to make up
recalibration is equal to the average case relative weights from one year to the for not adjusting payments to hospitals
weight prior to recalibration. While this next affect aggregate SCH and MDH that are paid based on hospital-specific
adjustment is intended to ensure that payments, which in turn affect total rates.
recalibration does not affect total Medicare payments to hospitals under Concerns have been raised that
payments to hospitals under section section 1886(d) of the Act. Because hospitals paid under section 1886(d) of
1886(d) of the Act, our analysis has SCHs and MDHs are paid under section the Act whose reimbursement is based
on a hospital-specific rate should not be hospital-specific rates for hospitals paid After consideration of the public
subject to the wage index component of under section 1886(d) of the Act. The comments received, as we proposed, we
the budget neutrality adjustment. DRG reclassification and recalibration are adding a new paragraph (f) to
Hospital-specific rates reflect the effects factor component of the budget § 412.73, a new paragraph (i) to
of hospitals’ area wage levels and, neutrality adjustment will still apply to § 412.75, and a new paragraph (j) to
therefore, are not adjusted by an area these hospitals, as payments to SCHs § 412.77 relating to the computation of
wage index. Accordingly, the concern is and MDHs are based on DRGs and affect the hospital-specific rate to clarify our
that a budget neutrality factor for total Medicare payments to hospitals longstanding policy that CMS makes an
changes in the wage index should not be under section 1886(d) of the Act. In adjustment to the hospital-specific rate
applied to hospitals that are paid based applying this budget neutrality to ensure that changes to the DRG
on a hospital-specific rate. In addition, adjustment factor, which would include reclassifications and recalibrations of
it has been suggested that the budget only the DRG reclassification and the DRG relative weights are made in a
neutrality adjustment that CMS applies recalibration factor component, to the manner so that aggregate payments to
to hospitals paid on a hospital-specific hospital-specific rate, we will not hospitals under section 1886(d) of the
rate should be similar to the budget remove the prior years’ budget Act are not affected, and that this
neutrality adjustment made to hospitals neutrality adjustment factors. This will adjustment is made without removing
in Puerto Rico. Hospitals in Puerto Rico satisfy the statutory requirement that the budget neutrality adjustment for the
that are paid under the IPPS are paid estimated aggregate payments after the prior year. These provisions are cross-
based on a blend of the national changes in the DRG relative weights referenced in § 412.92 for SCHs and
prospective payment rate and the Puerto equal estimated aggregate payments § 412.108 for MDHs for purposes of
Rico-specific prospective payment rate prior to the changes. As we proposed, computing the hospital-specific rates for
(§ 412.212). Beginning in FY 1991, the the wage index portion of the budget these hospitals. The text of these new
Puerto Rico-specific standardized neutrality adjustment will not be provisions reflects changes to the way
amount became subject to a budget applied to hospital-specific amounts, as CMS applies the budget neutrality
neutrality adjustment. This budget these amounts are not adjusted by an adjustment to hospitals paid under
neutrality adjustment included both the area wage index. While this may result section 1886(d) of the Act based on a
DRG reclassification and recalibration in the application of a slightly higher hospital-specific rate. Specifically, it
factor component and the wage index budget neutrality adjustment to all other indicates that the budget neutrality
component. However, beginning in FY IPPS hospitals, because these hospitals adjustment made to hospitals paid
1998, the Puerto Rico-specific rate has actually are paid based on the revised under section 1886(d) of the Act based
been subject only to the DRG wage indices and are affected by wage on a hospital-specific rate will only
reclassification and recalibration factor index changes, we believe this is account for the DRG reclassification and
component of the budget neutrality appropriate. In addition, we note that in recalibration factor component. The
adjustment (62 FR 46038) and not to the FY 1990 when this policy was first budget neutrality adjustment will no
wage index component of the budget discussed, we did not calculate a budget longer include the wage index factor
neutrality adjustment. In other words, neutrality factor that reflected only the component.
beginning in FY 1998, the budget DRG changes. Because we now calculate 3. Technical Change
neutrality adjustment for the Puerto such a budget neutrality factor for In the FY 1991 IPPS final rule (55 FR
Rico-specific rate reflects only the DRG Puerto Rico hospitals, it would not be 36056), we made changes to the
reclassification and recalibration factor administratively burdensome to apply regulations at § 412.92 to incorporate
component. This adjustment is the same budget neutrality factor to the provisions of section 6003(e) of Pub.
computed, as described above, for all SCHs and MDHs. L. 101–239. Section 6003(e) of Pub. L.
hospitals paid under section 1886(d) of Comment: Several commenters 101–239 provided for a permanent
the Act, without removing the previous requested that CMS provide more payment methodology for SCHs that
year’s budget neutrality adjustment. detailed information regarding the recognized distortions in operating costs
We have considered the concern that impact of the proposed change on FY in years subsequent to the
it is inappropriate to apply a budget 2006 payments as well as the impact of implementation of the IPPS and
neutrality factor that includes a the proposed change if it were imposed provided for opportunity for payment
component for changes in the wage retroactively. based on a new base year. As a result
index to a hospital with a payment rate Response: The impact of this of this legislation, we deleted from the
that is not adjusted by a wage index provision can be found in column 10 of regulations a special provision that we
adjustment. In cases in which a the impact section (Appendix A) of both had included under § 412.92 (g) that
hospital’s payments are ultimately the FY 2006 proposed rule and this final provided for a payment adjustment to
based on a hospital-specific rate, that rule. Our analysis shows that the impact compensate SCHs reasonably for the
portion of the payment is not adjusted on FY 2006 payments will be minimal. increased operating costs resulting from
by a wage index. We believe that our With respect to applying this policy the addition of new services or facilities.
current policy is valid, for the reasons retroactively, section 903 of Pub. L. In the FY 2006 IPPS proposed rule,
indicated above and in previous 108–173 prohibits us from issuing we indicated that we had discovered
rulemaking documents, but we retroactive rulemaking unless it is that, in making the changes to § 412.92
recognize that there are also valid necessary to comply with statutory in the FY 1991 IPPS final rule to remove
grounds to review the regulations and requirements or failure to apply the paragraph (g), we inadvertently failed to
consider other approaches. Accordingly, change retroactively would be contrary make a conforming change to paragraph
in the FY 2006 IPPS proposed rule, we to public interest. We do not believe this (d)(3) that references the provisions of
revisited this policy. After further policy meets either of the conditions for paragraph (g) relating to a payment
consideration of these issues, as we making the policy retroactive. adjustment for significant increases in a
proposed, we are removing the wage Therefore, we have not assessed the SCH’s operating costs. We proposed to
index component from the budget fiscal impact of this policy if it were to make a technical correction by revising
neutrality adjustment applied to the be imposed retroactively. paragraph (d)(3). We did not receive any
comments on this proposed correction. Otherwise, a hospital seeking rural posted to CMS’ records through March
Therefore, in this final rule, we are referral center status must satisfy the 2005.
adopting the proposed technical applicable criteria. For FYs 1984 In the FY 2006 IPPS proposed rule,
correction as final. through 2004, we used the definitions of (70 FR 23428) [May 4, 2005] we
‘‘urban’’ and ‘‘rural’’ in § 412.63. For FY proposed that, in addition to meeting
D. Rural Referral Centers (§ 412.96)
2005 and subsequent years, the revised other criteria, if they are to qualify for
Under the authority of section definitions of ‘‘urban’’ and ‘‘rural’’ in initial rural referral center status for cost
1886(d)(5)(C)(i) of the Act, the § 412.64 apply. reporting periods beginning on or after
regulations at § 412.96 set forth the One of the criteria under which a October 1, 2005, rural hospitals with
criteria that a hospital must meet in hospital may qualify as a rural referral fewer than 275 beds must have a case-
order to qualify under the IPPS as a center is to have 275 or more beds mix index value for FY 2004 that is at
rural referral center. For discharges available for use (§ 412.96(b)(1)(ii)). A least—
occurring before October 1, 1994, rural rural hospital that does not meet the bed • 1.3659; or
referral centers received the benefit of size requirement can qualify as a rural • The median case-mix index value
payment based on the other urban referral center if the hospital meets two (not transfer-adjusted) for urban
standardized amount rather than the mandatory prerequisites (a minimum hospitals (excluding hospitals with
rural standardized amount. Although case-mix index and a minimum number approved teaching programs as
the other urban and rural standardized of discharges) and at least one of three identified in § 412.105) calculated by
amounts are the same for discharges optional criteria (relating to specialty CMS for the census region in which the
occurring on or after October 1, 1994, composition of medical staff, source of hospital is located. (See the table set
rural referral centers continue to receive inpatients, or referral volume) forth in the FY 2006 IPPS proposed rule
special treatment under both the DSH at 70 FR 23430.)
(§ 412.96(c)(1) through (c)(5)). (See also
payment adjustment and the criteria for Based on the latest data available (FY
the September 30, 1988 Federal Register
geographic reclassification. 2004 bills received through March
Section 402 of Pub. L. 108–173 raised (53 FR 38513)). With respect to the two
mandatory prerequisites, a hospital may 2005), in addition to meeting other
the DSH adjustment for other rural criteria, hospitals with fewer than 275
hospitals with less than 500 beds and be classified as a rural referral center
if— beds, if they are to qualify for initial
rural referral centers. Other rural rural referral center status for cost
hospitals with less than 500 beds are • The hospital’s case-mix index is at
subject to a 12-percent cap on DSH least equal to the lower of the median
October 1, 2005, must have a case-mix
payments. Rural referral centers are not case-mix index for urban hospitals in its
index value for FY 2004 that is at least—
subject to the 12.0 percent cap on DSH census region, excluding hospitals with • 1.3721; or
payments that is applicable to other approved teaching programs, or the • The median case-mix index value
rural hospitals (with the exception of median case-mix index for all urban (not transfer-adjusted) for urban
rural hospitals with 500 or more beds). hospitals nationally; and hospitals (excluding teaching programs
Rural referral centers are not subject to • The hospital’s number of discharges as identified in § 412.105) calculated by
the proximity criteria when applying for is at least 5,000 per year, or, if fewer, the CMS for the census region in which the
geographic reclassification, and they do median number of discharges for urban hospital is located.
not have to meet the requirement that a hospitals in the census region in which The final median case-mix index
hospital’s average hourly wage must the hospital is located. (The number of values by region are set forth in the
exceed 106 percent of the average discharges criterion for an osteopathic following table:
hourly wage of the labor market area hospital is at least 3,000 discharges per
where the hospital is located. year, as specified in section Case-mix
Region
Section 4202(b) of Pub. L. 105–33 1886(d)(5)(C)(i) of the Act.) index value
states, in part, ‘‘[a]ny hospital classified
1. Case-Mix Index 1. New England (CT, ME, MA,
as a rural referral center by the Secretary
NH, RI, VT) ........................... 1.2300
* * * for fiscal year 1991 shall be Section 412.96(c)(1) provides that
2. Middle Atlantic (PA, NJ, NY) 1.2469
classified as such a rural referral center CMS will establish updated national 3. South Atlantic (DE, DC, FL,
for fiscal year 1998 and each subsequent and regional case-mix index values in GA, MD, NC, SC, VA, WV) .. 1.3277
year.’’ In the August 29, 1997 final rule each year’s annual notice of prospective 4. East North Central (IL, IN,
with comment period (62 FR 45999), we payment rates for purposes of MI, OH, WI) ........................... 1.2762
also reinstated rural referral center determining rural referral center status. 5. East South Central (AL, KY,
status for all hospitals that lost the The methodology we use to determine MS, TN) ................................. 1.2911
status due to triennial review or MGCRB the national and regional case-mix 6. West North Central (IA, KS,
reclassification, but not to hospitals that index values is set forth in regulations MN, MO, NE, ND, SD) .......... 1.2252
7. West South Central (AR, LA,
lost rural referral center status because at § 412.96(c)(1)(ii). The national
OK, TX) ................................. 1.3532
they were now urban for all purposes median case-mix index value for FY 8. Mountain (AZ, CO, ID, MT,
because of the OMB designation of their 2006 includes all urban hospitals NV, NM, UT, WY) ................. 1.3620
geographic area as urban. However, nationwide, and the regional values for 9. Pacific (AK, CA, HI, OR,
subsequently, in the August 1, 2000 FY 2006 are the median values of urban WA) ....................................... 1.3241
final rule (65 FR 47089), we indicated hospitals within each census region,
that we were revisiting that decision. excluding those hospitals with Hospitals seeking to qualify as rural
Specifically, we stated that we would approved teaching programs (that is, referral centers or those wishing to
permit hospitals that previously those hospitals receiving indirect know how their case-mix index value
qualified as a rural referral center and medical education payments as compares to the criteria should obtain
lost their status due to OMB provided in § 412.105). These values are hospital-specific case-mix index values
redesignation of the county in which based on discharges occurring during (not transfer-adjusted) from their fiscal
they are located from rural to urban to FY 2004 (October 1, 2003 through intermediaries. Data are available on the
be reinstated as a rural referral center. September 30, 2004) and include bills Provider Statistical and Reimbursement
(PS&R) System. In keeping with our region is greater than the national hospitals. The statute also limits the
policy on discharges, these case-mix standard of 5,000 discharges. Therefore, adjustment to no more than 25 percent.
index values are computed based on all 5,000 discharges is the minimum According to the analysis conducted
Medicare patient discharges subject to criterion for all hospitals. for the FY 2005 IPPS final rule (69 FR
DRG-based payment. We reiterate that if an osteopathic 49099 through 49102), a 25 percent low-
hospital is to qualify for rural referral volume adjustment to all qualifying
2. Discharges hospitals with less than 200 discharges
center status for cost reporting periods
Section 412.96(c)(2)(i) provides that beginning on or after October 1, 2005, was found to be most consistent with
CMS will set forth the national and the hospital would be required to have the statutory requirement to provide
regional numbers of discharges in each at least 3,000 discharges for its cost relief to low-volume hospitals where
year’s annual notice of prospective reporting period that began during FY there is empirical evidence that higher
payment rates for purposes of 2002. incremental costs are associated with
determining rural referral center status. low numbers of total discharges.
As specified in section 1886(d)(5)(C)(ii) 3. Technical Change However, we acknowledged that the
of the Act, the national standard is set In the FY 1998 IPPS final rule (62 FR empirical evidence did not provide
at 5,000 discharges. In the FY 2006 IPPS 46028), we removed paragraph (f) from robust support for that conclusion and
proposed rule (70 FR 23428), we § 412.96. Paragraph (f) was removed indicated that we would reexamine the
proposed to update the regional when the requirement for triennial empirical evidence for the FY 2006 IPPS
standards based on discharges for urban reviews of rural referral centers was final rule with the intention of
hospitals’ cost reporting periods that terminated (62 FR 45998 through 45600, modifying or even eliminating the
began during FY 2002 (that is, October 46028 through 46029). However, we adjustment if the empirical evidence
1, 2001 through September 30, 2002), indicates that it is appropriate to do so.
inadvertently failed to address all of the
which is the latest available cost report In the FY 2005 IPPS final rule (69 FR
related cross-references to paragraph (f)
data we had at that time. 49102), we indicated that our analysis
in the entire § 412.96. Therefore, as we showed that there are fewer than 100
Therefore, in the FY 2006 IPPS proposed in the FY 2006 IPPS proposed
proposed rule, we proposed that, in hospitals with less than 200 total
rule (70 FR 23428), we are revising discharges. At that time, we were unable
addition to meeting other criteria, a § 412.96 to remove paragraphs (h)(4)
hospital, if it is to qualify for initial to determine how many of these
and (i)(4), consistent with the removal hospitals also meet the requirement that
rural referral center status for cost of paragraph (f).
reporting periods beginning on or after a low-volume hospital be more than 25
October 1, 2005, must have as the E. Payment Adjustment for Low-Volume road miles from the nearest IPPS
number of discharges for its cost Hospitals (§ 412.101) hospital in order to qualify for the
reporting period that began during FY adjustment. Our data systems currently
Section 1886(d)(12) of the Act, as indicate that 10 hospitals are receiving
2002 a figure that is at least—
• 5,000 (3,000 for an osteopathic added by section 406 of Pub. L. 108– the low-volume adjustment.
hospital); or 173, provides for a payment adjustment As indicated in the FY 2005 IPPS
• The median number of discharges to account for the higher costs per final rule, we have now conducted a
for urban hospitals in the census region discharge of low-volume hospitals more detailed multivariate analysis on
in which the hospital is located. (See under the IPPS. Section the empirical basis for a low-volume
the table set forth in the FY 2006 IPPS 1886(d)(12)(C)(i) of the Act defines a adjustment for FY 2006. In order to
proposed rule at 70 FR 23430.) low-volume hospital as a ‘‘subsection further evaluate the need for a change in
Based on the latest discharge data (d) hospital * * * that the Secretary the development of the low-volume
available at this time, that is, for cost determines is located more than 25 road adjustment, we replicated much of the
reporting periods that begin during FY miles from another subsection (d) analysis conducted for the FY 2005 IPPS
2003, the final median number of hospital and that has less than 800 final rule, using updated data. We again
discharges for urban hospitals by census discharges during the fiscal year.’’ empirically modeled the relationship
region area are as follows: Section 1886(d)(12)(C)(ii) of the Act between hospital costs-per-case and
further stipulates that the term total discharges in several ways. We
Number of ‘‘discharge’’ refers to total discharges, used both regression analysis and
Region discharges and not merely to Medicare discharges. straight-line statistics to examine this
Specifically, the term refers to the relationship.
1. New England (CT, ME, MA, ‘‘inpatient acute care discharge of an We conducted three different
NH, RI, VT) ........................... 7,494
individual regardless of whether the regression analyses. For all of the
2. Middle Atlantic (PA, NJ, NY) 9,332
3. South Atlantic (DE, DC, FL, individual is entitled to benefits under analyses, we simulated the FY 2005 cost
GA, MD, NC, SC, VA, WV) .. 10,001 part A.’’ Finally, the provision requires environment by inflating FY 2002 and
4. East North Central (IL, IN, the Secretary to determine an applicable FY 2003 hospital cost report data to FY
MI, OH, WI) ........................... 8,261 percentage increase for these low- 2005 using the full hospital market
5. East South Central (AL, KY, volume hospitals based on the basket updates. We note that, at the time
MS, TN) ................................. 7,812 ‘‘empirical relationship’’ between ‘‘the of this analysis, we only had cost report
6. West North Central (IA, KS, standardized cost-per-case for such data from FY 2003 for approximately 57
MN, MO, NE, ND, SD) .......... 7,084 hospitals and the total number of percent of the IPPS hospitals. Therefore,
7. West South Central (AR, LA,
discharges of these hospitals and the we have placed a greater weight on the
OK, TX) ................................. 7,093
8. Mountain (AZ, CO, ID, MT, amount of the additional incremental results from the simulated FY 2002 cost
NV, NM, UT, WY) ................. 9,288 costs (if any) that are associated with data, which are significantly more
9. Pacific (AK, CA, HI, OR, such number of discharges.’’ The statute complete. We again simulated the FY
WA) ....................................... 6,885 thus mandates the Secretary to develop 2005 payment environment because
an empirically justifiable adjustment payments have undergone several
We note that the median number of based on the relationship between costs changes between FY 2002 and FY 2003
discharges for hospitals in each census and discharges for these low-volume and FY 2005, making the results of the
earlier data less relevant. Furthermore, significant relationship between the volume increase. By extending the
many of these policy changes may cost-to-payment ratio and total adjustment to hospitals with slightly
already have helped increase payments discharges. more than 200 discharges and by
to low-volume hospitals. We were The third regression analysis phasing out the adjustment through the
unable to simulate the FY 2006 employed per discharge costs minus per use of a declining continuous
environment because payment factors discharge payments as the dependent adjustment, the commenter added,
for FY 2006 were not available at the variable and total discharges as an hospitals may be less likely to
time of our analysis. explanatory variable. The results of this experience significant year-to-year
In the first regression analysis, we analysis were similar to the other variation in payments; especially if a
used a dummy variable approach to regression analyses: some evidence was hospital has slightly less than 200
model the relationship between provided for an adjustment with the FY discharges one year and slightly more
standardized costs and total discharges. 2002 data, but not with the FY 2003 than 200 discharges the next. The
Using FY 2002 cost data, we found some data, simulated for FY 2005. In fact, the commenter indicated that such an
evidence for a low-volume payment FY 2003 data results suggest (with a adjustment might also alleviate any
adjustment for hospitals with up to 199 positive intercept and positive possible payment inequities for
discharges, consistent with our current coefficient on total discharges) that hospitals with just over 200 discharges
policy. Using FY 2003 cost data, the payments are greater than costs for all in comparison to those with less than
empirical evidence only supported an hospitals, including the low-volume 200 discharges within any given year.
adjustment for hospitals with up to 99 hospitals. Response: Our analysis for the low-
total discharges. Based upon these multivariate volume adjustment included an
We also used a descriptive analysis analyses using the FY 2002 cost report investigation of the use of a continuous
approach to understand empirically the data, a case can be made that hospitals formula. Neither the payment-to-cost
relationship between costs and total with fewer than 200 total discharges ratios nor the regressions models of
discharges. We grouped all hospitals by have per discharge costs that are standardized costs per discharge and
their total discharges and compared the statistically significantly higher relative total discharges revealed any pattern
mean Medicare per discharge payment to their Medicare per discharge that could be used to model a
to Medicare per discharge cost ratios. payments in comparison to hospitals continuous formula given the
Hospitals with less than 800 total with 200 or more total discharges. constraints on the maximum
discharges were split into 24 cohorts Therefore, as we proposed in the FY adjustment. As mentioned above, the
based on increments of 25 discharges. 2006 IPPS proposed rule, in this final descriptive analysis of the data indicates
When using the FY 2002 cost report rule we are extending the existing low- that, for a large majority of the hospitals
data, the mean payment-to-cost ratios volume adjustment for FY 2006. That is, with less than 200 discharges, the
were below one (implying that Medicare a low-volume adjustment would again maximum adjustment of 25 percent
per discharge costs exceeded Medicare be provided for qualifying hospitals would be appropriate because, for
per discharge payments) for all cohorts with less than 200 discharges. As noted example, the payment-to-cost ratios for
of hospitals with less than 200 above, the descriptive data do not reveal more than 70 percent of these hospitals
discharges, after which the ratio was any pattern that could provide a formula are 0.80 or less. The maximum
consistently above one. When using the for calculating an adjustment in relation adjustment of 25 percent would still
FY 2003 cost report data, the mean to the number of discharges. However, leave most of these hospitals with
payment-to-cost ratios were below one the descriptive analysis of the data does payment-to-cost ratios below 1.00.
for all but two cohorts up to those with indicate that, for a large majority of the When looking at the FY 2002 data, the
less than 175 total discharges, after hospitals with less than 200 discharges, mean payment-to-cost ratio for hospitals
which the ratio was consistently above the maximum adjustment of 25 percent with between 175 and 199 total
one. No obvious increasing trend in the would be appropriate because, for discharges was 0.79. Therefore, there is
ratios, from which it would be possible example, the payment-to-cost ratios for some empirical evidence that the
to infer a formula to generate more than 70 percent of these hospitals maximum adjustment of 25 percent is
adjustments for hospitals based upon are 0.80 or less. The maximum appropriate even for hospitals with
the number of discharges, was evident. adjustment of 25 percent would still slightly less the 200 hospitals. In
Because more than 70 percent of leave most of these hospitals with addition, as indicated above, our
hospitals with less than 200 discharges payment-to-cost ratios below 1.00. analysis, including both the regressions
had ratios below 0.80, this analysis Because a large majority of hospitals and payment-to-cost ratios, did not
supports applying the highest payment with less than 200 discharges have support adjustments for hospitals with
adjustment to all providers with less payment-to-cost ratios below 1.00, we 200 or more discharges. Thus, the
than 200 discharges that are eligible for believe that it is appropriate to again evidence does not suggest that there
the low-volume adjustment. provide hospitals with less than 200 would be an inequity in our policy for
The second regression analysis total discharges in the most recent hospitals with more than 200
modeled the Medicare per discharge submitted cost report an adjustment of discharges. We also do not have any
cost to Medicare per discharge payment 25 percent on each Medicare discharge. evidence from hospitals of significant
ratio as a function of total discharges. This policy is consistent with the year-to-year variation in payments due
The cost-to-payment ratio model more existing language in § 412.101(a) and to the low-volume adjustment.
explicitly accounts for the relative (b). Therefore, the most empirically
values of per discharge costs and per Comment: One commenter supported justifiable adjustment that we found was
discharge payments. These models a continuous adjustment rather than the to give the maximum percentage
provided some evidence for a application of the same percentage adjustment to all low-volume hospitals
statistically significant negative adjustment to all qualifying low-volume with less than 200 discharges.
relationship between the cost-to- hospitals. The commenter indicated that Comment: Commenters suggested that
payment ratio and total discharges. the continuous adjustment should use it is not necessary to update the analysis
However, that result was limited to FY an empirically-based formula to lower and adjustment for the low-volume
2002 data. FY 2003 data displayed no the adjustment for hospitals as their adjustment every year. The rationale
behind this comment is that the is effective for discharges occurring on have an unweighted FTE resident limit
adjustment should reflect the long-term or after October 1, 1997. A similar limit for IME.
relationship between volume and costs, is effective for direct GME purposes for To address this situation, in the FY
which should not change significantly cost reporting periods beginning on or 2006 IPPS proposed rule (70 FR 23432),
from year to year. after October 1, 1997. we proposed to incorporate in the
Response: Because the IPPS policy When these provisions were enacted, regulations (proposed
environment can significantly change hospitals reported their weighted FTE § 412.105(f)(1)(xiii)) CMS’ existing
from year to year, we do believe that is resident count for direct GME and their policy in such situations which
important to regularly investigate the unweighted FTE resident count for IME provides for the establishment of an IME
relationship between hospitals’ on the Medicare cost report. The cost FTE cap for a hospital that was
standardized costs per discharge and report was subsequently modified to excluded from the IPPS during the FTE
volume of discharges for purposes of the require reporting of unweighted FTE cap base year and that subsequently
low-volume adjustment. In addition, the resident counts for both direct GME and became subject to the IPPS. We clarified
initial analysis of the FY 2003 data does IME. However, for cost reporting and proposed to adopt into regulations
not seem to provide strong empirical periods ending on or before December our existing policy that, in such a
evidence for a relationship between 31, 1996 (the cost report on which the situation, the fiscal intermediary would
Medicare per discharge costs and total FTE limit is based), hospitals were not determine an IME FTE cap for the
discharges. Therefore, we will required to report unweighted FTE hospital, applicable beginning with the
reevaluate the appropriateness of the resident counts for direct GME hospital’s payments under the IPPS,
low-volume adjustment in the FY 2007 purposes. Therefore, a separate data based on the FTE count of residents
proposed rule. collection effort was required to obtain during the cost reporting period(s) used
the unweighted FTE resident counts. to determine the hospital’s direct GME
F. Indirect Medical Education (IME) The fiscal intermediaries worked with FTE cap in accordance with existing
Adjustment (§ 412.105) hospitals to determine the unweighted § 412.105(f) of the regulations. The new
1. Background FTE resident counts for direct GME for IPPS hospital’s IME FTE cap would be
cost reporting periods ending on or subject to the same rules and
Section 1886(d)(5)(B) of the Act before December 31, 1996, for purposes adjustments as any IPPS hospital’s IME
provides that prospective payment of implementing the FTE cap. FTE cap in accordance with § 412.105(f)
hospitals that have residents in an During this process, the fiscal of the regulations.
approved graduate medical education intermediaries did not determine IME While calculation of the IME FTE cap
(GME) program receive an additional FTE resident counts for hospitals that for a formerly IPPS-excluded hospital
payment to reflect the higher indirect were excluded from the IPPS (that is, that converts to an IPPS hospital may
costs of teaching hospitals relative to psychiatric hospitals, LTCHs, require that fiscal intermediaries obtain
nonteaching hospitals. The regulations rehabilitation hospitals, children’s information from cost reporting periods
regarding the calculation of this hospitals, and cancer hospitals) because that are closed, allowing a fiscal
additional payment, known as the these hospitals were not paid under the intermediary to obtain this information
indirect medical education (IME) IPPS and, therefore, did not receive any should not be understood as allowing a
adjustment, are located at § 412.105. IME payment adjustments. Only the fiscal intermediary to reopen closed cost
The IME adjustment to the DRG FTE resident data related to direct GME reports that are beyond the normal
payment is based in part on the payments were relevant for these reopening period in order to carry out
applicable IME adjustment factor. The excluded hospitals and, therefore, only the provisions of this regulation.
IME adjustment factor is calculated those data were collected. However, it Finally, there may be situations where
using a hospital’s ratio of residents to has come to our attention that some the data necessary to carry out this
beds, which is represented as r, and a hospitals that were excluded from the policy are not available. For example,
formula multiplier, which is IPPS during the cost reporting period under our proposal, if a children’s
represented as c, in the following ending on or before December 31, 1996 hospital converts to an IPPS hospital on
equation: c × [{1 + r} .405¥1]. The (that is, the cost reporting period during July 1, 2007, the fiscal intermediary may
formula is traditionally described in which the hospital’s FTE resident limit need to determine the count of FTE
terms of a certain percentage increase in was established under section residents for IME purposes training at
payment for every 10-percent increase 1886(h)(4)(F) of the Act for purposes of the hospital during the most recent cost
in the resident-to-bed ratio. direct GME payments) have either failed reporting period ending on or before
to continue to qualify for exclusion from December 31, 1996, in order to establish
2. IME Adjustment for IPPS-Excluded an IME FTE cap for the hospital,
the IPPS or deliberately changed their
Hospitals Converting to IPPS Hospitals effective for discharges occurring on or
operations in a way to become subject
The Balanced Budget Act of 1997 to the IPPS and, as a result, have after October 1, 2007. However, the
(Pub. L. 105–33) established a limit on subsequently become subject to the IME count of FTE residents for IME purposes
the number of allopathic and payment adjustment provisions of the from the cost reporting period ending on
osteopathic residents that a hospital IPPS. For example, a provider that was or before December 31, 1996, may no
may include in its full-time equivalent a rehabilitation hospital during its cost longer be available, as the minimum
(FTE) resident count for direct GME and reporting period ending on December time that hospitals are required to retain
IME payment purposes. Under section 31, 1996, but no longer meets the records is 5 years from the date the
1886(h)(4)(F) of the Act, a hospital’s regulatory criteria to qualify as a hospital submits the cost report. We
unweighted FTE count of residents may rehabilitation hospital would become believe this problem may not occur with
not exceed the hospital’s unweighted subject to the IPPS and be able to sufficient frequency to warrant specific
FTE count for its most recent cost receive IME payments. However, regulatory action. In the FY 2006 IPPS
reporting period ending on or before because no IME FTE resident count for proposed rule, we specifically solicited
December 31, 1996. Under section the cost reporting period ending on or comments as to whether and how
1886(d)(5)(B)(v) of the Act, the limit on before December 31, 1996, was hospitals believe this is a problem that
the FTE resident count for IME purposes determined, such a hospital does not needs to be addressed.
Comment: Commenters pointed out established IME cap remains unaffected. from cost reports ending on or before
that the proposed rule applies to an We note further that the hospital’s direct December 31, 1996.
IPPS excluded hospital that is GME cap is unaffected by the closure of Response: We agree with the
subsequently certified as an acute the unit because the direct GME limit commenters that using data from 1996
hospital and is subject to IPPS. was established based on the FTE to establish the IME cap for IPPS-
However, the commenters added, the residents training in the hospital excluded hospitals converting to the
proposed rule is silent on the complex, including the IPPS-excluded IPPS many years after 1996 could be
applicability of the proposed unit. Furthermore, such units are problematic. However, section
methodology to adjust the IME resident nonetheless provider-based as defined 1886(d)(5)(B)(v) of the Act explicitly
cap of an acute hospital that had an in 42 CFR 413.65 and, therefore, have requires that ‘‘the total number of full-
excluded unit and the unit subsequently always been integrally related to the time equivalent interns and residents
becomes subject to the IPPS. Some hospital. While commenters have * * * may not exceed the number
commenters believed CMS should apply argued that the transition of IPPS- * * * of such full-time equivalent
the same methodology and treat these excluded units into acute care hospitals interns and residents in the hospital
formerly IPPS-excluded units in the is comparable to the transition of with respect to the hospital’s most
same way as the freestanding IPPS- freestanding IPPS-excluded hospitals to recent cost reporting period ending on
excluded hospitals that are the IPPS, we believe the more accurate or before December 31, 1996.’’
subsequently certified as acute care comparison is the one we have Therefore, the statute requires that the
hospitals subject to the IPPS. One presented above. That is, when a former IME cap be based on the 1996 data.
commenter maintained that the IPPS-excluded unit is subsumed within However, because FTE residents are
situations are comparable because, if a an acute care hospital and, thereby, counted differently for purposes of IME
teaching hospital in 1996 had residents becomes subject to the IPPS, it is and direct GME payments (for example,
training in a rehabilitation department equivalent to an expansion in the bed in 1996, FTE residents were not counted
that was not an excluded unit, those size of the acute care hospital. in an IPPS-excluded unit for IME and,
residents would have been included in Therefore, we believe the acute care therefore, would not have been included
the hospital’s IME cap. However, the hospital’s established IME FTE resident in determining the IME cap) even where
commenter added that if the cap should remain unaffected as the hospital has an existing direct GME
rehabilitation unit was excluded from consistent with bed size expansions FTE cap that was determined for the
the IPPS during the FTE cap base year, under other circumstances. IPPS-excluded hospital based on data
the hospital was not permitted to Regarding the possibility of a from the hospital’s 1996 cost report, an
include the resident counts from the discrepancy between the IME and direct appropriate IME FTE resident count
excluded unit in its IME cap GME FTE resident caps, we note that, by must be determined based on data from
calculation. Therefore, the commenter virtue of the statute and our regulations, the hospital’s most recent cost reporting
contended that an acute care hospital the rules differ for counting of FTE period ending on or before December
that no longer has a separately certified residents for purposes of IME and GME, 31, 1996. In some instances, the
IPPS-excluded unit should be able to and many hospitals currently have necessary data from 1996 to determine
add the resident count of the formerly different FTE resident caps for IME and the IME cap may no longer be available.
excluded unit to the hospital’s IME cap. direct GME payments. Accordingly, where 1996
The commenter noted that adding the Comment: In response to our documentation is no longer available,
FTE count from the formerly excluded expression of concern about the we will use the following methodology.
unit to the acute care hospital’s existing potential that FTE resident information In order to be consistent with the statute
IME cap avoids a discrepancy between may no longer be available to establish that requires IPPS IME FTE caps to be
the direct GME and IME resident caps. an IME FTE cap for a 1996 base year, determined based on the 1996 cost
Response: In the case where a and our solicitation of comments on that reporting period data, we will use the
psychiatric or rehabilitation unit within issue, some commenters recommended hospital’s direct GME cap, which is
the hospital is no longer separately that CMS make IME cap determinations from the 1996 cost reporting period, be
certified from the acute care hospital, based on more current data than the cost used as a starting point for determining
we do not believe it is appropriate to reports ending on or before December the IME cap. However, because the rules
recalculate the acute care hospital’s IME 31, 1996. The commenters supported for counting FTEs for direct GME differ
cap to include the IME FTE resident using either or both of the following cost somewhat from the rules for counting
count from the base year for which the reporting periods: (1) The most recent FTEs for IME, particularly prior to the
hospital’s FTE limits were previously cost report period prior to November 15, BBA of 1997, IME data from the
established. Section 1886(d)(5)(B)(v) of 2004, which CMS used in the policy to hospital’s most recent cost reporting
the Act has already established the establish the adjustments to the PPS period ending on or before December
methodology for determining an acute payments due to ‘‘teaching status’’ for 31, 2004, will be used to adjust the 1996
care hospital’s IME cap. We note that if the IPF PPS; and (2) the most recent cost direct GME cap in order to establish the
the hospital creates a new rehabilitation report period prior to November 15, hospital’s 1996 IME cap. For example,
or psychiatric unit within the acute care 2003, which CMS proposed for the IRF since in 1996, residents training in
IPPS hospital, the hospital’s IME cap is PPS. nonhospital sites could be counted for
not adjusted, because the cap is One commenter pointed out that direct GME but not for IME, if the data
established for the hospital based on the teaching hospitals have changed from the hospital’s most recent cost
number of residents it was training in significantly since 1996, the year on reporting period ending on or before
1996. In the case of an acute care which caps are based. Therefore, the December 31, 2004, showed that
hospital that ‘‘closes’’ its IPPS-excluded commenter believed it would be unfair residents spent 10 percent of their time
unit, at best it is only adding beds to the to establish new IME caps on hospitals’ training at nonhospital sites, then the
existing acute care IPPS hospital. In situations from 10 years ago. 1996 direct GME cap would be reduced
instances where an acute care hospital Some commenters supported our by 10 percent to reflect that in 1996,
adds or removes beds, the previously proposal to base the IME cap on the data residents training in nonhospital sites
would not have been included in the IPPS. In order to be consistent with the its direct GME FTE resident cap to the
IME count. statute at section 1886(d)(5)(B)(v), aggregate FTE resident cap for the
Comment: One commenter requested which requires the limit on the total group. This is because, as long as a
that CMS make it clear that any new number of FTE residents for payment hospital remains excluded from the
IME cap for a hospital that was purposes to be based on the 1996 cost IPPS, that hospital will not have an FTE
excluded from the IPPS will be based on reporting period, we believe it is resident cap established for purposes of
the count of FTEs rotating both within appropriate to determine the IME cap IME. Under no circumstances may an
the hospital and in qualifying based on the hospital’s data from 1996 IPPS-excluded hospital be considered to
nonhospital sites. when the data are available. However, contribute any FTE residents to a
Response: We disagree with the in instances where IME-specific 1996
commenter and clarify that the IME cap Medicare GME affiliation group for
data are unavailable, the IME data for purposes of the aggregate IME FTE
for formerly IPPS-excluded hospitals the most recent cost reporting period
will not include FTE counts of residents resident cap. IPPS-excluded hospitals
ending on or before December 31, 2004,
training at nonhospital sites. The IME do not currently, and would not under
must be used to determine the 1996 IME
cap will be established for the base year this policy, have an IME FTE resident
cap. In some cases, a hospital that was
in accordance with the IME regulations previously excluded from the IPPS may cap.
that were in effect in 1996. Those become subject to the IPPS as a result In this final rule, we are incorporating
regulations did not allow residents of a merger between two or more in the regulations at
training at nonhospital sites to be hospitals where the surviving hospital is §§ 412.105(f)(1)(xiii) and (f)(1)(xiv)
included in the IME FTE count. subject to the IPPS (which we (proposed § 412.105(f)(1)(xiii) in the
Accordingly, only residents training in distinguish from a merger that results in proposed rule) CMS’ existing policy in
the inpatient (the portion of the hospital an IPPS hospital with an excluded unit). situations that provide for the
subject to IPPS) and outpatient In such cases, CMS policy is that the establishment of an IME FTE cap for a
departments of the hospital can be FTE resident cap for the surviving IPPS hospital that was excluded from the
counted to establish the IME FTE cap hospital should reflect the combined
for 1996. The BBA revised the statute to IPPS during its base year and that
FTE resident caps for the hospitals that subsequently became subject to the
allow residents training at nonhospital merged. If two or more hospitals merge
sites to be counted for purposes of IME IPPS. We are providing that, in such a
after the conclusion of each hospital’s situation, the fiscal intermediary will
payments only effective October 1, base year for purposes of calculating
1997. Therefore, the hospitals’ FTE determine an IME FTE cap for the
FTE resident caps, the surviving hospital, applicable beginning with the
count in 1996, the base year for hospital’s FTE resident cap is an
establishing the IME cap, may not hospital’s payments under the IPPS,
aggregation of the FTE resident cap for
include any residents training at based on the FTE count of residents
each hospital participating in the
nonhospital sites. during the cost reporting period(s) used
merger. When a merger involves an
Comment: One commenter to determine the hospital’s direct GME
IPPS-excluded hospital, the base year
interpreted our proposal in the FTE cap in accordance with existing
IME FTE resident count for the IPPS-
proposed rule to mean the hospital’s § 412.105(f) of the regulations. The new
excluded hospital would not have been
IME cap would equal the resident count IPPS hospital’s IME FTE cap will be
determined previously. As we proposed,
that was used to establish the direct subject to the same rules and
we are clarifying and codifying in
GME cap. adjustments as any IPPS hospital’s IME
Response: We believe the commenter regulations our existing policy that, in
such cases, the fiscal intermediary FTE cap in accordance with § 412.105(f)
misunderstood our proposal. Under the of the regulations. We note that, while
proposed rule, we would have would determine an IME FTE resident
cap for the IPPS-excluded hospital for we are finalizing the policy under
determined the IME cap based on the
purposes of determining the merged which the fiscal intermediary will
FTE resident data in the most recent
hospital’s IME FTE cap in accordance determine an IPPS IME FTE cap for an
cost reporting period ending on or
before December 31, 1996. Because FTE with § 412.105(f) of the regulations. IPPS-excluded hospital that merges with
residents are counted differently for Once this cap is determined, the an IPPS hospital if no IPPS-excluded
purposes of IME and direct GME aggregate IME FTE resident cap of the unit is created, we will be vigilant to
payments (for example, FTE residents surviving entity may be calculated in ensure that this policy is not
are not counted in an IPPS-excluded accordance with existing CMS policy for inappropriately manipulated. For
unit for IME), we note that the FTE mergers. example, in a merger between an IPPS
resident data for computing the IME cap We note that we would compute an hospital and an IPPS-excluded hospital
would have come from the same cost IME cap for an IPPS-excluded hospital where no IPPS-excluded unit is created
reporting period used to establish the only in cases of a merger between an initially, and the surviving IPPS
direct GME cap, but not necessarily be IPPS-excluded hospital and an acute hospital benefits from the determination
the direct GME cap itself. care IPPS hospital, where the entire of an IPPS IME FTE cap relating to the
Comment: Some commenters opposed surviving entity is subject to the IPPS. formerly IPPS-excluded hospital, we
the reduction in the FY 2006 IME No IME FTE resident cap would be would continue to monitor whether the
formula and urged CMS to maintain the computed for an IPPS-excluded hospital hospital ultimately creates an IPPS-
formula at its current percentage. in instances where an IPPS-excluded excluded unit. If the hospital did create
Response: We did not propose any hospital and an acute care IPPS hospital an IPPS-excluded unit, we would
changes in policy concerning this issue. agree to form a Medicare GME affiliated closely examine the facts to determine
In summary, we are changing the group for purposes of aggregating FTE
whether the unit was created ‘‘as a
policy in response to comments resident caps. In cases where an IPPS-
result of the merger’’ and, therefore, the
regarding the base year to use to excluded hospital enters into a
establish the IME cap for a hospital that Medicare GME affiliation agreement determination and application of an
was excluded from the IPPS and that with other IPPS hospitals, the IPPS- IPPS IME FTE cap was not appropriate.
subsequently becomes subject to the excluded hospital can contribute only
3. Section 1886(d)(8)(E) Teaching hospitals might reclassify to rural areas Response: We appreciate the
Hospitals That Withdraw Rural under section 1886(d)(8)(E) of the Act commenters’ concerns. We agree with
Reclassification for a short period of time solely as a the commenters that, if an urban
In section V.I. of this preamble, we means of receiving an increase to their hospital were reclassified as rural for a
discuss situations in which an urban IME FTE caps. These hospitals could significant amount of time, the urban
hospital may become rural under a reclassify for as little as one year, simply hospital should be allowed to retain any
reclassification request under section in order to receive a permanent increase adjustments to its IME FTE cap.
1886(d)(8)(E) of the Act. Under section to their IME FTE caps. Because section However, we believe 10 years is a more
1886(d)(8)(E) of the Act, an urban 1886(d)(8)(E) hospitals have control appropriate time period than 5 years. A
hospital may file an application to be over when they switch in and out of 10-year time period is most similar to
treated as being located in a rural area. rural status, we believe any other policy the period in which the OMB reassesses
Becoming rural under this provision would be subject to gaming and its urban and rural designations, and we
affects only payments under section inappropriate usage of the section have historically reviewed our
1886(d) of the Act. If the hospital is a 1886(d)(8)(E) authority. In contrast, geographic designations. Thus, hospitals
teaching hospital, the hospital could not hospitals that become urban due to the generally maintain their urban or rural
receive any adjustments to its direct OMB-revised labor area designations status (absent any action on their part to
GME FTE cap that are available only to have no control in the matter, and reclassify) for 10 years. In other words,
therefore would not be subject to the because the census is taken every 10
rural hospitals because payments for
same type of manipulation of payment years, and revisions to the labor market
direct GME are made under section
rates we believe would exist with the areas are based on such census data,
1886(h) of the Act and the section
section 1886(d)(8)(E) hospitals.10 hospitals generally will maintain urban
1886(d)(8)(E) reclassifications affect Comment: Several commenters
only the payments that are made under or rural status for a period of 10 years,
commended CMS and supported our
section 1886(d) of the Act. Therefore, an and changes would occur only once
proposal to revise the current
urban hospital that reclassifies as rural new census figures have been issued.
regulations that would allow a rural
under this provision may receive the Any shorter time period would treat
hospital redesignated as urban as a
130-percent adjustment to its IME FTE hospitals that voluntarily obtain rural
result of the changes to CBSA that were
resident cap. In addition, its IME FTE status through section 1886(d)(8)(E) of
effective October 1, 2004, to retain any
cap may be adjusted for any new the Act differently from hospitals
cap adjustments that it received as a
programs (as can a hospital that is rural hospital. However, some assigned rural status solely due to our
actually located in an area designated as commenters recommended that, under implementation of revisions to the OMB
rural) under section 1886(d)(5)(B)(v) of certain circumstances, an urban labor market areas. Thus, we believe it
the Act, as amended by section 407 of teaching hospital that reclassifies under is most equitable to utilize a 10-year
Pub. L. 106–113 (BBRA). section 1886(d)(8)(E) of the Act to period, and we are providing in this
An urban hospital treated as rural become rural and then subsequently final rule that, effective October 1, 2005,
under section 1886(d)(8)(E) of the Act withdraws its election to return to urban a hospital that rescinds its section
may subsequently withdraw its election status should be allowed to retain any 1886(d)(8)(E) reclassification will forfeit
and return to its urban status under the IME FTE cap adjustments it might have any adjustments to its IME FTE cap it
regulations at § 412.103. In the FY 2006 received while rural, if that hospital has received due to its rural status if that
IPPS proposed rule, we proposed that, been reclassified as rural for a hospital were reclassified as rural for
effective with discharges occurring on significant period of time (for example, fewer than 10 years. We are amending
or after October 1, 2005, hospitals that 5 or 10 years). The commenter believed the regulations at § 412.105 by adding a
rescind their section 1886(d)(8)(E) rural that, in such a scenario, the urban new paragraph (f)(1)(xv) to provide that
reclassifications and return to being hospital obviously did not reclassify a hospital that maintained a section
urban could not retain permanently the merely as a means of receiving an 1886(d)(8)(E) reclassification for fewer
30-percent increases in their IME caps. increase to its IME FTE caps and, than 10 years and that rescinds such
Rather, any adjustments the hospitals therefore, should be allowed to keep any reclassification will forfeit any
received to their IME FTE resident caps increase to its FTE caps. adjustments to its IME FTE cap it
due to their rural status would be received due to its rural status. Thus, for
forfeited upon returning to urban status. 10 We note that the proposed policy would have example, a hospital that reclassified as
Although we read the relevant IME FTE no effect on rural track resident training programs. rural for fewer than 10 years under
cap provisions in section 1886(d)(5)(B) Section 1886(h)(4)(H)(iv) of the Act, which governs section 1886(d)(8)(E) of the Act with an
direct GME, provides that an urban hospital may
of the Act as effecting a permanent receive adjustments to its FTE caps for establishing IME FTE cap of 10 would have received
increase to the FTE cap, we believe we ‘‘separately accredited approved medical residency a 130 percent adjustment to its IME cap
have the statutory authority under training programs (or rural tracks) in an [sic] rural (that is, 10 FTEs x 1.3). Furthermore, if
section 1886(d)(5)(I) of the Act to make area.’’ The provisions governing IME payments this hospital, while reclassified as rural,
state that ‘‘Rules similar to the rules of subsection
necessary adjustments to these caps that (h)(4)(H) shall apply for purposes of’’ determining started a new 3-year residency program
we believe are appropriate. Section FTE resident caps (section 1886(d)(5)(B)(viii) of the with 2 residents in each program year,
1886(d)(5)(I)(i) of the Act grants the Act). Since the requirement that the hospital be its FTE cap would have been increased
located in a rural area is found in the provisions
Secretary authority to provide by governing direct GME (section 1886(h) of the Act), by an additional 6 FTEs (due to the cap
regulation for ‘‘such other exceptions not the provision governing IME, and since adjustment under § 413.79(e)(1)(iii) or
and adjustments to such payment hospitals cannot reclassify as rural for purposes of (e)(3), which is only applicable to rural
amounts under this subsection as the section 1886(h) of the Act, we believe that, as hospitals) to 19 FTEs (that is, 13 FTEs
provided in section 1886(h) of the Act, the hospital
Secretary deems appropriate.’’ We with which the urban hospital establishes the rural + 6 FTEs). However, once this hospital
believe it is appropriate that a section track must be physically located in an area rescinds its reclassification under
1886(d)(8)(E) hospital forfeit the designated as rural. We do not believe we would section 1886(d)(8)(E) of the Act to
be properly incorporating the rules of section
adjustments it received solely due to its 1886(h) of the Act or creating a rule similar to that
become urban again, its IME FTE cap
reclassification to rural status when it used in section 1886(h) of the Act if we were to would return to 10 FTEs (its original
returns to being urban. Otherwise, urban allow counting of such reclassified hospitals. pre-reclassification IME FTE cap).
Comment: One commenter requested a new program cannot receive an subsection (d) hospitals that serve a
clarification regarding whether the adjustment to their IME FTE resident disproportionate share of low-income
urban hospital that rescinded its section caps. patients. The Act specifies two methods
1886(d)(8)(E) rural reclassification For the reasons stated above, in this for a hospital to qualify for the Medicare
under our proposal would also forfeit final rule we are amending the disproportionate share hospital (DSH)
new program IME FTE cap adjustments regulations at § 412.105 by adding a new adjustment. Under the first method,
that it received while reclassified as paragraph (f)(1)(xv) (changed from hospitals that are located in an urban
rural. proposed paragraph (f)(1)(xiv) in the area and have 100 or more beds may
Response: In the proposed rule, we proposed rule) to provide that a hospital receive a DSH payment adjustment if
stated that an urban hospital that that rescinds its section 1886(d)(8)(E) the hospital can demonstrate that,
reclassifies under section 1886(d)(8)(E) reclassification and that has been
of the Act is treated as rural for payment during its cost reporting period, more
reclassified under such section for fewer than 30 percent of its net inpatient care
purposes under section 1886(d) of the than 10 years will forfeit any
Act and, as such, can receive a 130- revenues are derived from State and
adjustments to its IME FTE resident cap
percent IME FTE cap adjustment and local government payments for care
it received due to its rural status. Thus,
can also receive IME FTE resident cap furnished to indigent patients. These
as stated in the example given above, a
adjustments based on new programs. hospital that reclassified as rural under hospitals are commonly known as
We proposed that an urban hospital that section 1886(d)(8)(E) of the Act with an ‘‘Pickle hospitals.’’ The second method,
rescinds its section 1886(d)(8)(E) IME FTE cap of 10 would have received which is also the most commonly used
reclassification would forfeit any a 130 percent adjustment to its IME FTE method for a hospital to qualify, is
increases to its IME cap that it received cap (that is, 10 FTEs × 1.3). based on a complex statutory formula
as a result of being reclassified as rural. Furthermore, if this hospital, while under which payment adjustments are
As mentioned above in this final rule, reclassified as rural, started a new 3- based on the level of the hospital’s DSH
we are modifying our proposal to state year residency program with 2 residents patient percentage, which is the sum of
that only an urban hospital that had in each program year, its IME FTE two fractions: the ‘‘Medicare fraction’’
reclassified as rural for fewer than 10 resident cap would have been increased and the ‘‘Medicaid fraction.’’ The
years will forfeit the cap adjustments by an additional 6 FTEs to 19 FTEs (that Medicare fraction is computed by
that it received as a result of being is, 13 FTEs + 6 FTEs). However, if the dividing the number of patient days that
reclassified as rural. Therefore, in hospital maintains its rural status for a are furnished to patients who were
response to the commenter, where the
period of fewer than 10 continuous entitled to both Medicare Part A and
hospital had been reclassified as rural
years, once the hospital rescinds its Supplemental Security Income (SSI)
under section 1886(d)(8)(E) of the Act
reclassification under section benefits by the total number of patient
for fewer than 10 years and then
1886(d)(8)(E) of the Act to become urban days furnished to patients entitled to
rescinds its rural reclassification, the
again, its IME FTE resident cap would benefits under Medicare Part A. The
hospital’s IME FTE resident cap would
return to 10 FTEs (its original pre- Medicaid fraction is computed by
be adjusted to eliminate any adjustment
reclassification IME FTE cap). dividing the number of patient days
for training residents in a new program.
Only rural hospitals may receive a cap G. Payment to Disproportionate Share furnished to patients who, for those
adjustment at any time for starting new Hospitals (DSHs) (§ 412.106) days, were eligible for Medicaid but
programs. Unless the urban hospital were not entitled to benefits under
qualifies for a cap adjustment for new 1. Background Medicare Part A by the number of total
programs under § 413.79(e)(1), an urban Section 1886(d)(5)(F) of the Act hospital patient days in the same
hospital that begins training residents in provides for additional payments to period.
Medicare, SSI Days Medicaid, Non - Medicare Days

DHS Patient Percentage = +
Total Medicare Days Total Patient Days
2. Implementation of Section 951 of the Medicare and Medicaid fractions, 3. Calculation of the Medicare Fraction
Pub. L. 108–173 (MMA) we interpret section 951 to require CMS
The first component of the Medicare
to arrange to furnish the personally
In the FY 2006 IPPS proposed rule (69 DSH patient percentage calculation is
FR 23434), we proposed to implement a identifiable information that would the Medicare fraction. As indicated
mechanism for implementing section enable a hospital to compare and verify above, the numerator of the Medicare
951 of Pub. L. 108–173, which requires its records, in the case of the Medicare fraction includes the number of patient
the Secretary to arrange to furnish the fraction, against the CMS’ records, and days furnished by the hospital to
data necessary for hospitals to compute in the case of the Medicaid fraction, patients who were entitled to both
the number of patient days used in against the State Medicaid agency’s Medicare Part A and SSI benefits. This
calculating the disproportionate patient records. Currently, as explained in more number is divided by the hospital’s total
percentages. The provision is not detail below, CMS provides the number of patient days furnished to
specific as to whether it applies to the Medicare SSI days to certain hospitals patients entitled to benefits under
patient day data used to determine the that request these data. Hospitals are Medicare Part A. In order to determine
Medicare fraction or the Medicaid currently required under the regulation the numerator of this fraction for each
fraction. We interpret section 951 to at § 412.106(b)(4)(iii) to provide the data hospital, CMS obtains a data file from
require the Secretary to arrange to adequate to prove eligibility for the the Social Security Administration
furnish to hospitals the data necessary Medicaid, non-Medicare days. (SSA). CMS matches personally
to calculate both the Medicare and identifiable information from the SSI
ER12AU05.009</MATH>
Medicaid fractions. With respect to both file against its Medicare Part A
entitlement information for the fiscal use that was described in the August 18, eliminate the need for a pending appeal
year to determine the number of 2000 Federal Register. Currently, a in order to receive the data and to
Medicare/SSI days for each hospital hospital qualifies under the routine use eliminate the corresponding fee.
during each fiscal year. These data are if it has an appeal properly pending Several commenters requested that
maintained in the MedPAR Limited before the Provider Reimbursement CMS expedite the publication of the
Data Set (LDS) as described in more Review Board (PRRB) or before an updated routine use for the MedPAR
detail below and discussed in a notice intermediary on the issue of whether it system of records, which will reflect the
published on August 18, 2000 in the is entitled to DSH payments, or the changes necessary to implement section
Federal Register (65 FR 50548). The amount of such payments. Once 951 of Pub. L. 108–173. One commenter
number of patient days furnished by the determined eligible to receive the data urged CMS to eliminate the fee
hospital to Medicare beneficiaries under the routine use, the hospital is associated with data requests for all
entitled to SSI is divided by the then required to sign a data use years and not just years that span
hospital’s total number of Medicare agreement with CMS to ensure that the December 8, 2004. In addition, the
days (the denominator of the Medicare data are appropriately used and commenter recommended the
fraction). CMS determines this number protected, and pay the requisite fee. elimination of the appeals requirement
from Medicare claims data; hospitals Beginning with cost reporting periods for all years, including those that occur
also have this information in their that include December 8, 2004 (within before the cost reporting period that
records. The Medicare fraction for each one year of the date of enactment of includes December 8, 2004.
hospital is posted on the CMS Web site Pub. L. 108–173), we will arrange to One commenter recommended that
(http://www.cms.hhs.gov) under the furnish, consistent with the Privacy Act, CMS clarify how hospitals will receive
SSI/Medicare Part A Disproportionate MedPAR LDS data for a hospital’s the SSI/Medicare data for both the
Share Percentage File. Under current patients eligible for both SSI and Federal fiscal year and the hospital’s
regulations at § 412.106(b)(3), a hospital Medicare at the hospital’s request, cost reporting period. The commenter
may request to have its Medicare regardless of whether there is a properly also asked whether CMS expected or
fraction recomputed based on the pending appeal relating to DSH would require hospitals to elect the
hospital’s cost reporting period if that payments. We will make the same time period from year to year.
year differs from the Federal fiscal year. information available for either the Another commenter requested that CMS
This request may be made only once per Federal fiscal year or, if the hospital’s provide specific guidance to hospitals
cost reporting period, and the hospital fiscal year differs from the Federal fiscal and fiscal intermediaries on how to use
must accept the resulting DSH year, for the months included in the 2 this information to support the
percentage for that year, whether or not Federal fiscal years that encompass the Medicare DSH calculation. One
hospital’s cost reporting period. Under commenter requested that CMS clarify
it is a more favorable number than the
this provision, the hospital will be able whether the data provided to the
DSH percentage based on the Federal
to use these data to calculate and verify hospitals will be patient-specific and
fiscal year.
its Medicare fraction, and to decide whether the data will include the date
In accordance with section 951 of whether it prefers to have the fraction of discharge.
Pub. L. 108–173, as we proposed in the determined on the basis of its fiscal year Response: We appreciate the
FY 2006 IPPS proposed rule, we are rather than a Federal fiscal year. The commenters’ support for our proposed
changing the process that we use to data set made available to hospitals will policies and kept their views in mind in
make Medicare data used in the DSH be the same data set CMS uses to developing the final regulations set forth
calculation available to hospitals. calculate the Medicare fractions for the below. We understand hospitals’ need
Currently, as stated above, CMS Federal fiscal year. for more information on the updated
calculates the Medicare fraction for each Because we interpret section 951 to routine use and data use agreement and
section 1886(d) hospital using data from require the Secretary to arrange to are working to release these documents
the MedPAR LDS (as established in a furnish these data, we do not believe as soon as possible. As we stated in the
notice published in the August 18, 2000 that it will continue to be appropriate to FY 2006 IPPS proposed rule, the new
Federal Register (65 FR 50548)). The charge hospitals to access the data. routine use and data use agreement will
MedPAR LDS contains a summary of all These changes will require CMS to require neither a fee nor a properly
services furnished to a Medicare modify the current routine use for the pending appeal before the fiscal
beneficiary, from the time of admission MedPAR LDS to reflect changes in the intermediary or the PRRB for us to
through discharge, for a stay in an data provided and the circumstances furnish information from the MedPAR
inpatient hospital or skilled nursing under which they are made available to LDS to hospitals. Hospitals must submit
facility, or both; SSI eligibility hospitals. In a future Federal Register a written request to CMS through the
information; and enrollment data on document, we will publish the details of fiscal intermediary to receive this
Medicare beneficiaries. The MedPAR any necessary modifications to the information. With respect to applying
LDS is protected by the Privacy Act of current routine use to implement this policy retroactively, section 903 of
1974 (5 U.S.C. 552a) and the Privacy section 951 of Pub. L. 108–173. Pub. L. 108–173 prohibits us from
Rule of the Health Insurance Portability Comment: Several commenters issuing retroactive rulemaking unless it
and Accountability Act of 1996 (Pub. L. supported our proposal to release is necessary to comply with statutory
104–191). The Privacy Act allows us to information from the MedPAR LDS to requirements, or failure to apply the
disclose information without an hospitals so that they can verify their change retroactively would be contrary
individual’s consent if the information Medicare DSH calculation. The to public interest. We do not believe this
is to be used for a purpose that is commenters also supported our policy meets either of the conditions for
compatible with the purpose(s) for proposal to allow hospitals to choose making the policy retroactive to cost
which the information was collected. whether they prefer to have their reporting periods prior to those that
Any such compatible use of data is calculations performed using data from span December 8, 2004.
known as a ‘‘routine use.’’ In order to the Federal fiscal year or the hospital’s We expect that hospitals will use
obtain this privacy-protected data, the cost reporting period. In addition, most these data to calculate and verify their
hospital must qualify under the routine commenters agreed with our proposal to DSH Medicare fraction, and to decide
whether they prefer to have the fraction addition, SSA is prohibited from system once and conduct no further
determined on the basis of their cost disclosing this information by Federal matches after that time. For cost
reporting period rather than a Federal law and regulations. While we cannot reporting periods that span 2 Federal
fiscal year. The information from the release the SSI eligibility information fiscal years, a hospital will receive the
MedPAR LDS released to hospitals will provided by SSA, we are permitted to data for the 2 Federal fiscal years once
contain the matched patient-specific disclose the results of the data match of the data from the second year have been
Medicare Part A inpatient days/SSI SSI eligibility information with the matched against the SSI data available
eligibility data on a month-to-month Medicare inpatient hospital billing data to CMS 6 months after the end of that
basis for the 2 Federal fiscal years that as a routine use for the MedPAR LDS year. Although it is possible that these
comprise a hospital’s cost reporting system of records. The routine use data will be available up to 17 months
period. At this time, we are not allows us to release the information to after the cost reporting period has
requiring hospitals to select either the hospitals that sign a data use agreement ended, hospitals will continue to be
Federal fiscal year or their cost reporting that limits the uses and protects the permitted to use the data to determine
period and use that selection for each privacy of the SSI/MedPAR LDS match whether they prefer to base their
subsequent year. A hospital may opt to information. calculation on data from the Federal
use the data from either time period Comment: One commenter stated that fiscal year or their cost reporting period.
each year. Regardless, a hospital will SSA has expressed a willingness to The calculation from the requested time
continue to be required under the provide CMS with updated SSI period will be used in the final
regulations at § 412.106(b)(3) to submit eligibility information that may include settlement for the cost reporting period.
a written request to CMS, through its retroactive grants or denials of This policy will be reflected in the
fiscal intermediary, if it prefers to use its eligibility, which would then be used by updated routine use and in the data use
cost reporting period data instead of the CMS to revise calculations of hospitals’ agreement, which hospitals will sign
Federal fiscal year data in determining DSH Medicare fractions. with CMS to obtain the privacy
the DSH Medicare fraction. The Response: We understand that many protected MedPAR LDS data match. As
resulting fraction will become the hospitals are concerned that later data previously mentioned, we will publish
hospital’s official DSH Medicare matches may produce a different the updated notice of routine use for the
fraction for that period and will be Medicare fraction. However, we believe MedPAR system of records in a future
binding for that cost reporting period. that there needs to be administrative Federal Register document.
Comment: One commenter cautioned finality to the calculation of a hospital’s Comment: One commenter requested
that, while access to the data could Medicare fraction. CMS has previously that CMS allow hospitals to choose the
reduce the number of appeals to the stated that its goal is to obtain data field CMS would use to conduct
PRRB on the DSH calculation, CMS reasonably accurate but not perfect the SSI eligibility/MedPAR LDS data
must respond in a timely manner to calculations (51 FR 16777). match. The commenter suggested that
hospital requests for the SSI/Medicare Additionally, our data have shown that hospitals be allowed to request that the
data for this policy to be effective. 98 to 99 percent of SSI eligibility data match be made by social security
Response: We understand that it is determinations are made and remain number, health insurance claim account
imperative that we release information unchanged 6 months after the end of the number (HICAN), name, gender, date of
from the MedPAR LDS to hospitals in a Federal fiscal year. There will be a birth, or Title II identifier, or a
timely manner to ensure that they can minimum of 6 months between the end combination of these factors.
calculate their Medicare DSH fraction. of the hospital’s cost reporting period Response: We do not use social
When we publish the updated routine and the April 1 date that we receive SSI security numbers to conduct the SSI/
use, we will indicate the timeframes eligibility information. The time lag MedPAR data match because social
within which we expect to make these between the close of a hospital’s cost security numbers are used on a ‘‘wage
data available to hospitals. Currently, reporting period and the April 1 date earner’’ basis that is not necessarily
we publish the prior Federal fiscal that we obtain the eligibility specific to an individual Medicare
year’s DSH Medicare fractions (also information could actually be much beneficiary (or hospital patient). The
called ‘‘SSI ratios’’) for all providers in longer for many hospitals. For a hospital HICANs are unique to each beneficiary.
August of each year. with an October 1 to September 30 cost Because of this, we do not have social
Comment: Several commenters reporting period, we will use SSI security numbers for every Medicare
suggested that we release the data file of eligibility information from 6 months beneficiary in the MedPAR data.
SSI eligibility information provided to after its year ends. However, we will be In addition, we do not agree that
CMS by SSA. The commenters using SSI eligibility 17 months after a individual hospitals should be given the
indicated that hospitals need access to hospital’s year ends with a November 1 choice to run the SSI/MedPAR data
the SSI eligibility file in order to to October 31 cost reporting period. match by alternative criteria. Such
compute their own Medicare DSH Given the time between the end of variation between providers would
adjustment. One commenter suggested hospital cost reporting periods and result in an inconsistent matching
that CMS modify the routine use to when we are furnished with SSI methodology, and inconsistent DSH
allow SSI eligibility information to be eligibility information for that period, Medicare fraction calculations, among
provided directly to hospitals. we believe it is highly unlikely that a providers.
Response: In accordance with the subsequent data run will produce data Comment: One commenter suggested
published routine use for the SSI system that is significantly different than one that, in place of using the MedPAR
of records maintained by the SSA, CMS completed 6 months after the end of the system, CMS use the Provider Statistical
signs a data use agreement with SSA to Federal fiscal year. and Reimbursement (PS&R) data file to
receive the SSI data file for the sole Therefore, we will use the SSI determine the denominator of the
purpose of administering the Medicare eligibility information provided to CMS Medicare fraction.
and Medicaid programs. While we by SSA 6 months after the end of the Response: We believe it is appropriate
understand the commenters’ concern, Federal fiscal year (or April 1) to to continue to use the MedPAR for
CMS is strictly prohibited from calculate the DSH Medicare fraction. We Medicare DSH calculations. Principally,
disclosing SSI eligibility information. In will match these data to the MedPAR as documented in the Federal Register,
the MedPAR system has been the appropriate days are included in the applicable statutory and regulatory
Medicare Part A data source for the DSH Medicare fraction. provisions governing the disclosure of
Medicare DSH calculation since the In addition, on several occasions we individually identifiable data on
implementation of the DSH adjustment. have stated our policies concerning the Medicaid applicants and recipients to
More importantly, the MedPAR system treatment of MCO, dual-eligible with provide hospitals the data needed to
and the PS&R do not necessarily contain exhausted Medicare Part A benefits, meet their obligation under
the same data. The MedPAR system dual-eligible without entitlement to SSI, § 412.106(b)(4)(iii) in the context of
contains utilized days and the PS&R and third party payer patient days in the either an ‘‘eligibility inquiry’’ with the
contains days paid to the provider by Medicare DSH calculation. We suggest State plan or in order to assist the
Medicare. The PS&R does not contain that the commenter refer to the FY 2005 hospital, and thus the State plan, in
certain types of days that should be IPPS final rule for our policy on dual- determining the amount of medical
included in the denominator of the eligible patient days, including those assistance.
Medicare fraction, such as covered days with exhausted Medicare Part A In the process of developing a plan for
that were paid by a Medicare managed hospital coverage and MCO days (69 FR implementing section 951 with respect
care organization (‘‘MCO’’). For these 49098 and 49099). Commenters may to the data necessary to calculate the
reasons, we are not proceeding with the also review the IPPS final rule for FY Medicaid fraction, we asked our
commenter’s recommendation at this 1991 regarding when the MedPAR was regional offices to report on the
time. updated to include MCO days (55 FR availability of this information to
Comment: Several commenters 35994, September 4, 1990). Regarding hospitals and on any problems that
suggested that CMS allow a hospital to third party payer days, we refer hospitals face in obtaining the
submit additional days that it believes commenters to the IPPS final rule for FY information that they need. The
were omitted in error from the SSI/ 1987, which states our policy prior to information we received suggested that,
MedPAR system data match. One our FY 2005 policy change (51 FR in the vast majority of cases, there are
commenter acknowledged that the 31460, September 3, 1986). For FY 2005 established procedures for hospitals or
hospital would bear the burden of and subsequent fiscal years, we have their authorized representatives to
proving SSI/Medicare entitlement for updated the regulations at § 412.106(b) obtain the information needed for
each patient day claimed. to reflect the inclusion of days for which hospitals to meet their obligation under
Response: If a hospital disagrees with Medicare was not the primary payer. § 412.106(b)(4)(iii) and to calculate their
the fiscal intermediary’s determination Medicaid fraction. There is no uniform
regarding the final amount of Medicare 4. Calculation of the Medicaid Fraction
national method for hospitals to verify
DSH payment to which it is entitled, the The second component of the Medicaid eligibility for a specific
hospital has the right to appeal the fiscal Medicare DSH patient percentage patient on a specific day. For instance,
intermediary’s decision in accordance calculation is the Medicaid fraction. The some States, such as Arizona, have
with the procedures set forth in the numerator of the Medicaid fraction secure online systems that providers
regulations at 42 CFR Part 405, Subpart includes hospital inpatient days that are may use to check eligibility information.
R, which concern provider payment furnished to patients who, for those However, in most States, providers send
determinations and appeals. Generally, days, were eligible for Medicaid but a list of patients to the State Medicaid
during the first stage of the appeals were not entitled to benefits under office for verification. Other States, such
process, a fiscal intermediary will Medicare Part A. Under the regulation at as Hawaii, employ a third party private
consider any documentation a hospital § 412.106(b)(4)(iii), hospitals are company to maintain the Medicaid
has submitted for review. The fiscal responsible for proving Medicaid database and run eligibility matches for
intermediary will assess whether the eligibility for each Medicaid patient day providers. The information that
information provided is sufficient to and verifying with the State that providers submit to State plans (or third
warrant a reconsideration of the DSH patients were eligible for Medicaid on party contractors) differs among States
Medicare fraction at that point in the the claimed days. The number of as well. Most States require the patient’s
appeals process. Medicaid, non-Medicare days is divided name, date of birth, gender, social
Comment: One commenter requested by the hospital’s total number of security number, Medicaid
that CMS clarify ‘‘Medicare days’’ inpatient days in the same period. Total identification, and admission and
included in the Medicare fraction and inpatient days are reported on the discharge dates. States or the third
explain how the MedPAR system Medicare cost report. (This number is parties may respond with either ‘‘Yes/
captures all of the days that should be also available in the hospital’s own No’’ or with more detailed Medicaid
included, especially if Medicare did not records.) enrollment and eligibility information
pay the claim. The commenter Much of the data used to calculate the such as whether or not the patient is a
specifically requested that CMS address Medicaid fraction of the DSH patient dual-eligible, whether the patient is
the treatment of MCO or ‘‘Medicare percentage are available to hospitals enrolled in a fee-for-service or HMO
Advantage’’ days, dual-eligible with from their own records or from the plan, and under which State assistance
exhausted Medicare Part A benefits, States. We recognize that Medicaid State category the individual qualified for
dual-eligible without SSI, and third plans are only permitted to use and Medicaid.11
party payer patient days. disclose information concerning We note that we have been made
Response: Although we believe that applicants and recipients for ‘‘purposes aware of at least one instance in which
this comment is generally out of the directly connected with the a State is concerned about providing
scope of the FY 2006 IPPS proposed administration of the [State] plan’’ hospitals with the requisite eligibility
rule regarding the implementation of under section 1902(a)(7) of the Act. data. We understand that the basis for
section 951 of the MMA, we understand Regulations at 42 CFR 431.302 define the State’s objections is section
the commenter’s concern regarding the these purposes to include establishing
possible exclusion of certain days from eligibility (§ 431.302(a)) and 11 Bear in mind that States and hospitals should,
the Medicare DSH calculation. Due to determining the amount of medical in keeping with the HIPAA Privacy Rule, limit the
data exchanged in the context of these inquiries and
this concern, we are currently assistance (§ 431.302(b)). Thus, State responses to the minimum necessary to accomplish
examining our system to ensure that all plans are permitted under the currently the task.
1902(a)(7) of the Act. The State is eligibility information available in a aid hospitals in calculating their own
concerned that section 1902(a)(7) of the timely manner, such as 90 days after Medicare DSH patient percentage.
Act prohibits the State from providing receipt of a hospital’s request. This Response: While we are aware that
eligibility data for any purpose other commenter believed that States should section 951 requires that CMS provide
than a purpose related to State plan be prohibited from charging hospitals a the data necessary for hospitals to
administration. However, as described fee for accessing the data. Several calculate their Medicare DSH patient
above, we believe that States are commenters suggested that CMS modify percentage, we stand by our belief that
permitted to verify Medicaid eligibility the Medicaid State plan requirements to hospitals are in a better position to
for hospitals as a purpose directly require that any contract between the verify Medicaid eligibility with the State
related to State plan administration State Medicaid agency and an MCO Medicaid agencies through their
under § 431.302. specify that the MCO would be required established mechanisms. Therefore, we
In addition, we believe it is to submit reliable utilization data to the believe hospitals have available to them
reasonable to continue to place the State to verify managed care days/ the data necessary to calculate the
burden of furnishing the data adequate patients. Medicaid fraction for their Medicare
to prove eligibility for each Medicaid Response: We are dedicated to DSH patient percentage. CMS will
patient day claimed for DSH percentage working with the State Medicaid continue to work with State Medicaid
calculation purposes on hospitals agencies to ensure that hospitals have agencies to ensure that Medicaid
because, since they have provided access to data to verify Medicaid eligibility information is made available
inpatient care to these patients for eligibility. While the commenters to hospitals.
which they billed the relevant payers, expressed concern that some hospitals Comment: Several commenters
including the State Medicaid plan, they find it burdensome to adapt the indicated that some State Medicaid
will necessarily already be in possession Medicaid eligibility data available from agencies are refusing to provide
of much of this information. We the States to their records, we do not hospitals with Medicaid eligibility
continue to believe hospitals are best believe these types of data processing information.
situated to provide and verify Medicaid concerns are significant enough to Response: We are not aware of any
eligibility information. Although we warrant changes to the State plan State Medicaid agency that is refusing to
believe the mechanisms are currently in requirements. We are also aware that provide hospitals with current Medicaid
place to enable hospitals to obtain the not all State agencies have the resources eligibility information, and the
data necessary to calculate their available to modify their systems in a commenters did not cite any such
Medicaid fraction of the DSH patient standardized way. We note that the circumstances. However, we are aware
percentage, there is currently no Center for Medicaid and State that several State Medicaid agencies
mandatory requirement imposed upon Operations in CMS has communicated have previously expressed concern
State Medicaid agencies to verify CMS’ expectation of compliance with regarding hospital requests for historic
eligibility for hospitals. At this point, hospitals’ requests for Medicaid Medicaid eligibility information. We
we continue to believe there is no need eligibility information to the State note that section 2080.18 of the State
to modify the Medicaid State plan Medicaid agencies. If the State Medicaid Medicaid Manual limits the timeframe
regulations to require that State plans agencies refuse to provide data to enable within which the State Medicaid
verify Medicaid eligibility for hospitals. hospitals to calculate their DSH agencies may provide eligibility
However, should we find that States are Medicaid fraction and meet their information to requesting hospitals.
not voluntarily providing or verifying obligations under our regulations at Section 2018.18 clearly specifies that
Medicaid eligibility information for § 412.106(b)(4)(iii), we will consider State Medicaid agencies may only
hospitals, we will consider amending amending the Medicaid State plan provide eligibility information for dates
the State plan regulations to add a requirements to require the State agency within 12 months of the date of the
requirement that State plans provide to release the information to the request. Therefore, many States have
certain eligibility information to requesting hospitals. expressed concern that responding to
hospitals. We also do not believe that we have requests for eligibility data outside of
Comment: Several commenters the authority to require State Medicaid that 12-month window would be in
encouraged CMS to amend the Medicaid agencies to provide the Medicaid violation of CMS’ policy. In light of past
State plan requirements to require States eligibility information free-of-charge. and pending appeals and litigation, we
to furnish Medicare eligibility data to However, we do note that the State are working with the States to make sure
requesting hospitals. Several Medicaid Manual already requires that historic information is available to
commenters believed that variability in States not impose unreasonable fees on requesting hospitals. The Center for
how State Medicaid agencies collect and hospitals seeking eligibility information. Medicaid and State Operations released
manage Medicaid data make the process With respect to Medicaid MCO a memo to the CMS Regional Offices to
to convert and match hospital records to utilization, State Medicaid agencies be shared with the Medicaid State
State Medicaid records extremely time- must maintain Medicaid eligibility agencies. This memo, dated September
consuming and complex. The information on beneficiaries enrolled in 9, 2003, requested the full cooperation
commenter believed that requiring every MCOs in order to make payments to of the State Medicaid agencies in
State to report Medicaid eligibility data those MCOs. Because hospitals are responding to hospital requests for
in the same manner would decrease seeking Medicaid eligibility information historic Medicaid eligibility
hospitals’ administrative work. Several and not inpatient hospital utilization information. The States were
other commenters suggested that CMS information, we do not believe that it is specifically encouraged to retain
not make any change to the States’ appropriate for CMS to oblige the State Medicaid eligibility records in order to
requirements at this time, but continue Medicaid agencies to record and make be able to comply with hospital requests
to consider this idea as an option for the available to hospitals MCO utilization for historic data, even if their normal
future. Another commenter suggested data. record retention schedule would have
that CMS amend the State plan Comment: Several commenters argued allowed the destruction of such records.
requirements to include a requirement that Congress intended that CMS CMS’ request to Medicaid State
that the States must make Medicaid provide the Medicaid eligibility data to Agencies to provide hospitals with
historical Medicaid eligibility data information provided to CMS by the the days that should be included in the
represents an exception to the general Regional Offices indicated that there are DSH Medicaid fraction calculation.
rule as stated in section 2080.18 of the established procedures for hospitals or Response: We encourage hospitals to
State Medicaid Manual intended to their authorized representatives to continue working with individual State
assist hospitals to respond to the past obtain the information needed for Medicaid agencies to ensure that they
and pending appeals and litigation. hospitals to meet their obligation under have access to the information needed
Comment: Several commenters stated § 412.106(b)(4)(iii) and to calculate their to determine Medicaid eligibility for
that the data provided to hospitals from Medicaid fraction. In light of this, we do purposes of the DSH Medicaid fraction.
the Medicaid State agencies are often not believe that fiscal intermediaries If hospitals are unable to obtain from the
inaccurate. They noted that several should be made responsible for Medicaid State agencies data needed to
fiscal intermediaries have refused to verifying Medicaid eligibility with the calculate their DSH Medicaid fraction,
accept data from hospitals, which was State Medicaid agencies. we encourage them to notify their CMS
obtained from the State Medicaid Comment: One commenter suggested Regional Office for assistance.
agencies. that CMS issue explicit instructions to
Response: The Medicaid State Comment: One commenter suggested
fiscal intermediaries indicating that that CMS establish a more efficient
agencies maintain eligibility hospitals may submit their own data to
information on Medicaid recipients. To method for hospitals to verify dual
support the days included in the eligibility using the Common Working
date, we have been made aware of Medicaid fraction.
accuracy problems insofar as the data File (CWF).
Response: While hospitals do bear the
requested are historic and the complete Response: We encourage hospitals to
burden of verifying Medicaid eligibility
records may no longer be available. As continue working with individual State
for the patient days they submit to be
previously noted, we have requested Medicaid agencies and fiscal
included in calculation of their DSH
that the State Medicaid agencies comply intermediaries to ensure that they have
Medicaid fraction, the State Medicaid
with hospital requests for historic data access to the information needed to
agency must verify that, for those days,
and modify their record retention determine Medicaid eligibility for
the particular patient was eligible for
schedules appropriately. We suggest purposes of the DSH Medicaid fraction.
inpatient hospital benefits under an
that hospitals experiencing problems If hospitals are unable to obtain data
approved Medicaid State plan or section
with the quality of current Medicaid from the Medicaid State agencies
eligibility data work with their fiscal 1115 waiver program. If a hospital
needed to calculate their DSH Medicaid
intermediaries and State Medicaid believes that the State Medicaid agency
fraction, we encourage them to notify
agency to address the specific problems did not correctly determine the
their CMS Regional Office for
the hospital is encountering. Medicaid eligibility of a patient on a
assistance.
Comment: One commenter suggested specific day for which the hospital has
that CMS establish a formal process for additional and distinct evidence to H. Geographic Reclassifications
hospitals to report States that are not indicate that the patient was in fact (§§ 412.103, 412.230, and 412.234)
complying with hospital requests for eligible for Medicaid on that day, the
1. Background
Medicaid eligibility information. The hospital may submit this information for
commenter proposed that CMS dedicate review by the fiscal intermediary. The With the creation of the MGCRB,
an area on the CMS Web site for fiscal intermediary retains the right to beginning in FY 1991, under section
hospitals to report problems determine whether the documentation 1886(d)(10) of the Act, hospitals could
encountered with State Medicaid is sufficient to warrant the inclusion of request reclassification from one
agencies. the days in the Medicaid fraction. While geographic location to another for the
Response: We are interested in the we currently have no plans to issue purpose of using the other area’s
commenter’s proposals and will instructions to fiscal intermediaries on standardized amount for inpatient
consider this for future modification of the verification of Medicaid eligibility, operating costs or the wage index value,
the CMS Web site. Although we are not we will consider addressing this or both (September 6, 1990 interim final
adopting the proposal at this time, we concern in future communication with rule with comment period (55 FR
ask that hospitals that experience fiscal intermediaries. 36754), June 4, 1991 final rule with
difficulty obtaining Medicaid eligibility Comment: One commenter stated that comment period (56 FR 25458), and
information from a State Medicaid certain Medicaid eligibility information June 4, 1992 proposed rule (57 FR
agency contact the appropriate CMS must be made available to hospitals 23631)). As a result of legislative
Regional Office. We will continue to through the State Medicaid agencies. changes under section 402(b) of Pub. L.
work with the individual State agencies The commenter indicated that solely 108–7, Pub. L. 108–89, and section 401
to ensure that hospitals have access to providing whether a patient is eligible of Pub. L. 108–173, the standardized
such information. for Medicaid is not sufficient to amount reclassification criterion for
Comment: One commenter suggested determine whether the hospital days large urban and other areas is no longer
that the fiscal intermediaries process associated with that patient should be necessary or appropriate and has been
hospital requests for Medicaid eligibility included in the DSH Medicaid fraction removed from our reclassification policy
data and work with the State Medicaid calculation. Specifically, this (69 FR 49103). We implemented this
agencies to obtain such data. commenter indicated that the State must provision in the FY 2005 IPPS final rule
Response: Under the regulations at also provide: the dates of eligibility for (69 FR 49103). As a result, hospitals can
§ 412.106(b)(4)(iii), hospitals bear the Medicaid or whether the patient was request reclassification for the purposes
burden of furnishing data adequate to eligible for Medicaid during an of the wage index only and not the
provide eligibility for each Medicaid inpatient stay, whether the recipient has standardized amount. Implementing
patient day claimed in the Medicare met spend down requirements (if regulations in Subpart L of Part 412
DSH calculation. This includes applicable), and the type of Medicaid (§§ 412.230 et seq.) set forth criteria and
verifying with the State that a patient benefits the recipient received. The conditions for reclassifications for
was eligible for Medicaid on each of the commenter indicated that this purposes of the wage index from rural
claimed days. As stated above, the information is critical in determining to urban, rural to rural, or from an urban
area to another urban area, with special reclassifications for FY 2006, the by the MGCRB do not address the
rules for SCHs and rural referral centers. MGCRB used the 3-year average hourly circumstances under which a single
Under section 1886(d)(8)(E) of the wages published in Table 2 of the campus of a multicampus hospital may
Act, an urban hospital may file an August 11, 2004 IPPS final rule (69 FR seek reclassification. That is, a hospital
application to be treated as being 49295). These average hourly wages are must provide data from the CMS
located in a rural area if certain taken from data used to calculate the hospital wage survey for the average
conditions are met. The regulations wage indexes for FY 2003, FY 2004, and hourly wage comparison that is used to
implementing this provision are located FY 2005, based on cost reporting support a request for reclassification.
under § 412.103. periods beginning during FY 1999, FY However, because a multicampus
Comment: One commenter sought 2000, and FY 2001, respectively. hospital is required to report data for the
clarification as to whether a hospital can entire entity on a single cost report,
apply for and be granted MGCRB 2. Multicampus Hospitals (§ 412.230)
there is no wage survey data for the
reclassification for a future year if the As discussed in section III.B. of this individual hospital campus that can be
hospital is currently designated rural preamble, on June 6, 2003, the OMB used in a reclassification application. In
under section 1886(d)(8)(E) of the Act announced the new CBSAs, comprised an effort to remedy this situation, for FY
but also received an approved notice of Metropolitan Statistical Areas (MSAs) 2007 and subsequent year
canceling its rural designation from the and Micropolitan Statistical Areas, reclassifications, in the FY 2006 IPPS
CMS Regional Office. based on Census 2000 data. Effective proposed rule, we proposed to allow a
Response: Section 412.230(a)(5)(iii) of October 1, 2004, for the IPPS, we campus of a multicampus hospital
the regulations specifies that ‘‘an urban implemented new labor market areas system that wishes to seek geographic
hospital that has been granted based on the CBSA definitions of MSAs. reclassification to another labor market
redesignation as rural under § 412.103 In some cases, the new CBSAs resulted area to report campus-specific wage data
cannot receive an additional in previously existing MSAs being using a supplemental Form S–3 (CMS’
reclassification by the MGCRB based on divided into two or more separate labor manual version of Worksheet S–3) for
the acquired rural status as long as such market areas. In the FY 2005 IPPS final purposes of the wage data comparison.
redesignation is in effect.’’ If a hospital, rule (69 FR 48916), we acknowledged These data would then constitute the
at the time of applying to the MGCRB, that the implementation of the new appropriate wage data under
has written notice from the CMS MSAs would have a considerable § 412.230(d)(2) for purposes of
Regional Office demonstrating that its impact on hospitals. Therefore, we comparing the hospital’s wages to the
rural redesignation will cancel prior to made every effort to implement
wages of hospitals in the area to which
the effective date of the MGCRB transitional provisions that would
it seeks reclassification as well as the
decision, the MGCRB should approve mitigate the negative effects of the new
area in which it is located. Before the
the hospital for reclassification, labor market areas on hospitals that
data could be used in a reclassification
assuming all other criteria have been request reclassification to another area
application, the hospital’s fiscal
satisfied. For purposes of subpart L of for purposes of the wage index and on
Part 412 of the regulations, the hospital intermediary would have to review the
all hospitals.
will be considered urban because it is Subsequent to the publication of the allocation of the entire hospital’s wage
physically located in an urban area and FY 2005 IPPS final rule, we became data among the individual campuses.
will longer be in rural status upon the aware of a situation in which, as a result For FY 2006 reclassification
effective date of the MGCRB decision. of the new labor market areas, a applications, we proposed to allow a
Thus, the hospital will be subject to multicampus hospital previously campus of a multicampus hospital
reclassification rules that apply to urban located in a single MSA is now located system to use the average hourly wage
hospitals for individual hospital in more than one CBSA. Under our data submitted for the entire
reclassification applications under current policy, a multicampus hospital multicampus hospital system as its
§ 412.230 and countywide group with campuses located in the same labor appropriate wage data under
reclassification applications under market area receives a single wage § 412.230(d)(2). We proposed to
§ 412.234. We note that index. However, if the campuses are establish this special rule for FY 2006
§ 412.230(a)(5)(iv) may imply that a located in more than one labor market reclassifications because the deadline
hospital cannot receive a reclassification area, payment for each discharge is for submitting an application to the
by the MGCRB while it has acquired determined using the wage index value MGCRB was September 1, 2004, and
rural status under § 412.103. We are for the MSA (or metropolitan division, there no longer is an opportunity to
modifying § 412.230(a)(5)(iv) to indicate where applicable) in which the campus provide a Supplemental Form S–3 that
that a hospital may not be granted of the hospital is located. In addition, allocates the wage data by individual
reclassification by the MGCRB for a year the current provision set forth in section hospital campus. This special rule will
in which ‘‘such designation’’ is in effect. 2779F of the Medicare State Operations be applied only to an individual campus
Effective with reclassifications for FY Manual provides that, in the case of a of a multicampus hospital system that
2003, section 1886(d)(10)(D)(vi)(II) of merger of hospitals, if the merged made an application for reclassification
the Act provides that the MGCRB must facilities operate as a single institution, for FY 2006 and that otherwise meets all
use the average of the 3 years of hourly the institution must submit a single cost of the reclassification criteria. We do not
wage data from the most recently report, which necessitates a single believe that the special rule is necessary
published data for the hospital when provider identification number. This for reclassifications for FY 2007 because
evaluating a hospital’s request for provision does not differentiate between the deadline for making those
reclassification. The regulations at merged facilities in a single wage index applications has not yet passed and a
§ 412.230(d)(2)(ii) stipulate that the area or in multiple wage index areas. As hospital seeking reclassification will be
wage data are taken from the CMS a result, the wage index data for the able to provide the Supplemental Form
hospital wage survey used to construct merged facility is reported for the entire S–3 that allocates the wage data by
the wage index in effect for prospective entity on a single cost report. individual hospital campus. We
payment purposes. To evaluate The current criteria for a hospital proposed to apply these new criteria to
applications for wage index being reclassified to another wage area geographic reclassification applications
that were received by September 1, we proposed that a campus of a begin in October 2005. Thus, the cost
2004, and that will take effect for FY multicampus hospital that seeks report changes that would be necessary
2006. geographic reclassification to another to report wage index data by individual
We proposed to revise the regulations labor market area must submit a manual campus would have needed to be in
at § 412.230(d)(2) by redesignating version of Worksheet S–3 of the place for campus-specific wage data to
paragraph (d)(2)(iii) as paragraph Medicare cost report that allocates the be subject to the same reporting and
(d)(2)(v) and adding new paragraph wage data by individual campus. We audit requirements that apply generally
(d)(2))(iii) and (d)(2)(iv) to incorporate also stated that before the data could be to hospitals’ wage data. While making
the proposed new criteria for used for a reclassification, the hospital’s formal changes to the Medicare cost
multicampus hospitals. fiscal intermediary would have to report to allow multicampus hospitals
Comment: Many commenters review the allocation of the entire to electronically report their wage data
supported our proposal to allow hospital’s wage data among the by individual campus is a possibility for
reporting of campus-specific wage data individual campuses. Based on the future years, it is certainly not a feasible
using a supplemental Worksheet S–3 for public comments, we have further option for the FY 2007 or FY 2008
campuses of multicampus hospitals that considered the potential burden to reclassification applications.
are located in a wage area that is hospitals and fiscal intermediaries that In addition to burden that would be
different from the wage area in which the use of a manual Worksheet S–3 associated with requiring a manual cost
the main provider is located. The would entail. We have realized that the report, we also considered several other
commenters stated that the proposal proposal concerning the manual issues when deciding on a final policy.
would provide equitable treatment for Worksheet S–3 presents certain We believe that it is appropriate to have
these hospitals under the difficulties, particularly when the campus use the average hourly wage
reclassification rules. However, one considering that the MGCRB’s deadline data submitted on the cost report for the
commenter expressed concern that the for informing hospitals of whether their entire multicampus hospital for several
proposal may encourage an individual reclassification applications are reasons.
hospital that is part of a multicampus approved is February 1. In particular,
hospital to seek reclassification to First, under the criteria for geographic
because the information on the reclassification, a hospital must already
different labor market areas. The Worksheet S–3 flows from and is linked
commenter believed that this option demonstrate a close proximity to the
to other worksheets in the Medicare cost area to which it seeks reclassification.
should only be available in cases where report, it would not be sufficient for
an individual campus is requesting When the campus meets such proximity
campuses to submit only the Worksheet requirements, it is reasonable to
reclassification for purposes of S–3; other worksheets would need to be
reclassifying to an area where another speculate that the average hourly wages
submitted manually as well. In addition, for an individual campus and the whole
one of the campuses is located.
since beginning with FY 2005, hospital are similar because the two (or
Another commenter recommended
hospitals’ wage data include an more) campuses are operating as a
that CMS modify its policy and include
only salaries and hours of the workforce occupational mix adjustment, reporting single entity under one Medicare
attributable to the campus or campuses of campus-specific occupational mix provider number, are under common
located in the area in order to calculate data would also be necessary. Because ownership and control, and are
an area wage index. The commenter hospitals currently do not report their clinically and financially integrated.
recommended that CMS require that all wage or occupational mix data by Accordingly, when the facilities are in
multicampus hospitals with campuses individual campus, we believe it could close proximity to each other (and share
in more than one wage area complete be difficult for hospitals to prepare and a common labor market area and are
the manual Worksheet S–3 by area. If submit the appropriate information within normal commuting distance), we
reporting wage data by campus proves between the time that this final rule is believe there may not be a wide range
to be administratively burdensome, the published and the September 1, 2005 of salaries for the same occupational
commenter suggested that all of the deadline for FY 2007 reclassifications. categories within the same institution.
multicampus hospital’s wage data be Furthermore, the submission of manual (In contrast, if, when, using the wage
included in the area in which the cost report data would require a lengthy data of the entire hospital, the campus
majority of the multicampus hospital’s and tedious manual audit process for cannot meet either the proximity criteria
employees work. fiscal intermediaries, making it of § 412.230(b) or the wage comparison
Other commenters questioned how extremely difficult for them to complete criteria of § 412.230(d), the campus
the manual Worksheet S–3s would be these supplemental reviews and for cannot be reclassified. The failure to
reviewed and when and how often (that CMS to calculate the average hourly meet either of these criteria indicates
is, once a year or every 3 years) the wages of these campuses in time for the that either (a) the campus is not
hospitals would be required to submit MGCRB to make its decisions by sufficiently proximate to assume similar
the manual Worksheet S–3s. February 1, 2006. wage data, or (b) the data of the entire
Response: We appreciate the We also note that our process for hospital is either not sufficiently
commenters’ suggestions and their collecting wage index data precludes us comparable to the reclassification area
interest in this matter. We are finalizing from adopting changes to the cost report or is not sufficiently different from the
our proposal for FY 2006 for FY 2008 reclassifications. The wage area in which the campus is already
reclassifications to allow a campus of a data that will be used for an FY 2008 located, to warrant a reclassification. It
multicampus hospital to use the average reclassification will be data from a would be inappropriate to assign a
hourly wage data submitted for the hospital’s FY 2003 cost report, which is campus the wage index of an area that
entire multicampus hospital as its wage used to determine the FY 2007 wage the entire hospital would not qualify to
data under § 412.230(d)(2), if that index. Hospitals have already submitted receive, if not for the fact that one
campus applied for reclassification for their FY 2003 cost reports to their fiscal campus of that hospital happens to be
FY 2006 and it otherwise meets all of intermediaries and the CMS data located within the boundaries of a
the reclassification criteria. For FY 2007 reporting systems. The process for geographic area with a higher wage
and subsequent year reclassifications, reviewing and auditing these data will index.)
Second, the use of the entire hospital to use the average hourly wage hospitals must be located in counties
hospital’s wage data is practical and for the entire hospital to reclassify to the that are in the same Combined
administratively feasible for hospitals, labor market area where the other Statistical Area (under the MSA
CMS, and the fiscal intermediaries campus(es) is located. We believe this definitions announced by the OMB on
because wage data for all campuses are limitation is warranted because, June 6, 2003) as the urban area to which
reported together on a single cost report currently, the data available for which they seek redesignation to qualify as
under a single Medicare provider the campus to base a reclassification on meeting the proximity requirement for
number. are the wage data reported for the entire reclassification to the urban area to
Third, we note that use of the wage hospital on the Medicare cost report. We which they seek redesignation. We
data for the entire multicampus hospital will consider further the comments that believed that this proposed change
is consistent with our treatment of recommend that we modify our policy would improve the overall consistency
multicampus hospitals for calculating to include only salaries and hours of the of our policies by using a single labor
area wage index values, GME, DSH, and employees actually working in a market area definition for all aspects of
provider-based purposes, under which particular labor market area when the wage index and reclassification. We
multicampus hospitals operating under determining the wage index for that also proposed to make a conforming
a single Medicare provider number are area. We believe this recommendation change by eliminating the term
treated as a single hospital for payment presents certain logistical challenges ‘‘NECMA’’ from the regulations at
purposes. that we would like to consider in the § 412.234(b)(1).
For the reasons described above, we context of possible permanent cost Comment: Many commenters opposed
have decided not to finalize our report changes to accommodate the CMS’ proposal to eliminate the CMSA
proposed policy to require a campus of electronic reporting of separate wage criterion for urban county group
a multicampus hospital to submit data by individual campus. We reclassifications. They were concerned
manual Worksheet S–3s with campus- anticipate having a full discussion of that eliminating the CMSA criterion
specific wage data to support a these issues as part of a future would result in a reduction in the
reclassification application at this time. rulemaking. number of hospitals eligible for
Rather, we are extending the policy that reclassification. Some commenters
we had proposed for FY 2006 3. Urban Group Hospital suggested that CMS postpone
reclassifications to FY 2007 and FY Reclassifications eliminating this criterion until at least
2008. That is, for FY 2006, FY 2007, or Section 412.234(a)(3)(ii) of the FY 2008, which would coincide with
FY 2008, for a campus of a multicampus regulations sets forth criteria for urban the expiration of a 3-year transition
hospital that wishes to seek hospitals to be reclassified as a group for period for hospitals that changed status
reclassification to a geographic wage FY 2006 and thereafter. Under such from urban to rural as a result of the
area where another campus(es) is criteria, ‘‘hospitals located in counties redefined labor market areas.
located, we are requiring that a campus that are in the same Combined Response: We continue to believe that
of a multicampus hospital use the Statistical Area (under the MSA it is reasonable to use the area
average hourly wage data submitted on definitions announced by the OMB on definitions that are based on the most
the cost report for the entire June 6, 2003); or in the same recent definitions. The new
multicampus hospital as its wage data Consolidated Metropolitan Statistical designations were released on June 6,
under § 412.230(d)(2). We are modifying Area (CMSA) (under the standards 2003. In essence, we have already
the regulations at § 412.230(d)(2)(iv) published by the OMB on March 30, delayed the implementation of the new
accordingly. We will continue to 1990) as the urban area to which they Census information. Consistent with our
explore options that will allow seek redesignation qualify as meeting proposal to use the area definitions
individual campuses of multicampus the proximity requirement for announced by OMB on June 3, 2003, we
hospitals to submit wage data necessary reclassification to the urban area to are also further modifying
for geographic reclassification without which they seek redesignation.’’ § 412.234(b)(1) to eliminate ‘‘or
undue administrative burden. We will As a result of adopting the new labor NECMA’’ for purposes of the wage data
also monitor the number of market area definitions, we reexamined comparison. Because New England
multicampus hospitals affected by this in the proposed rule whether to retain County Metropolitan Areas (NECMAs)
provision. old standards that allowed proximity to are no longer used in our area wage
The proposal to allow campuses of be determined on the basis of being definitions, we believe this term should
multicampus hospitals to reclassify was included in the same CMSA (under the be deleted from the regulations.
intended to mitigate the negative effects standards published by the OMB on We note that the ‘‘3-year transition’’ to
the new labor market areas had on March 30, 1990). Based on our which commenters refer was not in any
multicampus hospitals that were experiences now that the new labor way related to MGCRB reclassifications
previously located in a single MSA and market areas have been in effect for one and was solely directed toward the wage
are now located in more than one CBSA. year, we no longer believe it is index that would be received by
Although this proposal was an necessary to use a 1990-based standard hospitals that changed status from urban
outgrowth of the change to the new as a criterion for determining whether to rural as a result of the redefined labor
labor market areas, we have decided to an urban county group is eligible for market areas—a limited group of
apply this provision to any reclassification. We believe it is hospitals that is not representative of
multicampus hospitals with campuses reasonable to use the area definitions the broader hospital community.
in more than one labor market area. We that are based on the most recent Therefore, we are finalizing the
believe the same opportunity to statistics; in other words, the CSA proposed policy in this final rule.
reclassify should be available to all standard. Therefore, in the FY 2006 Comment: A group of hospitals in
multicampus hospitals in this situation, IPPS proposed rule, we proposed to New England protested an MGCRB
even those that were located in different delete § 412.234(a)(3)(ii) to remove decision under which they were denied
wage areas prior to the change in the reference to the CMSA eligibility reclassification. The hospitals believed
OMB definitions. Further, we will only criterion. For reclassifications beginning they were unfairly denied an
allow a campus of a multicampus FY 2007, we proposed to require that opportunity to reclassify for Medicare
wage purposes for FY 2006 because of provision is implemented in our Modification criteria and no longer
a narrow interpretation of the urban regulations at § 412.103(a)(1). qualify under the new RUCAs. They
county group reclassification The original Goldsmith Modification indicated that a loss of rural status
regulations by the MGCRB. The hospital was developed using data from the 1980 would be devastating for many
group applied for reclassification for FY census. In order to more accurately hospitals, particularly CAHs.
2006, but was subsequently denied by reflect current demographic and Response: Currently § 412.103(a)(1)
the MGCRB, and the decision was later geographic characteristics of the Nation, requires that hospitals be located in a
upheld by the Administrator on the the Office of Rural Health Policy, in rural census tract of a Metropolitan
basis that the applying county did not partnership with the Department of Statistical Area (MSA) as determined
meet the regulatory requirements in Agriculture’s Economic Research under the most recent version of the
§ 412.234(a)(3)(ii). The county was Service and the University of Goldsmith Modification. The RUCAs are
neither part of the same CMSA (1990 Washington, has developed the Rural- the most recent of the Goldsmith
Standard) or CSA as the requested area Urban Commuting Area codes (RUCAs) Modification. Therefore, hospitals must
(2000 Standard). The hospital group (69 FR 47518 through 47529, August 5, qualify on the basis of the new RUCAs.
argued that the county would have been 2004). Rather than being limited to large CMS will continue to monitor how the
included in the same CMSA as Boston area metropolitan counties (LAMCs), new standards affect hospitals’ rural
if the CMSA standards had been applied RUCAs use urbanization, population status.
at the county-level rather than at the density, and daily commuting data to In this final rule, we are adopting as
township level in New England. The categorize every census tract in the final, without modification, our
hospital group requested that CMS grant country. RUCAs are the updated version proposal to update the regulations at
their reclassification request for FY 2006 of the Goldsmith Modification and are § 412.103(a)(1) to incorporate the change
through FY 2008. used to identify rural census tracts in all in the identification of rural census
metropolitan counties. tracts and to update the Web site and
Response: We are not granting the
In the FY 2006 IPPS proposed rule, the agency location at which the RUCA
hospital group’s request. The hospital
we proposed to update the Medicare codes are accessible.
has asked us to reverse an Administrator
regulations at § 412.103(a)(1) to
decision. However, Administrator 5. Cross-Reference Changes
incorporate this change in the
decisions are considered to be the final identification of rural census tracts. We In the FY 2005 IPPS final rule, in
decision of the Department also proposed to update the Web site conjunction with changes made by
(§ 412.278(f)(3)) and are subject to and the agency location at which the various sections of Pub. L. 108–173 and
reopening only in very limited RUCA codes are accessible. changes in the OMB standards for
circumstances which are not present in Comment: Two commenters indicated defining labor market areas, we
this case. In addition, we note that that the use of RUCA codes results in an established a new § 412.64 governing
Administrator decisions are not subject inaccurate classification of their rural rules for establishing Federal rates for
to judicial review (§ 412.278(f)(4)). As communities as urban. They urged CMS inpatient operating costs for FY 2005
the Administrator has already found, to work with the Office of Rural Health and subsequent years. In this new
the hospitals did not meet the regulatory Policy to address problems in the section, we included definitions of
requirements of § 412.234 to be methodology and to ensure that rural ‘‘urban’’ and ‘‘rural’’ for the purpose of
reclassified to the Boston-Worcester- areas are not inadvertently classified as determining the geographic location or
Lawrence CMSA. A Boston-Worcester- urban. classification of hospitals under the
Lawrence CMSA existed under the 1990 Response: We appreciate the IPPS. These definitions were previous
township-based MSA system in New comments regarding use of the RUCA located in § 412.63(b), applicable to FYs
England. However, approximately one- codes. CMS will continue to work 1985 through 2004, and in § 412.62(f),
half of the townships in the applicant closely with the ORHP to ensure the applicable to FY 1984. References to the
county fall outside of the CMSA adequacy of rural health policy issues. definitions under § 412.62(f) and
boundaries (including at least two of the Comment: Commenters stated that § 412.63(b), appear throughout 42 CFR
three townships where the applicant they had difficulty locating the Rural- Chapter IV. However, when we finalized
hospitals are located). Therefore, as the Urban Commuting Area codes on the the provisions of § 412.64, we
Administrator has already held, the Web site identified in the proposed rule. inadvertently omitted updating some of
applicant county is not within the They requested a more detailed Web site these cross-references to reflect the
Boston CMSA, and there is no provision reference as a link to the codes. change in the location of the two
in the regulations that will allow us to Response: The Rural-Urban definitions for FYs 2005 and subsequent
reclassify the Bristol County hospital to Commuting Area codes are maintained years. We are changing the cross-
the Boston-Worcester-Lawrence CMSA. by the Office of Rural Health Policy references to the definitions of ‘‘urban’’
4. Clarification of Goldsmith (ORHP). Since Web site links are subject and ‘‘rural’’ to reflect their current
Modification Criterion for Urban to change, we encourage commenters to locations in Subpart D of Part 412, as
Hospitals Seeking Reclassification as contact the ORHP directly for applicable.
Rural information regarding the RUCA codes.
Commenters may also request copies of Other Comments
Under section 1886(d)(8)(E) of the the RUCA codes from the Department of Comment: We received a number of
Act, certain urban hospitals may file an Health and Human Services, Health suggestions for revising the geographic
application for reclassification as rural if Resources and Services Administration, reclassification rules that were
the hospital meets certain criteria. One Office of Rural Health Policy, 5600 independent from the policies we
of these criteria is that the hospital is Fishers Lane, Room 9A–55, Rockville, proposed. Some commenters
located in a rural census tract of a MD 20857. recommended that CMS develop criteria
CBSA, as determined under the most Comment: Commenters urged CMS to that would allow areas within CBSAs to
recent version of the Goldsmith provide grandfather status to protect qualify as core urban areas and for all
Modification as determined by the hospitals that were redesignated as rural providers located in those areas to
Office of Rural Health Policy. This based on the old Goldsmith receive their own wage indices. In
addition, they suggested that CMS and SCHs are eligible for special access Pub. L. 106–113 amended section
develop MGCRB criteria through which rules under section 1886(d)(10)(D)(i)(III) 1886(h)(2) of the Act to establish a
hospitals not located in the core urban of the Act. Under these provisions, methodology for the use of a national
area, but within the same CBSA, could where a hospital is the sole source of average PRA in computing direct GME
apply for reclassification into the core inpatient hospital care or is the only payments for cost reporting periods
urban area. Other commenters requested provider of needed tertiary services in beginning on or after October 1, 2000,
that CMS expand the urban group rural areas—as, by definition, RRCs and and on or before September 30, 2005.
reclassification eligibility criteria to SCHs are—special proximity rules apply Pub. L. 106–113 established a ‘‘floor’’
allow hospitals in counties that are in in cases of reclassification, in order to for hospital-specific PRAs equal to 70
the same CBSA as the urban area to ensure access to care. These rules were percent of the locality-adjusted national
which they seek redesignation to qualify implemented in a 1992 rulemaking and average PRA. In addition, the BBRA
as meeting the proximity requirement. are specific to RRCs and SCHs. (See the established a ‘‘ceiling’’ that limited the
One commenter proposed alternative June 4, 1992 proposed rule (57 FR 23618 annual adjustment to a hospital-specific
reclassification criteria by which a and 23634) and the September 1, 1992 PRA if the PRA exceeded 140 percent of
hospital in a single hospital final rule (57 FR 39746 and 39769).) the locality-adjusted national average
Metropolitan Statistical Area could We will consider this issue further PRA. Section 511 of the BIPA (Pub. L.
apply for reclassification to a and whether future rulemaking is 106–554) increased the floor established
noncontiguous urban area for wage warranted to address this situation. by the BBRA to equal 85 percent of the
index purposes. locality-adjusted national average PRA.
Response: In the FY 2006 IPPS I. Payment for Direct Graduate Medical
Education (§ 413.79) Existing regulations at § 413.77(d)(2)(iii)
proposed rule, we did not propose any specify that, for purposes of calculating
changes that are specific to these 1. Background direct GME payments, each hospital-
comments. Because these proposals specific PRA is compared to the floor
Section 1886(h) of the Act, as added
would have a negative effect on some and the ceiling to determine whether a
by section 9202 of the Consolidated
hospitals or might appear inequitable to hospital-specific PRA should be revised.
Omnibus Budget Reconciliation Act
similarly situated hospitals, we do not Section 1886(h)(4)(F) of the Act
(COBRA) of 1985 (Pub. L. 99–272) and
believe it would be prudent to adopt established limits on the number of
implemented in regulations at existing
any of them in this final rule without allopathic and osteopathic residents that
§§ 413.75 through 413.83, establishes a
first opening them up for public hospitals may count for purposes of
comment. methodology for determining payments
to hospitals for the costs of approved calculating direct GME payments. For
Comment: One commenter stated that most hospitals, the limits were the
a Pennsylvania hospital in a single graduate medical education (GME)
programs. Section 1886(h)(2) of the Act, number of allopathic and osteopathic
hospital MSA surrounded by rural FTE residents training in the hospital’s
counties is at a competitive as added by COBRA, sets forth a
payment methodology for the most recent cost reporting period ending
disadvantage because the rural hospitals on or before December 31, 1996.
that surround the hospital have been determination of a hospital-specific,
reclassified to higher wage index areas base-period per resident amount (PRA) 2. Direct GME Initial Residency Period
or have been designated as rural referral that is calculated by dividing a (IRP) (§ 413.79(a)(10))
centers, SCHs, MDHs, or CAHs. The hospital’s allowable costs of GME for a
base period by its number of residents a. Background
urban hospital is ineligible for
reclassification to a higher wage area in the base period. The base period is, As we have generally described
either as an individual hospital or as a for most hospitals, the hospital’s cost above, the amount of direct GME
group under current regulations. The reporting period beginning in FY 1984 payment to a hospital is based in part
commenter advocated a change to the (that is, the period beginning between on the number of FTE residents the
urban county group reclassification October 1, 1983, through September 30, hospital is allowed to count for direct
regulations whereby a hospital in a 1984). Medicare direct GME payments GME purposes during a year. The
single hospital MSA surrounded by are calculated by multiplying the PRA number of FTE residents, and thus the
rural counties would be able to times the weighted number of full-time amount of direct GME payment to a
reclassify to the closest urban area equivalent (FTE) residents working in hospital, is directly affected by CMS
which is part of a Combined Statistical all areas of the hospital (and policy on how ‘‘initial residency
Area (CSA) located in the same state as nonhospital sites, when applicable), and periods’’ are determined for residents.
the hospital. the hospital’s Medicare share of total Section 1886(h)(4)(C)(ii) of the Act,
Response: As we indicated above, we inpatient days. In addition, as specified implemented at § 413.79(b)(1), provides
did not propose any changes that are in section 1886(h)(2)(D)(ii) of the Act, that while a resident is in the ‘‘initial
specific to these comments in the FY for cost reporting periods beginning on residency period’’ (IRP), the resident is
2006 IPPS proposed rule and do not or after October 1, 1993, through weighted at 1.00. Section
believe it would be prudent to adopt September 30, 1995, each hospital- 1886(h)(4)(C)(iii) of the Act,
any of them in this final rule without specific PRA for the previous cost implemented at § 413.79(b)(2), requires
first opening them up for public reporting period is not updated for that if a resident is not in the resident’s
comment and being able to fully inflation for any FTE residents who are IRP, the resident is weighted at .50 FTE
consider the effect on other hospitals not either a primary care or an obstetrics resident.
that are similarly situated. For this and gynecology resident. As a result, Section 1886(h)(5)(F) of the Act
reason, we are unable to address this hospitals that train primary care and defines ‘‘initial residency period’’ as the
issue at this time without further study. obstetrics and gynecology residents, as ‘‘period of board eligibility,’’ and,
We note that the comment raises a point well as nonprimary care residents in FY subject to specific exceptions, limits the
about the hospital competing with other 1994 or FY 1995, have two separate initial residency period to an ‘‘aggregate
rural hospitals that are able to reclassify PRAs: one for primary care and period of formal training’’ of no more
under special access rules that apply to obstetrics and gynecology residents and than 5 years for any individual. Section
RRCs and SCHs. Rural referral centers one for nonprimary care residents. 1886(h)(5)(G) of the Act generally
defines ‘‘period of board eligibility’’ for training programs. Typically, a medical specified in § 413.79(a)(10) that the
a resident as ‘‘the minimum number of student who wants to train to become a nonprimary care PRA would apply for
years of formal training necessary to specialist is ‘‘matched’’ to both the the entire duration of the initial
satisfy the requirements for initial board clinical base year program and the residency period. By treating the first
eligibility in the particular specialty for specialty residency training program at year as part of a nonprimary care
which the resident is training.’’ Existing the same time. For example, the medical specialty program, the hospital will be
§ 413.79(a) of the regulations generally student who wants to become an paid at the lower nonprimary care PRA
defines ‘‘initial residency period’’ as the anesthesiologist will apply and ‘‘match’’ rather than the higher primary care
‘‘minimum number of years required for simultaneously for a clinical base year PRA, even if the residents are training
board eligibility.’’ Existing § 413.79(a)(5) in an internal medicine program for year in a primary care program during the
provides that ‘‘time spent in residency 1 and for an anesthesiology training clinical base year.
programs that do not lead to program beginning in year 2. In the FY 2005 IPPS final rule (69 FR
certification in a specialty or Prior to October 1, 2004, CMS’ policy 49170 and 49171), we also defined
subspecialty, but that otherwise meet was that the IRP is determined for a ‘‘residency match’’ to mean, for
the definition of approved programs resident based on the program in which purposes of direct GME, a national
* * * is counted toward the initial he or she participates in the resident’s process by which applicants to
residency period limitation.’’ Section first year of training, without regard to approved medical residency programs
1886(h)(5)(F) of the Act further provides the specialty in which the resident are paired with programs on the basis of
that ‘‘the initial residency period shall ultimately seeks board certification. preferences expressed by both the
be determined, with respect to a Therefore, for example, a resident who applicants and the program directors.
resident, as of the time the resident chooses to fulfill the clinical base year These policy changes, which were
enters the residency training program.’’ requirement for an anesthesiology effective October 1, 2004, are only
The IRP is determined as of the time program with a preliminary year in an applicable to residents that
the resident enters the ‘‘initial’’ or first internal medicine program will be simultaneously match in both a clinical
residency training program and is based ‘‘labeled’’ with the IRP associated with base year program and a longer specialty
on the period of board eligibility internal medicine, that is, 3 years (3 residency program. We have become
associated with that medical specialty. years of training are required to become aware of situations where residents,
Thus, these provisions limit the amount board eligible in internal medicine), upon completion of medical school,
of FTE resident time that may be even though the resident may seek only match for a program beginning in
counted for a resident who, after board certification in anesthesiology, the second residency year in an
entering a training program in one which requires a minimum of 4 years of advanced specialty training program but
specialty, switches to a program in a training to become board eligible. As a fail to match for a clinical base year of
specialty with a longer period of board result, this resident would have an IRP training. Residents that match into an
eligibility or completes training in a one of 3 years and, therefore, be weighted at advanced program but fail to match into
specialty training program and then 0.5 FTE in his or her fourth year of a clinical base year program may
continues training in a subspecialty (for anesthesiology training for purposes of independently pursue unfilled
example, cardiology and direct GME payment. residency positions in preliminary year
gastroenterology are subspecialties of Effective with portions of cost programs after the match process is
internal medicine). reporting periods beginning on or after complete. However, because these
October 1, 2004, to address programs residents do not ‘‘simultaneously
b. Direct GME Initial Residency Period that require a clinical base year, we match’’ into both a preliminary year and
Limitation: Simultaneous Match revised our policy in the FY 2005 IPPS an advanced program, currently their
We understand that there are final rule (69 FR 49170 through 49174) IRP cannot be determined based on the
numerous programs, including concerning the IRP. Specifically, under period of board eligibility associated
anesthesiology, dermatology, the revised policy, if a hospital can with the advanced program, as specified
psychiatry, and radiology, that require a document that a particular resident in § 413.79(a)(10). Rather, the IRP for
year of generalized clinical training to matches simultaneously for a first year such residents would continue to be
be used as a prerequisite for the of training in a clinical base year in one determined based on the specialty
subsequent training in the particular medical specialty, and for additional associated with the preliminary year
specialty. For example, in order to year(s) of training in a different program. For example, a student in the
become board eligible in anesthesiology, specialty program, the resident’s IRP final year of medical school may match
a resident must first complete a will be based on the period of board into a radiology program that begins in
generalized training year and then eligibility associated with the specialty the second residency year, but not
complete 3 years of training in program in which the resident matches match with any clinical base year
anesthesiology. This first year of for the subsequent year(s) of training program. Under our current policy, if
generalized residency training is and not on the period of board subsequent to conclusion of the match
commonly known as the ‘‘clinical base eligibility associated with the clinical process, this resident secured a
year.’’ Often, the clinical base year base year program. This change in preliminary year position in an internal
requirement is fulfilled by completing policy is codified at § 413.79(a)(10) of medicine program, the resident would
either a preliminary year in internal the regulations. This policy applies not have met the requirements at
medicine (although the preliminary year regardless of whether the resident § 413.79(a)(10) for a simultaneous match
can also be in other specialties such as completes the first year of training in a and the IRP for this resident would be
general surgery or family practice), or a separately accredited transitional year based on the length of time required to
transitional year program (which is not program or in a preliminary (or first) complete an internal medicine program
associated with any particular medical year in another residency training (3 years) rather than the length of the
specialty). program such as internal medicine. radiology program (4 years).
In many cases, during the final year In addition, because programs that The intent of the ‘‘simultaneous
of medical school, medical students require a clinical base year are match’’ provision of § 413.79(a)(10) is to
apply for training in specialty residency nonprimary care specialties, we identify in a verifiable manner the
specialty associated with the program in residents who participated in a clinical participates in a clinical base year
which the resident will initially train base year in a specialty and then program based on the specialty
and seek board certification. It is also continued training in that specialty, and associated with the resident’s second
the intent of § 413.79(a)(10) that a those residents who simply switched year of training as suggested by the
resident’s IRP would not change if the specialties in their second year. Rather, Conference Committee language. We
resident, after initially entering a we proposed that, if a hospital can ultimately rejected this policy because
training program in one specialty, document that a particular resident had we believe that, if we were to establish
changes programs to train in another matched in an advanced specialty a ‘‘second year’’ policy, there would be
medical specialty. The ‘‘simultaneous program that requires completion of a no way to distinguish between those
match’’ provisions of § 413.79(a)(10) clinical base year prior to the resident’s residents who matched to a specialty
allow CMS to both identify the specialty first year of training, the IRP would not program for a second year of training
associated with the program in which be determined based on the period of prior to beginning their first year of
the resident is ultimately expected to board eligibility for the specialty training, and those residents who
train and seek board certification and associated with the clinical base year simply switched specialties in their
prevent inappropriate revision of the program, for purposes of direct GME second year. Because section
IRP in cases where a resident changes payment. Rather, under those 1886(h)(5)(F) of the Act provides that
specialties subsequent to beginning circumstances, the IRP would be the IRP must be determined ‘‘as of the
residency training. However, we note determined based upon the period of time the resident enters the residency
that when a medical student in his or board eligibility associated with the training program,’’ we believe the IRP
her final year of medical school matches specialty program in which the resident needs to be determined based on the
into an advanced program (for example, has matched and is expected to begin ‘‘initial’’ or first program in which a
anesthesiology) for the second program training in the second program year. resident trains. Thus, we are not
year, but fails to match in a clinical base Comment: Several commenters adopting the commenters’ suggestion
year, and obtains a preliminary year commended and supported our that we ignore the specifics of the first
position outside the match process, we proposal to revise the current year of training and wait to establish the
can still identify the specialty associated regulations to state that a resident who ‘‘initial’’ residency period based solely
with the program in which the resident initially matches only to an advanced on the program in which the resident is
is ultimately expected to train and seek program without simultaneously training during his or her second year.
board certification and prevent matching to a clinical base year program The policy advocated by the commenter
inappropriate changes to the IRP if the will have his or her IRP determined would lead us to establish the IRP based
resident changes specialties subsequent based on the number of years required on the period of board eligibility for a
to beginning residency training. for the advanced program. A number of specialty training program the resident
Therefore, in the FY 2006 IPPS commenters suggested that we entered in the second year even where
proposed rule, we proposed to revise implement a standard second-year the resident had clearly switched
§ 413.79(a)(10) to state that, when a policy in which the resident’s IRP specialties in the second year. We do
hospital can document that a resident would always be based on the specialty not believe this would be consistent
matched in an advanced residency that a resident enters in his or her with legislative intent.
training program beginning in the second year of training, regardless of Comment: Some commenters stated
second residency year prior to what occurred during the residents first that a resident who enters into a
commencement of any residency year of GME training. These transitional year program or a
training, the resident’s IRP will be commenters suggested that a ‘‘second preliminary training year program in an
determined based on the period of board year’’ policy would be less complicated, internal medicine residency should be
eligibility for the specialty associated less administratively burdensome, and assigned an IRP based on the program
with the advanced program, without could be applied more universally, as that the resident enters in his or her
regard to the fact that the resident had many residents enter an advanced second year of training, since such a
not matched for a clinical base year or program in their second year of training resident could never receive
transitional year training program. without being involved in the match certification from his or her clinical base
We noted that this proposed policy process. The commenters also added year of training.
change would not result in a policy to that this seems more consistent with Response: In the FY 2005 rule, we
determine the IRP for all residents who legislative intent as stated in the finalized an IRP policy stating that for
must complete a clinical base year Conference report language a resident that matches in a clinical base
during the second residency training accompanying section 712 of Pub. L. year program and simultaneously
year based on the specialty associated 108–173. That language states that ‘‘the matches in a specialty training program,
with that second residency training initial residency period for any Medicare will use the period of board
year. That is, we did not propose that, residency for which the ACGME eligibility of the specialty training
for any resident whose first year of requires a preliminary or general program to determine the resident’s IRP.
training is completed in a program that clinical year of training is to be In this final rule, we are revising our
provides a general clinical base year as determined the resident’s second year of policy to state that the IRP for a resident
required by the ACGME for certain training.’’ who initially matches, prior to
specialties, an IRP should be assigned in Response: We appreciate the beginning any residency training, only
the second year based on the specialty commenters’ support for our proposal. to an advanced program without
the resident enters in the second year of However, we do not agree with the simultaneously matching to a clinical
training. As we stated in the FY 2005 comment that we should revise the base year or transitional year program,
IPPS final rule (69 FR 49172), a ‘‘second regulations and establish a ‘‘second will have his or her IRP determined
year’’ policy would not allow CMS to year’’ policy for determining the IRP for based on the period of board eligibility
distinguish between those residents residents. As we indicated in the FY for the advanced program.
who, in their second year of training, 2005 IPPS final rule (69 FR 49171), we In the limited circumstance where a
match in a specialty program prior to considered proposing a change in policy resident trains in the transitional year
their first year of training, those to determine the IRP for a resident who program without matching in a specialty
program for the second year, we would, Response: As stated in the proposed who initially matches only to a specialty
in fact, establish the IRP in the second rule, we were ‘‘proposing to revise program, to begin in the resident’s
year of the resident’s training because § 413.79(a)(10)’’ and that this is a second year of training, without
there is no specialty associated with ‘‘policy change.’’ While this policy simultaneously matching to a clinical
transitional year programs, and even change is similar to the policy change base year or transitional year program,
though the resident would have we made last year regarding the IRP is established in the resident’s
‘‘entered’’ a residency training program, simultaneous matches, nevertheless it is first year of training based on the period
we would be unable to identify any a change in policy. Accordingly, the of board eligibility associated with the
specialty with the transitional year change will not be effective October 1, specialty program, that is, the program
program for purposes of determining the 2004, but rather the effective date for the in which the resident will seek
IRP. Because training in a transitional final policy change in this final rule is certification. Because those specialties
year program cannot lead by itself to for portions of cost reporting periods that require a clinical base year are not
certification in any specialty, the occurring on or after October 1, 2005. primary care specialties, the specialty
earliest that Medicare is able to Comment: One commenter requested that the IRP is based on in the first year
determine such a resident’s IRP is when clarification as to what type of of training would be a non-primary care
the resident ‘‘enters’’ a specialty documentation would be needed to specialty. We believe it is only
program in the resident’s second year of demonstrate that a resident matched to consistent to apply the non-primary care
training. Thus, in the limited the advanced residency prior to PRA during the first clinical base year
circumstance of a resident that trains in beginning any training program. The of training as well.
a transitional year program without commenter was concerned that there Comment: One commenter suggested
having matched into a specialty may be confusion during audits if no that residents training in their clinical
program that begins in the second year, documentation standard was base year should be assigned a Med
we believe it is necessary, and therefore established. In particular, the School number of 8888 for IRIS diskette
appropriate, to look to the resident’s commenter mentioned that, although it purposes. The commenter indicated that
second year of training to identify the is fairly easy to acquire such this would be similar to foreign
specialty that should be used for the documentation from the National residents who are currently identified
purpose of determining the IRP. Resident Matching Program (NRMP), it with a 9999 Med School number on the
We note that the situation of the is harder to acquire such documentation IRIS diskette.
from the San Francisco Matching Response: In implementing this
resident in the transitional year program
Program. This commenter requested that policy change, we will consider within
is substantially different from the
we identify documentation from the San CMS the need for and possibility of
situation where the resident begins implementing such a change to the IRIS
Francisco Matching Program that would
training in other preliminary year diskette.
be consistent with the NRMP
programs, such as internal medicine. In Comment: One commenter requested
documentation.
the case of preliminary year programs, Response: As we understand it, the clarification on how the IRP would be
there is a specialty associated with the San Francisco Matching Program sends determined for a resident who, at the
training, and we could, therefore, letters to providers indicating which end of his or her clinical base year,
establish an IRP based on the period of residents matched into which specialty decides to enter a different subspecialty
board eligibility for that program. programs. This letter would be that does not require a clinical base
Therefore, it would not be necessary for sufficient documentation to show that, year.
us to wait until the second year to prior to beginning any residency Response: Medicare establishes the
establish the resident’s IRP. Under the training program, a resident matched IRP based on the specialty associated
policy revision we proposed, the IRP for into an advanced program for the with the program that the resident
a resident that enters a preliminary year second residency year. ‘‘enters’’ in his or her first year of
in internal medicine and continues Comment: Two commenters requested training (unless, prior to beginning any
training in an advanced specialty is clarification and provided training program, the resident matches
established based on the period of board recommendations on issues relating to to an advanced specialty program for
eligibility for the advanced specialty if residency training programs that were the second year of training, in which
the hospital documents that the resident not addressed in the proposed rule. case the IRP is based on the specialty
had matched to the advanced specialty Response: Because we did not program). The resident retains this IRP
program prior to commencement of any propose any changes in policy for the remainder of his or her residency
residency training. Without such concerning the issues addressed by the training, even if the resident decides
documentation, as mentioned before, commenters in the FY 2006 IPPS later to train in a different specialty
CMS would have no way to distinguish proposed rule, we are not responding to training program. Therefore, consider,
between those residents who matched those issues in this final rule. for example, a resident who matched
or planned to train in a particular Comment: One commenter noted that prior to beginning any residency
advanced specialty program prior to CMS did not mention which PRA would training to a radiology program that
entering their first year of training in an be applied to a resident training in his would begin in the second residency
internal medicine or other ‘‘preliminary or her clinical base year versus which year. The resident then completes
year,’’ and those residents who simply PRA would be applied once that training in an internal medicine clinical
switched specialties in their second resident enters his or her second year of base year program, and decides that
year. training. instead of continuing into the radiology
Comment: One commenter noted that Response: We believe it is appropriate program, he or she will continue
we indicated in the proposed rule that to finalize a policy that treats residents training in the internal medicine
this proposal best reflects our original consistently in terms of the specialty program. Under our policy, the IRP for
intent in revising the IRP rule effective program in which they are considered to this resident would have already been
October 1, 2004, and recommended that be training. For this reason, we are established in the first year of training
we clarify our current proposal to also finalizing our proposal from the FY at 5 years, based on the period of board
be effective October 1, 2004. 2006 proposed rule that for a resident eligibility for radiology. Thus, even after
the resident decides to continue training residents in newly approved programs For example, Hospital A had no
in internal medicine, the resident would under § 413.79(e)(1) are not permitted to allopathic or osteopathic residents in its
maintain the IRP that was established in be part of a Medicare GME affiliated most recent cost reporting period ending
the first year of training. group for purposes of establishing an on or before December 31, 1996. As
After consideration of the comments aggregate FTE cap. (A Medicare GME such, Hospital A’s caps for direct GME
received, we are adopting as final, affiliated group is defined in the and IME are both zero. Hospital A and
without modification, our proposal to regulations at § 413.75(b).) We Hospital B enter into a Medicare GME
revise § 413.79(a)(10) to indicate that, established this policy because of our affiliation for the academic year
when a hospital can document that a concern that hospitals with existing beginning on July 1, 2003, and ending
resident matched prior to medical residency training programs on June 30, 2004. On July 1, 2003,
commencement of any residency could otherwise, with the cooperation of Hospital A begins training residents
training in an advanced residency new teaching hospitals, circumvent the from an existing family medicine
training program beginning in the statutory FTE resident caps by program located at Hospital B. This
second residency year, the resident’s establishing new medical residency rotation will result in 5 FTE residents
IRP will be determined based on the programs in the new teaching hospitals training at Hospital A. Through the
period of board eligibility for the solely for the purpose of affiliating with affiliation agreement, Hospital A
specialty associated with the advanced the new teaching hospitals to receive an receives a positive adjustment of 5
program, without regard to the fact that upward adjustment to their FTE cap FTE’s for both its direct GME and IME
the resident had not matched for a under an affiliation agreement. This caps. Hospital B receives a
clinical base year training program. would effectively allow existing corresponding negative adjustment of 5
3. New Teaching Hospitals’ teaching hospitals to achieve an FTEs under the affiliation agreement.
Participation in Medicare GME increase in their FTE resident caps Hospital A’s Board of Directors is
Affiliated Groups (§ 413.79(e)(1)) beyond the number allowed by their interested in starting a new residency
statutory caps. program in Internal Medicine that
In the August 29, 1997 final rule (62
In contrast, hospitals in rural areas would begin training residents at
FR 46005 through 46006) and the May
that qualify for an adjustment under Hospital A on July 1, 2005. If Hospital
12, 1998 final rule (63 FR 26331 through
§ 413.79(e)(1)(v) are allowed to enter A establishes the new program, under
26336), we established rules for
into a Medicare GME affiliation. existing Medicare regulations, Hospital
applying the FTE resident limit (or
Although we recognize that rural A will have its direct GME and IME
‘‘FTE cap’’) for calculating Medicare
hospitals would not be immune from caps (which were both previously
direct GME and IME payments to
the kind of ‘‘gaming’’ arrangement established at zero) permanently
hospitals. We added regulations,
currently at § 413.79(e), to provide for described above, we allow new rural adjusted to reflect the additional
an adjustment to the FTE cap for certain teaching hospitals that begin training residents training in the newly
hospitals that begin training residents in residents in new programs, and thereby approved program in accordance with
new medical residency training increase their FTE cap, to affiliate § 413.79(e)(1). However, under existing
programs. For purposes of this because we understand that rural regulations, Hospital A may no longer
provision, a new program is one that hospitals may not have a sufficient enter into an affiliation with Hospital B
receives initial accreditation or begins volume of patient care utilization at the after it receives the adjustment to its
training residents on or after January 1, rural hospital site to be able to support FTE caps under § 413.79(e)(1).
1995. Although we refer only to the a training program that meets In the FY 2006 IPPS proposed rule,
direct GME provision throughout the accreditation standards. Securing we proposed to revise § 413.79(e)(1)(iv)
remainder of this discussion, a similar sufficient patient volumes to meet so that new urban teaching hospitals
cap adjustment is made under accreditation requirements may that qualify for an adjustment under
§ 412.105(f) for IME purposes. necessitate rotations of the residents to § 413.79(e)(1) may enter into a Medicare
Therefore, this discussion applies to another hospital. Accordingly, the GME affiliation agreement under certain
both IME and direct GME. regulations allow new teaching circumstances. Specifically, a new
A new teaching hospital is one that hospitals in rural areas to enter into urban teaching hospital that qualifies for
had no allopathic or osteopathic Medicare GME affiliation agreements. an adjustment to its FTE caps for a
residents in its most recent cost However, an affiliation is only newly approved program may enter into
reporting period ending on or before permitted if the rural hospital provides a Medicare GME affiliation agreement,
December 31, 1996. Under training for at least one-third of the FTE but only if the resulting adjustments to
§ 413.79(e)(1), if a new teaching hospital residents participating in all of the joint its direct GME and IME caps are
establishes one or more new medical programs of the affiliated hospitals ‘‘positive adjustments.’’ ‘‘Positive
residency training programs, the because, as we stated in the May 12, adjustment’’ means, for the purpose of
hospital’s unweighted FTE caps for both 1998 Federal Register (63 FR 26333), we this policy, that there is an increase in
direct GME and IME will be based on believe that requiring at least one-third the new teaching hospital’s caps as a
the product of the highest number of of the training to take place in the rural result of the affiliation agreement. At no
FTE residents in any program year in area allows operation of programs that time would the caps of a hospital
the third year of the hospital’s first new focus on, but are not exclusively limited located in an urban area that qualifies
program and the number of years in to, training in rural areas. for adjustment to its FTE caps for a new
which residents are expected to Through comment and feedback from program under § 413.79(e)(1), be
complete the program(s), based on the industry trade groups and hospitals, we allowed to decrease as a result of a
minimum number of years of training understand that, while these rules were Medicare GME affiliation agreement. We
that are accredited for the type of meant to prevent gaming on the part of believe the proposed policy change
program(s). existing teaching hospitals, they could would allow new urban teaching
The regulations at § 413.79(e)(1)(iv) also preclude affiliations that clearly are hospitals flexibility to start new
specify that hospitals in urban areas that designed to facilitate additional training teaching programs without jeopardizing
qualify for an FTE cap adjustment for at the new teaching hospital. their ability to count additional FTE
residents training at the hospital under caps. Some of the commenters stated requirements’’ and often need to rotate
an affiliation agreement. that the proposal allows new urban residents to other facilities in order to
We remain concerned that hospitals teaching hospitals the flexibility to start meet those requirements. The
with existing medical residency training new teaching programs without commenter believed that, because the
programs could cooperate with a new ‘‘jeopardizing their ability to count ‘‘used’’ portion of the teaching
teaching hospital to circumvent the additional FTE residents training at the hospitals’ direct GME and IME FTE
statutory FTE caps by establishing new hospital under an affiliation resident caps were reduced by 75
programs at the new teaching hospital, agreement.’’ These commenters stated percent in accordance with section 422
and, through a Medicare GME affiliation that an increase in Medicare payments of Pub. L. 108–173, new teaching
agreement, moving most or all of the received by the new urban teaching facilities may have difficulty finding a
new residency program to its own hospital when residents from existing hospital that will accept their residents
hospital, thereby receiving an upward teaching hospitals rotate to the new for the necessary rotations without an
adjustment to its FTE caps. For this urban teaching hospital is necessary to affiliation agreement. The commenter
reason, we proposed to revise cover both direct and indirect costs believed that, unless it could aggregate
§ 413.79(e)(1)(iv) of the regulations to incurred ‘‘to train the ‘in rotating’ its FTE resident limit with other
provide that a hospital that qualifies for residents from other hospital teaching hospital(s) through a Medicare GME
an adjustment to its caps under programs.’’ affiliation agreement, it may become
§ 413.79(e)(1) would not be permitted to Response: We appreciate the necessary for the new teaching hospital
enter into an affiliation agreement that comments in support of our proposal to to pay for training the residents in the
would produce a negative adjustment to allow for new urban teaching hospitals new program at another hospital in
its FTE resident cap. to join a Medicare GME affiliated group order for another hospital to agree to
Continuing the example shown above, if, under the agreement, there is a provide a training site for the residents.
under the proposed change in policy, positive increase to the FTE cap of the The commenter suggested CMS revise
Hospital A and Hospital B would be new teaching hospital. We agree that the regulations to allow new teaching
able to continue the Medicare GME our proposal will allow new urban hospitals to join an affiliated group and
affiliation agreement under which teaching hospitals greater flexibility in allow for a cap decrease as long as the
Hospital A trained residents from starting new teaching programs without new teaching facility can document
Hospital B’s family practice program endangering their ability to train other that, at a minimum, 75 percent of the
because Hospital A would receive an FTE residents from existing programs total training hours for each resident
increase in its direct GME or IME caps under an affiliation agreement. was completed at the new teaching
under an affiliation after qualifying for Comment: One commenter urged facility, and no more than 25 percent of
a new program adjustment under CMS to consider ‘‘replacing the training was done at another hospital
§ 413.79(e)(1). However, Hospital B permanent exclusion of negative site during the cost report period.
would not be able to receive an increase adjustments for new urban teaching Response: We disagree with the
in its caps as a result of a Medicare GME facilities with a temporary exclusion for commenter’s suggestions. We continue
affiliation agreement with Hospital A. the first 3 to 5 years.’’ The commenter to be concerned that hospitals with
Thus, we proposed the above policy believed that such a replacement would existing medical residency training
change to provide some flexibility to permit new urban teaching facilities programs could cooperate with a new
hospitals that are currently prohibited flexibility similar to that allowed for teaching hospital to circumvent the
from entering into a Medicare GME new rural teaching facilities and allow statutory FTE caps by establishing new
affiliation agreement, while continuing for adjustments due to ‘‘unforeseen programs at the new teaching hospital,
to protect the statutory FTE resident future circumstances.’’ and, through a Medicare GME affiliation
caps from being undermined by gaming. Response: We disagree with the agreement, moving some of the new
We specifically solicited comments on commenter’s suggestion. We continue to residency program to its own hospital,
the proposed change. be concerned that hospitals with thereby receiving an upward adjustment
We would like to clarify a statement existing medical residency training to its FTE caps. For this reason, we
made at 70 FR 23440 of the FY 2006 programs could affiliate with a new limited our proposal to revise
IPPS proposed rule in which we state, teaching hospital to circumvent the § 413.79(e)(1)(iv) of the regulations to
‘‘However, under existing regulations, statutory FTE caps by establishing new provide that a hospital that qualifies for
Hospital A may no longer enter into an programs at the new teaching hospital, an adjustment to its caps under
affiliation with Hospital B after it and move the additional FTE slots to its § 413.79(e)(1) would not be permitted to
receives the adjustment to its FTE caps own hospital, thus receiving an upward enter into a Medicare GME affiliation
under § 413.79(e)(1)’’ (emphasis added). adjustment to its FTE caps. For this agreement that would produce a
The sentence could be read to reason, we limited our proposal to negative adjustment to its FTE cap,
mistakenly imply that the new teaching revise § 413.79(e)(1)(iv) of the Comment: Several commenters
Hospital A is not permitted to affiliate regulations to provide that a hospital requested that CMS consider
only once its cap becomes effective that qualifies for an adjustment to its ‘‘broadening its proposed changes to the
beginning with the fourth program year caps under § 413.79(e)(1) would not be affiliation agreement requirement.’’ The
of the new program. In fact, the new permitted to enter into an affiliation commenters believed that CMS’
teaching Hospital A cannot affiliate agreement that would produce a concerns regarding possible gaming are
from the time it begins training negative adjustment to its FTE cap. unnecessary and therefore the policy is
residents in the newly accredited Comment: One commenter believed ‘‘too restrictive.’’ The commenters
program(s). CMS’s proposal to permit an affiliation indicated that hospitals do not decide to
Comment: Numerous commenters agreement as long as it results in an become teaching hospitals and become
agreed with the proposed policy change increase in the new teaching hospital’s involved with the accreditation process
to allow new urban teaching hospitals to resident cap is a ‘‘positive’’ change but with the intention of ‘‘gaming’’ the
enter into a Medicare GME affiliation stated that the proposal does not system. The commenters stated that
agreement if the adjustment results in address the issue that ‘‘all teaching CMS has not provided any evidence
an increase in their direct GME and IME programs must meet specific teaching ‘‘that this type of gaming has ever
occurred.’’ The commenters further caps by establishing new programs at commenter requested guidance on how
asserted that, in imposing restrictions the new teaching hospital, and, through the increases in FTE resident limits
on affiliation agreements for new urban a Medicare GME affiliation agreement, under section 422 of Pub. L. 108–173
teaching hospitals to prevent gaming, moving FTE slots to its own hospital, would be applied. On a different
CMS has not considered the safeguards thus receiving an upward adjustment to subject-matter, the commenter
that are already in place to avert gaming. its FTE caps. In order to prevent the recommended that we perform an
They added that the ‘‘intensive process’’ artificial expansion of the aggregate FTE analysis to determine the validity of the
of accreditation by an appropriate limits for all teaching hospitals that Council on Graduate Medical
accrediting body is one of the several could otherwise result, we proposed a Education’s recommendations that CMS
existing safeguards against gaming. The limited revision to § 413.79(e)(1)(iv) of gradually increases its resident caps in
commenters believed that an additional the regulations to provide that a hospital the face of a possible physician shortage
safeguard against gaming is the that qualifies for an adjustment to its in the future. Another commenter
requirement that a hospital ‘‘must caps under § 413.79(e)(1) would not be requested clarification on how CMS
maintain its new program for a period permitted to enter into a Medicare GME would treat two affiliation agreements
of three years before it qualifies to affiliation agreement that would for payment purposes where Hospital A,
receive a permanent FTE cap.’’ Referring produce a negative adjustment to its Hospital B, Hospital C, and Hospital D
to the previous sentence, the FTE resident cap. agree to affiliate and then Hospital D
commenters believed that ‘‘establishing We would also like to clarify, from an and Hospital E enter into a separate
a program requires concerted action by operational perspective, what a affiliation agreement that specifically
staff throughout a facility, which actions Medicare GME affiliation agreement states the agreement’s intent not to
must be sustained for a subsequent would look like between an existing include Hospital E as part of the
period of time. It is unlikely that many urban teaching hospital with a 1996 cap agreement between Hospitals A, B, C,
institutions would undertake such and a new urban teaching hospital that and D.
action merely to help another hospital is receiving a permanent cap adjustment Response: In the FY 2006 IPPS
to obtain a purported improper gain in for a newly approved program. Because, proposed rule, we did not propose any
its GME payment.’’ The commenters under § 413.79(e)(1)(ii), the new changes that are specific to these
stated that additional protection against teaching hospital does not have comments. Therefore, we are not
gaming is provided through changes permanent FTE caps within the first 3 responding to them at this time.
CMS has made over time to affiliation years of the new program’s existence, In this final rule, we are adopting as
agreement requirements. They gave as the new teaching hospital would final, without modification, our
an example of such changes to affiliate with its FTE caps of zero. That proposal to revise § 413.79(e)(1)(iv) so
affiliation agreement requirements the is, the affiliation agreement between the that new urban teaching hospitals that
requirement that there be ‘‘a bona fide new teaching hospital and the existing qualify for an adjustment under
shared rotational arrangement between teaching hospital would show a positive § 413.79(e)(1) may enter into a Medicare
two hospitals as a pre-condition to entry adjustment to the new teaching GME affiliation agreement under certain
into an affiliation agreement.’’ hospital’s 1996 FTE cap of zero. circumstances. Specifically, a new
The commenters asserted that CMS’ However, once the FTE caps have been urban teaching hospital that qualifies for
affiliation agreement policy could have permanently established beginning with an adjustment to its FTE caps for a
a negative impact on medical education. the fourth program year of the new newly approved program may enter into
The commenters stated that, due to program’s existence, the affiliation a Medicare GME affiliation agreement,
circumstances that are unforeseen, a agreement between the new teaching but only if the resulting adjustments to
hospital may need to shift a group of hospital and the existing teaching its direct GME and IME caps are
residents to another hospital in its hospital would show a positive ‘‘positive adjustments.’’ ‘‘Positive
affiliated group. The commenters adjustment to the new teaching adjustment’’ means, for the purpose of
believed that CMS would penalize the hospital’s adjusted cap resulting from this policy, that there is an increase in
receiving hospital for circumstances the new program(s). the new teaching hospital’s caps as a
beyond its control by disallowing the Comment: One commenter urged result of the affiliation agreement. This
receiving hospital to increase its FTE CMS to make the provision allowing provision is effective for affiliation
cap ‘‘through a shift of a portion of the new urban teaching hospitals to enter agreements entered into on or after
new teaching hospital’s FTE cap.’’ The into affiliation agreements only if there October 1, 2005.
commenters believed that this lack of is an increase in direct GME and IME
4. GME FTE Cap Adjustment for Rural
flexibility will ‘‘discourage parties from cap(s) ‘‘effective for affiliation
Hospitals (§ 413.79(c) and (k))
entering into affiliation agreements with agreements entered into on or after
new teaching hospitals because of the October 1, 2005, and be noted in the As stated earlier under section V.I.1.
fear of adverse financial implications final rule.’’ of this preamble, Medicare makes both
arising from unforeseen circumstances.’’ Response: Although this final rule direct and indirect GME payments to
The commenters requested that CMS generally takes effect on October 1, hospitals for the training of residents.
reconsider the policy to allow a new 2005, because hospitals must affiliate by Direct GME payments are made in
teaching hospital to enter into affiliation July 1 of a given year, as a practical accordance with section 1886(h) of the
agreements only when they result in an matter, the new policy will be effective Act, based generally on the hospital-
increase in the new hospital’s FTE cap. for affiliation agreements entered into specific PRA, the number of FTE
Response: We appreciate, but disagree on or after July 1, 2006, which is the residents a hospital trains, and the
with, the commenter’s views. Despite first academic year that new teaching hospital’s percentage of Medicare
the commenters’ examples of safeguards hospitals could affiliate under these inpatient utilization. Indirect GME
against gaming, we continue to be new rules. payments (referred to as IME) are made
concerned that hospitals with existing Comment: Two commenters requested in accordance with section 1886(d)(5)(B)
medical residency training programs clarification and provided of the Act as an adjustment to DRG
could cooperate with a new teaching recommendations on topics not payment and are based generally on the
hospital to circumvent the statutory FTE addressed in the proposed rule. One ratio of the hospital’s FTE residents to
the number of hospital beds. It is well- 10 residents in each of its first 3 cap adjustments while it was designated
established that the calculation of both program years (for a total of 30 residents or classified as rural. The issue is
direct GME and IME payments is in the entire program in the program’s whether the adjusted caps would
affected by the number of FTE residents third year), the hospital’s direct GME continue to apply after the hospital
a hospital is allowed to count; generally, FTE cap of 100 would be permanently becomes urban or returns to being
the greater the number of FTE residents adjusted at the conclusion of the third treated as urban. Below we first address
a hospital counts, the greater the program year by 30, and the hospital’s hospitals that lost their status as urban
amount of Medicare direct GME and new FTE cap would be 130. A similar hospitals due to new labor market areas.
IME payments the hospital will receive. adjustment would be made to the We then address hospitals that
Effective October 1, 1997, Congress hospital’s FTE cap for IME in rescinded their section 1886(d)(8)(E)
instituted caps on the number of accordance with the regulations at reclassifications. (We note that
allopathic and osteopathic residents a § 412.105(f)(1)(iv)(A). However, the reclassification by the MGCRB under
hospital is allowed to count for direct rural hospital would not be able to section 1886(d)(10) of the Act, as well
GME and IME purposes at sections receive adjustments to its FTE cap for as reclassifications under section
1886(h)(4)(F) (direct GME) and any expansion of a preexisting program. 1886(d)(8)(B) of the Act, are effective
1886(d)(5)(B)(v) (IME) of the Act. These In 1999, Congress passed an only for purposes of the wage index and
caps were instituted in an attempt to additional provision under section 407 would not affect the hospital’s IME or
end the implicit incentive for hospitals of Pub. L. 106–113 (BBRA) to promote direct GME payments.)
to increase the number of FTE residents. physician training in rural areas.
Dental and podiatric residents were not Section 407 of the Pub. L. 106–113 a. Formerly Rural Hospitals That
included in these statutorily mandated amended the FTE caps provision at Became Urban Due to the New CBSA
caps. sections 1886(h)(4)(F) and Labor Market Areas
Congress provided certain exceptions 1886(d)(5)(B)(v) of the Act to provide In the FY 2005 IPPS final rule, we
for rural hospitals when establishing the that ‘‘effective for cost reporting periods adopted the new CBSA-based labor
1996 caps ‘‘with the intent of beginning on or after April 1, 2000, [a market areas announced by OMB on
encouraging physician training and rural hospital’s FTE cap] is 130 percent June 6, 2003, and these areas became
practice in rural areas’’ (65 FR 47032). of the unweighted FTE count * * * for effective October 1, 2004. As a result of
For example, the statute states at section those residents for the most recent cost these new labor market areas, a number
1886(h)(4)(H)(i) that, in promulgating reporting period ending on or before of hospitals that previously were located
rules regarding application of the FTE December 31, 1996.’’ In other words, the outside of an MSA and therefore
caps to training programs established otherwise applicable FTE caps for rural considered rural are now located in a
after January 1, 1995, ‘‘the Secretary hospitals were multiplied by 1.3 to CBSA that is designated as urban and
shall give special consideration to encourage rural hospitals to expand considered urban.
facilities that meet the needs of preexisting residency programs. (As We believe that previously rural
underserved rural areas.’’ Accordingly, described above, even prior to the BBRA hospitals that received adjustments due
in implementing this provision, we change, rural hospitals were able to to establishing new medical training
provided in the regulations under receive FTE cap adjustments for new programs should not now be required to
§ 413.86(g)(6)(i)(C) (now programs.) For example, a hospital that forego such adjustments simply because
§ 413.79(e)(1)(iii)) that ‘‘except for rural was rural as of April 1, 2000, and had they have now been redesignated as
hospitals, the cap will not be adjusted a direct GME cap of 100 FTEs would urban. Such hospitals added and
for new programs established more than receive a permanent cap adjustment of received accreditation for new medical
3 years after the first program begins 30 FTEs (100 FTEs × 1.3 = 130 FTEs) training programs under the assumption
training residents. In other words, only and effective for cost reporting periods that such programs would affect a
hospitals located in rural areas (that is, beginning on or after April 1, 2000, its permanent increase in their FTE caps.
areas that are not designated as an FTE for direct GME would be 130. (A Indeed, we believe it would be
MSA), receive adjustments to their similar adjustment would be made to nonsensical to view the fact that these
unweighted FTE caps to reflect the FTE cap for IME for discharges hospitals are now urban as causing them
residents in new medical residency occurring on or after April 1, 2000.) to lose the adjustments that stemmed
training programs past the third year We recently received questions directly from the permissible and
after the first residency program began regarding the application of the 130- encouraged establishment of new
training in that hospital (62 FR 46006). percent FTE cap adjustment and the medical training programs. Such
Section 413.79(e)(1) specifies the new new program adjustment for rural hospitals cannot reach back into the
program adjustment as the ‘‘product of hospitals in instances in which a rural past and alter whether they added the
the highest number of residents in any teaching hospital is later redesignated as new programs or not. Nor would it be
program year during the third year of an urban hospital or reclassifies back to reasonable to prohibit them from
the * * * program’s existence * * * being an urban hospital after having counting FTE residents training in new
and the number of years in which been classified as rural. We are aware of programs that they worked to accredit.
residents are expected to complete the two circumstances when a rural hospital (We note that the hospitals would not be
program based on the minimum may subsequently be reclassified as required to close the programs. Rather,
accredited length for the type of urban. The first circumstance involves if they were not permitted to retain the
program.’’ The regulation applies only labor market area changes, and the adjustments to their FTE caps they
to new programs (as defined under second involves urban hospitals, after received as a result of having
§ 413.79(1)) established by rural having been reclassified as rural through established new programs, they would
hospitals, not for expansion of section 1886(d)(8)(E) of the Act, that no longer be permitted to count FTE
previously existing programs. For elect to be considered urban again. In residents that exceeded their original,
example, if a rural hospital has an both situations, if the hospital in preadjustment FTE caps for purposes of
unweighted FTE cap for direct GME of question was a teaching hospital, its direct GME and IME payments. The
100 and begins training residents in a FTE caps would have been subject to effect might be that the hospital would
new 3-year residency program that has the 130 percent and new program FTE have to close the program(s) as a result
of decreased Medicare funding, but the addition of new programs, we interpret 1886(h)(4)(H)(iv) of the Act states: ‘‘In
hospital would be free to continue to the language ‘‘130 percent of such the case of a hospital that is not located
operate the programs(s).) number in the case of a hospital located in a rural area but establishes separately
For these reasons, we believe the best in a rural area,’’ as meaning only that accredited approved medical residency
reading of our regulation at the hospital was required to be rural at training programs (or rural tracks) in an
§ 413.79(e)(3), which states that if a the time it received the 30-percent (sic) rural area or has an accredited
hospital ‘‘is located in a rural area,’’ it increase. Once the hospital received training program with an integrated
may adjust its FTE cap to reflect such increase, the increase became a rural track, the Secretary shall adjust the
residents training in new programs, is permanent increase in the FTE cap and limitation under subparagraph (F) in an
that hospitals were permitted to receive should not be rescinded based on appropriate manner insofar as it applies
a permanent adjustment to their FTE subsequent designation as an urban to such programs in such rural areas in
caps if, at the time of adding a new hospital. order to encourage the training of
program, the hospitals were rural. A We believe our interpretations are physicians in rural areas.’’
hospital’s subsequent designation as consistent with legislative intent. Again, we believe that the reading
urban or rural due to labor market area Congress provided for these FTE cap that best carries out Congressional
changes becomes irrelevant, because the adjustments for rural hospitals with the intent is one that allows the adjustment
central question is whether the hospital intent of encouraging physician training for rural tracks to remain permanent as
is rural at the time it adds the new and practice in rural areas. If rural long as the rural track training programs
programs. Therefore, as we proposed in hospitals had believed that new CBSAs continue, even if the once-rural tracks
the FY 2006 IPPS proposed rule, we are would cause them to lose the are now urban due to new labor market
clarifying in this final rule our policy adjustments, they would not have had area boundaries. Congress clearly
that hospitals that became urban in FY the incentives Congress wished to intended to encourage the training of
2005 due to the new labor market areas increase the number of FTE residents physicians in the rural tracks identified
will nevertheless be permitted to retain training in their programs. These by the statute. However, if the FTE cap
the adjustments they received for new hospitals might have feared losing the adjustments were merely temporary,
programs as long as they were rural at adjustments as a result of new labor and hospitals could not rely on
the time they received them. (Once such market areas, and therefore not carried retaining the adjustments relating to the
hospitals receive a designation as out Congress’ intent to expand their rural training programs in which they
‘‘urban,’’ they may no longer seek FTE already existing residency training invested, then Congress’ wishes to
cap adjustments relating to new training programs or add new residency training encourage rural training programs might
programs; they may only retain the programs. not have been realized. Hospitals would
adjustments they received for the new To provide an example of the how the always need to speculate as to whether
programs they added when they were above statutory interpretations would be the FTE cap adjustments relating to the
rural.) applied, a hospital located in a rural rural track programs they established
Similarly, we believe that rural area prior to October 1, 2004, with an would be lost each time new labor
hospitals that received the statutorily unweighted direct GME FTE cap of 100 market areas were adopted (which
mandated 130 percent adjustment to would have received a 30-percent normally occurs once every 10 years).
their FTE caps would be disadvantaged increase in its FTE cap so that its Thus, we believe the statutory language
if we were to rescind this adjustment adjusted cap was 130 FTEs. The rural should be interpreted as allowing an
due to new urban designation. Such hospital also could have received an urban hospital to retain its FTE cap
hospitals expanded their already adjustment for any new medical adjustment for rural track programs as
existing training programs under the residency program. If this hospital, long as the tracks were actually located
assumption that these expansions while rural, started a new 3-year in rural areas at the time the urban
would cause a permanent increase in residency program with 10 residents in hospital received its adjustment.
their FTE caps. Many of these hospitals each program year, its FTE cap would However, if the urban hospital wants to
expanded their programs only once the have been increased by an additional 30 receive a cap adjustment for a new rural
BBRA became effective (in 2000). Thus, FTEs to 160 FTEs (that is, (100 FTEs × track residency program, the rural track
they have had only a few years to 1.3) + 30 FTEs = 160 FTEs). Under our must involve rural hospitals that are
expand their programs and receive the reading of the statute, if this hospital is located in rural areas based on the most
cap adjustment mandated by statute. For now located in an urban area due to the recent OMB labor market designations
these reasons, we believe it is new CBSAs, it would retain this cap of as specified in the FY 2005 IPPS final
permissible to read sections 160 FTEs. rule. As we proposed in the FY 2006
1886(h)(4)(F)(i) and 1886(d)(5)(B)(v) of We also believe that the statute IPPS proposed rule, we are adding a
the Act as permitting a permanent should be interpreted as permitting new paragraph (k)(7) to § 413.79 to
adjustment to the FTE caps at the time urban hospitals with rural track training incorporate this policy.
a rural hospital adds residents to its programs to retain the adjustment they Comment: Several commenters
already existing program(s). The received for such programs at commended CMS and supported our
language states that the total number of § 413.79(k), even if the ‘‘rural’’ tracks as proposal to revise the current
FTE residents with respect to a of October 1, 2004, are now located in regulations that would allow a rural
‘‘hospital’s approved medical residency urban areas due to the new OMB labor hospital redesignated as urban as a
training program in the fields of market areas. As explained in the FY result of the changes to CBSAs that were
allopathic medicine and osteopathic 2001 IPPS final rule (66 FR 47033), we effective on October 1, 2004, to retain
medicine may not exceed the number provided that an urban hospital that any adjustment that it received as a
(or 130 percent of such number in the establishes a separately accredited rural hospital.
case of a hospital located in a rural area) medical residency training program in a Response: We appreciate the
of such full-time equivalent residents rural area (that is, a rural track) may commenters’ support of our proposal.
for the hospital’s most recent cost receive an adjustment to reflect the Accordingly, in this final rule, we are
reporting period ending on or before number of residents in that program adopting the proposal as final without
December 31, 1996.’’ As with the (existing § 413.79(k)). Section modification.
b. Section 1886(d)(8)(E) Hospitals corresponding redesignation of § 413.80 the August 24, 2001 proposed rule and
As stated above, a second situation as § 413.89. In this final rule, we are making appropriate revisions, we
exists where a hospital that is treated as correcting cross-references to § 413.80 in published a final rule on November 30,
rural returns to being urban under 42 CFR Parts 412, 413, 417, and 419 to 2001 setting forth the provider-based
section 1886(d)(8)(E) of the Act reflect the redesignation of this section regulations (66 FR 59909).
as § 413.89. • On May 9, 2002, we proposed
(§ 412.103 of the regulations). Under
further significant revisions to the
this provision, an urban hospital may J. Provider-Based Status of Facilities provider-based regulations at § 413.65
file an application to be treated as being and Organizations Under Medicare (67 FR 31480). After considering public
located in a rural area. A hospital’s
1. Background comments on the May 9, 2002 proposed
reclassification as located in a rural area
rule and making appropriate revisions,
under this provision affects only Since the beginning of the Medicare
on August 1, 2002, we published a final
payments under section 1886(d) of the program, some providers, which we rule specifying the criteria that must be
Act. Accordingly, a hospital that is refer to as ’’main providers,’’ have met to qualify for provider-based status
treated as rural under this provision can functioned as a single entity while (67 FR 50078). These regulations remain
receive the FTE cap adjustments that owning and operating multiple in effect and continue to be codified at
any other rural hospital receives, but provider-based departments, locations, § 413.65.
only to the FTE cap that applies for and facilities that were treated as part of Following is a discussion of the major
purposes of IME payments, which are the main provider for Medicare provisions of the provider-based
made under section 1886(d) of the Act. purposes. Having clear criteria for regulations: Section 413.65(a) of the
The hospital could not receive provider-based status is important regulations describes the scope of that
adjustments to its direct GME FTE cap because this designation can result in section and provides definitions of key
because payments for direct GME are additional Medicare payments for terms used in the regulations. Paragraph
made under section 1886(h) of the Act services furnished at the provider-based (b) describes the procedure for making
and the section 1886(d)(8)(E) facility, and may also increase the provider-based determinations, and
reclassifications affect only the coinsurance liability of Medicare paragraph (c) imposes requirements for
payments that are made under that beneficiaries for those services. reporting material changes in
section 1886(d) of the Act. Therefore, a To set forth Medicare policies with relationships between main providers
hospital that reclassifies as rural under regard to the provider-based status of and provider-based facilities or
section 1886(d)(8)(E) of the Act may facilities and organizations, we have organizations. In paragraph (d), we
receive the 130-percent adjustment to its published a number of Federal Register specify the requirements that are
IME FTE cap and its IME FTE cap may documents as follows: applicable to all facilities or
be adjusted for any new programs, • In a proposed rule published in the organizations seeking provider-based
similar to hospitals that are actually Federal Register on September 8, 1998 status, and in paragraph (e), we describe
located in a rural location. A hospital (63 FR 47552), we proposed specific and the additional requirements applicable
treated as rural under section comprehensive criteria for determining to off-campus facilities or organizations
1886(d)(8)(E) of the Act may whether a facility or organization is (generally, those located more than 250
subsequently withdraw its election and provider-based. In the preamble to the yards from the provider’s main
return to its urban status under the proposed rule, we explained why we buildings). Paragraphs (f) through (o) set
regulations at § 412.103. As we believed meeting each criterion would forth policies regarding joint ventures,
proposed in the FY 2006 IPPS proposed be necessary to a finding that a facility obligations of provider-based facilities,
rule, we are providing that, effective or organization qualifies for provider- facilities operated under management
with discharges occurring on or after based status. After considering public contracts or providing all services under
October 1, 2005, a different policy comments on the September 8, 1998 arrangements, procedures in connection
applies for hospitals that reclassify proposed rule and making appropriate with certain provider-based
under section 1886(d)(8)(E) of the Act revisions, on April 7, 2000 (65 FR determinations, and specific types of
than the policy that applies to rural 18504), we published a final rule setting facilities such as Indian Health Service
hospitals redesignated as urban due to forth the provider-based regulations at (IHS) and Tribal facilities and Federally
changes in labor market areas, as 42 CFR 413.65. qualified health centers (FQHCs).
discussed in section IV.F.3 of this • Before the regulations that were
issued on April 7, 2000 could be 2. Limits on the Scope of the Provider-
preamble.
implemented, Congress enacted the Based Regulations—Facilities for Which
5. Technical Changes: Cross References Medicare, Medicaid, and SCHIP Provider-Based Determinations Will Not
• In the FY 2005 IPPS final rule (69 Benefits Improvement and Protection Be Made
FR 49234), we redesignated the contents Act of 2000 (BIPA), Pub. L. 106–544. In § 413.65(a)(1)(ii), we list specific
of § 413.86 as §§ 413.75 through 413.83. Section 404 of BIPA delayed types of facilities and organizations for
We also updated cross-references to implementation of the April 7, 2000 which determinations of provider-based
§ 413.86 that were located in various provider-based rules with respect to status will not be made. We previously
sections under 42 CFR Parts 400 many providers, and mandated changes concluded that provider-based
through 499. We inadvertently did not in the criteria at § 413.65 for determinations should not be made for
capture all of the needed cross-reference determining provider-based status. these facilities because the outcome of
changes. In this final rule, we are • In order to conform our regulations the determination (that is, whether a
correcting the additional cross- to the requirements of section 404 of facility, unit, or department is found to
references in 42 CFR Parts 405, 412, BIPA and to codify certain clarifications be freestanding or provider-based)
413, 415, 419, and 422 that were not of provider-based policy that had would not affect the methodology used
made in the August 11, 2004 final rule. previously been posted on the CMS Web to make Medicare or Medicaid payment,
• When we redesignated § 413.86 as site, we published another proposed the scope of benefits available to a
§§ 413.75 through 413.83 in the FY 2005 rule on August 24, 2001 (66 FR 44672). Medicare beneficiary in or at the
IPPS final rule, we also made a After considering public comments on facility, or the deductible or coinsurance
liability of a Medicare beneficiary in or we believe that such determinations Medicare (or medical assistance under
at the facility. have historically not been made for such a Medicaid State plan).
We have now concluded that, under clinics, and, therefore, we view this (§ 413.65(e)(3)(i))
the principle stated above, rural health revision to § 413.65 (a)(1)(ii) as a • The facility or organization
clinics affiliated with hospitals having clarification of existing policy and not demonstrates a high level of integration
50 or more beds should be added to the as the announcement of a new policy for with the main provider by showing that
list of facilities for which provider- which an effective date must be it meets all of the other provider-based
based status determinations are not specified. Therefore we have not made criteria and demonstrates that it serves
made. Therefore, in the FY 2006 IPPS any changes to § 413.65 (a)(1)(ii) based the same patient population as the main
proposed rule, we proposed to revise on this comment. The general effective provider, by submitting records showing
§ 413.65(a)(1)(ii) to add rural health date for this final rule is October 1, that, during the 12-month period
clinics with hospitals having 50 or more 2005. immediately preceding the first day of
beds to the listing of the types of the month in which the application for
facilities for which a provider-based 3. Location Requirement for Off-Campus
Facilities: Application to Certain provider-based status is filed with CMS,
status determination will not be made. and for each subsequent 12-month
We believe this proposed revision to Neonatal Intensive Care Units
period—
§ 413.65(a)(1)(ii) is appropriate because As we stated in the preamble to May —At least 75 percent of the patients
all rural health clinics affiliated with 9, 2002 proposed rule for changes in the served by the facility or organization
hospitals having 50 or more beds are provider-based rules (67 FR 31485), we reside in the same zip code areas as
paid on the same basis as rural health recognize that provider-based status is at least 75 percent of the patients
clinics not affiliated with any hospital, not limited to on-campus facilities or served by the main provider
and the scope of Medicare Part B organizations and that facilities or (§ 413.65(e)(3)(ii)(A)); or
benefits and beneficiary liability for organizations located off the main —At least 75 percent of the patients
Medicare Part B deductible and provider campus may also be served by the facility or organization
coinsurance amounts would be the sufficiently integrated with the main who required the type of care
same, regardless of whether the rural provider to justify a provider-based furnished by the main provider
health clinic was found to be provider- designation. However, the off-campus received that care from that provider
based or freestanding. location of the facilities or organizations (for example, at least 75 percent of the
In setting forth this policy, we may make such integration harder to patients of a rural health clinic
recognize that rural health clinics achieve, and such integration should seeking provider-based status
affiliated with hospitals report their not simply be presumed to exist. received inpatient hospital services
costs using the hospital’s cost report Therefore, to ensure that off-campus from the hospital that is the main
rather than by filing a separate rural facilities or organizations seeking provider (§ 413.65(e)(3)(ii)(B)).
health clinic cost report, and that provider-based status are appropriately
whether or not a rural health clinic is integrated, we have adopted certain Section 413.65(e)(3)(ii)(C) of the
hospital-affiliated will affect the requirements regarding the location of regulations allows new facilities or
selection of a fiscal intermediary for the off-campus facilities or organizations. organizations to qualify as provider-
clinic. However, we do not believe these These requirements are set forth in based entities. Under this section, if a
administrative differences provide a § 413.65(e)(3). Section 413.65(e)(3) facility or organization is unable to meet
sufficient reason to make provider-based specifies that a facility or organization the criteria in § 413.65(e)(3)(ii)(A) or
determinations for such rural health not located on the main campus of the (e)(3)(ii)(B) because it was not in
clinics. potential main provider can qualify for operation during all of the 12-month
Comment: Two commenters provider-based status only if it is period before the start of the period for
supported the proposed change but did located within a 35-mile radius of the which provider-based status is sought,
not comment in further detail on it. campus of the hospital or CAH that is the facility or organization may
Response: We appreciate the the potential main provider, or meets nevertheless meet the location
commenters’ views and have taken them any one of the following requirements. requirement of paragraph (e)(3) of
into consideration in developing the • The facility or organization is § 413.65 if it is located in a zip code area
final rule. owned and operated by a hospital or included among those that, during all of
Comment: One commenter CAH that has a disproportionate share the 12-month period before the start of
recommended that the final rule be adjustment (as determined under the period for which provider-based
revised to state that the inclusion of § 412.106) greater than 11.75 percent or status is sought, accounted for at least
rural health clinics affiliated with is described in § 412.106(c)(2) of the 75 percent of the patients served by the
hospitals having 50 or more beds in regulations which implement section main provider.
§ 413.65(a)(1)(ii) is effective for cost 1886(e)(5)(F)(i)(II) of the Act and is— CMS has been advised that, in some
reporting periods beginning on or after —Owned or operated by a unit of State cases, the location requirements in
October 1, 2005. or local government; current regulations may inadvertently
Response: Although rural health —A public or nonprofit corporation that impede the delivery of intensive care
clinics affiliated with hospitals having is formally granted governmental services to newborn infants in areas
50 or more beds were not previously powers by a unit of State or local where there is no nearby children’s
specifically listed in § 413.65(a)(1)(ii), it government; or hospital with a neonatal intensive care
has been CMS’ general policy that —A private hospital that has a contract unit (NICU). According to those who
determinations under § 413.65 are not with a State or local government that expressed this concern, hospitals
made for facilities or organizations if the includes the operation of clinics participating in the Medicare program
outcome of the determination would not located off the main campus of the as children’s hospitals establish off-site
have any effect on the amount of hospital to assure access in a well- neonatal intensive care units (NICUs)
Medicare payment or on the scope of defined service area to health care which they operate and staff but which
benefits or liability of Medicare services for low-income individuals are located in space leased from other
beneficiaries. Under this general policy, who are not entitled to benefits under hospitals. The hospitals in which the
offsite NICUs are housed typically are Comment: One commenter stated that payment under Medicaid, even though
short-term, acute care hospitals located it is aware of only one hospital in its those facilities would not qualify as
in rural areas. According to comments State that is in the situation described provider-based under Medicare. (We
that CMS has received, the nearest above. Another commenter echoed the note that under 42 CFR 440.10(a)(3)(iii),
children’s hospital in a rural area is same comment and stated that it is not services are considered to be ‘‘inpatient
usually located a considerable distance aware of any other children’s hospital hospital services’’ under the Medicaid
from individual rural communities, with off-campus NICU services in host program only if they are furnished in an
which prevents infants in these rural hospitals more than 35 miles from the institution that meets the requirements
communities from having ready access main campus of the children’s hospital. for participation in Medicare as a
to the specialized care offered by NICUs. Another commenter indicated that it is hospital. Because of the age of the
We have received a suggestion that aware of only one hospital in the patients they serve, NICUs typically
this configuration (that of a hospital country that is in the situation described have no Medicare utilization but a
participating in the Medicare program above. substantial proportion of their patients
as a hospital whose inpatients are Response: We appreciate the may be Medicaid patients.)
predominantly individuals under 18 information provided by these Comment: Several commenters
years of age under section commenters and have taken it into supported this option, stating that it
1886(d)(1)(B)(iii) of the Act, establishing account in developing the final rule set would be the most effective in ensuring
an offsite NICU which it operates and forth below. access to crucial services in underserved
staffs but which is located in space We also asked those who believed areas.
leased from another hospital) can be such a problem is currently occurring to Response: We understand and have
very helpful in making neonatal comment on which of the following considered the views of these
intensive care more quickly available in approaches would be most effective in commenters. However, we believe this
areas where community hospitals are resolving it. The proposed approaches final rule is not the appropriate vehicle
located. In addition, this configuration on which we solicited specific for such a change to the national
can offer relief to families who comments were: Medicaid regulations. As stated earlier
otherwise would be required to travel • A change in the Medicare provider- and for the reasons set forth below, we
long distances to obtain this care for based regulations to create an exception are adopting as final the approach
their infants. However, offsite NICUs to the location requirements for NICUs proposed for public comment as Option
would not be able to qualify for located in community hospitals that are 1, with some modification.
provider-based status under the location more than 35 miles from the children’s • A change in an individual State’s
criteria in our current regulations if they hospital that is the potential main Medicaid plans that would provide
are located more than 35 miles from the provider. The exception might take the enhanced financial incentives for
children’s hospital that would be the form of a more generous mileage community hospitals to establish
main provider, are not owned and allowance (such as being within 50 NICUs, possibly in collaboration with
operated by a hospital meeting the miles of the potential main provider) or children’s hospitals.
requirements of § 413.65(e)(3)(i), and could require other criteria to be met. Comment: Two commenters
cannot meet either of the ‘‘75 percent However, the exception would be expressed disapproval of this option,
tests’’ for service to the same patient available only if there is no other NICU stating that a change in State Medicaid
population as the potential main within 35 miles of the community plans would be too difficult for
provider that are specified in existing hospital. individual hospitals to achieve. Two
§ 413.65(e)(3)(ii)(A) and Comment: Two commenters stated other commenters noted that
§ 413.65(e)(3)(ii)(B). that this option, that of providing a discussions with State Medicaid
We understand the concern that more generous mileage allowance for officials have indicated that changing
requiring a patient to be transported to NICUs for which provider-based status the State Medicaid plan is not a feasible
a NICU located on the campus of a is sought, would not fully account for option in that State.
distant children’s hospital could create the appropriate provision of crucial Response: We understand the
an unacceptable medical risk to the life services in underserved areas. Two concerns of these commenters and, after
of a newborn at a most critical time. To other commenters noted that a mileage further review of this option, have
help us better understand this issue and allowance of 50 miles would not decided not to adopt it in this final rule.
determine what action, if any, CMS accommodate both current and • The establishment of children’s
should take on it, in the FY 2006 IPPS proposed off-campus NICUs. Thus, hospitals that meet the requirements for
proposed rule, we solicited specific these commenters recommended that being hospitals-within-hospitals under
public comment on the following this option not be adopted. 42 CFR 412.22(e). (We note that this
question: Response: We understand and have option, unlike the three above, would
• Is the problem as described above considered the concerns of these not require any revision of Medicare or
actually occurring and, if so, in what commenters. However, for the reasons Medicaid regulations or individual State
locations? We were particularly set forth below, we are adopting as final Medicaid plans.)
interested in learning which areas of an approach under which a NICU Comment: Two commenters
which States are experiencing such a seeking provider-based status that is expressed disapproval of this option,
problem, and in receiving specific unable to meet existing location criteria stating that it would be unrealistic to
information, such as the rates of transfer can be located up to 100 miles from the expect 6 to 8 bed facilities to operate as
of newborns from community hospitals main provider, as long as it meets separate hospitals because they would
to children’s hospital on-campus NICUs certain other requirements described in then not have the support of a full-
relative to adult or non-neonatal detail below. service children’s hospital. Two other
pediatric transfers for intensive care • A change in the national Medicaid commenters noted that operating these
services, which describe the problem regulations to allow off-campus NICUs NICUs as separately certified hospitals
objectively. Such objective information that meet other provider-based located within the community hospitals
will be much more useful than requirements under § 413.65 to qualify would result in a reduced level of
expressions of opinion or anecdotes. as provider-based for purposes of Medicaid DSH funding to the main
hospital under Medicaid rules in that • The facility or organization meets Comment: One commenter suggested
State. all other requirements for provider- that the text of paragraph (a)(2) be
Response: We understand the based status under § 413.65. revised to state that the change
concerns of these commenters and, after We took several factors into account described above is effective with respect
further review of this option, have in adopting these final rules. By to determinations made on or after
decided not to adopt it in this final rule. requiring compliance with existing October 1, 2005.
We also solicited suggestions for Medicare requirements for intensive
Response: The general effective date
specific options other than those listed care-type units, we can ensure that only
for this final rule is October 1, 2005.
above but did not receive any specific qualified NICUs are considered under
Therefore, the commenter is correct in
recommendations regarding alternative this new provision, while at the same
approaches to the NICU issue. time not imposing any added burden on understanding that this change will
After consideration of the comments existing NICUs. The rural location apply to determinations made on or
received on the four options we offered requirement is consistent with the after that date, and this policy will be
for comment, we have decided to adopt description of these facilities as being communicated to all CMS staff involved
Option 1, but to modify it by located in rural areas. The enhanced in provider-based determinations.
specifically requiring a NICU that is mileage allowance (100 miles) takes into However, we believe it could be
seeking provider-based status but is account the comments of those who confusing to readers if we were to
unable to meet existing location criteria stated that a 50-mile standard would be specifically revise the definition of
to qualify for provider-based status only overly restrictive, but nevertheless ‘‘provider-based entity’’ in § 413.65(a)(2)
if the facility or organization meets all establishes a clear location standard for to specify an effective date for this
of the following requirements: the NICUs to meet. We believe the 100- change since the word ‘‘name’’ will no
• The facility or organization meets mile criterion will sufficiently address longer appear in the definition.
the criteria for identifying intensive care the two currently operating remote Therefore, we are not making any
type units as set forth in the Medicare NICUs that commenters identified. The changes in the final rule based on this
reasonable cost reimbursement complementary requirement for a comment.
regulations at § 413.53(d), and as further minimum separation of at least 35 miles We received no other comments on
explained in section 2202.7 II.A. of the should help to ensure that hospitals in this proposed technical revision, and
Medicare Provider Reimbursement which the remote NICUs are located are after consideration of the comment
Manual (CMS Pub. 15–1). Generally, not currently adequately served by summarized above, we are adopting the
these criteria state that an intensive care another NICU. The requirement that the revision as final without change in this
type unit must— facility or organization accept only final rule.
—Be located in a hospital; patients who are newborn infants who
require intensive care on an inpatient b. Provider-based determinations. In
—Be physically and identifiably
basis will ensure that facilities or paragraph (b)(3)(ii) of § 413.65, we state
separate from general routine patient
organizations are able to take advantage that, in the case of a facility not located
care areas;
—Have specific written policies that of the more generous mileage allowance on the campus of the potential main
include criteria for admission to, and only if they are dedicated to the care of provider, the provider seeking a
discharge from, the unit; neonates. determination would be required to
—Have registered nursing care available These criteria are set forth in new submit an attestation stating that the
on a continuous 24-hour basis with at § 413.65(e)(3)(v) of this final rule. facility meets the criteria in paragraphs
least one registered nurse present in (d) and (e) of § 413.65, and if the facility
4. Technical and Clarifying Changes to is operated as a joint venture or under
the unit at all times; § 413.65
—Maintain a minimum nurse-patient a management contract, the
ratio of one nurse to two patients per a. Definitions. In paragraph (a)(2) of requirements of paragraph (f) or
patient day; and § 413.65, we state that the term paragraph (h) of § 413.65, as applicable.
—Be equipped with, or have available ‘‘Provider-based entity’’ means a However, paragraph (f), which sets forth
for immediate use, life-saving provider of health care services, or an rules regarding provider-based status for
equipment needed to treat the RHC as defined in § 405.2401(b), that is joint ventures, states clearly that a
critically ill patients for which the either created by, or acquired by, a main facility or organization operated as a
unit is designed. provider for the purpose of furnishing joint venture may qualify for provider-
• The facility or organization accepts health care services of a different type based status only if it is located on the
only patients who are newborn infants from those of the main provider under main campus of the potential main
who require intensive care on an the name, ownership and administrative provider. To avoid any
inpatient basis. and financial control of the main misunderstanding regarding the content
• The hospital that is the potential provider, in accordance with the of attestations for off-campus facilities,
main provider meets the criteria in provisions of § 413.65. In recognition of we proposed to revise paragraph
§ 412.23(d) for reimbursement under the fact that provider-based entities, (b)(3)(ii) by removing the reference to
Medicare as a children’s hospital. unlike departments of a provider, offer compliance with requirements in
• The hospital in which the facility or a type of services different from those of paragraph (f) for joint ventures. We also
organization is physically located is in the main provider and participate proposed to add a sentence to paragraph
a rural area as defined in separately in Medicare, we proposed to (b)(3)(i), regarding attestations for on-
§ 412.64(b)(1)(ii)(C). revise this requirement by deleting the campus facilities, to state that if the
• The facility or organization is word ‘‘name’’ from this definition. This facility is operated as a joint venture,
located within a 100-mile radius of the change would simplify compliance with the attestation by the potential main
children’s hospital that is the potential the provider-based criteria since entities provider regarding that facility would
main provider. that do not now operate under the also have to include a statement that the
• The facility or organization is potential main provider’s name will not provider will comply with the
located at least 35 miles from the be obligated to change their names in requirements of paragraph (f) of
nearest other NICU. order to be treated as provider-based. § 413.65.
We did not receive any comments on Comment: Regarding our proposal to also making a technical, clarifying
this proposed revision and are adopting revise the opening sentence of change to paragraph (e)(3)(i) of § 413.65
it without change in this final rule. paragraph (e)(3) of § 413.65 for clarity, by replacing the reference to section
c. Additional requirements applicable one commenter stated that our proposed 1886(e)(5)(F)(i)(II) of the Act with
to off-campus facilities or language did not clarify whether a section 1886(d)(5)(F)(i)(II) of the Act,
organizations—Operation under the facility or organization not located on which is the statutory basis for
ownership and control of the main the campus of the prospective main § 412.106(c)(2). Additionally, for
provider. In paragraph (e)(1)(i), provider is required to meet all of the consistency with the language of section
regarding 100 percent ownership by the requirements in paragraph (e)(3)(i), 404(b)(2)(B) of Pub. L. 106–554, we are
main provider of the business enterprise (e)(3)(ii), (e)(3)(iii), (e)(3)(iv), or, in the making a clarifying change in paragraph
that constitutes the facility or case of an RHC, paragraph (e)(3)(v) of (e)(3)(ii) by revising the phrase ‘‘and is
organization seeking provider-bases § 413.65 as well as the requirements in described in § 412.106(c)(2) of this
status, we proposed to add the word paragraph (e)(3)(vi) of § 413.65 or only chapter’’ to read ‘‘or is described in
‘‘main’’ before the word ‘‘provider’’, to any one of the requirements in § 412.106(c)(2) of this chapter’’.
clarify that the main provider must own paragraphs (e)(3)(i), (e)(3)(ii), (e)(3)(iii), e. Paragraph (g)—Obligations of
and control the facility or organization (e)(3)(iv), or, in the case of an RHC, hospital outpatient departments and
seeking provider-based status. We also paragraph (e)(3)(v) of § 413.65 as well as hospital-based entities. We proposed to
proposed, for purposes of clarifying the the requirements in paragraph (e)(3)(vi). revise the first sentence of paragraph
requirements in paragraph (e)(1), to add The commenter requested that we (g)(7), regarding beneficiary notices of
the word ‘‘main’’ before the word clarify that a facility or organization that coinsurance liability, to clarify that
‘‘provider’’ in paragraphs (e)(1)(ii) and is located within a 35-mile radius of the notice must be given only if the service
(e)(1)(iii). campus of the prospective main is one for which the beneficiary will
We did not receive any comments on provider is not also required to meet the incur a coinsurance liability for both an
this proposed revision and are adopting requirement in proposed paragraphs outpatient visit to the hospital and the
it without change in this final rule. (e)(3)(ii), (e)(3)(iii), (e)(3)(iv), or, in the physician service. This should help to
d. Additional requirements applicable case of an RHC, paragraph (e)(3)(v). make it clear that notice is not required
to off-campus facilities or Response: The commenter’s for visits that do not result in additional
organizations—Location. We proposed understanding of this requirement is coinsurance liability. In addition, we
several clarifying changes to this correct: a facility or organization that proposed to reorganize the subsequent
paragraph, as follows: meets the 35-mile requirement in paragraphs of that section for clarity.
Currently, the opening sentence of proposed paragraph (e)(3)(i) would not Comment: Two commenters
§ 413.65(e)(3) states that a facility or also be required to meet the criteria in expressed approval of this proposal,
organization for which provider-based proposed paragraphs (e)(3)(ii), (e)(3)(iii), stating that it would improve general
status is sought must be located within (e)(3)(iv), or, in the case of an RHC, understanding of the provider-based
a 35-mile radius of the campus of the paragraph (e)(3)(v). Because we did not requirements for off-campus facilities
hospital or CAH that is the potential receive other comments expressing and organizations.
main provider, except when the concern about the meaning of this Response: We appreciate the support
requirements in paragraph (e)(3)(i), paragraph, we have not included any of the commenters and have taken it
(e)(3)(ii) or (e)(3)(iii) of that section are further revision of it in this final rule. into account in developing this final
met. However, the regulation text that However, we understand the rule.
follows does not contain a paragraph commenter’s concern and will issue After consideration of all comments
designation as paragraph (e)(3)(iii). We clarifying instructions or educational received on this proposed revision, we
proposed to correct this error by materials in the future if there is are adopting it without change in this
redesignating existing paragraph evidence of misunderstanding of this final rule.
(e)(3)(ii)(C) as paragraph (e)(3)(iv). We paragraph.
also proposed to revise this sentence to After consideration of all of the K. Rural Community Hospital
state that the facility or organization comments received on these proposed Demonstration Program
must meet the requirements in revisions, we are adopting them with In accordance with the requirements
paragraph (e)(3)(i), (e)(3)(ii), (e)(3)(iii), only two changes in this final rule. of section 410A(a) of Pub. L. 108–173,
(e)(3)(iv) or, in the case of an RHC, Because we are adding a new paragraph the Secretary has established a 5-year
paragraph (e)(3)(v) of § 413.65 and the (e)(3)(v) to § 413.65 (see section V.J.3. of demonstration (beginning with selected
requirements in paragraph (e)(3)(vi) of this preamble) that sets forth new hospitals’ first cost reporting period
§ 413.65. provider-based requirements for NICUs beginning on or after October 1, 2004)
We proposed to revise the opening located in rural areas, we are to test the feasibility and advisability of
sentence of § 413.65(e)(3) to reflect the redesignating certain provisions of establishing ‘‘rural community
changes in the coding of this paragraph paragraph (e)(3) and are making hospitals’’ for Medicare payment
as described above. appropriate changes in the references to purposes for covered inpatient hospital
We also proposed to redesignate proposed paragraphs (e)(3)(v), (e)(3)(vi), services furnished to Medicare
paragraph (v) of § 413.65(e)(3) as and (e)(3)(vii) to accommodate this beneficiaries. A rural community
paragraph (e)(3)(vi) and correct a addition. In addition, to provide a hospital, as defined in section
drafting error by adding the word ‘‘that’’ reference to the definition of ‘‘rural’’ 410A(f)(1), is a hospital that—
before ‘‘has fewer than 50 beds’’. This applicable to Federal fiscal years 2005 • Is located in a rural area (as defined
proposed addition is a grammatical and subsequent fiscal year for purposes in section 1886(d)(2)(D) of the Act) or
change that is intended only to clarify of paragraph (e)(3), in § 413.65(e)(3)(v) treated as being so located under section
the size of the hospital with which a (redesignated by this final rule as 1886(d)(8)(E) of the Act;
rural health clinic must have a provider- section 413.65(e)(3)(vi)), we are • Has fewer than 51 beds (excluding
based relationship in order to qualify removing the reference to beds in a distinct part psychiatric or
under the special location requirement § 412.62(f)(1)(iii) and replacing it with a rehabilitation unit) as reported in its
in that paragraph. reference to § 412.64(b)(1)(ii)(C). We are most recent cost report;
• Provides 24-hour emergency care payments to the participating providers a current expiration date of July 30,
services; and do not exceed the amount that would be 2006.
• Is not designated or eligible for paid to those same providers in the We did not receive any public
designation as a CAH. absence of the demonstration. This form comments on the Rural Community
As we indicated in the FY 2005 IPPS of budget neutrality is viable when, by Hospital Demonstration Program
final rule (69 FR 49078), in accordance changing payments or aligning discussed in the proposed rule.
with sections 410A(a)(2) and (4) of Pub. incentives to improve overall efficiency,
L. 108–173 and using 2002 data from or both, a demonstration may reduce the L. Definition of a Hospital in Connection
the U.S. Census Bureau, we identified use of some services or eliminate the With Specialty Hospitals
10 States with the lowest population need for others, resulting in reduced Section 1861(e) of the Act provides a
density from which to select hospitals: expenditures for the demonstration definition for a ‘‘hospital’’ for purposes
Alaska, Idaho, Montana, Nebraska, participants. These reduced of participating in the Medicare
Nevada, New Mexico, North Dakota, expenditures offset increased payments program. In order to be a Medicare-
South Dakota, Utah, and Wyoming. elsewhere under the demonstration, participating hospital, an institution
(Source: U.S. Census Bureau Statistical thus ensuring that the demonstration as must, among other things, be primarily
Abstract of the United States: 2003) a whole is budget neutral or yields engaged in furnishing services to
Thirteen rural community hospitals savings. However, the small scale of this inpatients. This requirement is
located within these States are demonstration, in conjunction with the incorporated in our regulations on
participating in the demonstration. payment methodology, makes it conditions of participation for hospitals
Under the demonstration, extremely unlikely that this at 42 CFR 482.1. An institution that
participating hospitals are paid the demonstration could be viable under the applies for a Medicare provider
reasonable costs of providing covered usual form of budget neutrality. agreement as a hospital but is unable to
inpatient hospital services (other than Specifically, cost-based payments to 13 meet this requirement will have its
services furnished by a psychiatric or small rural hospitals are likely to application denied in accordance with
rehabilitation unit of a hospital that is increase Medicare outlays without our authority at 42 CFR 489.12. In
a distinct part), applicable for
producing any offsetting reduction in addition, institutions that have a
discharges occurring in the first cost
Medicare expenditures elsewhere. Medicare hospital provider agreement
reporting period beginning on or after
Therefore, a rural community hospital’s but are no longer primarily engaging in
the October 1, 2004 implementation
participation in this demonstration is furnishing services to inpatients are
date of the demonstration program.
unlikely to yield benefits to the subject to having their provider
Payment will be the lesser amount of
participant if budget neutrality were to agreements terminated pursuant to 42
reasonable cost or a target amount in
be implemented by reducing other CFR 489.53. Although compliance with
subsequent cost reporting periods. The
payments for these providers. this requirement is not problematic for
target amount in the second cost
reporting period is defined as the In order to achieve budget neutrality most hospitals, the issue of whether an
reasonable costs of providing covered for this demonstration, as we proposed institution is primarily engaged in
inpatient hospital services in the first in the FY 2006 IPPS proposed rule, we providing care to inpatients has recently
cost reporting period, increased by the are adjusting national inpatient PPS come to our attention in two contexts.
inpatient prospective payment update rates by an amount sufficient to account First, an institution has applied to be
factor (as defined in section for the added costs of this certified as an ‘‘emergency hospital,’’
1886(b)(3)(B) of the Act) for that demonstration. In other words, we yet the institution has 29 outpatient
particular cost reporting period. The apply budget neutrality across the beds for emergency patients, including
target amount in subsequent cost payment system as a whole rather than observation and post-anesthesia care,
reporting periods is defined as the merely across the participants of this and only 2 inpatient beds. Emergency
preceding cost reporting period’s target demonstration. As we discussed in the treatment by nature does not usually
amount, increased by the inpatient FY 2005 IPPS final rule (69 FR 49183), involve overnight stays.
prospective payment update factor (as we believe that the language of the Second, it has come to our attention
defined in section 1886(b)(3)(B) of the statutory budget neutrality requirements that some entities that describe
Act) for that particular cost reporting permits the agency to implement the themselves as surgical or orthopedic
period. budget neutrality provision in this specialty hospitals may be primarily
Covered inpatient hospital services manner. For FY 2006, using the most engaged in furnishing services to
means inpatient hospital services recent cost report data (that is, data for outpatients, and thus might not meet the
(defined in section 1861(b) of the Act) FY 2003), adjusted for increased definition of a hospital as contained in
and includes extended care services estimated cost for the 13 participating section 1861(e) of the Act. Therefore, if
furnished under an agreement under hospitals, the estimated adjusted we were to determine that a facility is
section 1883 of the Act. amount is $12,706,334. This adjusted not primarily engaged in inpatient care
Section 410A of Pub. L. 108–173 amount reflects the estimated difference at the time it seeks certification to
requires that ‘‘in conducting the between cost and IPPS payment based participate in the Medicare program as
demonstration program under this on data from hospitals’ cost reports. We a hospital, its application for a provider
section, the Secretary shall ensure that discuss the payment rate adjustment agreement would be denied. Further, if
the aggregate payments made by the that will be required to ensure the we were to determine that a specialty
Secretary do not exceed the amount budget neutrality of the demonstration hospital operating under an existing
which the Secretary would have paid if in section II.A.4. of the Addendum to Medicare provider agreement is not, or
the demonstration program under this this final rule. is no longer, primarily engaged in
section was not implemented.’’ The data collection instrument for the treating inpatients, the hospital is
Generally, when CMS implements a demonstration has been approved by subject to having its provider agreement
demonstration on a budget neutral basis, OMB under the title ‘‘Medicare Waiver terminated; in this event, it could no
the demonstration is budget neutral in Demonstration Application,’’ under longer take advantage of the whole
its own terms; in other words, aggregate OMB approval number 0938–0880, with hospital exception.
We received several comments established to phase in the PPS for special exceptions payments do not
concerning our observation in the FY hospital inpatient capital-related costs. exceed 10 percent of total capital IPPS
2006 IPPS proposed rule that some For cost reporting periods beginning in payments. Special exceptions payments
specialty hospitals may not meet the FY 2002, capital PPS payments are may be made only for the 10 years from
definition of a ‘‘hospital’’ contained in based solely on the Federal rate for most the cost reporting year in which the
section 1861(e) of the Act. As we stated acute care hospitals (other than certain hospital completes its qualifying
earlier, an institution must be new hospitals and hospitals receiving project, and the hospital must have
‘‘primarily engaged’’ in furnishing certain exception payments). The basic completed the project no later than the
services to inpatients in order to be a methodology for determining capital hospital’s cost reporting period
‘‘hospital’’ for purposes of participating prospective payments using the Federal beginning before October 1, 2001. Thus,
in Medicare. We noted in the proposed rate is set forth in § 412.312. For the an eligible hospital may receive special
rule that some specialty hospitals may purpose of calculating payments for exceptions payments for up to 10 years
be primarily engaged in furnishing care each discharge, the standard Federal beyond the end of the capital PPS
to outpatients. At least one commenter rate is adjusted as follows: transition period. Hospitals eligible for
was under the impression that we were (Standard Federal Rate) × (DRG special exceptions payments were
proposing to make changes in the Weight) × (Geographic Adjustment required to submit documentation to the
regulations in the FY 2006 IPPS Factor (GAF)) × (Large Urban Add-on, if intermediary indicating the completion
proposed rule to address the ‘‘primarily applicable) × (COLA Adjustment for date of their project. (For more detailed
engaged’’ requirement of the statute. In hospitals located in Alaska and Hawaii) information regarding the special
fact, that was not our intention. Over the × (1 + Capital DSH Adjustment Factor + exceptions policy under § 412.348(g),
next several months, we plan to review Capital IME Adjustment Factor, if refer to the August 1, 2001 IPPS final
our procedures for enrolling specialty applicable). rule (66 FR 39911 through 39914) and
hospitals in Medicare. During this Hospitals also may receive outlier the August 1, 2002 IPPS final rule (67
review, we will examine whether payments for those cases that qualify FR 50102).)
specialty hospitals meet the definition under the threshold established for each Under the PPS for capital-related
of a ‘‘hospital’’ contained in section fiscal year as specified in § 412.312(c) of costs, § 412.300(b) of the regulations
1861(e) of the Act. Following such the regulations. defines a new hospital as a hospital that
review, we may issue proposed The regulations at § 412.348(f) has operated (under current or previous
rulemaking for comment concerning the provide that a hospital may request an ownership) for less than 2 years. (For
definition of a ‘‘hospital’’ or other additional payment if the hospital more detailed information, see the
conditions of participation. incurs unanticipated capital August 30, 1991 final rule (56 FR
expenditures in excess of $5 million due 43418).) During the 10-year transition
VI. PPS for Capital-Related Costs to extraordinary circumstances beyond period, a new hospital was exempt from
In the FY 2006 IPPS proposed rule, the hospital’s control. This policy was the capital PPS for its first 2 years of
we did not propose any changes in the originally established for hospitals operation and was paid 85 percent of its
policies governing the determination of during the 10-year transition period, but reasonable costs during that period.
the payment rates for inpatient capital- as we discussed in the August 1, 2002 Originally, this provision was effective
related costs for short-term acute care IPPS final rule (67 FR 50102), we only through the transition period and,
hospitals under the IPPS. However, for revised the regulations at § 412.312 to therefore, ended with cost reporting
the readers’ benefit, we are providing a specify that payments for extraordinary periods beginning in FY 2002. Because
summary of the statutory basis for the circumstances are also made for cost we believe that special protection to
PPS for hospital inpatient capital- reporting periods after the transition new hospitals is also appropriate even
related costs and the methodology used period (that is, cost reporting periods after the transition period, as discussed
to determine capital-related payments to beginning on or after October 1, 2001). in the August 1, 2002 IPPS final rule (67
hospitals. A discussion of the rates and Additional information on the exception FR 50101), we revised the regulations at
factors for FY 2006 (determined under payment for extraordinary § 412.304(c)(2) to provide that, for cost
our established methodology) can be circumstances in § 412.348(f) can be reporting periods beginning on or after
found in section III. of the Addendum found in the FY 2005 IPPS final rule (69 October 1, 2002, a new hospital (defined
of this final rule. FR 49185 and 49186). under § 412.300(b)) is paid 85 percent of
Section 1886(g) of the Act requires the During the transition period, under its allowable Medicare inpatient
Secretary to pay for the capital-related §§ 412.348(b) through (e), eligible hospital capital-related costs through its
costs of inpatient acute hospital services hospitals could receive regular first 2 years of operation, unless the new
‘‘in accordance with a PPS established exception payments. These exception hospital elects to receive fully-
by the Secretary.’’ Under the statute, the payments guaranteed a hospital a prospective payment based on 100
Secretary has broad authority in minimum payment percentage of its percent of the Federal rate. (Refer to the
establishing and implementing the PPS Medicare allowable capital-related costs August 1, 2001 IPPS final rule (66 FR
for hospital inpatient capital-related depending on the class of hospital 39910) for a detailed discussion of the
costs. We initially implemented the PPS (§ 412.348(c)), but were available only statutory basis for the system, the
for capital-related costs in the August during the 10-year transition period. development and evolution of the
30, 1991 IPPS final rule (56 FR 43358), After the end of the transition period, system, the methodology used to
in which we established a 10-year eligible hospitals can no longer receive determine capital-related payments to
transition period to change the payment this exception payment. However, even hospitals both during and after the
methodology for Medicare hospital after the transition period, eligible transition period, and the policy for
inpatient capital-related costs from a hospitals receive additional payments providing exception payments.)
reasonable cost-based methodology to a under the special exceptions provisions Section 412.374 provides for the use
prospective methodology (based fully at § 412.348(g), which guarantees all of a blended payment amount for
on the Federal rate). eligible hospitals a minimum payment prospective payments for capital-related
Federal fiscal year (FY) 2001 was the of 70 percent of its Medicare allowable costs to hospitals located in Puerto Rico.
last year of the 10-year transition period capital-related costs provided that Accordingly, under the capital PPS, we
compute a separate payment rate and cancer hospitals that are excluded hospital’s own cost experience was no
specific to Puerto Rico hospitals using from the IPPS continues to be subject to longer involved in the payment process.
the same methodology used to compute the rate-of-increase limits based on the We have received questions regarding
the national Federal rate for capital- hospital’s own historical cost the determination of a target amount for
related costs. In general, hospitals experience. (We note that, in accordance FY 2003 for certain existing hospitals
located in Puerto Rico are paid a blend with § 403.752(a) of the regulations, and hospital units excluded from the
of the applicable capital PPS Puerto RNHCIs are also subject to the rate-of- IPPS, and whether § 413.40(c)(4)(iii)
Rico rate and the applicable capital PPS increase limits established under (specifically paragraph (c)(4)(iii)(A))
Federal rate. § 413.40 of the regulations.) continues to apply beyond FY 2002. In
Prior to FY 1998, hospitals in Puerto For the other three classes of excluded order to clarify the policy for periods
Rico were paid a blended capital PPS providers, rehabilitation hospitals and after FY 2002, we note that
rate that consisted of 75 percent of the units, psychiatric hospitals and units, § 413.40(c)(4)(iii) applies only to cost
capital PPS Puerto Rico specific rate and and LTCHs, payment provisions reporting periods beginning on or after
25 percent of the capital PPS Federal changed significantly for cost reporting October 1, 1997 through September 30,
rate. However, effective October 1, 1997 periods beginning on or after October 1, 2002, for psychiatric hospitals and
(FY 1998), in conjunction with the 1997. units, rehabilitation hospitals and units,
change to the operating PPS blend Section 1886(b)(3)(H) of the Act (as and LTCHs. We discussed this
percentage for Puerto Rico hospitals amended by section 4414 of Pub. L. applicable time period in the May 12,
required by section 4406 of Pub. L. 105– 105–33) established caps on the target 1998 Federal Register (63 FR 26344)
33, we revised the methodology for amounts for cost reporting periods when we discussed implementing the
computing capital PPS payments to beginning on or after October 1, 1997 caps. Specifically, we clarified our
hospitals in Puerto Rico to be based on through September 30, 2002, for certain regulations to indicate that the target
a blend of 50 percent of the capital PPS existing hospitals and hospital units amount for FYs 1998 through 2002 is
Puerto Rico rate and 50 percent of the excluded from the IPPS. Section equal to the lower of the hospital-
capital PPS Federal rate. Similarly, 413.40(c)(4)(iii) of the implementing specific target amount or the 75th
effective beginning in FY 2005, in regulations states that ‘‘In the case of a percentile of target amounts for
conjunction with the change in psychiatric hospital or unit, hospitals in the same class for cost
operating PPS payments to hospitals in rehabilitation hospital or unit, or long- reporting periods ending during FY
Puerto Rico for FY 2005 required by term care hospital, the target amount is 1996, increased by the applicable
section 504 of Pub. L. 108–173, we again the lower of amounts specified in market basket percentage for the subject
revised the methodology for computing paragraph (c) (4)(iii)(A) or (c) (4)(iii)(B) period. We did not intend for the
capital PPS payments to hospitals in of this section.’’ Accordingly, in general, provisions of § 413.40(c)(4)(iii) to apply
Puerto Rico to be based on a blend of for hospitals and units within these beyond FY 2002, as we specifically
25 percent of the capital PPS Puerto three classes of providers for the included an ending date; that is, we
Rico rate and 75 percent of the capital applicable 5-year period, the target stated that the target amount calculation
PPS Federal rate for discharges amount is the lower of either: the provisions were for FYs 1998 through
occurring on or after October 1, 2004. hospital-specific target amount 2002. More recently, in the FY 2003
(§ 413.40(c)(4)(iii)(A)) or the 75th IPPS final rule (67 FR 50103), we
VII. Changes for Hospitals and Hospital percentile cap (§ 413.40(c)(4)(iii)(B)). clarified again how the target amount
Units Excluded From the IPPS (We note that, in the case of LTCHs, for for FY 2003 was to be determined by
A. Payments to Existing Hospitals and cost reporting periods beginning during stating that: ‘‘* * * for cost reporting
Hospital Units (§§ 413.40(c), (d), and (f)) FY 2001, the hospital-specific target periods beginning in FY 2003, the
amount is the net allowable cost in a hospital or unit should use its previous
1. Payments to Existing Excluded base period increased by the applicable year’s target amount, updated by the
Hospitals and Hospital Units update factor multiplied by 1.25.) appropriate rate-of-increase
Historically, hospitals and units In addition, a new method of percentage.’’ Thus, the time-limited
excluded from the PPS received determining the payment amount for provision of § 413.40(c)(4)(iii) is neither
payment for inpatient hospital services ‘‘new’’ excluded providers was a new policy nor a change in policy.
they furnished on the basis of established at § 1886(b)(7) of the Act. For cost reporting periods beginning
reasonable costs, subject to a rate-of- The law was applicable for three classes on or after October 1, 2002, to the extent
increase ceiling. An annual per of excluded providers, rehabilitation one of the above-mentioned excluded
discharge limit (the target amount as hospitals and units, psychiatric hospitals or units has all or a portion of
defined in § 413.40(a)) was set for each hospitals and units, and LTCHs, with a its payment determined under
hospital or hospital unit based on the first cost reporting period beginning on reasonable cost principles, the target
hospital’s own cost experience in its or after October 1, 1997. These ‘‘new’’ amounts for the reasonable cost-based
base year. The target amount was excluded providers would be paid the portion of the payment are determined
multiplied by the Medicare discharges lesser of their net inpatient operating in accordance with section
and applied as an aggregate upper limit costs per case or 110 percent of the 1886(b)(3)(A)(ii) of the Act and the
(the ceiling as defined in § 413.40(a)) on national median of target amounts for regulations at § 413.40(c)(4)(ii). Section
total inpatient operating costs for a providers in its class, as adjusted for 413.40(c)(4)(ii) states, ‘‘Subject to the
hospital’s cost reporting period. Prior to differences in wage levels and updated provisions of [§ 413.40] paragraph
October 1, 1997, these payment to the first cost reporting period in (c)(4)(iii) of this section, for subsequent
provisions applied consistently to all which the hospital receives payment, as cost reporting periods, the target amount
categories of excluded providers implemented in the regulations at equals the hospital’s target amount for
(rehabilitation hospitals and units, § 413.40(f)(2)(ii). For providers in one of the previous cost reporting period
psychiatric hospitals and units, long the aforementioned classes of excluded increased by the update factor for the
term care hospitals, children’s hospitals, providers that were not paid as such subject cost reporting period unless the
and cancer hospitals excluded from the prior to October 1, 1997, a hospital provisions of [§ 413.40] paragraph
IPPS). Payment for children’s hospitals specific target amount based on the (c)(5)(ii) of this section apply.’’ Thus,
since § 413.40(c)(4)(ii) indicates that the provider’s target amount was limited to the first example, the commenter
provisions of that paragraph are subject the capped amount in FY 2002, it is that believed that because the 75th
to the provisions of § 413.40(c)(4)(iii), capped amount that is updated for FY percentile cap provision had expired
which are applicable only for cost 2003. with FY 2002, that the FY 2003 target
reporting periods beginning on or after Response: In order for us to clarify the amount should be the hospital specific
October 1, 1997 through September 30, applicability of the provisions of target amount (as determined in its base
2002, the target amount for FY 2003 is § 413.40(c)(4)(iii), we noted in the year), updated. This is incorrect. Once
determined by updating the target proposed rule that this subsection the 75th percentile cap provision in
amount for FY 2002 (the target amount applied only for cost reporting periods paragraph (c)(4)(iii) of § 413.40 expired,
from the previous period) by the beginning on or after October 1, 1997 the target amount is then determined
applicable update factor. Accordingly, through September 30, 2002, for based on § 413.40(c)(4)(ii) which states
as we proposed in the May 4, 2005 psychiatric hospitals and units, that, ‘‘* * * Subject to the provisions of
proposed rule, we are making a change rehabilitation hospitals and units, and paragraph (c)(4)(iii) of this section, for
to the language in § 413.40(c)(4)(iii) to long term hospitals. During this time subsequent cost reporting periods, the
clarify that the provisions of this period, payment to existing (in target amount equals the hospital’s
paragraph relating to the caps on target operation prior to FY 1998) providers target amount for the previous cost
amounts are for a specific period of time was limited by the 75th percentile cap, reporting period increased by the
only, that is, cost reporting periods i.e., the provider would be paid the update factor for the subject cost
beginning on or after October 1, 1997, lower of the hospital-specific target reporting period * * *’’ Thus, under
and before October 1, 2002. amount or the 75th percentile of target the requirements of § 413.40(c)(4)(ii), in
Comment: Two commenters amounts for hospitals in the same class this instance, the previous cost
submitted a comment regarding the for cost reporting periods ending during reporting period’s target amount would
proposed clarification of policy FY 1996, updated by the applicable be the capped amount increased by the
concerning the determination of a market basket percentage. As we applicable update factor to arrive at the
hospital’s target amount as described in pointed out in the proposed rule, we target amount for FY 2003.
§ 413.(c)(4)(iii) for the cost reporting had previously clarified how the target
In the commenter’s second example,
period beginning on or after October 1, amount for FY 2003 was to be
the provider was established in FY
2002. One of the commenters, in determined. In the FY 2003 final rule
1999, thus, making it a ‘‘new’’ provider
submitting two scenarios, asked CMS to (67 FR 50103), we stated that, ‘‘* * *
affirm his understanding of the for cost reporting periods beginning in and therefore, subject to payment in
proposed clarification regarding the FY 2003, the hospital or unit should use accordance with § 413.40(f)(2)(ii) and
calculation of the target amount for cost its previous year’s target amount, not § 413.40(c)(4)(iii), which is the
reporting periods beginning on or after updated by the appropriate rate-of- subject of our clarification. Section
October 1, 2002. The first scenario increase percentage.’’ The provisions of 413.40(f)(2)(ii) of the regulations state
involved a psychiatric unit that existed § 413.40(c)(4)(iii) are for a specific that, ‘‘For cost reporting periods
prior to FY 1998 (the first year of the period of time and the provider’s target beginning on or after October 1, 1997,
75th percentile limitation), and amount for FY 2003 is determined by the amount of payment for a new
therefore, was subject to the provisions updating the target amount for FY 2002 psychiatric hospital or unit, a new
in § 413.40(c)(4)(iii) where the target (the target amount from the previous rehabilitation hospital or unit, or a new
amount is limited by the 75th percentile period). LTCH that was not paid as an excluded
cap. The provider was paid the capped The intent of our proposal to clarify hospital prior to October 1, 1997, is the
amount in FY 2002, and the fiscal the language in § 413.40(c)(4(iii) was to lower of the hospital’s net inpatient
intermediary used this capped amount, emphasize that because operating costs per case or 110 percent
increasing it by the update factor to § 413.40(c)(4)(iii) was no longer of the national median of the target
arrive at the provider’s target amount for applicable for cost reporting periods amounts for the class of excluded
FY 2003. However, the commenter beginning on or after October 1, 2002, hospitals and units (psychiatric,
believed that the correct target amount the target amount for FY 2003 is rehabilitation, or long-term care), as
for FY 2003 should be the hospital determined according to adjusted for differences in wage levels
specific target amount, as determined in § 413.40(c)(4)(ii) which states that and updated to the first cost reporting
the base year and updated. ‘‘Subject to the provisions of paragraph period in which the hospital receives
The second scenario involved a (c)(4)(iii), for subsequent cost reporting payment.’’ This provision further states
psychiatric unit that was established in periods, the target amount equals the that the second cost reporting period for
FY 1999. In this case, as stated in the hospital’s target amount for the previous such providers is subject to the same
comment, the fiscal intermediary used cost reporting period increased by the target amount as in the first cost
the ‘‘capped rate trended forward with update factor for the subject cost reporting period, that is, the first year
the update factors as specified by CMS’’ reporting period, unless the provisions payment amount is not updated for
as the target amount for each year, of paragraph (c)(5)(ii) of this section purposes of determining the payment
including years subsequent to FY 2002. apply.’’ Therefore, if a provider was amount for the second cost reporting
Based on the proposed clarification, the paid the cap amount in FY 2002, the period. With respect to the third 12-
commenter believes that the higher target amount for FY 2003 would be the month cost reporting period for these
hospital-specific target rate should be cap amount paid in FY 2002, updated new providers, the regulations at
used for those cost reporting periods to FY 2003 (that is, the target amount § 413.40(c)(4)(v) specify that the target
beginning in FY 2003 instead of the from the previous year increased by the amount is the payment amount from the
capped amount. applicable update factor). second cost reporting period (the
The second commenter stated that The commenter who submitted the payment amount determined under
while there was a clarification of policy two examples showing how the target § 413.40(f)(2)(ii)(A)), updated to the
regarding the effective period for the amount for FY 2003 should be third cost reporting period. Thus, the
75th percentile cap on target amounts, determined misinterpreted the point of commenter is incorrect that a hospital-
CMS should also clarify that if a our proposed clarification. That is, in specific target amount in a base year
should be used for cost reporting criteria under § 413.40(f)(2)(ii) (that is, § 412.426(c), new IPFs (those facilities
periods beginning in FY 2003 instead of not paid as excluded hospitals prior to that under present or previous
the ‘‘capped amount.’’ October 1, 1997), but were paid as ownership (or both) have their first cost
We point out that, with the LTCHs before October 1, 2002, may be reporting period as an IPF begin on or
implementation of a payment limit for paid under the LTCH PPS transition after January 1, 2005) are paid the fully
‘‘new providers,’’ a hospital-specific methodology with the reasonable cost Federal per diem payment amount
target amount (base year cost per portion of the payment subject to rather than a blended payment amount.
discharge updated) is not calculated. § 413.40(f)(2)(ii). Finally, LTCHs that (See section VII.A.5. of the preamble of
This is because, under the new provider existed prior to October 1, 1997, may this final rule for further discussion of
limit, the amount of payment for the also be paid under the LTCH PPS the IPF PPS.) Thus, the payment
first two cost reporting periods (if less transition methodology with the limitations under the TEFRA payment
than a new provider’s inpatient reasonable cost portion of the payment system are not applicable for new IPFs
operating costs) is based on the 110 subject to § 413.40(c)(4)(ii). (The last that meet the definition of new inpatient
percent of the national median LTCHs that were subject to the payment psychiatric facilities in § 412.426(c).
provision in § 413.40(f)(2)(ii). The amount limitation for ‘‘new’’ LTCHs However, ‘‘new’’ IPFs that meet the
second cost reporting period is subject under § 413.40(f)(2)(ii) were new LTCHs criteria under § 413.40(f)(2)(ii) (that is,
to the same target amount as the first that had their first cost reporting period that were not paid as an excluded
cost reporting period. For a new beginning on September 30, 2002. In hospital prior to October 1, 1997) and
provider’s third 12-month cost reporting that case, the payment amount had their first cost reporting period
period, the payment amount in the limitation remained applicable for the beginning before January 1, 2005, are
second cost reporting period is updated. next 2 years—September 30, 2002 paid under the IPF PPS transition
We also note that, unlike through September 29, 2003, and methodology with the reasonable cost
§ 413.40(c)(4)(iii) with the 75th September 30, 2003 through September portion of the payment determined
percentile cap provision, the regulation 29, 2004. This is because, under existing according to § 413.40(f)(2)(ii), that is,
for new providers at § 413.40(f)(2)(ii) is regulations at § 413.40(f)(2)(ii), a ‘‘new subject to the payment amount
not time limited. While it has the same hospital’’ would be subject to the same limitation. The last IPFs that were
effective date as the 75th percentile cap payment in its second cost reporting subject to the payment amount
provision (cost reporting periods period that was applicable to the LTCH limitation were IPFs that had their first
beginning on or after October 1, 1997), in its first cost reporting period. cost reporting period beginning on
it remains effective for cost reporting Accordingly, for these hospitals, the December 31, 2004. For these hospitals,
periods beyond FY 2002 to the extent a updated payment amount limitation the payment amount limitation that was
provider’s payment or part of the that we published in the FY 2003 IPPS published in the FY 2005 IPPS final rule
payment is based on reasonable cost. final rule (67 FR 50103) applied through
As we stated in the proposed rule, (69 FR 49189) for cost reporting periods
September 29, 2004. Consequently, beginning on or after October 1, 2004,
‘‘* * * the target amount for FY 2003 is there is no longer a need to publish
determined by updating the target and before January 1, 2005, remains
updated payment amounts for new applicable for the IPF’s first two cost
amount for FY 2002 (the target amount (§ 413.40(f)(2)(ii)) LTCHs. A discussion
from the previous period) by the reporting periods. As stated above, IPFs
of how the payment limitations were
applicable update factor.’’ We believe with a first cost reporting period
calculated can be found in the August
that this more than adequately responds beginning on or after January 1, 2005,
29, 1997 final rule with comment period
to the second commenter’s concerns are paid 100 percent of the Federal per
(62 FR 46019); the May 12, 1998 final
with regard to the determination of the diem payment amount; they are not
rule (63 FR 26344); the July 31, 1998
target amount for FY 2003 and subject to the payment amount
final rule (63 FR 41000); and the July 30,
thereafter. limitation in accordance with
1999 final rule (64 FR 41529).
A freestanding inpatient rehabilitation § 412.426(c). Therefore, since the last
2. Updated Caps for New Excluded IPFs eligible for a blended payment
hospital, an inpatient rehabilitation unit
Hospitals and Units have a cost reporting period beginning
of an acute care hospital, and an
Section 1886(b)(7) of the Act inpatient rehabilitation unit of a CAH on December 31, 2004, the payment
established the method for determining are referred to as IRFs. Effective for cost limitation published for FY 2005
the payment amount for new reporting periods beginning on or after remains applicable for these IPFs, and
rehabilitation hospitals and units, October 1, 2002, this payment limitation publication of the updated payment
psychiatric hospitals and units, and is also no longer applicable to new amount limitation is no longer needed.
LTCHs that first received payment as a rehabilitation hospitals and units We note that IPFs that existed prior to
hospital or unit excluded from the IPPS because they are paid 100 percent of the October 1, 1997, are also be paid under
on or after October 1, 1997. However, Federal prospective rate under the IRF the IPF transition methodology with the
effective for cost reporting periods PPS. Therefore, it is also no longer reasonable cost portion of the payment
beginning on or after October 1, 2002, necessary to update the payment subject to § 413.40(c)(4)(ii).
this payment amount (or ‘‘new provider limitation for new rehabilitation The payment limitations for new
cap’’) no longer applies to any new hospitals or units. hospitals under TEFRA
rehabilitation hospital or unit because For psychiatric hospitals and units, (§ 413.40(f)(2)(ii)) do not apply to those
they now are paid 100 percent of the under the IPF PPS, there is a 3-year LTCHs or IPFs that have their first cost
Federal prospective rate under the IRF transition period during which existing reporting period beginning on or after
PPS. IPFs will receive a blended payment of the date that the particular class of
In addition, LTCHs that meet the the Federal per diem payment amount hospitals implemented their respective
definition of a new LTCH under and the payment amount that IPFs PPS, or for new IRFs that are paid under
§ 412.23(e)(4) are also paid 100 percent would receive under the reasonable the IRF PPS. Therefore, for the reasons
of the fully Federal prospective payment cost-based payment (TEFRA) noted above, we are discontinuing the
rate under the LTCH PPS. In contrast, methodology had the IPF PPS not been publication of Tables 4G and 4H (Pre-
those ‘‘new’’ LTCHs that meet the implemented. However, under Reclassified Wage Index for Urban and
Rural Areas, respectively) in the annual for each LTC–DRG with additional of the Federal per diem payment
proposed and final IPPS rules. adjustments applied. amount.
We published in the Federal Register
3. Implementation of a PPS for IRFs on May 7, 2004, a final rule (69 FR 6. Report of Adjustment (Exceptions)
Section 1886(j) of the Act, as added by 25673) that updated the payment rates Payments
section 4421(a) of Pub. L. 105–33, for the upcoming rate year LTCH PPS Section 4419(b) of Pub. L. 105–33
provided for the phase-in of a case-mix and made policy changes effective as of requires the Secretary to publish
adjusted PPS for inpatient hospital July 1, 2004. The 5-year transition annually in the Federal Register a
services furnished by a rehabilitation period to the fully Federal prospective report describing the total amount of
hospital or a rehabilitation unit (referred rate will end with cost reporting periods adjustment payments made to excluded
to in the statute as rehabilitation beginning on or after October 1, 2005 hospitals and units, by reason of section
facilities (IRFs)) for cost reporting and before October 1, 2006. For cost 1886(b)(4) of the Act, during the
periods beginning on or after October 1, reporting periods beginning on or after previous fiscal year.
2000, and before October 1, 2002, with October 1, 2006, payment is based
The process of requesting,
payments based entirely on the adjusted entirely on the adjusted Federal
adjudicating, and awarding an
Federal prospective payment for cost prospective payment rate. However,
adjustment payment is likely to occur
reporting periods beginning on or after existing hospitals can elect payment
under 100 percent of the adjusted over a 2-year period or longer. First,
October 1, 2002. Section 1886(j) of the
Federal prospective payment rate. generally, an excluded hospital or
Act was amended by section 125 of Pub.
Moreover, LTCHs as defined in excluded unit of a hospital must file its
L. 106–113 to require the Secretary to
§ 412.23(e)(4) are paid 100 percent of cost report for a fiscal year with its fiscal
use a discharge as the payment unit
the adjusted Federal prospective intermediary within 5 months after the
under the PPS for inpatient hospital
payment rate. close of its cost reporting period in
services furnished by IRFs and to
accordance with § 413.24(f)(2). The
establish classes of patient discharges by 5. Implementation of a PPS for IPFs fiscal intermediary then reviews the cost
functional-related groups. Section 305
In accordance with section 124 of the report and issues a Notice of Program
of Pub. L. 106–554 further amended
BBRA and section 405(g)(2) of Pub. L. Reimbursement (NPR) within
section 1886(j) of the Act to allow
108–173, we established a PPS for approximately 2 months after the filing
inpatient rehabilitation facilities, subject
inpatient hospital services furnished in of the cost report. If the hospital’s
to the blend methodology, to elect to be
psychiatric hospitals and psychiatric operating costs are in excess of the
paid the full Federal prospective
units of acute care hospitals and CAHs ceiling, the hospital may file a request
payment rather than the transitional
(inpatient psychiatric facilities (IPFs)). for an adjustment payment within 180
period payments specified in the Act.
On August 7, 2001, we issued a final On November 15, 2004, we issued in the days from the date of the NPR. The
rule in the Federal Register (66 FR Federal Register a final rule (69 FR fiscal intermediary, or CMS, depending
41316) establishing the PPS for IRFs, 66922) that established the IPF PPS, on the type of adjustment requested,
effective for cost reporting periods effective for IPF cost reporting periods then reviews the request and determines
beginning on or after January 1, 2002. beginning on or after January 1, 2005. if an adjustment payment is warranted.
There was a transition period for cost Under the final rule, we compute a This determination is often not made
reporting periods beginning on or after Federal per diem base rate to be paid to until more than 6 months after the date
January 1, 2002, and ending before all IPFs for inpatient psychiatric the request is filed. However, in an
October 1, 2002. For cost reporting services based on the sum of the average attempt to provide interested parties
periods beginning on or after October 1, routine operating, ancillary, and capital with data on the most recent
2002, payments are based entirely on costs for each patient day of psychiatric adjustments for which we do have data,
the adjusted Federal prospective care in an IPF, adjusted for budget we are publishing data on adjustment
payment rate determined under the IRF neutrality. The Federal per diem base payments that were processed by the
PPS. rate is adjusted to reflect certain patient fiscal intermediary or CMS during FY
characteristics, including age, specified 2004.
4. Implementation of a PPS for LTCHs DRGs, selected high-cost comorbidities, The table below includes the most
In accordance with the requirements and day of the stay, and certain facility recent data available from the fiscal
of section 123 of Pub. L. 106–113, as characteristics, including a wage index intermediaries and CMS on adjustment
modified by section 307(b) of Pub. L. adjustment, rural location, indirect payments that were adjudicated during
106–554, we established a per teaching costs, the presence of a full- FY 2004. As indicated above, the
discharge, DRG-based PPS for LTCHs, as service emergency department, and adjustments made during FY 2004 only
described in section 1886(d)(1)(B)(iv) of cost-of-living adjustments for IPFs pertain to cost reporting periods ending
the Act for cost reporting periods located in Alaska and Hawaii. We have in years prior to FY 2003. Total
beginning on or after October 1, 2002, in established a 3-year transition period adjustment payments awarded to
a final rule issued on August 30, 2002 during which IPFs whose first cost excluded hospitals and units during FY
(67 FR 55954). The LTCH PPS uses reporting periods began before January 2004 are $5,896,215. The table depicts
information from LTCH hospital patient 1, 2005, will be paid based on a blend for each class of hospitals, in the
records to classify patients into distinct of reasonable cost-based payment and aggregate, the number of adjustment
LTC–DRGs based on clinical IPF PPS payments. For cost reporting requests adjudicated, the excess
characteristics and expected resource periods beginning on or after January 1, operating cost over ceiling, and the
needs. Separate payments are calculated 2008, all IPFs will be paid 100 percent amount of the adjustment payments.
Excess cost over Adjustment

Class of hospital Number ceiling payments
Rehabilitation ............................................................................................................... 3 $825,008 $129,529

Psychiatric .................................................................................................................... 11 7,491,268 2,628,817
Excess cost over Adjustment

Class of hospital Number ceiling payments
Long-Term Care .......................................................................................................... 3 3,348,078 2,570,034

Children’s ..................................................................................................................... 1 99,942 58,825
Cancer ........................ ................................ ................................
Religious Nonmedical Health Care Institution ............................................................. 13 1,317,098 509,010
B. Critical Access Hospitals (CAHs) county that is adjacent to one or more proposed rule we stated our belief that
urban counties are considered to be when a CAH’s status as being located in
1. Background
located in the urban MSA to which the a Lugar county occurs as a result of
Section 1820 of the Act provides for greatest number of workers in the changes that the CAH did not originate
the establishment of Medicare Rural county commute, if certain conditions, and that were beyond its control, it is
Hospital Flexibility Programs specified in section 1886(d)(8)(B) of the appropriate for the CAH to be allowed
(MRHFPs), under which individual Act, are met. Regulations implementing a reasonable opportunity to reclassify to
States may designate certain facilities as this provision are set forth in 42 CFR rural status. Thus, in the proposed rule,
critical access hospitals (CAHs). 412.62(f)(1) (for FY 1984), 42 CFR we stated that we would clarify our
Facilities that are so designated and 412.63(b)(3) (for FYs 1985 through policy that CAHs in counties that were
meet the CAH conditions of 2004), and at 42 CFR 412.64(b)(3) (for designated as Lugar counties effective
participation (CoPs) under 42 CFR Part FY 2005 and subsequent fiscal years). October 1, 2004, because of
485, Subpart F, will be certified as The provision (section 1886(d)(8)(B) of implementation of the new labor market
CAHs by CMS. Regulations governing the Act) is referred to as the ‘‘Lugar area definitions announced by OMB on
payments to CAHs for services to provision’’ and the counties described June 6, 2003, were to be given the same
Medicare beneficiaries are located in 42 by it are referred to as the ‘‘Lugar reclassification opportunity under
CFR Part 413. counties.’’ § 412.103. In other words, we proposed
As explained more fully in the FY to revise § 485.610(b)(3) to allow CAHs
2. Proposed Policy Change Relating to
2005 IPPS final rule (69 FR 48916), in counties that were designated as
Continued Participation by CAHs in
certain counties that previously were Lugar counties effective October 1,
Lugar Counties
not considered Lugar counties were, 2004, to remain in compliance with the
Criteria for the designation of a CAH effective October 1, 2004, redesignated conditions of participation at
under the MRHFP at section as Lugar counties as a result of the most § 485.610(b)(2) through a reclassification
1820(c)(2)(b)(i) of the Act require that a recent census data and the new labor under § 412.103. In addition, consistent
hospital be located in a rural area as market area definitions announced by with the clarification of the policy, we
defined in section 1886(d)(2)(D) of the OMB on June 6, 2003. Some CAHs proposed to amend the regulations at
Act or be treated as being located in a located in these newly designated Lugar § 412.103(a)(4) to reflect the proposed
rural area in accordance with section counties are now unable to meet the change in the text of the CAH location
1886(d)(8)(E) of the Act. The regulations rural location requirements described regulations at § 485.610(b)(3).
currently at § 485.610 further define above, even though they were in full Comment: Several commenters
‘‘rural area’’ for purposes of being a compliance with the location supported our proposal to permit CAHs
CAH. Under the current regulations at requirements in effect at the time they in newly designated Lugar counties to
§ 485.610(b), a CAH must meet any one converted from short-term, acute care reclassify to be considered ‘‘rural’’
of the following three location hospital to CAH status. under the regulations at § 412.103.
requirements. First, a CAH must not be Prior to the issuance of the FY 2006 Response: We appreciate the
located in an MSA as defined by the IPPS proposed rule, we received commenters’ support and kept their
Office of Management and Budget, not comments that suggested that it would views in mind in finalizing the
be deemed to be located in an urban be inappropriate for a facility to be proposed policy change in this final
area under § 412.63(b), and not be required to terminate participation as a rule.
reclassified by CMS or the MGCRB as CAH and resume participating as a Comment: Several commenters
urban for purposes of the standardized short-term, acute care hospital because disagreed with our proposed policy
payment amount, nor be a member of a of a change in county classification that because they believed that the rules
group of hospitals reclassified to an did not result from any change in under which a facility can reclassify
urban area under § 412.232. Second, if functioning by the CAH. After under § 412.103 do not sufficiently
a CAH does not meet the first criterion, consideration of these comments, as we protect all facilities. They stated, for
if located in an MSA, a CAH will be discussed in the proposed rule, we instance, that while rural referral
treated as rural if it has reclassified proposed to clarify our policy with centers, SCHs, and CAHs receive special
under § 412.103. Third, as we stated in respect to facilities located in Lugar consideration for purposes of
the FY 2005 IPPS final rule, if the CAH counties. The FY 2005 IPPS final rule reclassification, MDHs do not.
cannot meet either of the first two already contained provisions allowing Response: We believe that addressing
requirements and is located in a revised facilities located in counties that began the reclassification regulations at
labor market area (CBSA) under the to be considered part of MSAs effective § 412.103 in the context of the
standards announced by OMB on June October 1, 2004, as a result of data from commenter’s statements is outside of the
6, 2003 and adopted by CMS effective the 2000 census and implementation of scope of our proposed rule change. This
October 1, 2004, it has until September the new labor market area definitions is especially true for section 1886(d)
30, 2006, to meet one of the other announced by OMB on June 6, 2003, an hospitals, such as MDHs, which are
classification requirements without opportunity to obtain rural designations subject to the statutory provisions for
losing its CAH status. under applicable State law or Lugar status under section 1886(d)(8)(B)
Under section 1886(d)(8)(B) of the regulations from their State legislatures of the Act. Our proposal dealt only with
Act, hospitals that are located in a rural or regulatory agencies. Similarly, in the CAHs and did not include any proposal
to change the way in which other in an urban area for purposes of CAH Accordingly, in light of the above, in
facilities, such as subsection 1886(d) participation because it is in a Lugar this final rule, we are not adopting the
hospitals, are treated. Consequently, we county. proposed revisions to § 412.103(a)(4)
are not making any change to the final While CAHs are not subsection and § 485.610(b)(1)(ii) that were
rule based on this comment. 1886(d) hospitals, they are subject to the included in the proposed rule. Instead,
Comment: Several commenters regulations at § 485.610, which we are amending the regulations at
believed that the process to reclassify reference the definitions of ‘‘rural’’ and § 485.610(b)(1) to remove paragraph
under § 412.103 is burdensome and ‘‘urban’’ at § 412.63(b) (for FYs 1985 (b)(1)(ii), which references a facility
unnecessary because, in their view, the through 2004). (For FYs 2005 and being recognized as urban under the
Secretary has the authority to allow a subsequent fiscal years, the regulations implementing the Lugar
facility to opt out of the reclassification implementing regulations are at provision (§ 412.63(b)(3) for FYs 1984
under section 1886(d)(5)(I)(i) of the Act. § 412.64(b).) The regulations at through 2004. (As noted earlier,
As an alternative to our proposal, the § 412.63(b)(3) and § 412.64(b)(3) specify implementing regulations for the Lugar
commenters suggested that CMS allow that a hospital in a Lugar county is provisions are set forth at § 412.64(b)(3)
hospitals that are disadvantaged by the urban in accordance with section for FY 2005 and subsequent fiscal
Lugar reclassification to waive or reject 1886(d)(8)(B) of the Act. Accordingly, years.)
the reclassification. One of the under the current regulations at In addition, as a technical conforming
commenters suggested that waiver of § 485.610, CAHs in a Lugar county are change, we are revising paragraph
Lugar status be allowed during a limited considered under such regulations to be (b)(1)(i) of § 485.610 by removing the
time period. In support of their in an urban area. We believe these reference to § 412.62(f), which relates to
recommendation, the commenters stated regulations maintained consistency FYs 1984 through 2004, and replacing it
that CMS currently allows hospitals to throughout the program, and that it was with a reference to § 412.64(b),
waive other geographic reclassifications excluding paragraph (b)(3), which
permissible and appropriate to apply
during a defined period. Several relates to FY 2005 and subsequent fiscal
Lugar status (and, hence, urban status)
commenters pointed out that the Lugar years.
to all facilities in those counties,
provision was intended to help many
including CAHs. 3. Policy Change Relating to Designation
rural hospitals and not disadvantage the
few facilities that were more benefited However, in light of the major of CAHs as Necessary Providers
by participating in a rural facility revisions caused by the new OMB areas, Section 405(h) of Pub. L. 108–173
program. our review of the statute, and in amended section 1820(c)(2)(B)(i)(II) of
Response: While we understand that consideration of the commenters’ the Act by adding language that
Lugar designation affects hospitals as concerns that the process for terminated a State’s authority to waive
well as CAHs, we do not believe it is reclassification may create an the location requirement for a CAH by
within the scope of our proposed rule to unnecessary burden, we have concluded designating the CAH as a necessary
address changes in the way CMS treats that it is appropriate in this final rule to provider, effective January 1, 2006.
hospitals in Lugar counties. Therefore, amend the regulations at Currently, a CAH is required to be
we considered this comment and are § 485.610(b)(1)(i) to remove all located more than a 35-mile drive (or in
responding to it only insofar as it relates references to a facility being recognized the case of mountainous terrain or
to CAHs in Lugar counties. as urban under the regulations secondary roads, a 15-mile drive) from
We considered the commenters’ implementing the Lugar provision a hospital or another CAH, unless the
concerns that reclassification under (§ 412.63(b)(3) for FYs 1984 through CAH is certified by the State as a
§ 412.103 is unnecessarily burdensome. 2004 and § 412.64(b)(3) for FY 2005 and necessary provider of health care
In light of the stated concerns, we subsequent fiscal years). The effect of services to residents in the area. Under
revisited the statutory requirements this change is that, beginning in FY this provision, after January 1, 2006,
under sections 1820(c)(2)(B)(i) and 2006, facilities in Lugar counties will be States will no longer be able to
1886(d)(8)(B) of the Act and the considered, for purposes of CAH designate a CAH based upon a
regulatory requirements of § 485.610. participation, to be located in rural determination that it is a necessary
Section 1886(d)(8)(B) of the Act defines areas. In other words, the Lugar provider of health care. In addition,
the conditions under which a county is reclassifications under section section 405(h) of Pub. L. 108–173
considered ‘‘Lugar.’’ The statute 1886(d)(8)(B) of the Act will not be amended section 1820(h) of the Act to
specifically states that ‘‘(f)or purposes of considered in determining whether a include a grandfathering provision for
this subsection, the Secretary shall treat hospital is rural for purposes of section CAHs that are certified as necessary
a hospital located in a rural county 1820 of the Act. As a result, CAHs will providers prior to January 1, 2006. In
adjacent to one or more urban areas as not need to submit an application for the FY 2005 IPPS final rule (69 FR
being located in (a) urban metropolitan reclassification under § 412.103 to 49220), we incorporated these
statistical area. * * * ’’ CAHs do not fall remain in compliance with the amendments in our regulations at
under subsection 1886(d) of the Act. In conditions of participation at § 485.610. § 485.610(c). Under that regulation, any
addition, section 1820(c)(2)(B)(i) of the We believe this change will achieve the CAH that is designated as a necessary
Act permits a facility to qualify for result of our original proposal without provider in its State rural health plan
designation as a CAH only if it is increasing the administrative burden for prior to January 1, 2006, will be
located in a rural area as defined in CAHs or the Medicare program. We permitted to maintain its necessary
section 1886(d)(2)(D) of the Act or in an emphasize that this change will be provider designation. However, the
area being treated as rural under section effective only for purposes of CAH regulations are limited to CAHs that
1886(d)(8)(E) of the Act. Because section participation and will not otherwise were necessary providers as of January
1820(c)(2)(B)(i) of the Act does not affect the status of hospitals or CAHs in 1, 2006, and does not address the
include any reference to the Lugar Lugar counties. In addition, section situation where the CAH is no longer
provision (section 1886(d)(8)(B) of the 1886(d) hospitals in Lugar counties will the same facility due to relocation,
Act), we do not believe that the statute be considered to be in a rural area for cessation of business, or a substitute
requires CMS to treat a facility as being purposes of applying for CAH status. facility. Currently, CMS Regional
Offices make the decision for continued current provider or a cessation of provider in obtaining an agreement to
certification following relocation of a business at one location and participate under a new provider
certified facility on a case-by-case basis. establishment of a new business at number. Furthermore, in such a
The criteria used to qualify a CAH as another location. In the event of situation, the regulations require the
a necessary provider were established relocation, the CAH must ensure that provider to give advanced notice to
by each State in its MRHFP. The State’s the provider is functioning as CMS and the public regarding its intent
MRHFP defined those CAHs that essentially the same provider in order to to stop providing medical services to the
provide necessary services to a operate under the same provider community. There is no appeals process
particular patient community in the agreement. A provider that is changing for a voluntary termination. Under our
event that the facility did not meet the location is considered to have closed the current policies, the cessation of
required 35-mile (or 15-mile with stated old facility if the original community or business by a CAH automatically
exceptions) distance requirement from service area can no longer be expected terminates the CAH designation,
the nearest hospital or CAH. Each to be served at the new location. The regardless of whether the designation
State’s criteria are different, but the distance of the moved CAH from its old was obtained through a necessary
criteria share certain similarities and all location will be considered, but it will provider determination.
define a necessary provider related to not be the sole determining factor in b. Relocation of a CAH Using a
the facility location. Therefore, it granting the relocation of a CAH under Necessary Provider Designation To Meet
becomes crucial to define whether the the same provider agreement. For the CoP for Distance
necessary provider designation remains example, a specialty hospital may move Once it has been determined that
pertinent in the event the certified CAH a considerable distance and still care for constructing a new facility will cause
builds in a different location. generally the same inpatient population, the CAH to relocate, the second step is
Accordingly, the first step of this while the relocation of a CAH at a to determine if the CAH that has a
process is to determine whether relatively short distance within a rural necessary provider designation can
building a new CAH facility in a area may greatly affect the community maintain this designation after
different location is a replacement of an served. relocating.
existing facility in essentially the same In the event that CMS determines the We recognize that § 485.610(c)
location, a relocation of the facility in a rebuilding of the CAH in a different relating to location relative to other
new location, or a cessation of business location to be a relocation, the provider facilities or necessary provider
at one location and establishment of agreement would continue to apply to certification states that, after January 1,
new business at another location. the CAH at the new location. In addition 2006, the ‘‘necessary provider’’
a. Determination of the Relocation to the relocation being within the same designation will no longer be used to
Status of a CAH service area, serving the same waive the mileage requirements. In
(1) Replacement in the same location. population, the CAH would need to be addition, CMS policy regarding a
Under this approach, in the FY 2006 providing essentially the same services change of size or location of a provider
IPPS proposed rule, we proposed that, with the same staff; that is, at least 75 states that there may be situations where
if the CAH is constructing renovation of percent of the same staff and 75 percent the facility relocation is so far removed
the same building in the same location, of the range of services are maintained from the originally approved site that
the renovation is considered to be a in the new location as the same provider we would conclude that this is a
replacement of the same provider and of services. We proposed the use of a 75- different provider or supplier, for
not relocation. We proposed that we percent threshold because we believe it example, it has different employees,
would consider a construction of the indicates that the CAH that is relocating services, and patients. Furthermore, as
CAH to be a replacement if construction demonstrates that it will maintain a noted previously, the language of
was undertaken within 250 yards of the high level of involvement, as opposed to section 1820(c)(2)(i) of the Act allowed
current building, as set by prior just a majority involvement, in the a State to exempt the mileage
precedence in defining a hospital current community. We note that CMS requirement and designate such a
campus. In addition, if the replacement has also used a 75-percent threshold in facility as a necessary provider of health
is constructed on land that is contiguous other provider designation policies such care services to residents in the area. We
to the current CAH, and that land was as the provider-based policies at have interpreted ‘‘services to residents
owned by the CAH prior to enactment § 413.65(e)(3)(ii). in the area’’ to mean that the necessary
of Pub. L. 108–173, and the CAH is In all cases of relocation, the CAH provider designation does not
operating under a State-issued necessary must continue to meet all of the CoPs automatically follow the provider if the
provider waiver that is grandfathered by found at 42 CFR Part 485, Subpart F, facility relocates to a different location
Pub. L. 108–173, we would consider including location in a rural area as because it is no longer furnishing
that construction to be a replacement of provided for at § 485.610. ‘‘services to patients’’ in the area
the existing provider and the provisions (3) Cessation of business at one determined to need a necessary
of the grandfathered necessary provider location. Under existing CMS policy, if provider.
designation would continue to apply the CAH relocation results in the We do not intend to change this
regardless of when the construction or cessation of furnishing services to the policy. Our proposal, noted below, was
renovation work commenced and was same community, we would not intended to establish a methodology to
completed. consider this to be a relocation, but be used by all CMS Regional Offices in
(2) Relocation of a CAH. Under our instead would consider such a scenario making such a decision consistent with
proposed approach, if the CAH is a cessation of business at one location the statutory provisions concerning
constructing a new facility in a location and establishment of a new business at necessary provider designation.
that does not qualify the construction as another location. Cessation of business In the FY 2006 IPPS proposed rule,
replacement of an existing facility in the is a basis for voluntary termination of we proposed to amend the regulations at
same location under the criteria in the the provider agreement under 42 CFR § 485.610 to set forth the criteria by
preceding paragraph, we indicated that Part 489. If the proposed move which those relocated CAHs designated
we would need to determine if this constitutes a cessation of business, the as necessary providers that embarked on
building would be a relocation of the CMS Regional Office may assist the a replacement facility project before the
sunset provision was enacted on rehabilitation or psychiatric distinct proposal. Specifically, under the
December 8, 2003, but find that they part units. proposed new paragraph (d) we
cannot be operational in the • A demonstration that construction specified that a CAH may maintain its
replacement facility by January 1, 2006, plans were ‘‘under development’’ prior necessary provider certification
can retain their necessary provider to the effective date of Pub. L. 108–173 provided for under § 485.610(c) if the
status. As required by statute, no (December 8, 2003) in the application new facility meets the requirements for
additional CAHs will be certified as a the CAH submits to continue using a either a replacement facility that is
necessary provider on or after January 1, necessary provider designation. constructed within 250 yards of the
2006. We recognize that the statute Supporting documentation could current building or contiguous to the
refers to a facility designated as a CAH include the drafting of architectural current CAH on land owned by the CAH
while relocation of a facility may result specifications, the letting of bids for prior to December 8, 2003; or as a
in a different building. However, to construction, the purchase of land and relocated CAH if, at the relocated site,
provide flexibility for a facility building supplies, documented efforts to the CAH provides essentially (75
designated as a CAH whose location secure financing for construction, percent) the same services to the same
may change, but is essentially the same expenditure of funds for construction, service area with essentially the same
facility in a different location, we and compliance with State requirements staff. We proposed that a CAH that
proposed to amend the regulations to for construction such as zoning plans to relocate must provide
account for this scenario. Essentially, requirements, application for a documentation demonstrating that its
we recognize that the necessary certificate of need, and architectural plans to rebuild in the relocated area
provider designation may need to be review. However, we recognize that it were undertaken prior to December 8,
applied to certain relocated CAHs. To may not have been feasible for a CAH 2003. We also proposed that if a CAH
this end, we proposed to use the to have completed all of these activities that has a necessary provider
specified relocation criteria as the initial noted above as examples prior to certification from the State places a new
step to determine continuing necessary December 8, 2003. Thus, we expect the facility in service on or after January 1,
provider status. Specifically, in the CMS Regional Offices to consider all of 2006, and does not meet either the
proposed rule, we proposed that, when the criteria and make case-by-case requirements for a replacement facility
a CAH is determined to have relocated, determinations of whether a relocated or a relocated facility, as specified in the
it may nonetheless continue to operate CAH continues to warrant necessary regulations, the action will be
under its necessary provider designation provider status. We note that we have considered a cessation of business.
that exempts the distance from other also used the above documentation We received approximately 150
providers only if the following guidelines in Publication 100–20 for timely pieces of correspondence
conditions are met: grandfathered specialty hospitals to commenting on the proposed policy
(1) The relocated CAH has submitted determine if construction plans were change regarding CAHs with a necessary
an application to the State agency for ‘‘under development.’’ provider designation being able to
relocation prior to the January 1, 2006, In proposing these criteria, our intent relocate and maintain their necessary
sunset date. If the CAH is applying in clarifying the sunset of the necessary provider designation.
under a grandfathered status under provider designation provision was to Comment: Most commenters opposed
section 1820(h)(3) of the Act, the allow CAHs to complete construction the proposed date restrictions that
following items would need to be projects that were initiated prior to the would require a CAH to have initiated
included in the application: enactment of Pub. L. 108–173, which we relocation plans prior to December 8,
• A demonstration that the CAH will believe is consistent with the statutory 2003, and to notify the CMS Regional
meet the same State criteria for the language of section 405(h) of Pub. L. Office by January 1, 2006 of plans to
necessary provider designation that 108–173. relocate their facility.
were established when the waiver was (2) In the application, the CAH Response: We have carefully
originally issued. For example, if the demonstrates that the replacement will considered the commenters’ concerns
location waiver was granted because the facilitate the access to care and improve regarding the proposed date
CAH was located in a health the delivery of services to Medicare requirement. Many commenters stated
professional shortage area (HPSA), the beneficiaries. We solicited comments on that the proposed date restrictions
CAH must remain in that HPSA. how a necessary provider CAH should would force CAHs to continue to
• Assurance that, after the relocation, demonstrate that the replacement will operate in outdated, inefficient facilities
the CAH will be servicing the same improve access to care. which could potentially put patients’
community and will be operating These guidelines are meant to be safety at risk or to lose their necessary
essentially the same services with applied to the relocated CAH that meets provider designation. As a result of our
essentially the same staff (that is, a the CoP in the new location and wishes review and in light of the compelling
demonstration that it is serving at least to maintain a necessary provider argument presented by the commenters,
75 percent of the same service area, with designation in order to meet the we have decided not to adopt as final
75 percent of the same services offered, distance requirement at § 485.610(c). the date requirement as proposed.
and staffed by 75 percent of the same They are not meant to preclude a CAH Under this final rule, we are allowing a
staff, including medical staff, contracted from relocating at any time if the CAH necessary provider CAH to replace its
staff, and employees). This is essentially does not seek to maintain the necessary facility at any time and maintain its
the same criteria used in determining provider designation. Any CAH may necessary provider designation,
whether the CAH has relocated. relocate at any time if the CAH meets provided it complies with the 75-
• Assurance that the CAH will remain the definition of relocation and can percent criteria specified at
in compliance with all of the CoPs at 42 meet all the CoPs at 42 CFR Part 485, § 485.610(d)(1).
CFR Part 485 in the new location. Subpart F, as determined by the CMS Comment: Many commenters opposed
Compliance will be established with a Regional Offices on a case-by-case basis. the proposed distance restriction of 250
full survey in the new location to Accordingly, we proposed to revise yards to qualify as a replacement
include the Life Safety Code and would § 485.610 of the regulations by adding a facility. They stated that the 250 yards
include any offsite locations and new paragraph (d) to incorporate this is arbitrary and will impede the progress
of health care. The commenters restrictions to state that a necessary constructs a new facility within the city
suggested that CMS should consider provider CAH can relocate its facility or town limits.
distances that ranged from 500 yards to and provide services at a new location Response: We do not believe that the
5 miles that would qualify a new CAH if the necessary provider is essentially use of city or town limits should be a
facility as a replacement facility and, the same facility in the new location. criterion for determining if a necessary
therefore, be considered to be serving Comment: A few commenters asked provider CAH has relocated its facility.
the same service area. CMS to explain how the necessary We have heard from several CAHs that
Many commenters agreed with the provider CAH would demonstrate that it have special circumstances (landlocked,
proposed 75-percent criteria (75 percent meets the 75-percent criteria. adjacent to a mountain, etc.) and, thus,
of the same service area, same services, Response: We will develop guidelines would find it difficult to relocate within
and same staff) as a way to ensure that for the CMS Regional Offices and State the town or city limits. We believe that
a necessary provider CAH will continue agencies to utilize when evaluating the 75-percent criteria set forth in
to provide access to care in its compliance with the 75-percent criteria. proposed paragraphs (d)(1) will better
community. However, one commenter One example could be to have the CAHs help to ensure that CAHs appropriately
opposed the 75-percent criteria, stating self attest that they meet the 75-percent relocate their facilities.
that it is not reasonable and that criteria in all areas. CMS could follow Comment: A few commenters stated
necessary provider CAHs should be up the attestation with an audit based that flexibility in measuring
allowed to relocate based on the needs on claims data. These data would demographics for a CAH should be
of the community. identify the services that the CAH allowed due to expected changes in the
Others commenters suggested that if a provides and their service area. CMS needs of the community.
CAH moves further than 5 miles, then could conduct an audit at the end of the Response: We believe that the three
an approach similar to the 75-percent year when CMS settles the cost report 75-percent criteria requirements will
test could be used to ensure that a (which also identifies the service area assist in ensuring continued access to
facility is serving the same population. and services provided). To address the care in the community for which the
One commenter suggested that a
employee criterion, the CAH can CAH was originally designated as a
necessary provider CAH be allowed to
provide a list of employees before and necessary provider. We also believe that
relocate within 2 miles of the current
after the move. These are some it is not the responsibility of CMS to
location or within 5 miles of the current
examples of how CMS may evaluate project future changes in demographics
location, provided that the nearest
compliance with the criteria and do not for a necessary provider CAH. We do
hospital is more than 15 miles away.
Several CAHs cited issues of being represent a final decision as to how the believe that we are responsible for
land-locked and poor beneficiary access 75-percent criteria will be administered. ensuring access to care under the
as examples of why it is not feasible to Currently, the CMS Regional Offices current conditions for which necessary
replace their facility on or adjacent to make the decision for continued provider CAHs were granted their
their current location. Several certification following relocation of a designations.
commenters highlighted the fact that certified facility on a case-by-case basis. Comment: Several commenters
being able to modernize their facilities We have not changed this policy. The suggested requiring a CAH to satisfy
in a new location will allow them to criteria used to qualify a CAH as a only three of five criteria for relocating.
expand their services and gain a necessary provider were established by The commenters stated that, in addition
competitive edge with larger full service each State in its MRHFP. The State, in to the staff, services and population
hospitals. its MRHFP, defined those CAHs that measures, CMS should consider adding
Response: After carefully considering provide necessary services to a a needs assessment and cost
the comments received, we have particular patient community. The State comparison. The commenters further
decided to modify proposed paragraph agencies and Regional Offices will stated that if a CAH can show through
(d)(1) to state that a necessary provider closely monitor each necessary provider a needs assessment that a change in
CAH can relocate its facility and begin CAH that relocates to ensure that it will services provided would be appropriate,
providing services at a new location, continue to provide services based on the CAH should not have to comply
provided the necessary provider will be the criteria that qualified the CAH to be with the requirement to provide 75
essentially the same facility in its new designated as a necessary provider. percent of the same services.
location. To help ensure that the facility The intent of the CAH program is to Response: We do not believe that it is
is the same, we will require the keep hospital-level services in rural necessary to add other requirements
relocated necessary provider CAH to communities, thereby ensuring access to such as a needs assessment and a cost
provide at least 75 percent of its current care. We are revising the regulation to comparison to the criteria. We would
services to 75 percent of the same allow a necessary provider CAH to expect a CAH, as part of its normal
service area with 75 percent of its relocate its facility and to continue to business practice, to compare the cost of
current staff in its new location. This ensure access to care in the community building a new facility with renovating
change effectively replaces the need to for which it was designated as a its current facility before making the
distinguish between replacement and necessary provider. The intent of this decision to relocate. We continue to
relocated necessary provider CAHs. All policy change is not to improve the believe that the 75-percent rule for the
new necessary provider CAH facilities competitive edge of necessary provider services provided, staff, and service area
that will be constructed after January 1, CAHs with full service hospitals. CMS allows sufficient flexibility to ensure
2006, will be considered relocated will monitor closely the effectiveness of continued access to care in the
facilities. this policy change on the CAHs and full communities that are served by the
Based on our review of comments, we service hospitals and, if necessary, will necessary provider CAHs.
have determined that a mileage revisit this issue through future Comment: Several commenters
requirement would not effectively rulemaking. suggested that we rescind the proposal
ensure access to care. Therefore, in this Comment: A few commenters and allow necessary provider CAHs to
final rule, we are modifying paragraph suggested that a CAH should be relocate as needed to meet the needs of
(d)(1) as proposed to delete all distance considered as a relocated facility if it their communities.
Response: We believe the revised percent of average wholesale price micrograms, based on one billing unit
policy does not interfere with any (AWP). Section 303 of Pub. L. 108–173 per 1.2 mg; that is, one billing unit per
CAH’s ability to serve the needs of its established section 1847A of the Act single dose.
community. We further believe that it is which requires that almost all Medicare In this final rule, we are adopting as
prudent to establish consistent Part B drugs not paid on a cost or final for FY 2006 that fiscal
guidelines whereby necessary provider prospective basis be paid at 106 percent intermediaries make payment for blood
CAHs can continue to provide care to of average sales price (ASP) and clotting factor using ASP+ 6 percent and
their service area and not violate the provided for payment of a furnishing fee make payment for the furnishing at
intent of the CAH program. We also for blood clotting factor, effective $0.14 per individual unit (I.U.) that is
believe that, by maintaining the January 1, 2005. On November 15, 2004, currently used for Medicare Part B
percentage criteria, CAHs will be able to we issued regulations in the Federal drugs. This furnishing fee will be
relocate appropriately and continue to Register (69 FR 66299) that updated each calendar year in
serve their communities. implemented the provisions of section accordance with § 410.63.
Comment: Several commenters chose 1847A for payment for Medicare Part B
to raise issues that are beyond the scope drugs. In accordance with the current IX. MedPAC Recommendations
of the proposed rule concerning the regulations at Subpart K of Part 414,
CAH necessary provider policy. effective January 1, 2005, blood clotting We are required by section
Response: In this final rule, we are not factor under Medicare Part B is paid 1886(e)(4)(B) of the Act to respond to
summarizing or responding to those based on the lesser of 106 percent of MedPAC’s IPPS recommendations in
comments. However, we will review the ASP (that is, ASP+ 6 percent) or the our annual IPPS rules. In March 2005,
comments and consider whether to take actual charge. MedPAC released the following two
other actions, such as revising or To ensure consistency in payment for reports to Congress, which included
clarifying CMS program operating Medicare Part A and Medicare Part B IPPS recommendations: ‘‘Report to
instructions or procedures. drugs, in the FY 2006 IPPS proposed Congress: Medicare Payment Policy’’
In this final rule, we are adopting the rule we proposed to revise §§ 412.2(f)(8) and ‘‘Report to Congress: Physician-
proposed new § 485.610(d), with and 412.115(b) of the regulations Owned Specialty Hospitals.’’ We have
modifications. We are removing the governing the IPPS to specify that, for reviewed each of these reports and have
proposed distinction between a discharges occurring on or after October given them careful consideration in
replacement and relocation of a 1, 2005, the additional payment for the conjunction with the policies set forth
necessary provider CAH. We are also blood clotting factor administered to in this document. These
eliminating the proposed distance hemophilia inpatients is made based on recommendations and our responses are
requirement for replacing a facility. As the average sales price methodology set forth below. For further information
a result, all CAHs that construct a new specified in Subpart K of 42 CFR Part relating specifically to the MedPAC
facility will be considered to have 414 and the furnishing fee specified in reports or to obtain a copy of the
relocated and may be able to maintain § 410.63. reports, contact MedPAC at (202) 653–
the necessary provider designation if The payment amount per unit and the 7220, or visit MedPAC’s Web site at:
they meet the requirements of unit payment for the furnishing fee for http://www.medpac.gov.
§ 485.610(d)(l). In addition, we are blood clotting factor administered to
eliminating the proposed date hospital inpatients who have A. Medicare Payment Policy in MedPAC
restriction. hemophilia that we proposed to apply March 2005 Reports to Congress
under the IPPS for FY 2006 are specified 1. Update Factor
VIII. Payment for Blood Clotting Factor
in section V. of the Addendum to this
Administered to Hemophilia Inpatients MedPAC’s Recommendation 2A–1 in
final rule.
Section 1886(a)(4) of the Act excludes Comment: One commenter supported the Report to Congress on Medicare
the costs of administering blood clotting the proposal to pay for blood clotting Payment Policy concerning the update
factors to individuals with hemophilia factors consistently under Medicare Part factor for inpatient hospital operating
from the definition of ‘‘operating costs A and Part B in FY 2006. The costs and for hospitals and distinct-part
of inpatient hospital services.’’ Section commenter pointed out that clotting hospital units excluded from the IPPS is
6011(b) of Pub. L. 101–239 (the factors are described in terms of discussed in Appendix B to this final
Omnibus Budget Reconciliation Act of International Units (IUs), and that one of rule.
1989) states that the Secretary of Health the blood clotting factors is dosed in
and Human Services shall determine the micrograms rather than IUs. The 2. Quality Incentive Payment Policy
payment amount made to hospitals commenter stated that, under Medicare Recommendation 4A in the Report to
under Part A of Title XVIII of the Act Part B, for the purpose of providing the Congress on Medicare Payment Policy:
for the costs of administering blood $0.14 per unit furnishing fee, a single The Congress should establish a quality
clotting factors to individuals with unit is equal to one microgram. In order incentive payment policy for hospitals
hemophilia by multiplying a to ensure consistency in payments for in Medicare.
predetermined price per unit of blood blood clotting factors, the commenter
clotting factor by the number of units requested that CMS designate one In the FY 2006 IPPS proposed rule,
provided to the individual. The microgram as one unit for the purpose we indicated that we are exploring
regulations governing payment for blood of payment under the ASP methodology provider payment policies that link
clotting factor furnished to hospital and for providing the furnishing fee to quality to Medicare reimbursement in a
inpatients are located in §§ 412.2(f)(8) hospital inpatient providers. cost neutral manner under our
and 412.115(b). Response: In the Medicare Claims demonstration authority. We currently
Consistent with the rates paid under Processing Manual (Pub. 100–4), have demonstrations underway that will
section 1842(o) of the Act for certain Chapter 3, section 20.7.3, we instruct identify and examine the components of
Medicare Part B drugs, in FY 2005, we the fiscal intermediaries to report such a policy.
made payments for blood clotting HCPCS code Q0187 (Factors viia We did not receive any public
factors furnished to inpatients at 95 recombinant) which is dosed 1.2 comments on this recommendation.
3. Refinement of DRGs Based on (Diseases and Disorders of the greater resource use. We are referring to
Severity of Illness Circulatory System), particularly those these conditions as ‘‘major
Section 2A of the Report to Congress DRGs that are commonly billed by cardiovascular conditions (MCVs).’’
on Medicare Payment Policy (page 64) specialty hospitals. To begin our They could be present as either a
and Recommendation 1 in the Report to analysis, we considered whether the principal diagnosis or a secondary
Congress on Physician-Owned Specialty approach that is currently used for diagnosis and, as shown below, lead to
Hospitals: The Secretary should paired DRGs 121 and 122 (Circulatory greater resource consumption. The
improve payment accuracy in the Disorders With AMI With and Without complete list of MCVs is shown below.
Major Complication Discharged Alive, Most of the conditions on the MCV
hospital inpatient PPS by—
respectively) and paired DRGs 124 and list are cardiovascular diagnoses
• Refining the current DRGs to more
125 (Circulatory Disorders Except AMI assigned to MDC 5 when present as a
fully capture differences in severity of
With Cardiac Catheterization With and principal diagnosis. In the chart below,
illness among patients.
Without Complex Diagnosis, a code that is labeled ‘‘PS’’ could be
• Basing the DRG relative weights on
respectively) would have applicability present as either a principal diagnosis or
the estimated cost of providing care
to other DRGs in MDC 5. Currently, a secondary diagnosis to be assigned to
rather than on charges.
DRGs 121 and 122 are split based on an MCV DRG (new DRGs 547, 549, 551,
• Basing the weights on the national
whether the patient is diagnosed with a 553, 555, and 557 identified later in this
average of hospitals’ relative values in
‘‘cardiovascular complication.’’ DRGs discussion). If only a ‘‘P’’ is shown, the
each DRG.
124 and 125 are split based on whether diagnosis would only assign the patient
In the FY 2006 IPPS proposed rule (70
the patient has a ‘‘complex diagnosis.’’ to an MCV DRG when present as a
FR 23454), we stated that we expected
There is some overlap between the lists principal diagnosis. Similarly, if only an
to make changes to the DRGs to better
of cardiovascular complications and ‘‘S’’ is shown, the diagnosis would only
reflect severity of illness. We indicated
complex diagnoses. The lists are used to assign a patient to an MCV DRG when
that it was our plan to conduct a present as a secondary diagnosis.
segregate patients into DRGs that use
comprehensive review of the Diagnosis codes with only an ‘‘S’’
greater resources. Because the hospital
complications and comorbidities (CC) shown are noncardiovascular conditions
industry is familiar with the major
list as well as of the possibility of using that, if present as a principal diagnosis,
complication and complex diagnosis
the All Patient Refined (APR) DRGs for would assign a patient to a
lists used within the cardiovascular
Medicare for FY 2007. The noncardiovascular DRG. For example,
DRGs, we began our analysis with these
comprehensive review of the CC list is code 415.19 (Pulmonary embolism and
two overlapping lists.
discussed in section II.B.12.b. of this These two lists were originally infarction) is shown with only an ‘‘S’’
preamble. We did not propose to adopt developed for the current DRG system on the chart because if it were present
APR–DRGs for FY 2006 because it because they contained conditions that as the principal diagnosis, the case
would represent a significant could have an impact on the resources would not be assigned to a
undertaking that could have a needed to treat a cardiovascular patient. cardiovascular DRG in MDC 5.
substantial effect on all hospitals. There Many of them are cardiovascular Therefore, code 415.19 could only be
was insufficient time to adopt a change diagnoses and, therefore, would be considered an MCV if it were listed as
of this magnitude through notice and classified to MDC 5. However, we have a secondary diagnosis. The principal
comment rulemaking between the determined that some of the diagnoses diagnosis must be a cardiovascular
release of the MedPAC reports in March are not cardiovascular, but would still condition that assigns the case to one of
2005 and the publication of the FY 2006 have an impact on a cardiovascular the new MCV or non-MCV DRGs (547
IPPS proposed rule for us to analyze patient. The conditions that are not through 558). The case would be
fully a change of this magnitude. cardiovascular diagnoses would not be classified to an MCV DRG if code 415.19
Nevertheless, we indicated that we assigned to MDC 5 if they were the was present as a secondary diagnosis.
planned to further consider all of principal diagnosis. An example would Using the MCV list, we tested our
MedPAC’s recommendations. be code 430 (Subarachnoid assumption that these conditions
As we indicated in section II.B.5.a. of hemorrhage). If code 430 were the described a more severe set of
this preamble, in response to the principal diagnosis, the condition cardiovascular surgery patients. We
proposed rule, we received a comment would be assigned to MDC 1 (Diseases grouped all the cardiovascular surgery
noting that section 507(c) of Pub. L. and Disorders of the Nervous System). patients within MDC 5 based on the
108–173 required MedPAC to conduct a However, we have determined that this presence or absence of an MCV
study to determine how the DRG system condition, if present as a secondary condition. We found that this split was
should be updated to better reflect the diagnosis, would be a major predictive of significantly increased
cost of delivering care in a hospital complication for a patient with a resource use for nine surgical
setting. The commenter noted that principal diagnosis of AMI included in cardiovascular DRGs. By splitting these
MedPAC reported that the ‘‘cardiac DRG 121. For a case to be assigned to surgical DRGs based on the presence or
surgery DRGs have high relative either DRG 121 or DRG 124, the absence of an MCV condition, we
profitability ratios.’’ While the cardiovascular complication or complex identified subgroups of patients with
commenter noted that it may take time diagnosis can be present as either a average charges that were 28 to 45
to conduct and complete a thorough principal diagnosis or a secondary percent higher than average charges for
evaluation of the MedPAC payment diagnosis. We retained this logic for our those cases without an MCV condition.
recommendations for all DRGs, the approach to identifying more severe We did not find that the MCV approach
commenter strongly encouraged CMS to cases in our focused review of the could explain patient severity and
revise the cardiac DRGs through patient cardiovascular DRGs. resource use among the cardiovascular
severity refinement as part of the IPPS Our clinical advisors reviewed the medical DRGs or surgical DRGs other
final rule effective for FY 2006. conditions on the two overlapping lists than the nine shown below. The other
As a result of this comment, we and identified conditions that they surgical DRGs within MDC 5 did not
performed an extensive review of the believed would lead to a more clearly identify more severe cases using
cardiovascular DRGs in MDC 5 complicated patient stay requiring this methodology. Applying the MCV
list to the other surgical cardiovascular Without Cardiac Catheterization), 516 of specific diagnoses such as AMI, heart
DRGs did not provide a sufficient (Percutaneous Cardiovascular failure, or shock that are on the MCV
difference in average charges or the Procedures With AMI), 526 list: DRG 115 (Permanent Cardiac
distribution of cases between the MCV (Percutaneous Cardiovascular Procedure Pacemaker Implant With AMI, Heart
and non-MCV patients to justify With Drug-Eluting Stent With AMI), and Failure, and Shock) and 116 (Other
adopting this approach. The chart below 527 (Percutaneous Cardiovascular Permanent Cardiac Pacemaker Implant),
illustrates our findings. Procedure With Drug-Eluting Stent DRGs 516 (Percutaneous Cardiovascular
We made one minor revision to this Without AMI). These two conditions Procedures With AMI) and 517
overall approach. Our clinical advisors are: (Percutaneous Cardiovascular
identified five diagnoses on the MCV • 411.1, Intermediate coronary Procedures With Non-Drug-Eluting
list which they believe would be the syndrome (unstable angina)
Stent Without AMI), and DRGs 526
reason for admission for the surgical • 411.81, Coronary occlusion without
myocardical infarction (Percutaneous Cardiovascular
procedure. Therefore, these five
diagnoses should not be counted as an Making this minor revision to the Procedures With Drug-Eluting Stent
MCV for specific surgical DRGs. For MCV list greatly increased the With AMI) and 527 (Percutaneous
instance, a complete atrioventricular predictive value of this methodology for Cardiovascular Procedures With Drug-
block (code 426.0) would be the reason the relevant cardiovascular DRGs. The Eluting Stent Without AMI). Rather than
a patient would receive a pacemaker. following chart illustrates the current further subdivide these DRGs, we are
This patient is currently assigned to DRGs that are being revised and the new expanding the DRGs that include AMI,
DRG 115 (Permanent Cardiac Pacemaker DRGs being created based on the heart failure, and shock to encompass
Implant With AMI/HF/Shock or AICD presence or absence of an MCV. all of the other conditions on the MCV
Lead or Generator Procedure) or DRG Current DRGs 107, 109, and 478 are list. Thus, DRGs 115 and 116 are being
116 (Other Permanent Cardiac being split based on the presence or replaced by new DRGs 551 (Permanent
Pacemaker Implant). Because the absence of an MCV. For instance, cases Cardiac Pacemaker Implant With MCV
patient’s heart block is the reason for the currently assigned to DRG 107 that have Diagnosis or AICD Lead or Generator)
pacemaker insertion, our clinical an MCV diagnosis will be assigned to and 552 (Other Permanent Cardiac
advisors advised that code 426.0 should new DRG 547 (Coronary Bypass With Pacemaker Implant Without MCV
not count as an MCV for our analysis of Cardiac Catheterization With MCV Diagnosis). DRGs 516 and 517 are being
the pacemaker implant DRGs. Therefore, Diagnosis). Cases in current DRG 107 replaced by new DRGs 555
code 426.0 will not count as an MCV for that do not have an MCV will be (Percutaneous Cardiovascular
current DRGs 115 and 116. assigned to new DRG 548 (Coronary Procedures With MCV Diagnosis) and
The complete list of conditions that Bypass With Cardiac Catheterization
556 (Percutaneous Cardiovascular
will not count as an MCV for current Without MCV Diagnosis). We are
Procedures With Nondrug-Eluting Stent
DRGs 115 and 116 because they are the deleting DRG 107. Similarly, we are
Without MCV Diagnosis). DRGs 526 and
reason for the pacemaker implant are: deleting DRGs 109 and 478 and
527 are being replaced by new DRGs
• 426.0, Atrioventricular block, assigning their cases to new DRG pairs
557 (Percutaneous Cardiovascular
complete 549 (Coronary Bypass Without Cardiac
Procedure With Drug-Eluting Stent With
• 426.53, Bilateral bundle branch Catheterization With MCV Diagnosis)
block and 550 (Coronary Bypass Without MCV Diagnosis) and 558 (Percutaneous
• 426.54, Trifascicular block Cardiac Catheterization Without MCV Cardiovascular Procedure With Drug-
Our clinical advisors identified two Diagnosis) and 553 (Other Vascular Eluting Stent Without MCV Diagnosis).
codes on the MCV condition list that Procedures With CC With MCV The left side of the chart shows the 9
would be the reason for the Diagnosis) and 554 (Other Vascular existing DRGs and their relevant
cardiovascular surgery for cases Procedures With CC Without MCV statistics. These 9 DRGs are being
currently assigned to DRGs 107 Diagnosis), respectively. deleted and replaced by the 12 new
(Coronary Bypass with Cardiac The following three DRG pairs are DRGs on the right side.
Catheterization), 109 Coronary Bypass already divided based on the presence BILLING CODE 4120–01–P
As can be seen from this chart, 6 of ill patients who use greater hospital DRGs better account for the less severely
these 12 new DRGs better identify resources than was possible under the ill patients who use fewer hospital
subgroups of significantly more severely previous DRGs, while the remaining 6 resources. For instance, current DRG
ER12AU05.003</GPH>
107 has average standardized charges of pairs of new DRGs show differences in ill patients who require more resources
$82,398. DRG 107 has been replaced by average standardized charges of 30.0 to while lowering our payments for less
new DRGs 547 and 548 with average 47.7 percent. Thus, we believe these severely ill and less resource-intensive
standardized charges of $92,542 and new DRGs are an improvement over the patients.
$71,906, respectively. These two new existing DRG structure because they The complete list of MCVs is shown
DRGs have a difference of $20,635, or better recognize a patient’s severity of
below:
28.7 percent, in average standardized illness and, accordingly, permit us to
charges. The chart illustrates that other make higher payments for more severely
DRGs 547, 548,

MCV code DRGs 551 and 549, 550, 553,
MCV code titles P-Principal, S-Secondary diagnosis
number 552 554, 555, 556,
557, and 558
398.91 ......... Rheumatic Heart Failure (Congestive) ..................................................................................... PS PS

402.01 ......... Hypertensive Heart Disease, Malignant, With Congestive Heart Failure ................................ PS PS
402.11 ......... Hypertensive Heart Disease, Benign, With Congestive Heart Failure ..................................... PS PS
402.91 ......... Hypertensive Heart Disease, With Congestive Heart Failure, Unspecified Benign or Malig- PS PS
nant.
404.01 ......... Malignant Hypertensive Heart and Renal Disease, With Congestive Heart Failure ............... PS PS
404.03 ......... Malignant Hypertensive Heart and Renal Disease, With Congestive Heart Failure and PS PS
Renal Failure.
404.11 ......... Benign Hypertensive Heart and Renal Disease, With Congestive Heart Failure .................... PS PS
404.13 ......... Benign Hypertensive Heart and Renal Disease, With Congestive Heart Failure and Renal PS PS
Failure.
404.91 ......... Hypertensive Heart and Renal Disease, Unspecified Benign or Malignant, With Congestive PS PS
Heart Failure.
404.93 ......... Hypertensive Heart & Renal Disease, Unspecified Benign or Malignant, W/ Congestive PS PS
Heart Failure & Renal Failure.
410.01 ......... Acute Myocardial Infarction, Anterolateral Wall, Initial Episode of Care ................................. PS PS
410.11 ......... Acute Myocardial Infarction, Anterior Wall, Initial Episode of Care ......................................... PS PS
410.21 ......... Acute Myocardial Infarction, Inferolateral Wall, Initial Episode of Care ................................... PS PS
410.31 ......... Acute Myocardial Infarction, Inferoposterior Wall, Initial Episode of Care ............................... PS PS
410.41 ......... Acute Myocardial Infarction, Inferior Wall, Initial Episode of Care ........................................... PS PS
410.51 ......... Acute Myocardial Infarction, Lateral Wall, Initial Episode of Care ........................................... PS PS
410.61 ......... True Posterior Wall Infarction, Initial Episode of Care ............................................................. PS PS
410.71 ......... Subendocardial Infarction, Initial Episode of Care ................................................................... PS PS
410.81 ......... Acute Myocardial Infarction, Other Specified Site, Initial Episode of Care .............................. PS PS
410.91 ......... Acute Myocardial Infarction, Unspecified Site, Initial Episode of Care .................................... PS PS
411.0 ........... Postmyocardial Infarction Syndrome ........................................................................................ PS PS
411.1 ........... Intermediate Coronary Syndrome (Unstable Angina) .............................................................. PS Code does not
count.
411.81 ......... Coronary Occlusion Without Myocardial Infarction .................................................................. PS Code does not
count.
414.10 ......... Heart (Wall) Aneurysm ............................................................................................................. PS PS
414.11 ......... Aneurysm of Coronary Vessel .................................................................................................. PS PS
414.12 ......... Dissection of Coronary Artery .................................................................................................. PS PS
414.19 ......... Aneurysm of Heart .................................................................................................................... PS PS
415.0 ........... Acute Cor Pulmonale ................................................................................................................ PS PS
415.11 ......... Iatrogenic Pulmonary Embolism and Infarction ........................................................................ S S
415.19 ......... Pulmonary Embolism and Infarction ......................................................................................... S S
420.0 ........... Acute Pericarditis In Diseases Classified Elsewhere ............................................................... PS PS
420.90 ......... Acute Pericarditis, Unspecified ................................................................................................. PS PS
420.91 ......... Acute Idiopathic Pericarditis ..................................................................................................... PS PS
420.99 ......... Acute Pericarditis ...................................................................................................................... PS PS
421.0 ........... Acute/Subacute Bacterial Endocarditis .................................................................................... PS PS
421.1 ........... Acute/Subacute Infective Endocarditis In Diseases Classified Elsewhere .............................. PS PS
421.9 ........... Acute Endocarditis, Unspecified ............................................................................................... PS PS
422.92 ......... Septic Myocarditis ..................................................................................................................... PS PS
423.0 ........... Hemopericardium ...................................................................................................................... PS PS
424.90 ......... Endocarditis, Valve Unspecified, Unspecified Cause .............................................................. PS PS
426.0 ........... Atrioventricular Block, Complete .............................................................................................. Code does not PS
count
426.53 ......... Bilateral Bundle Branch Block .................................................................................................. Code does not PS
count
426.54 ......... Trifascicular Block ..................................................................................................................... Code does not PS
count
427.1 ........... Paroxysmal Ventricular Tachycardia ........................................................................................ PS PS
427.41 ......... Ventricular Fibrillation ............................................................................................................... PS PS
427.5 ........... Cardiac Arrest ........................................................................................................................... PS PS
428.0 ........... Congestive Heart Failure .......................................................................................................... PS PS
428.1 ........... Left Heart Failure ...................................................................................................................... PS PS
428.20 ......... Unspecified Systolic Heart Failure ........................................................................................... PS PS
428.21 ......... Acute Systolic Heart Failure ..................................................................................................... PS PS
428.22 ......... Chronic Systolic Heart Failure .................................................................................................. PS PS
428.23 ......... Acute on Chronic Systolic Heart Failure .................................................................................. PS PS
DRGs 547, 548,

MCV code DRGs 551 and 549, 550, 553,
MCV code titles P-Principal, S-Secondary diagnosis
number 552 554, 555, 556,
557, and 558
428.30 ......... Unspecified Diastolic Heart Failure .......................................................................................... PS PS

428.31 ......... Acute Diastolic Heart Failure .................................................................................................... PS PS
428.32 ......... Chronic Diastolic Heart Failure ................................................................................................. PS PS
428.33 ......... Acute on Chronic Diastolic Heart Failure ................................................................................. PS PS
428.40 ......... Unspecified Combined Systolic and Diastolic Heart Failure .................................................... PS PS
428.41 ......... Acute Combined Systolic and Diastolic Heart Failure ............................................................. PS PS
428.42 ......... Chronic Combined Systolic and Diastolic Heart Failure .......................................................... PS PS
428.43 ......... Acute on Chronic Combined Systolic and Diastolic Heart Failure ........................................... PS PS
428.9 ........... Heart Failure, Unspecified ........................................................................................................ PS PS
429.5 ........... Chordae Tendineae Rupture .................................................................................................... PS PS
429.6 ........... Papillary Muscle Rupture .......................................................................................................... PS PS
429.71 ......... Acquired Cardiac Septal Defect ............................................................................................... PS PS
429.79 ......... Other Certain Sequelae of Myocardial Infarction, Not Elsewhere Classified .......................... PS PS
429.81 ......... Papillary Muscle Disorder ......................................................................................................... PS PS
430 .............. Subarachnoid Hemorrhage ....................................................................................................... S S
431 .............. Intracerebral Hemorrhage ......................................................................................................... S S
432.0 ........... Nontraumatic Extradural Hemorrhage ...................................................................................... S S
432.1 ........... Subdural Hemorrhage .............................................................................................................. S S
432.9 ........... Unspecified Intracranial Hemorrhage ....................................................................................... S S
433.01 ......... Occlusion and Stenosis of Basilar Artery With Cerebral Infarction ......................................... S S
433.11 ......... Occlusion and Stenosis of Carotid Artery With Cerebral Infarction ......................................... S S
433.21 ......... Occlusion and Stenosis of Vertebral Artery With Cerebral Infarction ...................................... S S
433.31 ......... Occlusion and Stenosis of Multiple and Bilateral Precerebral Arteries With Cerebral Infarc- S S
tion.
433.81 ......... Occlusion and Stenosis of Precerebral Artery With Cerebral Infarction .................................. S S
433.91 ......... Occlusion and Stenosis of Unspecified Precerebral Artery With Cerebral Infarction .............. S S
434.00 ......... Cerebral Thrombosis Without Cerebral Infarction .................................................................... S S
434.01 ......... Cerebral Thrombosis With Cerebral Infarction ......................................................................... S S
434.10 ......... Cerebral Embolism Without Cerebral Infarction ....................................................................... S S
434.11 ......... Cerebral Embolism With Cerebral Infarction ............................................................................ S S
434.90 ......... Unspecified Cerebral Artery Occlusion Without Cerebral Infarction ........................................ S S
434.91 ......... Unspecified Cerebral Artery Occlusion With Cerebral Infarction ............................................. S S
436 .............. Acute, But Ill-Defined, Cerebrovascular Disease ..................................................................... S S
441.00 ......... Dissection of Aorta, Unspecified Site ....................................................................................... PS PS
441.01 ......... Dissection of Aorta, Thoracic ................................................................................................... PS PS
441.02 ......... Dissection of Aorta, Abdominal ................................................................................................ PS PS
441.03 ......... Dissection of Aorta, Thoracoabdominal ................................................................................... PS PS
441.1 ........... Thoracic Aneurysm, Ruptured .................................................................................................. PS PS
441.3 ........... Abdominal Aneurysm, Ruptured ............................................................................................... PS PS
441.5 ........... Aortic Aneurysm of Unspecified Site, Ruptured ....................................................................... PS PS
441.6 ........... Thoracoabdominal Aneurysm, Ruptured .................................................................................. PS PS
443.22 ......... Dissection of Iliac Artery ........................................................................................................... PS PS
443.29 ......... Dissection of Other Artery ........................................................................................................ PS PS
444.0 ........... Embolism or Thrombosis of Abdominal Aorta .......................................................................... PS PS
444.1 ........... Embolism or Thrombosis of Thoracic Aorta ............................................................................. PS PS
445.81 ......... Atheroembolism of Kidney ........................................................................................................ S S
453.2 ........... Embolism and Thrombosis of Vena Cava ................................................................................ PS PS
785.50 ......... Shock, Unspecified ................................................................................................................... PS PS
785.51 ......... Cardiogenic Shock .................................................................................................................... PS PS
861.02 ......... Laceration of Heart Without Penetration of Heart Chambers or Open Wound Into Thorax ... PS PS
861.03 ......... Laceration of Heart With Penetration of Heart Chambers, Without Open Wound Into Thorax PS PS
861.10 ......... Unspecified Injury of Heart With Open Wound Into Thorax .................................................... PS PS
861.11 ......... Contusion of Heart With Open Wound Into Thorax ................................................................. PS PS
861.12 ......... Laceration of Heart Without Penetration of Heart Chambers With Open Wound Into Thorax PS PS
861.13 ......... Laceration of Heart With Penetration of Heart Chambers, and Open Wound Into Thorax ..... PS PS
862.9 ........... Multiple/Unspecified Intrathoracic Organ Injury With Open Wound Into Cavity ...................... S S
996.61 ......... Infection and Inflammatory Reaction Due To Cardiac Device/Implant/Graft ........................... PS PS
996.62 ......... Infection and Inflammatory Reaction Due To Other Vascular Device/Implant/Graft ............... PS PS
996.72 ......... Complication Due To Other Cardiac Device/Implant/Graft ...................................................... PS PS
996.83 ......... Complications of Transplanted Heart ....................................................................................... PS PS
In this final rule, we are system for FY 2006 until we can 4. APR–DRGs
implementing new DRGs 547 through complete a more comprehensive In the FY 2006 IPPS proposed rule,
558 as described above for FY 2006. analysis of the APR–DRG system and we indicated that we were also
However, we emphasize that the the CC list as part of a complete analysis considering the use of alternative DRG
refinements to the DRGs described of the MedPAC recommendations that systems such as the all patient refined
above are being taken as an interim step we plan to perform over the next year. diagnosis related groups (APR–DRGs) in
to better recognize severity in the DRG place of Medicare’s current DRG system.
The APR–DRGs have a greater number extensive evaluation. As discussed in Comment: MedPAC also addressed
of DRGs that could relate payment rates the proposed rule, we will thoroughly our concern that significantly expanding
more closely to patient resource needs, study MedPAC’s recommendations over the number of DRGs could lead to
and thus reduce the advantages of the course of the next year and consider changes in hospitals’ case-mix reporting
selection of desirable patients within proposing changes for FY 2007 if our that may cause inappropriate increases
DRGs by specialty hospitals. However, analysis suggests that adopting in Medicare payments. According to
such a far-reaching structural change to MedPAC’s recommendations would MedPAC’s comment, the Secretary has
the current DRG system could have lead to improvements in the DRG authority to make a prospective
substantial effects across all hospitals. system. We are currently in the process adjustment to the national base payment
Therefore, we believe we must of engaging a contractor experienced in amounts to offset expected increases in
thoroughly analyze the options and Medicare payment issues to conduct a payments resulting from changes in
their impacts on the various types of comprehensive review of the MedPAC hospitals’ case-mix reporting. MedPAC
hospitals before making any proposal to recommendations. We note that any suggested that CMS use reabstracted
replace the current DRG system. In fundamental changes to our DRG medical records collected from
addition, as noted above, we indicated classification system in order to better Medicare’s quality assurance program to
our concern about our ability to account recognize severity; to use cost-based carry out this policy. It also suggested
for the effect of changes in coding weights; or to adopt hospital-specific that CMS exclude nonspecific
behavior on payment if we were to relative weights could have implications secondary diagnoses from more highly
significantly expand the number of for other payment adjustments that are valued severity DRGs; issue guidance to
DRGs. Therefore, before making a part of the IPPS (for example, the hospitals about appropriate coding
change of this magnitude, we must indirect medical education and practices; monitor case-mix changes for
consider how to mitigate the risk of disproportionate share adjustments). individual hospitals; and select
paying significantly more under an The contract we expect to award shortly hospitals for review and audit of
alternative DRG system, while will include tasks to study both the medical records and claims.
measuring the benefit for Medicare MedPAC recommendations and their Response: We agree that the law
beneficiaries. implications for these other payment provides the Secretary with authority to
We received the following comments adjustments. make a prospective adjustment to the
in response to the FY 2006 IPPS Comment: MedPAC responded to our national base payment rate to offset
proposed rule: concern that adopting an alternative
expected increases in payments
Comment: A number of commenters resulting from changes in hospital case-
payment system might improve
supported our proposal to consider the mix. We also appreciate MedPAC’s
payment accuracy but could also
APR–DRGs as an alternate DRG system suggestions for using reabstracted data
in response to the MedPAC substantially alter the distribution of
from Medicare’s quality data reporting
recommendation. Seventeen payments among hospitals. MedPAC
process and are interested in learning
commenters also agreed with the indicated that the potential
more from MedPAC about how the data
concerns we identified in the proposed redistribution of payments among
can be used for this purpose.
rule regarding the potential impact and hospitals provides strong evidence that
unpredictable effect a change of this the current payment system is distorted. 5. DRG Relative Weights
magnitude could have upon a hospital’s Therefore, MedPAC believes its In the FY 2006 proposed rule, in
reimbursement. One commenter payment recommendations should be response to MedPAC’s recommendation
recommended that CMS not implement adopted quickly. In addition, MedPAC that we improve payment accuracy by
any of the MedPAC recommendations indicated that our concern about the basing the DRG relative weights on the
administratively and that CMS impact of their suggested changes upon estimated cost of providing care rather
discourage Congress from requiring the current payment system should not than on charges, we noted that we do
such implementation in statute. This prevent us from taking steps toward not have access to any information that
commenter indicated that if CMS and improving the DRG system. would provide a direct measure of the
Congress are interested in pursuing Response: MedPAC believes that the costs of individual discharges. Claims
these ideas, they should first conduct a potential redistribution of payments filed by hospitals do provide
full-scale fiscal impact analysis. The resulting from improvements to the DRG information on the charges for
commenter stated that its own internal system should not deter us from making individual cases. At present, we use this
analysis, completed using data from the changes that are designed to increase information to set the relative weights
FY 2002 MedPAR file and the Hospital the accuracy of the DRG system. We for the DRGs. We obtain information on
Cost Reporting Information System agree. Given the potential for significant costs from the hospital cost reports, but
(HCRIS), of the APR–DRGs and hospital- redistribution in payments, our this information is at best at the
specific relative values showed that discussion of the MedPAC department level; it does not include
these changes alone would redistribute recommendations in the proposed rule information about the costs of
$1 billion in Medicare payments. was simply intended to indicate that the individual cases. Consequently, the
According to the commenter, hospitals changes MedPAC is recommending are most straightforward way to estimate
that would experience a significant and should be extensively costs of an individual case is to
disproportionate share of the losses studied before we make any broad, calculate a cost-to-charge ratio for some
from these changes would be rural fundamental changes to the current body of claims (for example, for a
hospitals, public hospitals, and major Medicare DRG system. As shown above, hospital’s radiology department), and
teaching hospitals. we are replacing 9 cardiovascular DRGs then apply this ratio to the charges for
Response: We appreciate the with 12 new DRGs that account for that department.
commenters’ support of our proposal. nearly 700,000 cases as an interim step However, this procedure is not
We agree that the process to determine to better recognize severity of illness in without disadvantages because
whether an APR–DRG system would be the DRG system until we can complete assignment of costs to departments is
an improvement over our current DRG a comprehensive analysis of MedPAC’s not uniform from hospital to hospital,
system will require a thorough and recommendations. given the variability of hospital
accounting systems, and because cost • Whether developing relative the overvaluing of low-cost cases) if we
information is not available until a year weights by estimating costs from were to shift to a hospital-specific
or more after claims information. In charges multiplied by cost-to-charge relative value method from the current
addition, the application of a single, ratios versus the use of charges method for determining DRG weights.
uniform cost-to-charge ratio across any improves payment accuracy; and We will need to consider whether the
body of claims may result in biased • How payments to hospitals would resultant level of compression is
estimates of individual costs if hospital be affected by MedPAC’s suggestion, appropriate.
charging behavior is not uniform. Thus, intended to simplify recalibration, to Comment: MedPAC responded that
it is alleged that hospitals mark up recalibrate weights based on costs every cost-based weights would better track
lower cost services less than higher cost few years, and to calculate an the true relative costliness of DRGs than
services, and to the extent they do so, adjustment to charge-based weights for charge-based weights. MedPAC
application of a uniform cost-to-charge the intervening periods. explained that hospital charge markups
ratio will result in overestimates of the In response to the recommendation are highly varied both among and
costs of higher cost services and vice that the Secretary should improve within hospitals. These differences will
versa. We use estimated costs, based on payment accuracy in the IPPS by basing result in varying amounts of distortion
hospital-specific, department-level cost- the weights on the national average of in charge-based relative weights. While
to-charge ratios, in the hospital hospitals’ relative values in each DRG, MedPAC agreed that there would be
outpatient prospective payment system. we note that presently we set the some level of distortion in cost-based
The accuracy of this procedure has relative weights using standardized weights because they are based in part
generated some concern, and without charges (adjusted to remove the effects on hospital charges, it indicated that the
further analysis, the extent to which the of differences in area wage costs and in substantial difference in markups across
accuracy of inpatient payments would IME and DSH payments). In contrast, departments are removed when cost-
be improved by adopting this method is MedPAC proposes that Medicare set the based weights are calculated while in
not obvious. DRG relative weights using charge-based weights they are included.
unstandardized, hospital-specific MedPAC noted that CMS had
In the proposed rule, we indicated
charges. Each hospital’s unstandardized correctly observed that cost data are not
that we would closely analyze the
charges would become the basis for as timely as charge data and, therefore,
impact of a change from the current
determining the relative weights for the cost-based weights may trail changes in
charge-based DRG weights to cost-based
DRGs for that hospital. These relative costliness compared to charge-based
DRG weights. We noted that such a weights would be adjusted by the weights. In response, MedPAC
change is complex and would require hospital’s case-mix index when commented that under its methodology,
further analysis. With this in mind, we combining each hospital’s relative CMS would recalibrate the weights
indicated that we would consider the weights to determine a national relative using cost estimates only periodically
following issues in performing this weight for all hospitals. This adjustment and would calculate the relationship
analysis: is designed to reduce the influence that between cost-based and charge-based
• The effect of using cost-to-charge a single hospital’s charge structure weights and adjust the weights to
ratio data, which are frequently older could have on determining the relative account for the relationship between
than the claims data we use to set the weight of a DRG when the hospital is cost-based and charge-based weights in
charge-based weights, and the impact on responsible for a high proportion of the intervening years, which would mitigate
these data of any changes in hospitals’ total, nationwide number of discharges the timeliness problem of using cost-
charging behavior that resulted from the in a particular DRG. based weights.
recent modifications to the outlier We will analyze the possibility of With respect to hospital-specific
payment methodology (68 FR 34494; moving to hospital specific relative relative weights, MedPAC commented
June 9, 2003); values while conducting the analysis on our point that data from a 1993
• Whether using this method has outlined above in response to the RAND study showed that this method
different effects on DRGs that have recommendations regarding adoption of could undervalue high-cost DRGs and
experienced substantial technological an improved severity adjustment and overvalue low-cost DRGs, a
change compared to DRGs with more the use of charges adjusted to estimated phenomenon known as ‘‘compression.’’
stable procedures for care; cost through the application of cost-to- MedPAC indicated that the conclusions
• The effect of using a routine cost-to- charge ratios to set the relative weights. from the RAND study may no longer
charge ratio and department-level We note that we use this method at apply today. It indicated that the
ancillary cost-to-charge data as present to set weights for the LTCH PPS. compression may not have resulted
compared to either an overall hospital We use this method for LTCHs because from the methodology itself but instead
cost-to-charge ratio or a routine cost-to- of the small volume of providers and the from the pattern of cross-subsidies in
charge ratio and an overall ancillary possibility that only a few providers charge markups by hospitals that
cost-to-charge ratio, particularly in provide care for certain DRGs. performed the majority of cardiac
considering earlier studies performed Therefore, the charges of one or a few surgeries. MedPAC indicated that
for the Prospective Payment Assessment hospitals could materially affect the charge markups were much smaller 15
Commission, the predecessor to relative weights for these DRGs. In this years ago than they are today and
MedPAC, indicating that an overall event, looking at relative values within cardiac surgeries are currently
ancillary cost-to-charge ratio led to more hospitals first can smooth out the performed by more hospitals than they
accurate estimates of case level costs; 12 hospital-specific effects on DRG were at the time of the RAND study.
weights. A 1993 Rand Report on Thus, MedPAC believed the hospital-
12 Cost Accounting for Health Care Organizations,
hospital-specific relative values noted specific relative value method is a more
Technical Report Series, I–93–01, ProPAC, March the possibility of DRG compression (or effective way of removing the effects on
1993, page 6. Using a cost report package, the the weights of the differences in the
contractor simulated single and multiple ancillary the undervaluing of high-cost cases and
cost-to-charge ratios and found that inpatient
level of costs or charges among
ancillary costs were 2.5 percent understated relative single cost-to-charge ratio, and 4.9 percent hospitals. MedPAC also stated that
to what hospitals thought their costs were with the understated with the multiple cost-to-charge ratios. CMS’ method of standardizing hospital
charges could also be causing Response: We appreciate these standardized charges that are included
distortions in the relative weights, in comments and will take them into in the relative weight calculation. We
particular because MedPAC believes consideration as we conduct further believe this latter factor can be
that the IME and DSH adjustments are analysis of MedPAC’s addressed without a change in law. As
poorly related to the cost impact on recommendations. we indicated in the proposed rule, the
hospitals of providing medical Comment: MedPAC clarified its law provides broad discretion to the
education and treating low-income earlier recommendation in its comments Secretary to consider all factors that
patients. on the proposed rule. MedPAC change the relative use of hospital
Response: We will consider these explained that, rather than finance resources in calculating the DRG
comments in our analysis of cost-based outlier payments through a single 5.1 relative weights. Thus, even in the
weights and hospital-specific DRGs. As percent adjustment to the standardized absence of a change in law, we expect
we have indicated above, these issues amount that is required under current to consider changes that would reduce
are among those that we have engaged law, it meant to recommend that outlier or eliminate the effect of high-cost
a contractor to assist us in analyzing. payments in each DRG be financed out outliers on the DRG relative weights for
of aggregate payments in the DRG. FY 2007.
6. High-Cost Outliers MedPAC believes that the current policy Finally, we believe that the
Recommendation 2 in the Report to makes DRGs with a high prevalence of recommendations made by MedPAC, or
Congress on Physician-Owned Specialty outliers more profitable for two reasons: some variants of them, have significant
Hospitals: The Congress should amend (1) These DRGs receive more in outlier promise to improve the accuracy of rates
the law to give the Secretary authority payments than the 5.1 percent that is in the IPPS. We agree with MedPAC that
to adjust the DRG relative weights to removed from the national standardized these possible refinements to our
account for differences in the amount; and (2) the relative weights for payment methodology should be
prevalence of high-cost outlier cases. these DRGs are overvalued because their explored, even in the absence of
In the FY 2006 IPPS proposed rule, values are influenced by the high concerns about the proliferation of
we noted that, while MedPAC’s standardized charges for outlier cases specialty hospitals. However, until we
language suggests that the law would included in the relative weight have completed further analysis of these
need to be amended for us to adopt this calculation. MedPAC’s recommendation options and their effects, we cannot
suggestion, we believe the statute may would require a change in law because predict the extent to which they will
give the Secretary broad discretion to the current law requires that the provide payment equity between
consider all factors that change the Secretary reduce the standardized specialty and general hospitals. In fact,
amount by 5 to 6 percent for cases paid we must caution that any system that
relative use of hospital resources in
as cost outliers. MedPAC further noted groups cases and provides a standard
calculating the DRG relative weights.
that, under its recommendation, outlier payment for all cases in the group (that
We believe that MedPAC’s
payments in each DRG would be is, the IPPS among other Medicare
recommendation springs from a concern
financed out of the aggregate payments payment systems) will always present
that including high-charge outlier cases
in the DRG which would reduce the some opportunities for providers to
in the relative-weight calculation results
distortion in the relative weights that specialize in cases where they believe
in overvaluing DRGs that have a high
comes from including the outlier cases margins may be better. Improving
prevalence of outlier cases. However,
in the calculation of the weight and payment accuracy should reduce these
we believe that excluding outlier cases
would correct the differences in opportunities, and it may do so to such
completely in calculating the relative profitability that stem from using a an extent that Medicare payments no
weights would be inappropriate. Doing uniform outlier offset for all cases. longer provide a significant impetus for
so would undervalue the relative weight MedPAC added that its the further development of specialty
for a DRG with a high percentage of recommendation would help make hospitals.
outliers by not including that portion of relative profitability more uniform Recommendation 3 of the Report to
hospital charges that is above the across all DRGs. Congress on Physician-Owned Specialty
median, but below the outlier threshold. Response: We appreciate MedPAC Hospitals: The Congress and the
We believe it would be preferable to clarifying and providing more detail on Secretary should implement the case-
adjust the charges used for calculating its outlier recommendation. Now that mix measurement and outlier policies
the relative weights to exclude the we better understand the over a transitional period.
portion of charges above the outlier recommendation, it is clear that the part In the FY 2006 IPPS proposed rule,
threshold, but to include the charges up of MedPAC’s proposal that would we stated that, before proposing any
to the outlier threshold. In the proposed replace the 5.1 percent offset to the fundamental changes to the DRGs
rule, we indicated that we expect to standardized amount would require a system, we would need to model the
further analyze these ideas as we change in the law. While CMS does impact of any specific proposal and our
consider the other changes have broad authority to determine how authority under the statute to determine
recommended by MedPAC and solicited the DRG relative weights are calculated, whether any changes should be
public comments on this issue. we are required by law to reduce the implemented immediately or over a
We received the following comments standardized amount by not less than 5 period of time. We did note that, in the
in response to the FY 2006 IPPS percent or more than 6 percent to event we replace the existing DRG
proposed rule. account for the additional payments system with a new DRG system that
Comment: One commenter disagreed made to outlier cases. However, as fully captures differences in severity,
with MedPAC’s proposal to exclude explained above, MedPAC found DRGs there would likely be unique
outliers from the computation of the with a high prevalence of outliers are complexities in creating a transition
DRG weights because this would overvalued both because they receive from one DRG system to another. Our
exacerbate the problem of more in outlier payments than is payment would be a blend of two
overestimating the outlier threshold, removed from the national standardized different relative weights that would
resulting in underpayments of outliers amount and the relative weights of these have to be determined using two
in a given fiscal year. DRGs are influenced by the high different systems of DRGs. The systems
and legal implications of such a Response: We are currently engaging Management and Budget (OMB) for
transition or any other major change to a contractor experienced in Medicare review and approval. In order to
the DRGs could be significant. payment issues to assist in CMS’s evaluate fairly whether an information
We received the following comments comprehensive review of the MedPAC collection should be approved by OMB,
in response to the FY 2006 IPPS recommendations. We also have made section 3506(c)(2)(A) of the Paperwork
proposed rule. significant progress in our review of the Reduction Act of 1995 requires that we
Comment: One commenter supported CC list. As a result, we are optimistic solicit comment on the following issues:
refinements to the DRGs that better that these analyses will be completed • The need for the information
capture cost variations among Medicare during the next year. collection and its usefulness in carrying
patients but expressed concern about out the proper functions of our agency.
B. Other MedPAC Recommendations • The accuracy of our estimate of the
the redistributive impact such a change
would have on Medicare reimbursement MedPAC also made the following information collection burden.
to hospitals. The commenter recommendations that we addressed in • The quality, utility, and clarity of
recommended that CMS evaluate DRG the Secretary’s Report to Congress on the information to be collected.
Specialty Hospitals. This report is • Recommendations to minimize the
case-mix severity outside of budget
available on our Web site at: http:// information collection burden on the
neutrality. The commenter also
www.cms.hhs.gov/media/press/files/ affected public, including automated
recommended that CMS make these
052005/RTC- collection techniques.
changes over a transition period of at
StudyofPhysOwnedSpecHosp.pdf. In the FY 2006 IPPS proposed rule (70
least 6 years. Many other commenters
Recommendation 4: The Congress FR 23459), we solicited public
suggested that CMS implement any
should extend the current [Pub. L. 108– comments on each of these issues for
changes over a transition period in order
173] moratorium on physician-owned the information collection requirements
to mitigate the financial impact on
single specialty hospitals until January discussed below. A summary of any
hospitals. Other commenters also urged
1, 2007. public comments we received and our
CMS to proceed slowly and deliberately
Recommendation 5: The Congress responses follow each requirement.
with extensive research as a foundation The following information collection
for any proposed changes. MedPAC should grant the Secretary the authority
to allow gainsharing arrangements requirements included in this rule and
noted it would continue to work with their associated burdens are subject to
CMS to develop ways to mitigate the between physicians and hospitals and to
regulate those arrangements to protect the PRA.
complexity and burden of a transition
methodology. the quality of care and minimize Section 412.64 Federal Rates for
Response: Section 1886(d)(4) of the financial incentives that could affect Inpatient Operating Costs for Federal
Act gives the Secretary broad discretion physician referrals. Fiscal Year 2005 and Subsequent Fiscal
to develop DRG classifications and We received no comments in response Years
weighting factors. However, it also to our discussion of these Section 412.64(d)(2) requires
requires that adjustments to the recommendations in the FY 2006 hospitals, in order to qualify for the full
classification or weighting factors proposed rule. We note, however, that annual market basket update, to submit
cannot change aggregate payments in section V.L. of the preamble to this quality data on a quarterly basis to CMS,
under the IPPS. Thus, while the final rule, we address comments relating as specified by CMS. In this document,
Secretary has authority to adopt DRGs to the definition of a hospital in we are setting out the specific
that better recognize severity of illness connection with specialty hospitals. requirements related to the data that
under current law, the law does not X. Other Required Information must be submitted. The burden
allow us to adopt these changes outside associated with this section is the time
of budget neutrality. As noted above, A. Requests for Data From the Public and effort associated with collecting,
before proposing any changes to the In order to respond promptly to copying and submitting these data. We
DRGs, we would need to model the public requests for data related to the estimate that there will be
impact of any specific proposal and prospective payment system, we have approximately 4,000 respondents per
assess our authority under the statute to established a process under which year. Of this number, approximately
determine whether any changes should commenters can gain access to raw data 3,600 hospitals are JCAHO accredited
be implemented immediately or over a on an expedited basis. Generally, the and are currently collecting measures
period of time. We appreciate data are available in computer tape or and submitting data to the JCAHO on a
MedPAC’s efforts in working with CMS cartridge format; however, some files are quarterly basis. Of the JCAHO
and note that we will take all of the available on diskette as well as on the accredited hospitals, approximately
comments into consideration as we Internet at http://www.cms.hhs.gov/ 3,300 are collecting the same measures
conduct further analysis of MedPAC’s providers/hipps. In the FY 2006 IPPS CMS will be collecting for public
recommendations. proposed rule, we published a list of reporting. Therefore, there will be no
Comment: MedPAC commented that data files that are available for purchase additional burden for these hospitals.
it was pleased that CMS shares its views from CMS or that may be downloaded Only approximately 300 of the JCAHO
on improving payment accuracy within from the internet without charge (70 FR accredited hospitals will need to collect
the IPPS. However, MedPAC was 23456 through 23459). an additional topic in addition to the
concerned that CMS may not be doing data already collected for maintaining
enough to address the distortions within B. Collection of Information
JCAHO accreditation. In addition, there
the IPPS pointed out by MedPAC. The Requirements
are approximately 400 hospitals that do
commission explained that the list of Under the Paperwork Reduction Act not participate in the JCAHO
analyses CMS included in response to of 1995 (PRA), we are required to accreditation process. These hospitals
MedPAC’s recommendation is long and provide 30-day notice in the Federal will have the additional burden of
broad, raising the risk that some Register and solicit public comment collecting data on all three topics.
analysis may not be complete by FY before a collection of information For JCAHO accredited hospitals that
2007. requirement is submitted to the Office of are not already collecting all of the
required measures, we estimate it will and, if it is a hospital, to also attest that a rural area; and (vii) the hospital is
take 25 hours per month per topic for it will fulfill the obligations of hospital located in the same State as the main
collection. We expect the burden for all outpatient departments and hospital- provider or, when consistent with the
of these hospitals to total 102,000 hours based entities described in § 413.65(g). If laws of both States, in adjacent States.
per year, including time allotted for the facility is operated under a Section 413.65(g)(7) provides that
overhead. For non-JCAHO accredited management contract, the potential when a Medicare beneficiary is treated
hospitals, we estimate the burden to be main provider must also attest that the in a hospital outpatient department that
136,000 hours per year. This estimate facility meets the requirements of is not located on the main provider’s
also includes overhead. The total § 413.65(h). campus, the treatment is not required to
number of burden hours for all hospitals We proposed to clarify the regulations be provided by the antidumping rules of
combined is 238,000. The number of under § 413.65(e)(3) which require that § 489.24, and the beneficiary will incur
responders will vary according to the a facility or organization for which a coinsurance liability for an outpatient
level of voluntary participation. One provider-based status is sought that is visit to the hospital, as well as for the
hundred percent of the data may be not located on the campus of a potential physician service, the hospital must
collected electronically. main provider must: (i) Be located provide written notice to the
In the preamble to the FY 2006 IPPS within a 35-mile radius of the campus beneficiary, before delivery of services
proposed rule, we proposed additional of the hospital or CAH that is the of the amount of the beneficiary’s
validation criteria to ensure that the potential main provider; or (ii) be potential financial liability. If the exact
quality data being sent to CMS are owned and operated by a hospital or
type and extent of care is not known,
accurate (70 FR 23424 through 23426). the hospital must provide written notice
CAH that has a disproportionate share
These validation criteria are finalized in to the beneficiary that explains that the
adjustment (as determined under
this final rule. Our validation process beneficiary will incur a coinsurance
§ 412.106) greater than 11.75 percent
requires participating hospitals to liability to the hospital that he or she
and is described in § 412.106(c)(2)
submit five charts per quarter. The would not incur if the facility were not
implementing section 1886(e)(5)(F)(i)(II)
burden associated with this requirement provider-based, an estimate based on
of the Act and is (A) owned or operated
is the time and effort associated with typical or average charges for visits to
by a unit of State or local government,
collecting, copying, and submitting the facility, and a statement that the
(B) a public or nonprofit corporation
these charts. It will take approximately patient’s actual liability will depend
formally granted governmental powers
2 hours per hospital to submit the 5 upon the actual services furnished by
charts per quarter. There will be a total by a unit of State or local government, the hospital.
of approximately 19,000 charts (3,800 or (C) a private hospital having a While the information collection
hospitals × 5 charts per hospital) contract with a State or local requirements contained in this section
submitted by the hospitals to CMS per government that includes the operation are subject to the PRA, the burden
quarter for a total burden of 7,600 hours of clinics located off the main campus associated with this requirement is
per quarter and a total annual burden of of the hospital to assure access in a currently approved under OMB
30,400 hours. well-defined service area to health care approval no. 0938–0798.
A summary of the public comments services for low-income individuals
who are not entitled to benefits under Section 485.610 Condition of
that we received and our responses on
Medicare (or medical assistance under a Participation: Status and Location
the quality data submission requirement
are included under section V.B. of this Medicaid State plan); or (iii) In the FY 2006 IPPS proposed rule,
preamble. demonstrate a high level of integration we proposed under proposed
with the main provider by showing that § 485.610(d)(2)(ii) that, in order to be
Section 413.65 Requirements for a it meets all of the other provider-based considered a relocation, a CAH would
Determination That a Facility or an criteria and demonstrate that it serves be required to provide documentation
Organization Has Provider-Based Status the same patient population as the main demonstrating that its plans to rebuild
We proposed under § 413.65(b)(3)(i) provider, by submitting certain records in a relocated area were undertaken
to require potential main providers showing the information contained in prior to December 8, 2003. This
seeking a determination of provider- § 413.65(e)(3)(iii)(A) or (e)(3)(iii)(B); or requirement would have imposed an
based status for a facility that is located (iv) if the facility or organization is information collection requirement if it
on the campus of the potential main unable to meet the criteria in were finalized. However, after
provider to submit an attestation stating § 413.65(e)(3)(iii)(A) or consideration of the public comments
that the facility meets the criteria in § 413.65(e)(3)(iii)(B) because it was not received, we have deleted this
§ 413.65(d) and, if it is a hospital, to also in operation during all of the 12-month provision, and hence the information
attest that it will fulfill the obligations period described in § 413.65(e)(3)(iii), be collection requirement, from the final
of hospital outpatient departments and located in a zip code area included regulation in this final rule.
hospital-based entities described in among those that, during all of the 12- We have submitted a copy of this rule
§ 413.65(g). We also proposed to amend month period described in to OMB for its review of the information
this paragraph to require that in the case § 413.65(e)(3)(iii), accounted for at least collection requirements described
of a facility that is operated as a joint 75 percent of the patients served by the above. The information collection and
venture, the potential main provider main provider; or (v) the facility or recording requirement of § 412.64(d)(2)
attest that it will comply with the organization meets the requirements are not effective until they are approved
requirements of § 413.65(f). applicable to neonatal intensive care by OMB. If you comment on these
We proposed under § 413.65(b)(3)(ii) units in § 413(e)(3)(v); or (vi) in the case information collection and
to provide that, if a facility is not of an RHC (A) the hospital is an RHC recordkeeping requirements, please mail
located on the campus of the potential that is otherwise qualified as a provider- copies directly to the following:
main provider, the potential main based entity of a hospital that has fewer Centers for Medicare & Medicaid
provider must submit an attestation than 50 beds, and (B) the hospital with Services, Office of Strategic
stating that the facility meets the criteria which the facility or organization has a Operations and Regulatory Affairs,
in paragraphs (d) and (e) of § 413.65 provider-based relationship is located in Regulations Development and
Issuances Group, Attn: Jim Wickliffe, § 405.2468 [Amended] through (d)(1)(iv) of this section for each
CMS–1500–F Room C5–13–28, 7500 ■ 2. In § 405.2468(f)(1), the reference subsequent fiscal year.
Security Boulevard, Baltimore, MD ‘‘§ 413.86(b)’’ is removed and the * * * * *
21244–1850; and reference ‘‘§ 413.75(b)’’ is added in its (3) For fiscal years beginning with FY
Office of Information and Regulatory place. 2006, for purposes of paragraph (c) of
Affairs, Office of Management and this section—
Budget, Room 10235, New Executive PART 412—PROSPECTIVE PAYMENT (i) The qualifying DRGs must meet the
Office Building, Washington, DC SYSTEMS FOR INPATIENT HOSPITAL following criteria using data from the
20503, Attn: Christopher Martin, CMS SERVICES March 2005 update of the FY 2004
Desk Officer, CMS–1500–F, MedPAR file and Version 23.0 of the
Christopher_Martin@omb.eop.gov. ■ B. Part 412 is amended as follows: DRG Definitions Manual (FY 2006):
Fax (202) 395–6974. ■ 1. The authority citation for Part 412 (A) The DRG has at least 2,050 total
continues to read as follows: postacute care transfer cases;
List of Subjects (B) At least 5.5 percent of the cases in
Authority: Secs. 1102 and 1871 of the
42 CFR Part 405 Social Security Act (42 U.S.C. 1302 and the DRG are discharged to postacute
1395hh). care prior to the geometric mean length
Administrative practice and of stay for the DRG;
procedure, Health facilities, Health § 412.1 [Amended] (C) The DRG must have a geometric
professions, Kidney diseases, Medicare, mean length of stay greater than 3 days;
■ 2. In § 412.1(a)(1), the reference
Reporting and recordkeeping (D) The DRG is paired with a DRG
‘‘§ 413.86’’ is removed and the reference
requirements, Rural area, X-rays. based on the presence or absence of a
‘‘§§ 413.75 through 413.83’’ is added in
42 CFR Part 412 its place. comorbidity or complication or major
cardiovascular condition that, it meets
Administrative practice and § 412.2 [Amended] the criteria specified in paragraphs
procedure, Health facilities, Medicare,
■ 3. In § 412.2— (d)(3)(i)(A) and (d)(3)(ii)(B) of this
Puerto Rico, Reporting and
■ a. In paragraph (f)(7), remove the section.
recordkeeping requirements. (ii) If a DRG did not exist in Version
reference ‘‘§ 413.86’’ and add in its place
42 CFR Part 413 the reference ‘‘§§ 413.75 through 23.0 of the DRG Definitions Manual or
413.83’’. a DRG included in Version 23.0 of the
Health facilities, Kidney diseases,
■ b. At the end of paragraph (f)(8), add DRG Definitions Manual is revised, the
Medicare, Puerto Rico, Reporting and
the following sentence: ‘‘For discharges DRG will be a qualifying DRG if it meets
recordkeeping requirements.
occurring on or after October 1, 2005, the the following criteria based on the
42 CFR Part 415 additional payment is made based on the version of the DRG Definitions Manual
Health facilities, Health professions, average sales price methodology in use when the new or revised DRG
Medicare, and Reporting and specified in Subpart K, Part 414 of this first becomes effective, using the most
recordkeeping requirements. subchapter and the furnishing fee recent complete year of MedPAR data:
specified in § 410.63 of this subchapter.’’ (A) The total number of discharges to
42 CFR Part 419 ■ 4. Section 412.4 is amended by— postacute care in the DRG must equal or
Hospitals, Medicare, Reporting and ■ a. Revising the introductory text of exceed the 55th percentile for all DRGs;
recordkeeping requirements. paragraph (d)(1). (B) The proportion of short-stay
■ b. Revising paragraph (d)(1)(v).
discharges to postacute care to total
42 CFR Part 422 discharges in the DRG exceeds the 55th
■ c. Adding a new paragraph (d)(3).
Health maintenance organizations ■ d. Revising the introductory text of
percentile for all DRGs; and
(HMO), Medicare+Choice, Provider paragraph (f)(2). (C) The DRG is paired with a DRG
sponsored organizations (PSO). based on the presence or absence of a
■ e. Adding a new paragraph (f)(5).
comorbidity or a complication or major
42 CFR Part 485 The revision and additions read as
cardiovascular condition that meets the
follows:
Grant programs—health, Health criteria specified under paragraph
facilities, Medicaid, Medicare, § 412.4 Discharges and transfers. (d)(3)(ii)(A) and (d)(3)(ii)(B) of this
Reporting and recordkeeping * * * * * section.
requirements. (d) Qualifying DRGs. (1) For a fiscal * * * * *
■ For the reasons stated in the preamble year prior to FY 2006, for purposes of (f) Payment for transfers.
of this final rule, the Centers for paragraph (c) of this section, and subject * * * * *
Medicare & Medicaid Services is to the provisions of paragraph (d)(2) of (2) Special rule for DRGs 209, 210,
amending 42 CFR chapter IV as follows: this section, the qualifying DRGs must and 211 for fiscal years prior to FY
meet the following criteria for both of 2006. For fiscal years prior to FY 2006,
PART 405—FEDERAL HEALTH the 2 most recent years for which data a hospital that transfers an inpatient
INSURANCE FOR THE AGED AND are available: under the circumstances described in
DISABLED * * * * * paragraph (c) of this section and the
■ A. Part 405 is amended as follows: (v) To initially qualify, the DRG must transfer is assigned to DRGs 209, 210, or
■ 1. The authority citation for Part 405 meet the criteria specified in paragraphs 211 is paid as follows:
continues to read as follows: (d)(1)(i) through (d)(1)(iv) of this section * * * * *
and must have a decline in the (5) Special rule for DRGs meeting
Authority: Secs. 1102, 1861, 1862(a), 1871,
1874, 1881, and 1886(k) of the Social
geometric mean length of stay for the specific criteria. For discharges
Security Act (42 U.S.C. 1302, 1395x, DRG during the most recent 5 years of occurring on or after October 1, 2005, a
1395y(a), 1395hh, 1395kk, 1395rr, and at least 7 percent. Once a DRG initially hospital that transfers an inpatient
1395ww(k)), and sec. 353 of the Public qualifies, the DRG is subject to the under the circumstances described in
Health Service Act (42 U.S.C. 263a). criteria specified in paragraphs (d)(1)(i) paragraph (c) of this section is paid
using the provisions of paragraph (A) The fiscal intermediary or CMS (or under § 412.63 for periods prior to
(f)(2)(i) and (f)(2)(ii) of this section if the made an error in tabulating data used FY 2005) or the hospital-specific rates
transfer case is assigned to one of the for the wage index calculation; for either FY 1982 under § 412.73 or FY
DRGs meeting the following criteria: (B) The hospital knew about the error 1987 under § 412.75, this 1996 rate will
(i) The DRG meets the criteria in its wage data and requested the fiscal be used in the payment formula set forth
specified in paragraph (d)(3)(i) or intermediary and CMS to correct the in § 412.92(d)(1).
(d)(3)(iii) of this section; error both within the established * * * * *
(ii) The average charges of the 1-day schedule for requesting corrections to (j) Maintaining budget neutrality.
discharge cases in the DRG must be at the wage data (which is at least before CMS makes an adjustment to the
least 50 percent of the average charges the beginning of the fiscal year for the hospital-specific rate to ensure that
for all cases in the DRG; and applicable update to the hospital changes to the DRG classifications and
(iii) The geometric mean length of inpatient prospective payment system) recalibrations of the DRG relative
stay for the DRG is greater than 4 days; and using the established process; and weights are made in a manner so that
and (C) CMS agreed before October 1 that aggregate payments to section 1886(d)
(iv) If a DRG is a paired with a DRG the fiscal intermediary or CMS made an hospitals are not affected.
based on the presence or absence of a error in tabulating the hospital’s wage ■ 9. Section 412.90 is amended by
comorbidity or complication or a major data and the wage index should be revising paragraph (e)(1) to read as
cardiovascular complication that meets corrected. follows:
the criteria specified in paragraph * * * * *
(f)(5)(i) through (f)(5)(iii) of this section, § 412.90 General rules.
■ 6. Section 412.73 is amended by
that DRG will also be paid under the * * * * *
adding a new paragraph (f) to read as (e) Hospitals located in areas that are
provisions of paragraph (f)(2)(i) and
follows: reclassified from urban to rural. (1) CMS
(f)(2)(ii) of this section.
■ 5. Section 412.64 is amended by— § 412.73 Determination of the hospital- adjusts the rural Federal payment
■ a. Adding a new paragraph (b)(5). specific rate based on a Federal fiscal year amounts for inpatient operating costs for
■ b. Revising paragraph (i)(3)(iv). 1982 base period. hospitals located in geographic areas
■ c. Revising paragraph (k)(2). * * * * * that are reclassified from urban to rural
The addition and revision reads as (f) Maintaining budget neutrality. as defined in subpart D of this part. This
follows: CMS makes an adjustment to the adjustment is set forth in § 412.102.
hospital-specific rate to ensure that * * * * *
§ 412.64 Federal rates for inpatient changes to the DRG classifications and ■ 10. Section 412.92 is amended by—
operating costs for Federal fiscal year 2005
recalibrations of the DRG relative ■ a. In paragraph (a) introductory text,
and subsequent fiscal years.
weights are made in a manner so that removing the reference ‘‘§ 412.83(b)’’
* * * * * aggregate payments to section 1886(d) and adding in its place the reference
(b) Geographic classifications. * * * hospitals are not affected. ‘‘§ 412.64’’.
(5) For hospitals that consist of two or ■ b Revising paragraph (d)(1)(i).
more separately located inpatient ■ c. Revising paragraph (d)(3).
hospital facilities, the national adjusted adding a new paragraph (i) to read as
The revisions and addition read as
prospective payment rate is based on follows:
follows:
the geographic location of the hospital § 412.75 Determination of the hospital-
facility at which the discharge occurred. specific rate for inpatient operating costs § 412.92 Special treatment: Sole
based on a Federal fiscal year 1987 base community hospitals.
* * * * *
(i) Adjusting the wage index to period. * * * * *
* * * * * (d) Determining prospective payment
account for commuting patterns of
(i) Maintaining budget neutrality. rates for inpatient operating costs for
hospital employees. * * *
CMS makes an adjustment to the sole community hospitals. (1) * * *
(3) Process for determining the (i) The Federal payment rate
adjustment. hospital-specific rate to ensure that
applicable to the hospitals as
* * * * * changes to the DRG classifications and
determined under subpart D of this part.
(iv) A hospital in a qualifying county recalibrations of the DRG relative
weights are made in a manner so that * * * * *
that receives a wage index adjustment (3) Adjustment to payments. A sole
under this paragraph (i) is not eligible aggregate payments to section 1886(d)
hospitals are not affected. community hospital may receive an
for reclassification under subpart L of adjustment to its payments to take into
this part or section 1886(d)(8) of the Act. ■ 8. Section 412.77 is amended by—
account a significant decrease in the
* * * * * ■ a. Revising paragraph (a)(1).
number of discharges, as described in
(k) Midyear corrections to the wage ■ b. Adding a new paragraph (j).
paragraph (e) of this section.
index. The revision and addition read as
follows: * * * * *
* * * * * ■ 11. Section 412.96 is amended by—
(2)(i) Except as provided in paragraph § 412.77 Determination of the hospital- ■ a. Revising paragraph (b)(1)
(k)(2)(ii) of this section, a midyear specific rate for inpatient operating costs introductory text.
correction to the wage index is effective for sole community hospitals based on a ■ b. Revising paragraph (c) introductory
prospectively from the date the change Federal fiscal year 1996 base period. text.
is made to the wage index. (a) Applicability. (1) This section ■ c. In paragraph (c)(1) introductory text,
(ii) Effective October 1, 2005, a change applies to a hospital that has been removing the reference ‘‘paragraph (g)’’
to the wage index may be made designated as a sole community and adding in its place the reference
retroactively to the beginning of the hospital, as described in § 412.92. If the ‘‘paragraph (h)’’.
Federal fiscal year, if, for the fiscal year 1996 hospital-specific rate exceeds the ■ d. In paragraph (c)(2)(i), removing the
in question, CMS determines all of the rate that would otherwise apply, that is, reference ‘‘paragraph (h)’’ and adding in
following— either the Federal rate under § 412.64 its place the reference ‘‘paragraph (i)’’.
■ e. Revising paragraph (g)(1). the U.S. Department of Health and under paragraph (f)(1)(xiii) of this
■ f. In the introductory text of paragraph Human Services, Health Resources and section.
(h), removing the phrase ‘‘paragraphs Services Administration, Office of Rural (xv) Effective for discharges occurring
(g)(1) through (g)(4)’’ and adding in its Health Policy, 5600 Fishers Lane, Room on or after October 1, 2005, an urban
place the phrase ‘‘paragraphs (h)(1) 9A–55, Rockville, MD 20857. hospital that reclassifies to a rural area
through (h)(4)’’. * * * * * under § 412.103 for fewer than 10
■ g. In paragraph (h)(2), removing the continuous years and then subsequently
■ 13. Section 412.105 is amended by—
reference ‘‘(g)(1)’’ and adding in its place elects to revert back to urban
■ a. Adding a new paragraph
the reference ‘‘(h)(1)’’. classification will not be allowed to
■ h. Removing paragraph (h)(4).
(f)(1)(iv)(D).
■ b. Adding a new paragraph (f)(1)(xiii).
retain the adjustment to its IME FTE
■ i. In paragraph (i)(2), removing the resident cap that it received as a result
reference ‘‘(h)(1)’’ and adding in its place ■ c. Adding a new paragraph (f)(1)(xiv).
■ d. Adding a new paragraph (f)(1)(xv).
of being reclassified as rural.
the reference ‘‘(i)(1)’’.
The additions read as follows: * * * * *
■ j. Removing paragraph (i)(4).
The revisions read as follows: ■ 14. Section 412.108 is amended by
§ 412.105 Special treatment: Hospitals that revising paragraph (c)(1) to read as
§ 412.96 Special treatment: Referral incur indirect costs for graduate medical
education programs.
follows:
centers.
* * * * * * * * * * § 412.108 Special treatment: Medicare-
(b) Criteria for cost reporting periods (f) Determining the total number of dependent, small rural hospitals.
beginning on or after October 1, 1983. full-time equivalent residents for cost * * * * *
* * * reporting periods beginning on or after (c) Payment methodology. * * *
(1) The hospital is located in a rural July 1, 1991. (1) * * * (1) The Federal payment rate
area (as defined in subpart D of this (iv) * * * applicable to the hospital, as
part) and has the following number of (D) A rural hospital redesignated as determined under subpart D of this part,
beds, as determined under the urban after September 30, 2004, as a subject to the regional floor defined in
provisions of § 412.105(b) available for result of the most recent census data § 412.70(c)(6).
use: and implementation of the new labor * * * * *
* * * * * market area definitions announced by ■ 15. Section 412.109 is amended by
(c) Alternative criteria. For cost OMB on June 6, 2003, may retain the revising paragraph (b)(2) to read as
reporting periods beginning on or after increases to its full-time equivalent follows:
October 1, 1985, a hospital that does not resident cap that it received under
meet the criteria of paragraph (b) of this paragraphs (f)(1)(iv)(A) and (f)(1)(vii) of § 412.109 Special treatment: Essential
section is classified as a referral center this section while it was located in a access community hospitals (EACHs).
if it is located in a rural area (as defined rural area. * * * * *
in subpart D of this part) and meets the * * * * * (b) Location in a rural area. * * *
criteria specified in paragraphs (c)(1) (xiii) For a hospital that was paid (2) Is not deemed to be located in an
and (c)(2) of this section and at least one under Part 413 of this chapter as a urban area under subpart D of this part.
of the three criteria specified in hospital excluded from the hospital * * * * *
paragraphs (c)(3), (c)(4), and (c)(5) of inpatient prospective payment system
this section. and that subsequently becomes subject § 412.113 [Amended]
* * * * * to the hospital inpatient prospective ■ 16. In § 412.113—
(g) Hospital cancellation of referral payment system, the limit on the total ■ a. In paragraph (b)(2), the reference
center status. (1) A hospital may at any number of FTE residents for payment ‘‘§ 413.86 of this chapter.’’ is removed
time request cancellation of its status as purposes is determined based on the and the reference ‘‘§§ 413.75 through
a referral center and be paid prospective data from the hospital’s most recent cost 413.83 of this subchapter.’’ is added in
payments per discharge based on the reporting period ending on or before its place.
applicable rural rate, as determined in December 31, 1996. ■ b. In paragraph (b)(3), the reference
accordance with subpart D of this part. (xiv) In the case of a merger of a ‘‘§ 413.86(c) of this chapter,’’ is removed
hospital that is excluded from the and the reference ‘‘§ 413.75(c) of this
* * * * *
hospital inpatient prospective payment subchapter,’’ is added in its place.
system and an acute care hospital
revising paragraph (a)(1) to read as § 412.115 [Amended]
subject to the hospital inpatient
follows: ■ 17. In § 412.115—
prospective payment system, if the
§ 412.103 Special treatment: Hospitals surviving hospital is a hospital subject ■ a. In paragraph (a), the reference
located in urban areas and that apply for to the hospital inpatient prospective ‘‘§ 413.80’’ is removed and the reference
reclassification as rural. payment system and no hospital unit ‘‘§ 413.89’’ is added in its place.
(a) * * * that is excluded from the hospital ■ b. At the end of paragraph (b), add the
(1) The hospital is located in a rural inpatient prospective payment system is following sentence: ‘‘For discharges
census tract of a Metropolitan Statistical created as a result of the merger, the occurring on or after October 1, 2005, the
Area (MSA) as determined under the surviving hospital’s number of FTE additional payment is made based on the
most recent version of the Goldsmith residents for payment purposes is equal average sales price methodology
Modification, the Rural-Urban to the sum of the FTE resident count of specified in subpart K, part 414 of this
Commuting Area codes, as determined the hospital that is subject to the chapter and the furnishing fee specified
by the Office of Rural Health Policy hospital inpatient prospective payment in § 410.63 of this subchapter.’’
(ORHP) of the Health Resources and system as determined under paragraph ■ 18. Section 412.230 is amended by—
Services Administration, which is (f)(1)(ii)(B) of this section and the limit ■ a. Revising paragraph (a)(5)(iv)
available via the ORHP Web site at: on the total number of FTE residents for ■ b. Redesignating paragraph (d)(2)(iii)
http://www.ruralhealth.hrsa.gov or from the excluded hospital as determined as paragraph (d)(2)(iv).
■ c. Adding new paragraph (d)(2)(iii). reclassification to the urban area to place the reference ‘‘§§ 413.75 through
The revision and additions read as which they seek redesignation. 413.83 and 413.85’’.
follows: * * * * * ■ b. Revising paragraph (c)(4)(iii).
§ 412.230 Criteria for an individual hospital § 412.278 [Amended] § 413.40 Ceiling on the rate of increase in
seeking redesignation to another rural area hospital inpatient costs.
or an urban area. ■ 20. In § 412.278(b)(1), the phrase
* * * * *
‘‘Office of Payment Policy’’ is removed (c) Costs subject to the ceiling— * * *
(a) General. * * *
and the phrase ‘‘Hospital and (4) Target amounts. * * *
(5) Limitations on redesignations.
Ambulatory Policy Group’’ is added in (iii) For cost reporting periods
* * *
its place. beginning on or after October 1, 1997
(iv) An urban hospital that has been
■ 21. Section 412.304 is amended by through September 30, 2002, in the case
granted redesignation as rural under
§ 412.103 cannot receive an additional revising paragraph (a) to read as follows: of a psychiatric hospital or unit,
reclassification by the MGCRB based on § 412.304 Implementation of the capital
rehabilitation hospital or unit, or long-
this acquired rural status for a year in prospective payment system. term care hospital, the target amount is
which such redesignation is in effect. the lower of the amounts specified in
(a) General rule. As described in
* * * * * paragraph (c)(4)(iii)(A) or paragraph
§§ 412.312 through 412.370, effective
(d) Use of urban or other rural area’s (c)(4)(iii)(B) of this section.
with cost reporting periods beginning
wage index.— * * * on or after October 1, 1991, CMS pays * * * * *
(2) Appropriate wage data. * * * an amount determined under the capital ■ 4. Section 413.65 is amended by—
(iii) For applications submitted for prospective payment system for each ■ a. Reprinting the introductory text of
reclassifications effective in FYs 2006 inpatient hospital discharge as defined paragraph (a)(1)(ii) and adding a new
through 2008, a campus of a in § 412.4. This amount is in addition to paragraph (a)(1)(ii)(L).
multicampus hospital may seek the amount payable under the ■ b. Revising the definition of ‘‘Provider-
reclassification to a CBSA in which prospective payment system for based entity’’ under paragraph (a)(2).
another campus(es) is located. If the inpatient hospital operating costs as ■ c. Revising paragraphs (b)(3)(i) and
campus is seeking reclassification to a determined under subpart D of this part. (b)(3)(ii).
■ d. Revising paragraph (e)(1)
CBSA in which another campus(es) is * * * * *
located, as part of its reclassification introductory text, (e)(1)(i), (e)(1)(ii), and
request, the requesting entity may § 412.521 [Amended] (e)(1)(iii).
■ e. Revising paragraph (e)(3).
submit the composite wage data for the ■ 22. In § 412.521—
■ f. Revising paragraph (g)(7).
entire multicampus hospital as its ■ a. Under paragraph (b)(2)(i), the
The addition and revision read as
hospital-specific data. reference ‘‘§§ 413.85, 413.86, and 413.87
follows:
* * * * * of this subchapter.’’ is removed and the
■ 19. Section 412.234 is amended by—
reference ‘‘§§ 413.75 through 413.83, § 413.65 Requirements for a determination
■ a. Revising paragraph (a)(3)(ii).
413.85, and 413.87 of this subchapter.’’ that a facility or an organization has
is added in its place. provider-based status.
■ b. Adding a new paragraph (a)(3)(iii).
■ b. Under paragraph (b)(2)(ii), the (a) Scope and definitions. * * *
■ c. In paragraph (b)(1), removing the
reference ‘‘§ 413.80’’ is removed and the (1) * * *
phrase ‘‘or NECMA’’.
reference ‘‘§ 413.89’’ is added in its (ii) The determinations of provider-
The addition reads as follows: based status for payment purposes
place.
§ 412.234 Criteria for all hospitals in an described in this section are not made
urban county seeking redesignation to PART 413—PRINCIPLES OF as to whether the following facilities are
another urban area. REASONABLE COST provider-based:
(a) * * * REIMBURSEMENT; PAYMENT FOR * * * * *
(3) * * * END-STAGE RENAL DISEASE (L) Rural health clinics (RHCs)
(ii) For fiscal year 2006, hospitals SERVICES; PROSPECTIVELY affiliated with hospitals having 50 or
located in counties that are in the same DETERMINED PAYMENT RATES FOR more beds.
Combined Statistical Area (CSA) (under SKILLED NURSING FACILITIES
* * * * *
the MSA definitions announced by the ■ C. Part 413 is amended as follows: (2) Definitions. * * *
OMB on June 6, 2003) as the urban area ■ 1. The authority citation for Part 413 Provider-based entity means a
to which they seek redesignation; or in continued to read as follows: provider of health care services, or an
the same Consolidated Metropolitan RHC as defined in § 405.2401(b) of this
Statistical Area (CMSA) (under the Authority: Secs. 1102, 1812(d), 1814(b), chapter, that is either created by, or
1815, 1833(a), (i), and (n), 1871, 1881, 1883,
standards published by the OMB on and 1886 of the Social Security Act (42
acquired by, a main provider for the
March 30, 1990) as the urban area to U.S.C. 1302, 1395d(d), 1395f(b), 1395g, purpose of furnishing health care
which they seek designation qualify as 1395l(a), (i), and (n), 1395hh, 1395rr, 1395tt, services of a different type from those of
meeting the proximity requirements for and 1395ww). the main provider under the ownership
reclassification to the urban area to and administrative and financial control
which they seek redesignation. § 413.13 [Amended] of the main provider, in accordance
(iii) For Federal fiscal year 2007 and ■ 2. In § 413.13 (d)(1), the reference with the provisions of this section. A
thereafter, hospitals located in counties ‘‘§ 413.80’’ is removed and the reference provider-based entity comprises both
that are in the same Combined ‘‘§ 413.89’’ is added in its place. the specific physical facility that serves
Statistical Area (CSA) (under the MSA ■ 3. Section 413.40 is amended by— as the site of services of a type for which
definitions announced by the OMB on ■ a. In paragraph(a)(3), under the payment could be claimed under the
June 6, 2003) as the urban area to which definition of ‘‘Net inpatient operating Medicare or Medicaid program, and the
they seek redesignation qualify as costs’’, removing the reference personnel and equipment needed to
meeting the proximity requirement for ‘‘§§ 413.85 and 413.86’’ and adding in its deliver the services at that facility. A
provider-based entity may, by itself, be remote location of a hospital, or a who required the type of care furnished
qualified to participate in Medicare as a satellite facility have the same by the main provider received that care
provider under § 489.2 of this chapter, governing body. from that provider (for example, at least
and the Medicare conditions of (iii) The facility or organization is 75 percent of the patients of an RHC
participation do apply to a provider- operated under the same organizational seeking provider-based status received
based entity as an independent entity. documents as the main provider. For inpatient hospital services from the
* * * * * example, the facility or organization hospital that is the main provider).
(b) Provider-based determinations.— seeking provider-based status must be (iv) If the facility or organization is
* * * subject to common bylaws and unable to meet the criteria in paragraph
(3)(i) Except as specified in operating decisions of the governing (e)(3)(iii)(A) or paragraph (e)(3)(iii)(B) of
paragraphs (b)(2) and (b)(5) of this body of the main provider where it is this section because it was not in
section, if a potential main provider based. operation during all of the 12-month
seeks a determination of provider-based * * * * * period described in paragraph (e)(3)(iii)
status for a facility that is located on the (3) Location. The facility or of this section, the facility or
campus of the potential main provider, organization meets the requirements in organization is located in a zip code
the provider would be required to paragraph (e)(3)(i), (e)(3)(ii), (e)(3)(iii), area included among those that, during
submit an attestation stating that the (e)(3)(iv), (e)(3)(v), or, in the case of an all of the 12-month period described in
facility meets the criteria in paragraph RHC, paragraph (e)(3)(vi) of this section, paragraph (e)(3)(iii) of this section,
(d) of this section and, if it is a hospital, and the requirements in paragraph accounted for at least 75 percent of the
also attest that it will fulfill the (e)(3)(vii) of this section. patients served by the main provider.
obligations of hospital outpatient (i) The facility or organization is (v) The facility or organization meets
departments and hospital-based entities located within a 35-mile radius of the all of the following criteria:
described in paragraph (g) of this campus of the hospital or CAH that is (A) The facility or organization is
section. The provider seeking such a the potential main provider. seeking provider-based status with
(ii) The facility or organization is respect to a hospital that meets the
determination would also be required to
owned and operated by a hospital or criteria in § 412.23(d) for reimbursement
maintain documentation of the basis for
CAH that has a disproportionate share under Medicare as a children’s hospital;
its attestations and to make that
adjustment (as determined under (B) The facility or organization meets
documentation available to CMS and to
§ 412.106 of this chapter) greater than the criteria for identifying intensive care
CMS contractors upon request. If the
11.75 percent or is described in type units set forth in the Medicare
facility is operated as a joint venture,
§ 412.106(c)(2) of this chapter reasonable cost reimbursement
the provider would also have to attest
implementing section 1886(d)(5)(F)(i)(II) regulations under § 413.53(d).
that it will comply with the
of the Act and is— (C) The facility or organization
requirements of paragraph (f) of this
(A) Owned or operated by a unit of
section. accepts only patients who are newborn
State or local government;
(ii) If the facility is not located on the (B) A public or nonprofit corporation infants who require intensive care on an
campus of the potential main provider, that is formally granted governmental inpatient basis.
the provider seeking a determination powers by a unit of State or local (D) The hospital in which the facility
would be required to submit an government; or or organization is physically located is
attestation stating that the facility meets (C) A private hospital that has a in a rural area as defined in
the criteria in paragraphs (d) and (e) of contract with a State or local § 412.64(b)(1)(ii)(C) of this chapter.
this section, and if the facility is government that includes the operation (E) The facility or organization is
operated under a management contract, of clinics located off the main campus located within a 100-mile radius of the
the requirements of paragraph (h) of this of the hospital to assure access in a children’s hospital that is the potential
section. If the potential main provider is well-defined service area to health care main provider.
a hospital, the hospital also would be services for low-income individuals (F) The facility or organization is
required to attest that it will fulfill the who are not entitled to benefits under located at least 35 miles from the
obligations of hospital outpatient Medicare (or medical assistance under a nearest other neonatal intensive care
departments and hospital-based entities Medicaid State plan). unit.
described in paragraph (g) of this (iii) The facility or organization (G) The facility or organization meets
section. The provider would be required demonstrates a high level of integration all other requirements for provider-
to supply documentation of the basis for with the main provider by showing that based status under this section.
its attestations to CMS at the time it it meets all of the other provider-based (vi) Both of the following criteria are
submits its attestations. criteria and demonstrates that it serves met:
* * * * * the same patient population as the main (A) The facility or organization is an
(e) * * * provider, by submitting records showing RHC that is otherwise qualified as a
(1) Operation under the ownership that, during the 12-month period provider-based entity of a hospital that
and control of the main provider. The immediately preceding the first day of has fewer than 50 beds, as determined
facility or organization seeking the month in which the application for under § 412.105(b) of this chapter; and
provider-based status is operated under provider-based status is filed with CMS, (B) The hospital with which the
the ownership and control of the main and for each subsequent 12-month facility or organization has a provider-
provider, as evidenced by the following: period— based relationship is located in a rural
(i) The business enterprise that (A) At least 75 percent of the patients area, as defined in § 412.64(b)(1)(ii)(C)
constitutes the facility or organization is served by the facility or organization of this subchapter.
100 percent owned by the main reside in the same zip code areas as at (vii) A facility or organization may
provider. least 75 percent of the patients served qualify for provider-based status under
(ii) The main provider and the facility by the main provider; or this section only if the facility or
or organization seeking status as a (B) At least 75 percent of the patients organization and the main provider are
department of the main provider, a served by the facility or organization located in the same State or, when
consistent with the laws of both States, § 413.77 [Amended] result of the most recent census data
in adjacent States. ■ 6. In § 413.77, under paragraph and implementation of the new MSA
* * * * * (e)(1)(iii), the reference ‘‘§ 412.62(f)(1)(i) definitions announced by OMB on June
(g) Obligations. * * * of this chapter.’’ is removed and the 6, 2003, may retain the increases to its
(7) When a Medicare beneficiary is reference ‘‘Subpart D of Part 412 of this FTE resident cap that it received under
treated in a hospital outpatient subchapter’’. is added in its place. paragraphs (c)(2)(i), (e)(1)(iii), and (e)(3)
department that is not located on the ■ 7. Section 413.79 is amended by— of this section while it was located in a
main provider’s campus, the treatment ■ a. Revising paragraph (a)(10). rural area.
is not required to be provided by the ■ b. Revising the introductory text of * * * * *
antidumping rules in § 489.24 of this paragraph (c)(2).
chapter, and the beneficiary will incur (e) New medical residency training
■ c. In paragraph (c)(3)(i), removing the
a coinsurance liability for an outpatient programs. * * *
reference ‘‘§ 412.62(f)(iii)’’ and adding in
visit to the hospital as well as for the its place the reference ‘‘Subpart D of Part (1) * * *
physician service, the following 412 of this subchapter’’. (iv) An urban hospital that qualifies
requirements must be met: ■ d. Adding a new paragraph (c)(6). for an adjustment to its FTE cap under
(i) The hospital must provide written ■ e. Revising paragraph (e)(1)(iv). paragraph (e)(1) of this section is
notice to the beneficiary, before the ■ f. In the introductory text of paragraph
delivery of services, of— permitted to be part of a Medicare GME
(k), removing the reference ‘‘(k)(6)’’ and affiliated group for purposes of
(A) The amount of the beneficiary’s adding in its place the reference ‘‘(k)(7)’’.
potential financial liability; or establishing an aggregate FTE cap only
■ g. Adding a new paragraph (k)(7).
(B) If the exact type and extent of care if the adjustment that results from the
The revisions and additions read as
needed are not known, an explanation affiliation is an increase to the urban
follows:
that the beneficiary will incur a hospital’s FTE cap.
coinsurance liability to the hospital that § 413.79 Direct GME payments: * * * * *
he or she would not incur if the facility Determination of the weighted number of
FTE residents. (k) Residents training in rural track
were not provider-based, an estimate programs. * * *
based on typical or average charges for * * * * *
visits to the facility, and a statement that (a) * * * (7) If an urban hospital had
the patient’s actual liability will depend (10) Effective for portions of cost established a rural track training
upon the actual services furnished by reporting periods beginning on or after program under the provisions of this
the hospital. October 1, 2004, if a hospital can paragraph (k) with a hospital located in
(ii) The notice must be one that the document that a resident a rural area and that rural area
beneficiary can read and understand. simultaneously matched for one year of subsequently becomes an urban area
(iii) If the beneficiary is unconscious, training in a particular specialty due to the most recent census data and
under great duress, or for any other program, and for a subsequent year(s) of implementation of the new labor market
reason unable to read a written notice training in a different specialty program, area definitions announced by OMB on
and understand and act on his or her the resident’s initial residency period June 6, 2003, the urban hospital may
own rights, the notice must be provided, will be determined based on the period continue to adjust its FTE resident limit
before the delivery of services, to the of board eligibility for the specialty in accordance with this paragraph (k)
beneficiary’s authorized representative. associated with the program for which for the rural track programs established
(iv) In cases where a hospital the resident matched for the subsequent prior to the adoption of such new labor
outpatient department provides year(s) of training. Effective for portions market area definitions. In order to
examination or treatment that is of cost reporting periods beginning on receive an adjustment to its FTE
required to be provided by the or after October 1, 2005, if a hospital can resident cap for a new rural track
antidumping rules of § 489.24 of this document that a particular resident,
residency program, the urban hospital
chapter, notice, as described in this prior to beginning the first year of
must establish a rural track program
paragraph (g)(7), must be given as soon residency training, matched in a
with hospitals that are designated rural
as possible after the existence of an specialty program for which training
based on the most recent geographical
emergency has been ruled out or the would begin at the conclusion of the
first year of training, that resident’s location designations adopted by CMS.
emergency condition has been
stabilized. initial residency period will be * * * * *
* * * * * determined in the resident’s first year of
§ 413.87 [Amended]
training based on the period of board
■ 5. Section 413.75 is amended in
eligibility associated with the specialty ■ 8. In § 413.87(d) introductory text, the
paragraph (b) by revising paragraph (1)
program for which the resident matched reference ‘‘§ 413.86(d)(4)’’ is removed
under the definition of ‘‘Medicare GME
for subsequent training year(s). and the reference ‘‘§ 413.76(d)(4)’’ is
affiliated group’’ to read as follows:
* * * * * added in its place.
§ 413.75 Direct GME payments: General (c) Unweighted FTE counts. * * *
requirements. (2) Determination of the FTE resident § 413.178 [Amended]
* * * * * cap. Subject to the provisions of ■ 9. In § 413.178—
(b) * * * paragraphs (c)(3) through (c)(6) of this
Medicare GME affiliated group section and § 413.81, for purposes of ■ a. In paragraph (a), the reference
means— determining direct GME payment— ‘‘§ 413.80(b)’’ is removed and the
(1) Two or more hospitals that are * * * * * reference ‘‘§ 413.89(b)’’ is added in its
located in the same urban or rural area (6) FTE resident caps for rural place.
(as those terms are defined in Subpart hospitals that are redesignated as ■ b. In paragraph (b), the reference
D of Part 412 of this subchapter. urban. A rural hospital redesignated as ‘‘§ 413.80’’ is removed and the reference
* * * * * urban after September 30, 2004, as a ‘‘§ 413.89’’ is added in its place.
PART 415—SERVICES FURNISHED BY ‘‘§§ 413.75 through 413.83’’ is added in § 422.216 [Amended]
PHYSICIANS IN PROVIDERS, its place. ■ 3. In § 422.216(a)(4), the reference
SUPERVISING PHYSICIANS IN ‘‘§§ 412.105(g) and 413.86(d)’’ is
§ 415.204 [Amended]
TEACHING SETTINGS, AND removed and the reference
RESIDENTS IN CERTAIN SETTINGS ■ 10. In § 415.204(a)(2), the reference ‘‘§§ 412.105(g) and 413.76’’ is added in
‘‘§ 413.86’’ is removed and the reference its place.
■ D. Part 415 is amended as follows: ‘‘§§ 413.75 through 413.83’’ is added in
■ 1. The authority citation for Part 415 its place. PART 485—CONDITIONS OF
continued to read as follows: PARTICIPATION: SPECIALIZED
§ 415.206 [Amended] PROVIDERS
Authority: Secs. 1102 and 1871 of the
Social Security Act (42 U.S.C. 1302 and ■ 11. In § 415.206(a), the reference
1395hh). ■ G. Part 485 is amended as follows:
‘‘§ 413.86(f)(1)(iii)’’ is removed and the
■ 1. The authority citation for Part 485
reference ‘‘§ 413.78’’ is added in its
§ 415.55 [Amended] continues to read as follows:
place.
■ 2. In § 415.55(a)(5), the reference Authority: Secs. 1102 and 1871 of the
‘‘§ 413.86’’ is removed and the reference § 415.208 [Amended] Social Security Act (42 U.S.C. 1302 and
1395hh.
‘‘§§ 413.75 through 413.83’’ is added in ■ 12. In § 415.208—
its place. ■ 2. Section 485.610 is amended by—
■ a. In paragraph (b)(1), the reference ■ a. In paragraph (b)(1)(i), removing the
§ 415.70 [Amended]
‘‘§ 413.86’’ is removed and the reference reference ‘‘§ 412.62(f)’’ and adding in its
‘‘§§ 413.75 through 413.83’’ is added in place the reference ‘‘§ 412.64(b),
■ 3. In § 415.70(a)(2), the reference its place. excluding paragraph (b)(3).’’
‘‘§ 413.86’’ is removed and the reference ■ b. In paragraph (b)(4), the reference ■ b. Removing paragraph (b)(1)(ii) and
‘‘§§ 413.75 through 413. 83’’ is added in ‘‘§ 413.86’’ is removed and the reference redesignating paragraph (b)(1)(iii) as
its place. ‘‘§§ 413.75 through 413. 83’’ is added in paragraph (b)(1)(ii).
§ 415.102 [Amended] its place. ■ c. Adding a new paragraph (d).
The revisions and additions read as
■ 4. In § 415.102(c)(1), the reference PART 419—PROSPECTIVE PAYMENT follows:
‘‘§ 413.86’’ is removed and the reference SYSTEM FOR OUTPATIENT
‘‘§§ 413.75 through 413.83’’ is added in DEPARTMENT SERVICES § 485.610 Condition of participation:
its place. Status and location.
■ F. Part 419 is amended as follows: * * * * *
§ 415.150 [Amended] ■ 1. The authority citation for part 419 (d) Standard: Relocation of CAHs with
■ 5. In § 415.150(b), the reference continues to read as follows: a necessary provider designation. A
‘‘§ 413.86’’ is removed and the phrase Authority: Secs. 1102, 1833(t), and 1871 of
CAH that has a necessary provider
‘‘§§ 413.75 through 413.83’’ is added in the Social Security Act (42 U.S.C. 1302, designation from the State that was in
its place. 1395l(t), and 1395hh). effect prior to January 1, 2006, and
relocates its facility after January 1,
§ 415.152 [Amended] § 419.2 [Amended] 2006, can continue to meet the location
■ 6. In § 415.152— ■ 2. In § 419.2— requirement of paragraph (c) of this
■ a. In paragraph (2) of the definition of ■ a. In paragraph (c)(1), the reference section based on the necessary provider
‘‘Approved graduate medical education ‘‘§ 413.86’’ is removed and the reference designation only if the relocated facility
program’’, the reference ‘‘§ 413.86(b)’’ is ‘‘§§ 413.75 through 413.83’’ is added in meets the requirements as specified in
removed and the reference ‘‘§ 413.75(b)’’ its place. paragraph (d)(1) of this section.
is added in its place. (1) If a necessary provider CAH
■ b. In paragraph (c)(6), the reference
■ b. In the definition of ‘‘Teaching
relocates its facility and begins
‘‘§ 413.80(b)’’ is removed and the
setting’’, the reference ‘‘§ 413.86,’’ is providing services in a new location, the
reference ‘‘§ 413.89(b)’’ is added in its CAH can continue to meet the location
removed and the reference ‘‘§§ 413.75 place. requirement of paragraph (c) of this
through 413.83,’’ is added in its place.
PART 422—SPECIAL RULES FOR section based on the necessary provider
§ 415.160 [Amended] SERVICES FURNISHED BY designation only if the CAH in its new
NONCONTRACT PROVIDERS location—
■ 7. In § 415.160— (i) Serves at least 75 percent of the
■ a. In paragraph (c)(2), the reference same service area that it served prior to
‘‘§ 413.86’’ is removed and the reference ■ G. Part 422 is amended as follows:
■ 1. The authority citation of part 422 its relocation;
‘‘§ 413.78’’ is added in its place. (ii) Provides at least 75 percent of the
■ b. In paragraph (d)(2), the reference continues to read as follows:
same services that it provided prior to
‘‘§ 413.86’’ is removed and the reference Authority: Secs. 1102 and 1871 of the the relocation; and
‘‘§§ 413.75 through 413.83’’ is added in Social Security Act (42 U.S.C. 1302 and (iii) Is staffed by 75 percent of the
its place. 1395hh). same staff (including medical staff,
§ 415.174 [Amended] § 422.214 [Amended] contracted staff, and employees) that
were on staff at the original location.
■ 8. In § 415.174(a)(1), the reference ■ 2. In § 422.214— (2) If a CAH that has been designated
‘‘§ 413.86.’’ is removed and the phrase ■ a. In paragraph (b), the phrase as a necessary provider by the State
‘‘§§ 413.75 through 413.83.’’ is added in ‘‘§§ 412.105(g) and 413.86(d))’’ is begins providing services at another
its place. removed and the phrase ‘‘§§ 412.105(g) location after January 1, 2006, and does
and 413.76))’’ is added in its place. not meet the requirements in paragraph
§ 415.200 [Amended]
■ b. In paragraph (b), the phrase ‘‘Section (d)(1) of this section, the action will be
■ 9. In § 415.200(a), the reference 413.86 (d)’’ is removed and the phrase considered a cessation of business as
‘‘§ 413.86’’ is removed and the reference ‘‘Section 413.76’’ is added in its place. described in § 489.52(b)(3).
(Catalog of Federal Domestic Assistance prospectively effective with discharges neutral, as provided for in section
Program No. 93.773, Medicare—Hospital occurring on or after October 1, 2005, affect 1886(d)(8)(D) of the Act, by removing the FY
Insurance; and Program No. 93.774, the calculation of the Federal rates. In section 2005 budget neutrality factor and applying a
Medicare—Supplementary Medical III. of this Addendum, we discuss our revised factor;
Insurance Program) changes for determining the prospective • An adjustment to apply the new outlier
Dated: July 26, 2005. payment rates for Medicare inpatient capital- offset by removing the FY 2005 outlier offset
related costs for FY 2006. Section IV. of this and applying a new offset;
Mark B. McClellan,
Addendum sets forth our changes for • An adjustment to ensure the effects of
Administrator, Centers for Medicare & determining the rate-of-increase limits for the rural community hospital demonstration
Medicaid Services. hospitals excluded from the IPPS for FY required under section 410A of Pub. L. 108–
Dated: July 27, 2005. 2006. Section V. of this Addendum sets forth 173 are budget neutral, as required under
Michael O. Leavitt, policies on payment for blood clotting factors section 410A(c)(2) of Pub. L. 108–173.
Secretary. administered to hemophilia patients. The
tables to which we refer in the preamble of A. Calculation of the Adjusted Standardized
[Editorial Note: The following Addendum this final rule are presented in section VI. of Amount
and appendixes will not appear in the Code this Addendum. 1. Standardization of Base-Year Costs or
of Federal Regulations.] Target Amounts
II. Changes to Prospective Payment Rates for
Hospital Inpatient Operating Costs for FY The national standardized amount is based
Addendum—Schedule of Standardized 2006 on per discharge averages of adjusted
Amount Effective With Discharges hospital costs from a base period (section
The basic methodology for determining
Occurring On or After October 1, 2005 prospective payment rates for hospital
1886(d)(2)(A) of the Act) or, for Puerto Rico,
and Update Factors and Rate-of- adjusted target amounts from a base period
inpatient operating costs for FY 2005 and
Increase Percentages Effective With subsequent fiscal years is set forth at (section 1886(d)(9)(B)(i) of the Act), updated
Cost Reporting Periods Beginning On or § 412.64. The basic methodology for and otherwise adjusted in accordance with
the provisions of section 1886(d) of the Act.
After October 1, 2005 determining the prospective payment rates
for hospital inpatient operating costs for The September 1, 1983 interim final rule (48
I. Summary and Background hospitals located in Puerto Rico for FY 2005 FR 39763) contained a detailed explanation
In this Addendum, we are setting forth the and subsequent fiscal years is set forth at of how base-year cost data (from cost
amounts and factors for determining §§ 412.211 and 412.212. Below we discuss reporting periods ending during FY 1981)
prospective payment rates for Medicare the factors used for determining the were established in the initial development
hospital inpatient operating costs and prospective payment rates. of standardized amounts for the IPPS. The
Medicare hospital inpatient capital-related In summary, the standardized amounts set September 1, 1987 final rule (52 FR 33043
costs. We are also setting forth the rate-of- forth in Tables 1A, 1B, 1C, and 1D of section and 33066) contains a detailed explanation of
increase percentages for updating the target VI. of this Addendum reflect— how the target amounts were determined,
amounts for hospitals and hospital units • Equalization of the standardized and how they are used in computing the
excluded from the IPPS. amounts for urban and other areas at the Puerto Rico rates.
For discharges occurring on or after level computed for large urban hospitals Sections 1886(d)(2)(B) and (d)(2)(C) of the
October 1, 2005, except for SCHs, MDHs, and during FY 2004 and onward, as provided for Act require us to update base-year per
hospitals located in Puerto Rico, each under section 1886(d)(3)(A)(iv) of the Act, discharge costs for FY 1984 and then
hospital’s payment per discharge under the updated by the applicable percentage standardize the cost data in order to remove
IPPS will be based on 100 percent of the increase required under sections the effects of certain sources of cost
Federal national rate, which will be based on 1886(b)(3)(B)(i)(XIX) and 1886(b)(3)(B)(vii) of variations among hospitals. These effects
the national adjusted standardized amount. the Act. include case-mix, differences in area wage
This amount reflects the national average • The two labor-related shares that are levels, cost-of-living adjustments for Alaska
hospital costs per case from a base year, applicable to the standardized amounts, and Hawaii, indirect medical education
updated for inflation. depending on whether the hospital’s costs, and costs to hospitals serving a
SCHs are paid based on whichever of the payments would be higher with a lower (in disproportionate share of low-income
following rates yields the greatest aggregate the case of a wage index below 1.0000) or patients.
payment: The Federal national rate; the higher (in the case of a wage index above Under section 1886(d)(3)(E) of the Act, the
updated hospital-specific rate based on FY 1.0000) labor share, as provided for under Secretary estimates, from time-to-time, the
1982 costs per discharge; the updated sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) proportion of hospitals’ costs that are
hospital-specific rate based on FY 1987 costs of the Act; attributable to wages and wage-related costs.
per discharge; or the updated hospital- • Updates of 3.7 percent for all areas (that The standardized amount is divided into
specific rate based on FY 1996 costs per is, the full market basket percentage increase labor-related and nonlabor-related amounts;
discharge. of 3.7 percent, as required by section only the proportion considered the labor-
Under section 1886(d)(5)(G) of the Act, 1886(b)(3)(B)(i)(XIX) of the Act, and related amount is adjusted by the wage
MDHs are paid based on the Federal national reflecting the requirements of section index. Section 403 of Pub. L. 108–173 revises
rate or, if higher, the Federal national rate 1886(b)(3)(B)(vii) of the Act to reduce the the proportion of the standardized amount
plus 50 percent of the difference between the applicable percentage increase by 0.4 that is considered labor-related. Specifically,
Federal national rate and the updated percentage points for hospitals that fail to section 1886(d)(3)(E) of the Act (as amended
hospital-specific rate based on FY 1982 or FY submit data, in a form and manner specified by section 403 of Pub. L. 108–173) requires
1987 costs per discharge, whichever is by the Secretary, relating to the quality of that 62 percent of the standardized amount
higher. MDHs do not have the option to use inpatient care furnished by the hospital; be adjusted by the wage index, unless doing
their FY 1996 hospital-specific rate. • An adjustment to ensure the DRG so would result in lower payments to a
For hospitals in Puerto Rico, the payment recalibration and wage index update and hospital than would otherwise be made.
per discharge is based on the sum of 25 changes are budget neutral, as provided for (Section 403(b) of Pub. L. 108–173 extended
percent of a Puerto Rico rate that reflects base under sections 1886(d)(4)(C)(iii) and this provision to the Puerto Rico
year average costs per case of Puerto Rico 1886(d)(3)(E) of the Act, by applying new standardized amounts.) We are updating the
hospitals and 75 percent of the Federal budget neutrality adjustment factors to the labor-related share to 69.7 percent for FY
national rate. (See section II.D.3. of this standardized amount; 2006, as discussed in section IV.B.3. of the
Addendum for a complete description.) • An adjustment to ensure the effects of preamble to this final rule. We note that the
As discussed below in section II. of this the special transition measures adopted in revised labor-related share for FY 2006 was
Addendum, we are making changes in the relation to the implementation of new labor determined to be 69.731 (the same amount
determination of the prospective payment market areas are budget neutral; that we proposed in the FY 2006 IPPS
rates for Medicare inpatient operating costs • An adjustment to ensure the effects of proposed rule ), as discussed in section IV of
for FY 2006. The changes, to be applied geographic reclassification are budget the preamble to this final rule. We used our
previous methodology and rounded the also amended section 1886(d)(9)(A) of the estimated aggregate payments after the
labor-related share to 69.7 percent for Act to equalize the Puerto Rico-specific changes in the DRG relative weights and
purposes of establishing the labor-related and urban and rural area rates. Accordingly, we wage index should equal estimated aggregate
nonlabor-related portions of the standardized are providing in this final rule for a single payments prior to the changes. If we removed
amount. As discussed in section IV. of the national standardized amount and a single the prior year adjustment, we would not
preamble to this final rule, we are also Puerto Rico standardized amount for FY satisfy this condition.
rebasing the current labor-related share for 2006. Budget neutrality is determined by
the Puerto Rico-specific amounts for FY 3. Updating the Average Standardized comparing aggregate IPPS payments before
2006. At the time we issued the proposed Amount and after making the changes that are
rule, we had not calculated a rebased Puerto required to be budget neutral (for example,
Rico labor-related share. Therefore, the In accordance with section reclassifying and recalibrating the DRGs,
proposed standardized amounts that 1886(d)(3)(A)(iv)(II) of the Act, we are updating the wage data, and geographic
appeared in Table 1C of the Addendum of updating the equalized standardized amount reclassifications). We include outlier
the proposed rule for providers with a wage for FY 2006 by the full estimated market payments in the payment simulations
index greater than 1.0000 reflected the FY basket percentage increase for hospitals in all because outliers may be affected by changes
2005 labor-related share for the Puerto Rico- areas, as specified in section in these payment parameters.
specific amounts of 71.3 percent for FY 2006. 1886(b)(3)(B)(i)(XIX) of the Act, as amended We are also adjusting the standardized
However, we subsequently calculated a by section 501 of Pub. L. 108–173. The amount this year by an amount estimated to
rebased labor-related share for Puerto Rico percentage change in the market basket ensure that aggregate IPPS payments do not
for FY 2006 of 58.7 percent which was reflects the average change in the price of exceed the amount of payments that would
posted on the CMS Web site the week of May goods and services purchased by hospitals to have been made in the absence of the rural
29, 2005. We are adopting this Puerto Rico furnish inpatient care. The most recent community hospital demonstration required
specific labor share of 58.7 in this final rule. forecast of the hospital market basket
under section 410A of Pub. L. 108–173. This
We are adjusting 62 percent of the national increase for FY 2006 is 3.7 percent
demonstration is required to be budget
standardized amount for all hospitals whose (compared to the proposed estimated forecast
neutral under section 410A(c)(2) of Pub. L.
wage indexes are less than or equal to 1.0000. of 3.2 percent). Thus, for FY 2006, the update
108–173.
For all hospitals whose wage values are to the average standardized amount is 3.7
greater than 1.0000, we are adjusting the percent for hospitals in all areas. a. Recalibration of DRG Weights and
national standardized amount by a labor- Section 1886(b)(3)(B) of the Act specifies Updated Wage Index—Budget Neutrality
related share of 69.7 percent. For hospitals in the mechanism used to update the Adjustment
Puerto Rico, we are adjusting 58.7 percent of standardized amount for payment for Section 1886(d)(4)(C)(iii) of the Act
the Puerto Rico specific standardized amount inpatient hospital operating costs. Section specifies that, beginning in FY 1991, the
for all hospitals whose wage indexes are less 1886(b)(3)(B)(vii) of the Act, as amended by
annual DRG reclassification and recalibration
than or equal to 1.0000 and 62 percent of the section 501(b) of Pub. L. 108–173, provides
of the relative weights must be made in a
Puerto Rico specific standardized amount for for a reduction of 0.4 percentage points to the
manner that ensures that aggregate payments
hospitals whose wage values are greater than update percentage increase (also known as
to hospitals are not affected. As discussed in
1.0000. the market basket update) for each of FYs
section II. of the preamble, we normalized
2005 through 2007 for any ‘‘subsection (d)
2. Computing the Average Standardized the recalibrated DRG weights by an
hospital’’ that does not submit data on a set
Amount adjustment factor, so that the average case
of 10 quality indicators established by the
Section 1886(d)(3)(A)(iv) of the Act weight after recalibration is equal to the
Secretary as of November 1, 2003. The statute
previously required the Secretary to compute average case weight prior to recalibration.
also provides that any reduction will apply
the following two average standardized only to the fiscal year involved, and will not However, equating the average case weight
amounts for discharges occurring in a fiscal be taken into account in computing the after recalibration to the average case weight
year: one for hospitals located in large urban applicable percentage increase for a before recalibration does not necessarily
areas and one for hospitals located in other subsequent fiscal year. This measure achieve budget neutrality with respect to
areas. In accordance with section establishes an incentive for hospitals to aggregate payments to hospitals because
1886(b)(3)(B)(i) of the Act, the large urban submit data on quality measures established payments to hospitals are affected by factors
average standardized amount was 1.6 percent by the Secretary. The standardized amounts other than average case weight. Therefore, as
higher than the other area average in Tables 1A through 1C of section VI. of this we have done in past years, we are making
standardized amount. In addition, under Addendum reflect these differential amounts. a budget neutrality adjustment to ensure that
sections 1886(d)(9)(B)(iii) and Although the update factors for FY 2006 the requirement of section 1886(d)(4)(C)(iii)
1886(d)(9)(C)(i) of the Act, the average are set by law, we are required by section of the Act is met.
standardized amounts per discharge were 1886(e)(4) of the Act to report to the Congress Section 1886(d)(3)(E) of the Act requires us
determined for hospitals located in urban our recommendation of update factors for FY to update the hospital wage index on an
and rural areas in Puerto Rico. 2006 for both IPPS hospitals and hospitals annual basis beginning October 1, 1993. This
Section 402(b) of Pub. L. 108–7 required and hospital units excluded from the IPPS. provision also requires us to make any
that, effective for discharges occurring on or Our recommendation on the update factors updates or adjustments to the wage index in
after April 1, 2003, and before October 1, (which is required by sections 1886(e)(4)(A) a manner that ensures that aggregate
2003, the Federal rate for all IPPS hospitals and (e)(5)(A) of the Act) is set forth as payments to hospitals are not affected by the
would be based on the large urban Appendix B of this final rule. change in the wage index. For FY 2006, we
standardized amount. Subsequently, Pub. L. are continuing to adjust 10 percent of the
4. Other Adjustments to the Average wage index factor for occupational mix. We
108–89 extended section 402(b) of Pub. L.
Standardized Amount describe the occupational mix adjustment in
108–7 beginning with discharges on or after
October 1, 2003 and before March 31, 2004. As in the past, we are adjusting the FY section III.C. of the preamble to this final
Finally, section 401(a) of Pub. L. 108–173 2006 standardized amount to remove the rule. Because section 1886(d)(3)(E) of the Act
amended section 1886(d)(3)(A)(iv) of the Act effects of the FY 2005 geographic requires us to update the wage index on a
to require that, beginning with FY 2004 and reclassifications and outlier payments before budget neutral basis, we are including the
thereafter, an equal standardized amount is applying the FY 2006 updates. We then effects of this occupational mix adjustment
to be computed for all hospitals at the level apply the new offsets for outliers and on the wage index in our budget neutrality
computed for large urban hospitals during FY geographic reclassifications to the calculations.
2003, updated by the applicable percentage standardized amount for FY 2006. In FY 2005, those urban hospitals that
update. This provision in effect makes We do not remove the prior year’s budget became rural under the new labor market
permanent the equalization of the neutrality adjustments for reclassification area definitions were assigned the wage
standardized amounts at the level of the and recalibration of the DRG weights and for index of the urban area in which they were
previous standardized amount for large urban updated wage data because, in accordance located under the previous labor market
hospitals. Section 401(c) of Pub. L. 108–173 with section 1886(d)(4)(C)(iii) of the Act, definitions for a 3-year period of FY 2005, FY
2006, and FY 2007. Because we are in the b. Reclassified Hospitals—Budget Neutrality cost-to-charge ratio is applied to the total
second year of this 3-year transition, we are Adjustment covered charges for the case to convert the
adjusting the standardized amounts for FY Section 1886(d)(8)(B) of the Act provides charges to costs. Payments for eligible cases
2006 to ensure budget neutrality for this that, effective with discharges occurring on are then made based on a marginal cost
policy. We discuss this adjustment in section or after October 1, 1988, certain rural factor, which is a percentage of the costs
III.B. of the preamble to this final rule. hospitals are deemed urban. In addition, above the fixed-loss cost threshold. The
Section 4410 of Pub. L. 105–33 provides section 1886(d)(10) of the Act provides for marginal cost factor for FY 2006 is 80
that, for discharges on or after October 1, the reclassification of hospitals based on percent—the same marginal cost factor we
1997, the area wage index applicable to any determinations by the MGCRB. Under section have used since FY 1995 (59 FR 45367).
hospital that is not located in a rural area 1886(d)(10) of the Act, a hospital may be In accordance with section
may not be less than the area wage index reclassified for purposes of the wage index. 1886(d)(5)(A)(iv) of the Act, outlier payments
Under section 1886(d)(8)(D) of the Act, the for any year are projected to be not less than
applicable to hospitals located in rural areas
Secretary is required to adjust the 5 percent nor more than 6 percent of total
in that State. This provision is required by
standardized amount to ensure that aggregate operating DRG payments plus outlier
section 4410(b) of Pub. L. 105–33 to be payments. Section 1886(d)(3)(B) of the Act
budget neutral. Therefore, we include the payments under the IPPS after
implementation of the provisions of sections requires the Secretary to reduce the average
effects of this provision in our calculation of standardized amount by a factor to account
the wage update budget neutrality factor. As 1886(d)(8)(B) and (C) and 1886(d)(10) of the
Act are equal to the aggregate prospective for the estimated proportion of total DRG
discussed in the FY 2005 IPPS final rule (69 payments made to outlier cases. Similarly,
FR 49110), we are in the second year of the payments that would have been made absent
these provisions. (We note that neither the section 1886(d)(9)(B)(iv) of the Act requires
3-year provision that uses an imputed wage the Secretary to reduce the average
wage index reclassifications provided under
index floor for States that have no rural areas standardized amount applicable to hospitals
section 508 of Pub. L. 108–173 nor the wage
and States that have geographic rural areas, in Puerto Rico to account for the estimated
index adjustments provided under section
but that have no hospitals actually classified proportion of total DRG payments made to
505 of Pub. L. 108–173 are budget neutral.
as rural. We are also adjusting for the effects Section 508(b) of Pub. L. 108–173 provides outlier cases. More information on outlier
of this provision in our calculation of the that the wage index reclassifications payments may be found on the CMS Web site
wage update budget neutrality factor. approved under section 508(a) of Pub. L. at http://www.cms.hhs.gov/providers/hipps/
To comply with the requirement that DRG 108–173 ‘‘shall not be effected in a budget ippsotlr.asp.
reclassification and recalibration of the neutral manner.’’ Section 505(a) of Pub. L. i. FY 2006 outlier fixed-loss cost threshold.
relative weights be budget neutral, and the 108–173 similarly provides that any increase For FY 2006, as we proposed, we are using
requirement that the updated wage index be in a wage index under that section shall not a refined methodology to calculate the outlier
budget neutral, we used FY 2004 discharge be taken into account ‘‘in applying any threshold. For FY 2004, we simulated outlier
data to simulate payments and compared budget neutrality adjustment with respect to payments by applying FY 2004 rates and
aggregate payments using the FY 2005 such index’’ under section 1886(d)(8)(D) of policies using cases from the FY 2002
relative weights and wage index to aggregate the Act.) To calculate this budget neutrality MedPAR file. In order to determine the FY
payments using the FY 2006 relative weights factor, we used FY 2004 discharge data to 2004 outlier threshold, it was necessary to
and wage index. The same methodology was simulate payments, and compared total IPPS inflate the charges on the MedPAR claims by
used for the FY 2005 budget neutrality payments prior to any reclassifications under 2 years, from FY 2002 to FY 2004. In order
adjustment. sections 1886(d)(8)(B) and (C) and to determine the FY 2004 outlier threshold,
Based on this comparison, we computed a 1886(d)(10) of the Act to total IPPS payments we used the 2-year average annual rate-of-
budget neutrality adjustment factor equal to after such reclassifications. Based on these change in charges-per-case to inflate FY 2002
1.002271. We also are adjusting the Puerto simulations, we are applying an adjustment charges to approximate FY 2004 charges. (We
Rico-specific standardized amount for the factor of 0.992521 to ensure that the effects refer the reader to the FY 2004 IPPS final rule
effect of DRG reclassification and of this reclassification are budget neutral. (67 FR 45476) for a complete discussion of
recalibration. We computed a budget The adjustment factor is applied to the the FY 2004 methodology.) In the IPPS
neutrality adjustment factor for the Puerto standardized amount after removing the proposed rule for FY 2005 (69 FR 28376), we
Rico-specific standardized amount equal to effects of the FY 2005 budget neutrality proposed to use the same methodology we
0.998993. These budget neutrality adjustment adjustment factor. We note that the FY 2006 used for determining the FY 2004 outlier
factors are applied to the standardized adjustment reflects FY 2006 wage index threshold to determine the FY 2005 outlier
amounts without removing the effects of the reclassifications approved by the MGCRB or threshold. We further noted that the rate-of-
the Administrator, and the effects of MGCRB increase in the 2-year average annual rate-of-
FY 2005 budget neutrality adjustments. In
reclassifications approved in FY 2004 and FY change in charges derived from the period
addition, as discussed in section V.C.2. of the
2005 (section 1886(d)(10)(D)(v) of the Act before the changes we made to the policy
preamble to this final rule, we are applying
makes wage index reclassifications effective affecting the applicable cost-to-charge ratios
the same DRG reclassification and
for 3 years). (68 FR 34494) and, therefore, they may have
recalibration budget neutrality factor of
represented rates-of-increase that could be
0.998993 to the hospital-specific rates that c. Outliers higher than the rates-of-increase under our
are effective for cost reporting periods Section 1886(d)(5)(A) of the Act provides new policy. As a result, we welcomed
beginning on or after October 1, 2005. for payments in addition to the basic comments on the data we were proposing to
Using the same data, we calculated a prospective payments for ‘‘outlier’’ cases use to update charges for purposes of the
transition budget neutrality adjustment to involving extraordinarily high costs. To threshold and specifically encouraged
account for the ‘‘hold harmless’’ policy under qualify for outlier payments, a case must commenters to provide recommendations for
which urban hospitals that became rural have costs greater than the sum of the data that might better reflect current trends
under the new labor market area definitions prospective payment rate for the DRG, any in charge increases.
were assigned the wage index of the urban IME and DSH payments, any new technology In the IPPS final rule for FY2005 (69 FR
area in which they were located under the add-on payments, and the ‘‘outlier 49275), in response to the many comments
previous labor market area definitions for a threshold’’ or ‘‘fixed loss’’ amount (a dollar we received on the proposed FY 2005
3-year period of FY 2005, FY 2006, and FY amount by which the costs of a case must methodology, we revised and used the
2007 (see Table 2 in section VI. of this exceed payments in order to qualify for following methodology to calculate the final
Addendum). Using the pre-reclassified wage outlier payment). We refer to the sum of the FY 2005 outlier fixed-loss threshold. Instead
index, we simulated payments under the new prospective payment rate for the DRG, any of using the 2-year average annual rate-of-
labor market area definitions and compared IME and DSH payments, any new technology change in charges-per-case from FY 2001 to
them to simulated payments under the ‘‘hold add-on payments, and the outlier threshold FY 2002 and FY 2002 to FY 2003, we used
harmless’’ policy. Based on this comparison, as the outlier ‘‘fixed-loss cost threshold.’’ To more recent data to determine the annual
we computed a transition budget neutrality determine whether the costs of a case exceed rate-of-change in charges for the FY 2005
adjustment of 0.998859. the fixed-loss cost threshold, a hospital’s outlier threshold. Specifically, we compared
the rate-of-increase in charges from the first policy for determining the applicable cost-to- been much closer to 5.1 percent of total IPPS
half-year of FY 2003 to the first half-year of charge ratios that became effective August 8, payments. These and other commenters also
FY 2004. We stated that we believed this 2003 (68 FR 34494). estimated what the outlier threshold for the
methodology would result in a more accurate Using this methodology, we proposed an past three fiscal years would have been if
determination of the rate-of-change in outlier fixed-loss cost threshold for FY 2006 CMS had used a methodology of inflating
charges-per-case between FY 2003 and FY equal to the prospective payment rate for the costs instead charges. The commenters
2005. Although a full year of data was DRG, plus any IME and DSH payments, and argued that using a cost inflation
available for FY 2003, we did not have a full any add-on payments for new technology, methodology would have resulted in total
year of FY 2004 data at the time we set the plus $26,675. outlier payment being much closer to 5.1
FY 2005 outlier threshold. Therefore, we For this final rule, we determined the FY percent of total IPPS payments. These
stated that we believed it was optimal to 2006 outlier threshold using the methodology commenters noted that CMS set the outlier
employ comparable periods in determining proposed in the proposed rule, but using threshold using cost inflation from FY 1994
the rate-of-change from one year to the next. updated data. We determined a charge to FY 2002. Using data from the March 31,
We used this methodology for determining inflation factor based on the first six months 2005 HCRIS update and using a cost inflation
the rate-of-change in charges-per-case of FY 2005 relative to same period for FY methodology, the commenter projected an
because it used the most recent charge data 2004. The new outlier policy was in effect for outlier threshold of $22,250. The commenters
available. Using this methodology, we this entire period, so we believe these charge recommended that CMS either return to
established an outlier fixed-loss cost inflation data will project charge inflation using cost inflation or adopt a methodology
threshold for FY 2005 equal to the more accurately than the data that were that takes into account the decline in cost-to-
prospective payment rate for the DRG, plus available when we established the outlier charge ratios as well as increases in charges
any IME and DSH payment, and any add-on thresholds for FYs 2004 and 2005. For this when calculating the outlier threshold.
payment for new technology, plus $25,800. final rule, we had hospital charge According to the commenters these
In the FY 2006 IPPS proposed rule, we information for two full 6-month periods methodologies have proven to be more
proposed to use a refined methodology to (October 1, 2003 through March 31, 2004 and accurate in predicting outlier payments than
calculate the outlier threshold that would October 1, 2004 through March 31, 2005) that the ones used by CMS.
take into account the lower inflation in span only two fiscal years (FY 2004 and FY Some commenters recommended that CMS
hospital charges that is occurring as a result 2005) and fully incorporate implementation consider making mid-year adjustments to the
of the outlier final rule (68 FR 34505, June of the new outlier policy. Using data from outlier threshold if it appears that outlier
9, 2003), which changed our methodology for this period, we determined a charge inflation payments are going to be less than 95 or more
determining outlier payments by factor of 14.94 percent, which is substantially than 105 percent of the 5.1 percent of total
implementing the use of more current and lower than the charge inflation factor of 18.04 IPPS payments. One commenter
recommended that CMS analyze the
accurate cost-to-charge ratios when paying percent in the proposed rule. We used
practicality and effects of making change to
for outliers. As we have done in the past, to updated cost-to-charge ratios from the March
the outlier threshold similar to the market
calculate the FY 2006 outlier threshold, we 2005 update of the Provider Specific File.
basket update forecast error adjustment.
proposed to simulate payments by applying This file includes cost-to-charge ratios taken
Another commenter suggested that CMS
FY 2006 rates and policies using cases from from the most recent tentatively settled cost
recalculate the outlier threshold that would
the FY 2004 MedPAR files. Therefore, in reports of hospitals. have been necessary in FY 2005 for outlier
order to determine the FY 2006 outlier Using this methodology, for FY 2006, we payments to be 5.1 percent of total IPPS
threshold, we proposed to inflate the charges are establishing an outlier fixed-loss cost payments and use that amount as the outlier
on the MedPAR claims by 2 years, from FY threshold equal to the prospective payment threshold for FY 2006.
2004 to FY 2006. rate for the DRG, plus any IME and DSH Response: We appreciate the alternative
However, we did not propose to inflate payments, and any add on payment for new methodologies suggested by the commenters
charges using a 2-year average annual rate-of- technology, plus $23,600. and have considered them carefully.
change in charges-per-case from FY 2002 to Comment: A number of commenters However, as explained above, we determined
FY 2003 and FY 2003 to FY 2004 because of opposed the proposed increase in the outlier the FY 2006 outlier threshold using the
the atypically high rate of hospital charge threshold because outlier payments over the methodology we had proposed in the
inflation during FYs 2002 and 2003. Instead, last several years have been less than the 5.1 proposed rule.
we proposed to use more recent data that percent removed from the standardized While our current estimates are that actual
reflected the rate-of-change in hospital amounts. These commenters requested an outlier payments were less than 5.1 percent
charges under the new outlier policy. explanation of why CMS proposed to of total IPPS payments for both FYs 2004 and
However, we stated we would continue to increase the outlier threshold for FY 2006 2005, we believe that there are special
consider other methodologies in the future when actual outlier payments are projected circumstances that applied in these years that
when calculating the outlier threshold once to be below 5.1 percent for FY 2004 and FY made it especially difficult to project the
we had 2 complete years of charge data under 2005 and result in a savings to Medicare of increase in Medicare charges when
the new outlier policy. $1.4 billion and $600 million for each of calculating the outlier threshold. To calculate
Specifically, we proposed to establish the these respective years. the outlier threshold for FY 2004 we used an
FY 2006 outlier threshold as follows: Using Several commenters suggested an inflation factor of 26.8 percent based on a 2-
the latest data available, we proposed to alternative to the methodology we proposed year average of the rate-of-change in charges
calculate the 1-year average annualized rate- using. These commenters indicated that in from FY 2000 to FY 2002. This high rate of
of-change in charges-per-case from the last addition to inflating charges from FY 2004 to charge inflation coincided with a period
quarter of FY 2003 in combination with the FY 2006, CMS similarly should adjust cost- when Medicare payments for outliers were
first quarter of FY 2004 (July 1, 2003 through to-charge ratios that will be used to calculate substantially in excess of the outlier
December 31, 2003) to the last quarter of FY the FY 2006 outlier threshold. Using cost thresholds for those years (7.7 percent for FY
2004 in combination with the first quarter of report data from the March 31, 2005 update 2001 and 7.8 percent for FY 2002). The actual
FY 2005 (July 1, 2004 through December 31, to HCRIS, the commenters calculated an rate of charge inflation subsided significantly
2004). This rate-of-change was 8.65 percent aggregate annual rate of increase in cost per in FY 2004 after we made significant changes
(1.0865) or 18.04 percent (1.1804) over 2 discharge from 2001–2003 of 6.57 percent. to our outlier policy (68 FR 34494, June 9,
years. As we have done in the past, in Taken together with the 8.65 percent increase 2003). We believe that hospitals changed
establishing the FY 2006 outlier threshold, in charges calculated by CMS in the their charging practices as a result of the
we proposed to use, hospital cost-to-charge proposed rule, the commenter projected a changes. Thus, the projected rate of charge
ratios from the most recent Provider-Specific decline in cost-to-charge ratios and estimated inflation used to set the outlier threshold in
File, which, at the time of the proposed rule an outlier threshold of $24,050 for FY 2006. the IPPS rule for FY 2004 was substantially
was the December 2004 update, in These commenters indicated that, if CMS in excess of the actual rate of charge inflation
establishing the FY 2006 outlier threshold. had applied the commenters’ methodology to during FY 2004
This file includes cost-to-charge ratios that calculate the outlier thresholds for FY 2004 Similarly, it was also difficult to project
reflect implementation of the changes to the and FY 2005 outlier payments would have charge inflation in setting the FY 2005 outlier
threshold using FY 2003 MedPAR data. The charge inflation methodology we used to a given fiscal year continue to be added to
effective date of the outlier final rule was simulate FY 2006 outlier payments, we the MedPAR file some time after the end of
August 8, 2003, almost 2 months before the applied the most recent provider-specific the fiscal year. (We update the MedPAR file
end of FY 2003. Thus, most of the FY 2003 cost-to-charge ratios we had available (which, for 2 full years after the end of the respective
MedPAR data reflected charges from as explained above, in some cases will be the fiscal year.) Therefore, precise figures on
discharges occurring prior to the effective same cost-to-charge ratios fiscal actual outlier payments for a given fiscal year
date of the changes to our outlier policy and intermediaries will use to calculate actual cannot be determined until well after that
other data reflected charges from after the outlier payments during FY 2006) to case- fiscal year ends. As a result, we do not
effective date of the changes. In addition, we specific FY 2004 MedPAR charge data that believe we would have sufficient data in time
used data from the first half of FY 2003 to had been inflated to approximate current to make a meaningful mid-year adjustment to
measure the rate of charge inflation, so all of hospital charge levels. the outlier threshold. We do publish
these data reflected charges from discharges If we estimated FY 2006 outlier payments estimates of ‘‘actual’’ outlier payments for
that occurred prior to the effective date of the using the cost inflation methodology we recent fiscal years, but those estimates are
changes in our outlier policy. employed from FY 1994 to FY 2002, we based on available bills (and sometimes
Therefore, we believe that the charge would apply historical cost-to-charge ratios based on simulations using bills for a
inflation used for setting both the FY 2004 from FY 2004 to FY 2004 MedPAR data and previous year, adjusted for estimates of
and FY 2005 cost thresholds was atypical then inflate the simulated FY 2004 costs inflation).
because of the significant growth in hospital using a cost inflation factor. As a commenter With respect to the commenter’s suggestion
charges in the years preceding the change to pointed out, this methodology would not that we analyze the practicality and effects of
our outlier policy as well as the instability in include an adjustment for the time lag a forecast error adjustment, it is not clear
hospital charging practices that followed the between the historical FY 2004 cost-to-charge how a forecast error adjustment would
adoption of our new outlier policy. ratios and the cost-to-charge ratios fiscal function in the outlier context. However, we
We also carefully analyzed the comments intermediaries will use to calculate actual note that our outlier policy is intended to
suggesting that we also adjust the cost-to- outlier payments in FY 2006. Because our reimburse hospitals for treating
charge ratios that are used in setting the charge inflation methodology simulates extraordinarily costly cases and, under the
outlier thresholds. We believe it is necessary outlier payments using much more recent statute, outlier payments are intended to
to inflate the charges from the FY 2004 cost-to-charge ratios, we believe that our approximate the marginal cost of providing
MedPAR file to project charge levels for FY charge inflation methodology is preferable to care above the outlier fixed-loss cost
2006, but we do not believe it is also the cost inflation methodology suggested by threshold. Any adjustment to the outlier
necessary to adjust the cost-to-charge ratios the commenters. We note that, as hospital threshold or standardized amount in a given
from the March 2005 Provider-Specific File. charging practices stabilize and we gain more year to account for ‘‘overpayments’’ or
‘‘underpayments’’ of outliers in other years
The FY 2004 MedPAR charge data include experience forecasting charge inflation, we
would result in us making outlier payments
charges for dates of service through August expect it will become easier to forecast
that were not directly related to the actual
31, 2003. Although these data are the most outlier payments.
cost of furnishing care in extraordinarily
recent case-specific charge information we As we did in establishing the FY 2005
costly cases.
have available for a complete fiscal year, the outlier threshold (69 FR 49278), in our
In addition, consistent with the policy and
FY 2004 MedPAR charge data are over 2 projection of FY 2006 outlier payments we statutory interpretation we have maintained
years old. We likely would greatly did not make an adjustment for the since the inception of the IPPS, we do not
underestimate FY 2006 outlier payments if possibility that hospitals’ cost-to-charge make retroactive adjustments to outlier
we did not inflate the MedPAR charge data. ratios and outlier payments may be payments to ensure that total outlier
On the other hand, the cost-to-charge ratios reconciled upon cost report settlement. We payments in a past year are equal to 5.1
from the March 2005 Provider-Specific File believe that, due to the policy implemented percent of total DRG payments. In short, we
reflect much more recent hospital-specific in the June 9, 2003 outlier final rule, cost-to- believe our outlier policies are consistent
data than the case-specific data in the FY charge ratios will no longer fluctuate with the statute and the goals of the
2005 MedPAR file. The March 2005 Provider- significantly and, therefore, few hospitals, if prospective payment system.
Specific File includes the cost-to-charge any, will actually have these ratios We finally note that CMS plans on issuing
ratios from hospitals’ most recent tentatively- reconciled upon cost report settlement. In instructions to fiscal intermediaries in the
settled cost report. In many cases, for part of addition, it is difficult to predict which near future that update the policies in the
FY 2006, fiscal intermediaries will determine specific hospitals will have cost-to-charge July 3, 2003 program memorandum (A–03–
actual outlier payment amounts using the ratios and outlier payments reconciled in 058) and detail the specifics of reconciling
same cost-to-charge ratios that are in the their cost reports in any given year. We also outlier payments and other policies related to
March 2005 Provider-Specific File. Fiscal note that reconciliation occurs because outliers.
intermediaries will begin using an updated hospitals’ actual cost-to-charge ratios for the ii. Other changes concerning outliers. As
cost-to-charge ratio to calculate the outlier cost reporting period are different than the stated in the FY 1994 final rule (58 FR 46348,
payments for a hospital only after a more interim cost-to-charge ratios used to calculate September 1, 1993), we establish outlier
recent cost report of the hospital has been outlier payments when a bill is processed. thresholds that are applicable to both
tentatively settled. We note that the cost-to- Our simulations assume that cost-to-charge hospital inpatient operating costs and
charge ratios that we are using from the ratios accurately measure hospital costs and, hospital inpatient capital-related costs. When
March 2005 Provider-Specific File are therefore, are more indicative of post- we modeled the combined operating and
approximately 3 percent lower on average reconciliation than pre-reconciliation outlier capital outlier payments, we found that using
than the cost-to-charge ratios from the payments. As a result, we omitted any a common set of thresholds resulted in a
December 2004 Provider-Specific File that assumptions about the effects of lower percentage of outlier payments for
we used in setting the proposed rule outlier reconciliation from the outlier threshold capital-related costs than for operating costs.
threshold. calculation. We project that the thresholds for FY 2006
In addition, we continue to believe that We also do not believe that a mid-year will result in outlier payments equal to 5.1
using charge inflation, rather than cost adjustment is consistent with the goals of the percent of operating DRG payments and 4.85
inflation, will more likely result in an outlier IPPS. We have responded to similar percent of capital payments based on the
threshold that leads to outlier payments comments a number of times, including the Federal rate.
equaling 5.1 percent of total IPPS payments. final rules for FY 1993 (57 FR 39784), FY In accordance with section 1886(d)(3)(B) of
Our current methodology of estimating 1994 (58 FR 46347), FY 1995 (59 FR 45408), the Act, we reduced the FY 2006
outlier payments more closely captures how FY 1996 (60 FR 45856), and FY 1997 (61 FR standardized amount by the same percentage
actual outlier payment amounts are 46299). to account for the projected proportion of
calculated. Fiscal intermediaries approximate The mid-year adjustments contemplated by payments paid to outliers.
the costs of a case by applying the hospital’s the commenters would be extremely difficult The outlier adjustment factors that will be
cost-to-charge ratio to the total covered or impracticable (if not impossible) to applied to the standardized amount for FY
charges for the case. Similarly, under the administer. Hospital bill data with respect to 2006 are as follows:
Operating standardized amounts Capital Federal rate
National ........................................................................ 0.948990 0.951511

Puerto Rico .................................................................. 0.974897 0.973755
We are applying the outlier adjustment total payments is lower than we projected amount sufficient to account for the added
factors to the FY 2006 rates after removing before FY 2004 (and, thus, is less than the costs of this demonstration. In other words,
the effects of the FY 2005 outlier adjustment percentage by which we reduced the we are applying budget neutrality across the
factors on the standardized amount. standardized amounts for FY 2004). We note payment system as a whole rather than
To determine whether a case qualifies for that, for FY 2005, the outlier threshold was merely across the participants of this
outlier payments, we apply hospital-specific lowered to $25,800 compared to $31,000 for demonstration. We believe that the language
cost-to-charge ratios to the total covered FY 2004. The outlier threshold was lower in of the statutory budget neutrality requirement
charges for the case. Operating and capital FY 2005 than FY 2004 as a result of slower permits the agency to implement the budget
costs for the case are calculated separately by growth in hospital charge inflation. We neutrality provision in this manner. This is
applying separate operating and capital cost- believe that this slower growth was due to because the statutory language requires that
to-charge ratios. These costs are then changes in hospital charge practices ‘‘aggregate payments made by the Secretary
combined and compared with the outlier following implementation of the outlier final do not exceed the amount which the
fixed-loss cost threshold. rule that went into effect on August 9, 2003. Secretary would have paid if the
The outlier final rule (68 FR 34494, June Nevertheless, consistent with the policy and demonstration * * * was not implemented,’’
9, 2003) eliminated the application of the statutory interpretation we have maintained but does not identify the range across which
statewide average cost-to-charge ratios for since the inception of the IPPS, we do not aggregate payments must be held equal.
hospitals whose cost-to-charge ratios fall plan to make retroactive adjustments to
5. FY 2006 Standardized Amount
below 3 standard deviations from the outlier payments to ensure that total outlier
national mean cost-to-charge ratio. However, payments for FY 2004 are equal to 5.1 The adjusted standardized amount is
for those hospitals for which the fiscal percent of total DRG payments. divided into labor-related and nonlabor-
intermediary computes operating cost-to- We currently estimate that actual outlier related portions. Tables 1A and 1B in section
charge ratios greater than 1.254 or capital payments for FY 2005 will be approximately VI. of this Addendum contain the national
cost-to-charge ratios greater than 0.169, or 4.1 percent of actual total DRG payments, 1 standardized amount that we are applying to
hospitals for whom the fiscal intermediary is percentage point lower than the 5.1 percent all hospitals, except hospitals in Puerto Rico.
unable to calculate a cost-to-charge ratio (as we projected in setting the outlier policies for The amounts shown in the two tables differ
described at (412.84(i)(3) of our regulations), FY 2005. This estimate is based on only in that the labor-related share applied to
we are still using statewide average cost-to- simulations using the FY 2004 MedPAR file the standardized amounts in Table 1A is 69.7
charge ratios to determine whether a hospital (discharge data for FY 2004 bills). We used percent, and the labor-related share applied
qualifies for outlier payments.13 Table 8A in these data to calculate an estimate of the to the standardized amounts in Table 1B is
section VI. of this Addendum contains the actual outlier percentage for FY 2005 by 62 percent. In accordance with sections
statewide average operating cost-to-charge applying FY 2005 rates and policies, 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act,
ratios for urban hospitals and for rural including an outlier threshold of $25,800 to we are applying the labor-related share of 62
hospitals for which the fiscal intermediary is available FY 2004 bills. percent, unless the application of that
unable to compute a hospital-specific cost-to- d. Rural Community Hospital percentage would result in lower payments
charge ratio within the above range. Effective Demonstration Program Adjustment (Section to a hospital than would otherwise be made.
for discharges occurring on or after October 410A of Pub. L. 108–173) The effect of this application is that the labor-
1, 2005, these statewide average ratios will Section 410A of Pub. L. 108–173 requires related share of the standardized amount is
replace the ratios published in the IPPS final the Secretary to establish a demonstration 62 percent for all hospitals whose wage
rule for FY 2005 (69 FR 49687). Table 8B in that will modify reimbursement for inpatient indexes are less than or equal to 1.0000. For
section VI. of this Addendum contains the services for up to 15 small rural hospitals. hospitals in Puerto Rico the labor-related
comparable statewide average capital cost-to- Section 410A(c)(2) of Pub. L. 108–173 share of the standardized amount is 58.7
charge ratios. Again, the cost-to-charge ratios requires that ‘‘in conducting the percent for all hospitals whose wage indexes
in Tables 8A and 8B will be used during FY demonstration program under this section, are less than or equal to 1.0000.
2006 when hospital-specific cost-to-charge the Secretary shall ensure that the aggregate As discussed in section IV.B.3. of the
ratios based on the latest settled cost report payments made by the Secretary do not preamble to this final rule (reflecting the
are either not available or are outside the exceed the amount which the Secretary Secretary’s current estimate of the proportion
range noted above. would have paid if the demonstration of costs that are attributable to wages and
iii. FY 2004 and FY 2005 outlier payments. program under this section was not wage-related costs), we are setting the labor-
In the FY 2005 IPPS final rule, we stated that, implemented.’’ As discussed in section V.K. related share of the standardized amount at
based on available data, we estimated that of the preamble to this final rule, we are 69.7 percent for hospitals whose wage
actual FY 2004 outlier payments would be satisfying this requirement by adjusting indexes are greater than 1.0000. For hospitals
approximately 3.6 percent of actual total DRG national IPPS rates by a factor that is in Puerto Rico the labor-related share of the
payments (69 FR 49278, as corrected at 69 FR sufficient to account for the added costs of standardized amount is 62 percent for all
60252). This estimate was computed based this demonstration. We estimate that the hospitals whose wage indexes are greater
on simulations using the FY 2003 MedPAR average additional annual payment that will than 1.0000. In addition, Tables 1A and 1B
file (discharge data for FY 2003 bills). That be made to each participating hospital under include standardized amounts reflecting the
is, the estimate of actual outlier payments did the demonstration will be approximately full 3.7 percent update for FY 2006, and
not reflect actual FY 2004 bills, but instead $977,410. We based this estimate on the standardized amounts reflecting the 0.4
reflected the application of FY 2004 rates and recent historical experience of the difference percentage point reduction to the update
policies to available FY 2003 bills. between inpatient cost and payment for applicable for hospitals that fail to submit
Our current estimate, using available FY hospitals that are participating in the quality data consistent with section 501(b) of
2004 bills, is that actual outlier payments for demonstration. For 13 participating Pub. L. 108–173. (Tables 1C and 1D show the
FY 2004 were approximately 3.52 percent of hospitals, the total annual impact of the standardized amounts for Puerto Rico for FY
actual total DRG payments. Thus, the data demonstration program is estimated to be 2006, reflecting the different labor-related
indicate that, for FY 2004, the percentage of $12,706,334. The required adjustment to the shares that apply, that is, 58.7 percent or 62
actual outlier payments relative to actual Federal rate used in calculating Medicare percent.)
inpatient prospective payments as a result of The following table illustrates the changes
13 These figures represent 3.0 standard deviations the demonstration is 0.999865. from the FY 2005 national average
from the mean of the log distribution of cost-to- In order to achieve budget neutrality, we standardized amount. The first column
charge ratios for all hospitals. are adjusting national IPPS rates by an shows the changes from the FY 2005
standardized amounts for hospitals that average standardized amount after restoring cumulative. Therefore, the FY 2005 factor is
satisfy the quality data submission the FY 2005 offsets for outlier payments, not removed from the amount in the table.
requirement for receiving the full update (3.7 demonstration budget neutrality, the wage We have added separate rows to this table to
percent). The second column shows the index transition budget neutrality and reflect the different labor-related shares that
changes for hospitals receiving the reduced geographic reclassification budget neutrality. apply to hospitals.
update (3.3 percent). The first row of the The DRG reclassification and recalibration
table shows the updated (through FY 2005) and wage index budget neutrality factor is
COMPARISON OF FY 2005 STANDARDIZED AMOUNTS TO FY 2006 SINGLE STANDARDIZED AMOUNT WITH FULL UPDATE
AND REDUCED UPDATE
Full update Reduced update

(3.7 percent) (3.3 percent)
FY 2005 Base Rate, after removing reclassification budget neutrality, demonstration budg- Labor: $3,373.02 ............ Labor: $3,373.02
et neutrality, wage index transition budget neutrality factors and outlier offset (based on Nonlabor: $1,466.32 ...... Nonlabor: $1,466.32
the labor and nonlabor market share percentage for FY 2006).
FY 2006 Update Factor .......................................................................................................... 1.037 .............................. 1.033
FY 2006 DRG Recalibrations and Wage Index Budget Neutrality Factor ............................. 1.002271 ........................ 1.002271
FY 2006 Reclassification Budget Neutrality Factor ................................................................ 0.992521 ........................ 0.992521
Adjusted for Blend of FY 2005 DRG Recalibration and Wage Index Budget Neutrality Fac- Labor: $3,479.54 ............ Labor: $3,466.12
tors. Nonlabor: $1,512.63 ...... Nonlabor: $1,506.79
FY 2006 Outlier Factor ........................................................................................................... 0.94899 .......................... 0.94899
FY 2006 Labor Market Wage Index Transition Budget Neutrality Factor .............................. 0.998859 ........................ 0.998859
Rural Demonstration Budget Neutrality Factor ...................................................................... 0.999865 ........................ 0.999865
Rate for FY 2006 (after multiplying FY 2005 base rate by above factors) where the wage Labor: $2,933.52 ............ Labor: $2,922.20
index is less than or equal to 1.0000. Nonlabor: $1,797.95 ...... Nonlabor: $1,791.02
Rate for FY 2006 (after multiplying FY 2005 base rate by above factors) where the wage Labor: $3,297.84 ............ Labor: $3,285.12
index is greater than 1.0000. Nonlabor: $1,433.63 ...... Nonlabor: $1,482.10
Under section 1886(d)(9)(A)(ii) of the Act, adjusted standardized amounts by the C. DRG Relative Weights
the Federal portion of the Puerto Rico appropriate wage index for the area in which As discussed in section II. of the preamble
payment rate is based on the discharge- the hospital is located. In section III. of the of this final rule, we have developed a
weighted average of the national large urban preamble to this final rule, we discuss the classification system for all hospital
standardized amount (as set forth in Table data and methodology for the FY 2006 wage discharges, assigning them into DRGs, and
1A). The labor-related and nonlabor-related index. The FY 2006 wage indexes are set have developed relative weights for each
portions of the national average standardized forth in Tables 4A, 4B, 4C, and 4F of section DRG that reflect the resource utilization of
amounts for Puerto Rico hospitals are set cases in each DRG relative to Medicare cases
VI. of this Addendum.
forth in Table 1C of section VI. of this in other DRGs. Table 5 of section VI. of this
Addendum. This table also includes the 2. Adjustment for Cost-of-Living in Alaska
Addendum contains the relative weights that
Puerto Rico standardized amounts. The and Hawaii
we are using for discharges occurring in FY
labor-related share applied to the Puerto Rico Section 1886(d)(5)(H) of the Act authorizes 2006. These factors have been recalibrated as
specific standardized amount is 58.7 percent, an adjustment to take into account the explained in section II. of the preamble of
or 62 percent, depending on which is more unique circumstances of hospitals in Alaska this final rule.
advantageous to the hospital. (Section
and Hawaii. Higher labor-related costs for
1886(d)(9)(C)(iv) of the Act, as amended by D. Calculation of Prospective Payment Rates
section 403(b) of Pub. L. 108–173, provides these two States are taken into account in the for FY 2006
that the labor-related share for hospitals in adjustment for area wages described above.
For FY 2006, we are adjusting the payments General Formula for Calculation of
Puerto Rico will be 62 percent, unless the Prospective Payment Rates for FY 2006
application of that percentage would result in for hospitals in Alaska and Hawaii by
lower payments to the hospital.) multiplying the nonlabor-related portion of The operating prospective payment rate for
the standardized amount by the appropriate all hospitals paid under the IPPS located
B. Adjustments for Area Wage Levels and adjustment factor contained in the table outside of Puerto Rico, except SCHs and
Cost-of-Living below. MDHs, equals the Federal rate based on the
Tables 1A through 1C, as set forth in corresponding amounts in Table 1A or Table
section VI. of this Addendum, contain the 1B in section VI. of this Addendum.
TABLE OF COST-OF-LIVING ADJUST- The prospective payment rate for SCHs
labor-related and nonlabor-related shares that
we are using to calculate the prospective MENT FACTORS, ALASKA AND HAWAII equals the higher of the applicable Federal
payment rates for hospitals located in the 50 HOSPITALS rate (from Table 1A or Table 1B) or the
States, the District of Columbia, and Puerto hospital-specific rate as described below. The
Rico. This section addresses two types of Cost of living prospective payment rate for MDHs equals
adjustments to the standardized amounts that Area Adjustment the higher of the Federal rate, or the Federal
are made in determining the prospective factor rate plus 50 percent of the difference between
payment rates as described in this the Federal rate and the hospital-specific rate
Addendum. Alaska—All areas ........... 1.25 as described below. The prospective payment
Hawaii: rate for Puerto Rico equals 25 percent of the
1. Adjustment for Area Wage Levels
County of Honolulu ..... 1.25 Puerto Rico rate from Table 1C in section VI.
Sections 1886(d)(3)(E) and County of Hawaii ......... 1.165 Of this addendum plus 75 percent of the
1886(d)(9)(C)(iv) of the Act require that we County of Kauai .......... 1.2325 applicable national rate from Table 1A or
make an adjustment to the labor-related County of Maui ............ 1.2375 Table 1B in section VI. of this Addendum.
portion of the national and Puerto Rico
County of Kalawao ...... 1.2375 1. Federal Rate
prospective payment rates, respectively, to
account for area differences in hospital wage (The above factors are based on data ob- For discharges occurring on or after
levels. This adjustment is made by tained from the U.S. Office of Personnel October 1, 2005 and before October 1, 2006,
multiplying the labor-related portion of the Management.) except for SCHs, MDHs, and hospitals in
Puerto Rico, payment under the IPPS is based the preamble to this final rule. The resulting III. Changes to Payment Rates for Acute Care
exclusively on the Federal rate. rate is used in determining the payment rate Hospital Inpatient Capital-Related Costs for
The Federal rate is determined as follows: an SCH or MDH will receive for its FY 2006
Step 1—Select the appropriate average discharges beginning on or after October 1, The PPS for acute care hospital inpatient
standardized amount considering the 2005. capital-related costs was implemented for
applicable wage index (Table 1A for wage cost reporting periods beginning on or after
indexes greater than 1.0000 and Table 1B for b. Updating the FY 1982, FY 1987, and FY
1996 Hospital-Specific Rates for FY 2005 October 1, 1991. Effective with that cost
wage indexes less than or equal to 1.0000) reporting period, hospitals were paid during
and whether the hospital has submitted We are increasing the hospital-specific
a 10-year transition period (which extended
qualifying quality data (full update for rates by 3.7 percent (the hospital market
through FY 2001) to change the payment
qualifying hospitals, update minus 0.4 basket percentage increase) for SCHs and
methodology for Medicare acute care hospital
percentage points for nonqualifying MDHs for FY 2006. Section 1886(b)(3)(C)(iv)
inpatient capital-related costs from a
hospitals). of the Act provides that the update factor
reasonable cost-based methodology to a
Step 2—Multiply the labor-related portion applicable to the hospital-specific rates for
prospective methodology (based fully on the
of the standardized amount by the applicable SCHs is equal to the update factor provided
Federal rate).
wage index for the geographic area in which under section 1886(b)(3)(B)(iv) of the Act,
The basic methodology for determining
the hospital is located or the area to which which, for SCHs in FY 2006, is the market
Federal capital prospective rates is set forth
the hospital is reclassified (see Tables 4A, 4B, basket rate of increase. Section 1886(b)(3)(D)
in regulations at §§ 412.308 through 412.352.
and 4C of section VI. of this Addendum). of the Act provides that the update factor
Below we discuss the factors that we are
Step 3—For hospitals in Alaska and applicable to the hospital-specific rates for
using to determine the capital Federal rate for
Hawaii, multiply the nonlabor-related MDHs also equals the update factor provided
FY 2006, which will be effective for
portion of the standardized amount by the under section 1886(b)(3)(B)(iv) of the Act,
discharges occurring on or after October 1,
appropriate cost-of-living adjustment factor. which, for FY 2006, is the market basket rate-
2005. The 10-year transition period ended
Step 4—Add the amount from Step 2 and of-increase.
with hospital cost reporting periods
the nonlabor-related portion of the 3. General Formula for Calculation of beginning on or after October 1, 2001 (FY
standardized amount (adjusted, if Prospective Payment Rates for Hospitals 2002). Therefore, for cost reporting periods
appropriate, under Step 3). Located in Puerto Rico Beginning On or After beginning in FY 2002, all hospitals (except
Step 5—Multiply the final amount from October 1, 2005 and Before October 1, 2006 ‘‘new’’ hospitals under § 412.304(c)(2)) are
Step 4 by the relative weight corresponding paid based on 100 percent of the capital
to the appropriate DRG (see Table 5 of Under section 504 of Pub. L. 108–173,
effective for discharges occurring on or after Federal rate. For FY 1992, we computed the
section VI. of this Addendum). standard Federal payment rate for capital-
The Federal rate as determined in Step 5 October 1, 2004, hospitals located in Puerto
Rico are paid based on a blend of 75 percent related costs under the IPPS by updating the
may then be further adjusted if the hospital FY 1989 Medicare inpatient capital cost per
qualifies for either the IME or DSH of the national prospective payment rate and
25 percent of the Puerto Rico-specific rate. case by an actuarial estimate of the increase
adjustment. in Medicare inpatient capital costs per case.
2. Hospital-Specific Rate (Applicable Only to a. Puerto Rico Rate Each year after FY 1992, we update the
SCHs and MDHs) The Puerto Rico prospective payment rate capital standard Federal rate, as provided at
is determined as follows: § 412.308(c)(1), to account for capital input
a. Calculation of Hospital-Specific Rate
Step 1—Select the appropriate average price increases and other factors. The
Section 1886(b)(3)(C) of the Act provides standardized amount considering the regulations at § 412.308(c)(2) provide that the
that SCHs are paid based on whichever of the applicable wage index (see Table 1C). capital Federal rate is adjusted annually by
following rates yields the greatest aggregate Step 2—Multiply the labor-related portion a factor equal to the estimated proportion of
payment: the Federal rate; the updated of the standardized amount by the outlier payments under the capital Federal
hospital-specific rate based on FY 1982 costs appropriate Puerto Rico-specific wage index rate to total capital payments under the
per discharge; the updated hospital-specific (see Table 4F of section VI. of the capital Federal rate. In addition,
rate based on FY 1987 costs per discharge; or Addendum). § 412.308(c)(3) requires that the capital
the updated hospital-specific rate based on Step 3—Add the amount from Step 2 and Federal rate be reduced by an adjustment
FY 1996 costs per discharge. the nonlabor-related portion of the factor equal to the estimated proportion of
Section 1886(d)(5)(G) of the Act provides standardized amount. payments for (regular and special) exceptions
that MDHs are paid based on whichever of Step 4—Multiply the amount from Step 3 under § 412.348. Section 412.308(c)(4)(ii)
the following rates yields the greatest by the appropriate DRG relative weight Step requires that the capital standard Federal rate
aggregate payment: the Federal rate or the 5—Multiply the result in Step 4 by 25 be adjusted so that the effects of the annual
Federal rate plus 50 percent of the difference percent (see Table 5 of section VI. of the DRG reclassification and the recalibration of
between the Federal rate and the greater of Addendum). DRG weights and changes in the geographic
the updated hospital-specific rates based on adjustment factor are budget neutral.
either FY 1982 or FY 1987 costs per b. National Rate For FYs 1992 through 1995, § 412.352
discharge. MDHs do not have the option to The national prospective payment rate is required that the capital Federal rate also be
use their FY 1996 hospital-specific rate. determined as follows: adjusted by a budget neutrality factor so that
Hospital-specific rates have been Step 1—Select the appropriate average aggregate payments for inpatient hospital
determined for each of these hospitals based standardized amount considering the capital costs were projected to equal 90
on the FY 1982 costs per discharge, the FY applicable wage index (see Table 1C). percent of the payments that would have
1987 costs per discharge, or, for SCHs, the FY Step 2—Add the amount from Step 1 and been made for capital-related costs on a
1996 costs per discharge. For a more detailed the nonlabor-related portion of the national reasonable cost basis during the fiscal year.
discussion of the calculation of the hospital- average standardized amount. That provision expired in FY 1996. Section
specific rates, we refer the reader to the FY Step 3—Multiply the amount from Step 2 412.308(b)(2) describes the 7.4 percent
1984 IPPS interim final rule (September 1, by the appropriate DRG relative weight (see reduction to the capital rate that was made
1983, 48 FR 39772); the April 20, 1990 final Table 5 of section VI. of the Addendum). in FY 1994, and § 412.308(b)(3) describes the
rule with comment (55 FR 15150); the FY Step 4—Multiply the result in Step 3 by 75 0.28 percent reduction to the capital rate
1991 IPPS final rule (September 4, 1990, 55 percent. made in FY 1996 as a result of the revised
FR 35994); and the FY 2001 IPPS final rule The sum of the Puerto Rico rate and the policy of paying for transfers. In FY 1998, we
(August 1, 2000, 65 FR 47082). In addition, national rate computed above equals the implemented section 4402 of Pub. L. 105–33,
for both SCHs and MDHs, the hospital- prospective payment for a given discharge for which required that, for discharges occurring
specific rate is adjusted by the budget a hospital located in Puerto Rico. This rate on or after October 1, 1997, and before
neutrality adjustment factor (that is, by the may then be further adjusted if the hospital October 1, 2002, the unadjusted capital
recalibration budget neutrality factor of qualifies for either the IME or DSH standard Federal rate is reduced by 17.78
0.998993) as discussed in section V.C.2. of adjustment. percent. As we discussed in the FY 2003
IPPS final rule (67 FR 50102) and hospitals from 50 percent to 62.5 percent and forecasts. The update factor for FY 2006
implemented in § 412.308(b)(6)), a small part decreased the Puerto Rico portion of the under that framework is 0.8 percent based on
of that reduction was restored effective operating IPPS payments from 50 percent to the best data available at this time. The
October 1, 2002. 37.5 percent for discharges occurring on or update factor is based on a projected 0.8
To determine the appropriate budget after April 1, 2004 through September 30, percent increase in the CIPI, a 0.0 percent
neutrality adjustment factor and the regular 2004 (see the March 26, 2004 One-Time adjustment for intensity, a 0.0 percent
exceptions payment adjustment during the Notification (Change Request 3158)). In adjustment for case-mix, a 0.0 percent
10-year transition period, we developed a addition, section 504 of Pub. L. 108–173 adjustment for the FY 2004 DRG
dynamic model of Medicare inpatient provided that the national portion of reclassification and recalibration, and a
capital-related costs; that is, a model that operating IPPS payments for Puerto Rico forecast error correction of 0.0 percent. As
projected changes in Medicare inpatient hospitals is equal to 75 percent and the discussed below in section III.C. of this
capital-related costs over time. With the Puerto Rico portion of operating IPPS Addendum, we believe that the CIPI is the
expiration of the budget neutrality provision, payments is equal to 25 percent for most appropriate input price index for
the capital cost model was only used to discharges occurring on or after October 1, capital costs to measure capital price changes
estimate the regular exceptions payment 2004. Consistent with that change in in a given year. We also explain the basis for
adjustment and other factors during the operating IPPS payments to hospitals in the FY 2006 CIPI projection in that same
transition period. As we explained in the FY Puerto Rico, for FY 2005 (as we discussed in section of this Addendum. Below we
2002 IPPS final rule (66 FR 39911), beginning the FY 2005 IPPS final rule), we revised the describe the policy adjustments that have
in FY 2002, an adjustment for regular methodology for computing capital payments been applied.
exception payments is no longer necessary to hospitals located in Puerto Rico to be The case-mix index is the measure of the
because regular exception payments were based on a blend of 25 percent of the Puerto average DRG weight for cases paid under the
only made for cost reporting periods Rico capital rate and 75 percent of the capital IPPS. Because the DRG weight determines
beginning on or after October 1, 1991, and Federal rate for discharges occurring on or the prospective payment for each case, any
before October 1, 2001 (see § 412.348(b)). after October 1, 2004. percentage increase in the case-mix index
Because, effective with cost reporting periods corresponds to an equal percentage increase
A. Determination of Federal Hospital
beginning in FY 2002, payments are no in hospital payments.
Inpatient Capital-Related Prospective
longer being made under the regular The case-mix index can change for any of
Payment Rate Update
exception policy, we no longer use the several reasons:
capital cost model. The capital cost model In the FY 2005 IPPS final rule (69 FR • The average resource use of Medicare
and its application during the transition 49283) and corrected in a December 30, 2004 patients changes (‘‘real’’ case-mix change);
period are described in Appendix B of the FY correction notice (69 FR 78532), we • Changes in hospital coding of patient
2002 IPPS final rule (66 FR 40099). established a capital Federal rate of $416.53 records result in higher weight DRG
Section 412.374 provides for the use of a for FY 2005. In the discussion that follows, assignments (‘‘coding effects’’); and
blended payment system for payments to we explain the factors that were used to • The annual DRG reclassification and
Puerto Rico hospitals under the PPS for acute determine the FY 2006 capital Federal rate. recalibration changes may not be budget
care hospital inpatient capital-related costs. In particular, we explain why the FY 2006 neutral (‘‘reclassification effect’’).
Accordingly, under the capital PPS, we capital Federal rate will increase We define real case-mix change as actual
compute a separate payment rate specific to approximately 1.0 percent compared to the changes in the mix (and resource
Puerto Rico hospitals using the same FY 2005 capital Federal rate. We also requirements) of Medicare patients as
methodology used to compute the national estimate aggregate capital payments will opposed to changes in coding behavior that
Federal rate for capital-related costs. In increase by 0.6 percent during this same result in assignment of cases to higher
accordance with section 1886(d)(9)(A) of the period. This increase is due to several factors, weighted DRGs but do not reflect higher
Act, under the IPPS for acute care hospital including the update to the capital Federal resource requirements. The capital update
operating costs, hospitals located in Puerto rate (discussed in section III.A.1.a. of this framework includes the same case-mix index
Rico are paid for operating costs under a Addendum) and a projected increase in adjustment used in the former operating IPPS
special payment formula. Prior to FY 1998, outlier payments. We are projecting a slight update framework (as discussed in the May
hospitals in Puerto Rico were paid a blended increase in capital outlier payments as a 18, 2005 IPPS proposed rule for FY 2005 (69
operating rate that consisted of 75 percent of result of the decrease in the outlier FR 28816)). (We are no longer using an
the applicable standardized amount specific thresholds (as discussed in section II.A.4.c. update framework in making a
to Puerto Rico hospitals and 25 percent of the this Addendum). Thus, we are projecting that recommendation for updating the operating
applicable national average standardized capital PPS payments will increase slightly IPPS standardized amounts as discussed in
amount. Similarly, prior to FY 1998, from FY 2005 to FY 2006. section III. of Appendix B of this final rule.)
hospitals in Puerto Rico were paid a blended Total payments to hospitals under the IPPS For FY 2006, we are projecting a 1.0
capital rate that consisted of 75 percent of the are relatively unaffected by changes in the percent total increase in the case-mix index.
applicable capital Puerto Rico specific rate capital prospective payments. Since capital We estimate that the real case-mix increase
and 25 percent of the applicable capital payments constitute about 10 percent of will also equal 1.0 percent in FY 2006. The
Federal rate. However, effective October 1, hospital payments, a 1-percent change in the net adjustment for change in case-mix is the
1997, in accordance with section 4406 of capital Federal rate yields only about 0.1 difference between the projected increase in
Pub. L. 105–33, operating payments to percent change in actual payments to case-mix and the projected total increase in
hospitals in Puerto Rico were revised to be hospitals. Aggregate payments under the case-mix. Therefore, the net adjustment for
based on a blend of 50 percent of the capital IPPS are estimated to increase slightly case-mix change in FY 2006 is 0.0 percentage
applicable standardized amount specific to in FY 2006 compared to FY 2005, as points.
Puerto Rico hospitals and 50 percent of the discussed above. The capital update framework also
applicable national average standardized 1. Projected Capital Standard Federal Rate contains an adjustment for the effects of DRG
amount. In conjunction with this change to Update reclassification and recalibration. This
the operating blend percentage, effective with adjustment is intended to remove the effect
discharges occurring on or after October 1, a. Description of the Update Framework on total payments of prior year changes to the
1997, we also revised the methodology for Under § 412.308(c)(1), the capital standard DRG classifications and relative weights, in
computing capital payments to hospitals in Federal rate is updated on the basis of an order to retain budget neutrality for all case-
Puerto Rico to be based on a blend of 50 analytical framework that takes into account mix index-related changes other than those
percent of the Puerto Rico capital rate and 50 changes in a capital input price index (CIPI) due to patient severity. Due to the lag time
percent of the capital Federal rate. and several other policy adjustment factors. in the availability of data, there is a 2-year
As we discussed in the FY 2005 IPPS final Specifically, we have adjusted the projected lag in data used to determine the adjustment
rule (69 FR 49185), section 504 of Pub. L. CIPI rate-of-increase as appropriate each year for the effects of DRG reclassification and
108–173 increased the national portion of the for case-mix index-related changes, for recalibration. For example, we are adjusting
operating IPPS payments for Puerto Rico intensity, and for errors in previous CIPI for the effects of the FY 2004 DRG
reclassification and recalibration as part of estimates of the proportions of the overall FY 2004 IPPS final rule (68 FR 45482) and
our update for FY 2006. We estimate that FY annual intensity increases that are due, the FY 2005 IPPS final rule (69 FR 49285),
2004 DRG reclassification and recalibration respectively, to ineffective practice patterns respectively. If hospitals were treating new or
will result in a 0.0 percent change in the and to the combination of quality-enhancing different types of cases, which would result
case-mix when compared with the case-mix new technologies and within-DRG in an appropriate increase in charges per
index that would have resulted if we had not complexity, we assume, as in the operating discharge, then we would expect hospitals’
made the reclassification and recalibration update framework, that one-half of the case-mix to increase proportionally.
changes to the DRGs. Therefore, we are annual increase is due to each of these As we discussed in the FY 2005 IPPS final
making a 0.0 percent adjustment for DRG factors. The capital update framework thus rule (69 FR 49285), because our intensity
reclassification and recalibration in the provides an add-on to the input price index calculation relies heavily upon charge data
update for FY 2006 to maintain budget rate of increase of one-half of the estimated and we believe that these charge data may be
neutrality. annual increase in intensity, to allow for inappropriately skewed, we established a 0.0
The capital update framework also within-DRG severity increases and the percent adjustment for intensity for FY 2005.
contains an adjustment for forecast error. The adoption of quality-enhancing technology. We believed that it was appropriate to apply
input price index forecast is based on We have developed a Medicare-specific a zero intensity adjustment until we believe
historical trends and relationships intensity measure based on a 5-year average. that any increase in charges can be tied to
ascertainable at the time the update factor is Past studies of case-mix change by the RAND intensity rather than to attempts to maximize
established for the upcoming year. In any Corporation (Has DRG Creep Crept Up? outlier payments. As discussed above, we
given year, there may be unanticipated price Decomposing the Case Mix Index Change believe that the most recently available
fluctuations that may result in differences Between 1987 and 1988’’ by G. M. Carter, J. charge data used to make this determination
between the actual increase in prices and the P. Newhouse, and D. A. Relles, R–4098– may still be inappropriately skewed.
forecast used in calculating the update HCFA/ProPAC (1991)) suggest that real case- Accordingly, in the FY 2006 IPPS proposed
factors. In setting a prospective payment rate mix change was not dependent on total rule (70 FR 23476), we proposed a 0.0
under the framework, we make an change, but was usually a fairly steady 1.0 to percent adjustment for intensity for FY 2006.
adjustment for forecast error only if our 1.4 percent per year. We use 1.4 percent as As we explained in that same proposed rule,
estimate of the change in the capital input the upper bound because the RAND study in the past (FYs 1996 through 2001) when we
price index for any year is off by 0.25 did not take into account that hospitals may found intensity to be declining, we believed
percentage points or more. There is a 2-year have induced doctors to document medical a zero (rather than negative) intensity
lag between the forecast and the records more completely in order to improve adjustment was appropriate. Similarly, we
measurement of the forecast error. A forecast payment. believe that it is appropriate to apply a zero
error of ¥0.1 percentage points was We calculate case-mix constant intensity as intensity adjustment for FY 2006 until any
calculated for the FY 2004 update. That is, the change in total charges per admission, increase in charges can be tied to intensity
current historical data indicate that the adjusted for price level changes (the CPI for rather than to attempts to maximize outlier
forecasted FY 2004 CIPI used in calculating hospital and related services), and changes in payments. Therefore, in this final rule, we are
the FY 2004 update factor (0.7 percent) real case-mix. As we noted above, in establishing a 0.0 percent adjustment for
slightly overstated the actual realized price accordance with § 412.308(c)(1)(ii), we began intensity for FY 2006.
increases (0.6 percent) by 0.1 percentage updating the capital standard Federal rate in Above we described the basis of the
points. This slight overprediction was mostly FY 1996 using an update framework that components used to develop the 0.8 percent
due to a prediction of the cuts in the interest takes into account, among other things, capital update factor for FY 2006 as shown
rate by the Federal Reserve Board in 2004. allowable changes in the intensity of hospital in the table below.
However, the Federal Reserve Board did not services. For FYs 1996 through 2001, we
cut interest rates during 2004, which found that case-mix constant intensity was CMS FY 2006 UPDATE FACTOR TO
impacted the interest component of the CIPI. declining and we established a 0.0 percent
THE CAPITAL FEDERAL RATE
However, since this estimation of the change adjustment for intensity in each of those
in the CIPI is less than 0.25 percentage years. For FYs 2002 and 2003, we found that
points, it is not reflected in the update case-mix constant intensity was increasing Capital Input Price Index .................... 0.8
recommended under this framework. and we established a 0.3 percent adjustment Intensity .............................................. 0.0
Therefore, we are making a 0.0 percent and 1.0 percent adjustment for intensity, Case-Mix Adjustment Factors:
adjustment for forecast error in the update for respectively. For FYs 2004 and 2005, we Real Across DRG Change .......... 1.0
FY 2006. found that the charge data appeared to be Projected Case-Mix Change ....... ¥1.0
Under the capital IPPS update framework, skewed (as discussed in greater detail below)
we also make an adjustment for changes in and we established a 0.0 percent adjustment Subtotal ................................ 0.0
intensity. We calculate this adjustment using in each of those years. Furthermore, we Effect of FY 2004 Reclassification
the same methodology and data that were stated that we would continue to apply a 0.0 and Recalibration ............................ 0.0
used in the framework used in the past under percent adjustment for intensity until any Forecast Error Correction ................... 0.0
the operating IPPS. The intensity factor for increase in charges can be tied to intensity
Total Update ......................... 0.8
the operating update framework reflects how rather than attempts to maximize outlier
hospital services are utilized to produce the payments.
final product, that is, the discharge. This Using the methodology described above, b. Comparison of CMS and MedPAC Update
component accounts for changes in the use for FY 2006 we examined the change in total Recommendation
of quality-enhancing services, for changes in charges per admission, adjusted for price As we discussed in the FY 2006 IPPS
within-DRG severity, and for expected level changes (the CPI for hospital and proposed rule (70 FR 23477), in the past,
modification of practice patterns to remove related services), and changes in real case- MedPAC has included update
noncost-effective services. mix for FYs 1999 through 2004. We found recommendations for capital PPS in a Report
We calculate case-mix constant intensity as that, over this period and in particular the to Congress. In its March 2005 Report to
the change in total charges per admission, last 4 years of this period (FYs 2000 through Congress, MedPAC did not make an update
adjusted for price level changes (the CPI for 2003), the charge data appear to be skewed. recommendation for capital PPS payments
hospital and related services) and changes in More specifically, we found a dramatic for FY 2006. However, in that same report,
real case-mix. The use of total charges in the increase in hospital charges for FYs 2000 MedPAC made an update recommendation
calculation of the intensity factor makes it a through 2004 without a corresponding for hospital inpatient and outpatient services
total intensity factor; that is, charges for increase in the hospital case-mix index. (page 40). MedPAC reviews inpatient and
capital services are already built into the These findings are similar to the considerable outpatient services together since they are so
calculation of the factor. Therefore, we have increase in hospitals’ charges, which we closely interrelated. MedPAC recommended
incorporated the intensity adjustment from found when we were determining the an increase in the payment rate for the
the operating update framework into the intensity factor in the FY 2004 and FY 2005 operating IPPS by the projected increase in
capital update framework. Without reliable update recommendations as discussed in the the hospital market basket index, less 0.4
percent for FY 2006, based on their 3. Budget Neutrality Adjustment Factor for on the FY 2006 relative weights and the FY
assessment of beneficiaries’ access to care, Changes in DRG Classifications and Weights 2006 GAF. As we established in the FY 2005
volume of services, access to capital, quality and the GAF IPPS final rule (69 FR 49287), the budget
of care, and the relationship of Medicare Section 412.308(c)(4)(ii) requires that the neutrality factors were 0.9914 for the national
payments and costs. In addition, the capital Federal rate be adjusted so that capital rate and 0.9895 for the Puerto Rico
Commission considered the efficient aggregate payments for the fiscal year based capital rate for discharges occurring on or
provision of services in making its FY 2006 on the capital Federal rate after any changes after October 1, 2004, through December 31,
update recommendations. (MedPAC’s Report resulting from the annual DRG 2004 (the first quarter of FY 2005). As a result
to the Congress: Medicare Payment Policy, reclassification and recalibration and changes of the corrections to the FY 2005 GAF values
March 2005, page 44.) in the GAF are projected to equal aggregate established in the December 30, 2004
2. Outlier Payment Adjustment Factor payments that would have been made on the correction notice (69 FR 78531), effective for
basis of the capital Federal rate without such January 1, 2005, through September 30, 2005
Section 412.312(c) establishes a unified changes. (the last three quarters of FY 2005), the
outlier methodology for inpatient operating Since we implemented a separate GAF for budget neutrality factor for the national
and inpatient capital-related costs. A single Puerto Rico, we apply separate budget capital rate is 0.9912 and the budget
set of thresholds is used to identify outlier neutrality adjustments for the national GAF neutrality factor for the Puerto Rico capital
cases for both inpatient operating and and the Puerto Rico GAF. We apply the same rate remained unchanged (0.9895). For FY
inpatient capital-related payments. Section budget neutrality factor for DRG 2005, the weighted average budget neutrality
412.308(c)(2) provides that the standard reclassifications and recalibration nationally adjustment factors were 0.9912 (0.9914 × 1⁄4
Federal rate for inpatient capital-related costs and for Puerto Rico. Separate adjustments + 0.9912 × 3⁄4) for the national capital rate
be reduced by an adjustment factor equal to were unnecessary for FY 1998 and earlier (calculations were done on unrounded
the estimated proportion of capital related because the GAF for Puerto Rico was numbers) and 0.9895 for the Puerto Rico
outlier payments to total inpatient capital- implemented in FY 1998. capital rate. In making the comparison, we
related PPS payments. The outlier thresholds In the past, we used the actuarial capital set the regular and special exceptions
are set so that operating outlier payments are cost model (described in Appendix B of the reduction factors to 1.00. To achieve budget
projected to be 5.1 percent of total operating FY 2002 IPPS final rule (66 FR 40099)) to
neutrality for the changes in the national
DRG payments. estimate the aggregate payments that would
GAF, based on calculations using updated
In the FY 2005 IPPS final rule (69 FR have been made on the basis of the capital
data, we are applying an incremental budget
49286), we estimate that outlier payments for Federal rate with and without changes in the
neutrality adjustment of 1.0019 for FY 2006
capital will equal 4.94 percent of inpatient DRG classifications and weights and in the
GAF to compute the adjustment required to to the weighted average of the previous
capital-related payments based on the capital cumulative FY 2005 adjustments of 0.9912
maintain budget neutrality for changes in
Federal rate in FY 2005. Based on the (yielding an adjustment of 0.9931) through
DRG weights and in the GAF. During the
thresholds as set forth in section II.A.4.c. of FY 2006 (calculations done on unrounded
transition period, the capital cost model was
this Addendum, we estimate that outlier numbers). For the Puerto Rico GAF, we are
also used to estimate the regular exception
payments for capital will equal 4.85 percent applying an incremental budget neutrality
payment adjustment factor. As we explain in
for inpatient capital-related payments based section III.A.4. of this Addendum, beginning adjustment of 1.0076 for FY 2006 to the
on the Federal rate in FY 2006. Therefore, we in FY 2002, an adjustment for regular previous cumulative FY 2005 adjustment of
are applying an outlier adjustment factor of exception payments is no longer necessary. 0.9895, yielding a cumulative adjustment of
0.9515 to the capital Federal rate. Thus, the Therefore, we are no longer using the capital 0.9970 through FY 2006.
percentage of capital outlier payments to cost model. Instead, we are using historical We then compared estimated aggregate
total capital standard payments for FY 2006 data based on hospitals’ actual cost capital Federal rate payments based on the
will be lower than the percentages for FY experiences to determine the exceptions FY 2005 DRG relative weights and the
2005. payment adjustment factor for special average FY 2005 GAF to estimated aggregate
The outlier reduction factors are not built exceptions payments. capital Federal rate payments based on the
permanently into the capital rates; that is, To determine the factors for FY 2006, we FY 2006 DRG relative weights and the FY
they are not applied cumulatively in compared (separately for the national capital 2006 GAF. The incremental adjustment for
determining the capital Federal rate. The FY rate and the Puerto Rico capital rate) DRG classifications and changes in relative
2006 outlier adjustment of 0.9515 is a 0.09 estimated aggregate capital Federal rate weights is 0.9989 both nationally and for
percent change from the FY 2005 outlier payments based on the FY 2005 DRG relative Puerto Rico. The cumulative adjustments for
adjustment of 0.9506. The net change in the weights and the average FY 2005 GAF (that DRG classifications and changes in relative
outlier adjustment to the capital Federal rate is, the weighted average of the GAFs applied weights and for changes in the GAF through
for FY 2006 is 1.0009 (0.9515/0.9506). Thus, from October 2004 through December 2004 FY 2005 are 0.9920 nationally and 9.9959 for
the outlier adjustment increases the FY 2006 and the GAFs applied from January 2005 Puerto Rico. The following table summarizes
capital Federal rate by 0.09 percent compared through September 2005) to estimated the adjustment factors for each fiscal year:
with the FY 2005 outlier adjustment. aggregate capital Federal rate payments based BILLING CODE 4120–01–P
The methodology used to determine the in the hospital wage index and the DRG payment parameters, such as the payments
recalibration and geographic (DRG/GAF) relative weights. Under the capital PPS, there for serving low-income patients, indirect
budget neutrality adjustment factor for FY is a single DRG/GAF budget neutrality medical education payments, or the large
2006 is similar to that used in establishing adjustment factor (the national capital rate urban add-on payments.
budget neutrality adjustments under the PPS and the Puerto Rico capital rate are In the FY 2005 IPPS final rule (69 FR
for operating costs. One difference is that, determined separately) for changes in the 49288), we calculated a GAF/DRG budget
under the operating PPS, the budget GAF (including geographic reclassification) neutrality factor of 1.0006 for FY 2005. As we
neutrality adjustments for the effect of and the DRG relative weights. In addition, noted above, as a result of the revisions to the
geographic reclassifications are determined there is no adjustment for the effects that GAF effective for discharges occurring on or
ER12AU05.004</GPH>
separately from the effects of other changes geographic reclassification has on the other after January 1, 2005, established in the
December 30, 2004 correction notice (69 FR accordance with § 412.308(c), we still need to The exceptions adjustment factor for FY 2006
78351), we calculated a GAF/DRG budget compute a budget neutrality adjustment for is 0.01 percent higher than the factor for FY
neutrality factor of 1.0004 for discharges special exception payments under 2005 published in the FY 2005 IPPS final
occurring in the remainder of FY 2005. For § 412.348(g). We describe our methodology rule (69 FR 49288). The exceptions reduction
FY 2006, we are establishing a GAF/DRG for determining the special exceptions factors are not built permanently into the
budget neutrality factor of 1.0008. The GAF/ adjustment used in calculating the FY 2006 capital rates; that is, the factors are not
DRG budget neutrality factors are built capital Federal rate below. applied cumulatively in determining the
permanently into the capital rates; that is, Under the special exceptions provision capital Federal rate. Therefore, the net
they are applied cumulatively in determining specified at § 412.348(g)(1), eligible hospitals change in the exceptions adjustment factor
the capital Federal rate. This follows from the include SCHs, urban hospitals with at least
used in determining the FY 2006 capital
requirement that estimated aggregate 100 beds that have a disproportionate share
Federal rate is 1.0001 (0.9997/0.9996).
payments each year be no more or less than percentage of at least 20.2 percent or qualify
they would have been in the absence of the for DSH payments under § 412.106(c)(2), and 5. Capital Standard Federal Rate for FY 2006
annual DRG reclassification and recalibration hospitals with a combined Medicare and In the FY 2005 IPPS final rule (69 FR
and changes in the GAF. The incremental Medicaid inpatient utilization of at least 70 49283) and corrected in a December 30, 2004
change in the adjustment from the average percent. An eligible hospital may receive correction notice (69 FR 78532), we
from FY 2005 to FY 2006 is 1.0008. The special exceptions payments if it meets (1) a established a capital Federal rate of $416.53
cumulative change in the capital Federal rate project need requirement as described at for FY 2005. In this final rule, we are
due to this adjustment is 0.9920 (the product § 412.348(g)(2), which, in the case of certain
establishing a capital Federal rate of $420.65
of the incremental factors for FYs 1993 urban hospitals, includes an excess capacity
for FY 2006. The capital Federal rate for FY
though 2005 and the incremental factor of test as described at § 412.348(g)(4); (2) an age
2006 was calculated as follows:
1.0008 for FY 2006). (We note that averages of assets test as described at § 412.348(g)(3);
and (3) a project size requirement as • The FY 2006 update factor is 1.0080; that
of the incremental factors that were in effect is, the update is 0.8 percent.
during FYs 2004 and 2005, respectively, were described at § 412.348(g)(5).
Based on information compiled from our • The FY 2006 budget neutrality
used in the calculation of the cumulative
fiscal intermediaries, six hospitals have adjustment factor that is applied to the
adjustment of 0.9920 for FY 2006.)
qualified for special exceptions payments capital standard Federal payment rate for
This factor accounts for DRG
reclassifications and recalibration and for under § 412.348(g). Since we have cost changes in the DRG relative weights and in
changes in the GAF. It also incorporates the reports ending in FY 2004 for all of these the GAF is 1.0008.
effects on the GAF of FY 2006 geographic hospitals, we calculated the adjustment • The FY 2006 outlier adjustment factor is
reclassification decisions made by the based on actual cost experience. Using data 0.95150.
MGCRB compared to FY 2005 decisions. from cost reports ending in FY 2004 from the • The FY 2006 (special) exceptions
However, it does not account for changes in March 2005 update of the HCRIS data, we payment adjustment factor is 0.9997.
payments due to changes in the DSH and divided the capital special exceptions Because the capital Federal rate has
IME adjustment factors or in the large urban payment amounts for the six hospitals that already been adjusted for differences in case-
add-on. qualified for special exceptions by the total mix, wages, cost-of-living, indirect medical
capital PPS payment amounts (including education costs, and payments to hospitals
4. Exceptions Payment Adjustment Factor
special exception payments) for all hospitals. serving a disproportionate share of low-
Section 412.308(c)(3) requires that the Based on the data from cost reports ending income patients, we are making no additional
capital standard Federal rate be reduced by in FY 2004, this ratio is rounded to 0.0003. adjustments in the capital standard Federal
an adjustment factor equal to the estimated Because we have not received all cost reports rate for these factors, other than the budget
proportion of additional payments for both ending in FY 2004, we also divided the FY neutrality factor for changes in the DRG
regular exceptions and special exceptions 2004 special exceptions payments by the relative weights and the GAF.
under § 412.348 relative to total capital PPS total capital PPS payment amounts for all We are providing a chart that shows how
payments. In estimating the proportion of hospitals with cost reports ending in FY each of the factors and adjustments for FY
regular exception payments to total capital 2003. This ratio also rounds to 0.0003. 2006 affected the computation of the FY 2006
PPS payments during the transition period, Because special exceptions are budget capital Federal rate in comparison to the
we used the actuarial capital cost model neutral, we are offsetting the capital Federal
originally developed for determining budget average FY 2005 capital Federal rate. The FY
rate by 0.03 percent for special exceptions 2006 update factor has the effect of
neutrality (described in Appendix B of the payments for FY 2006. Therefore, the
FY 2002 IPPS final rule (66 FR 40099)) to increasing the capital Federal rate by 0.80
exceptions adjustment factor is equal to
determine the exceptions payment percent compared to the average FY 2005
0.9997 (1–0.0003) to account for special
adjustment factor, which was applied to both Federal rate. The GAF/DRG budget neutrality
exceptions payments in FY 2006.
the Federal and hospital-specific capital In the FY 2005 IPPS final rule (69 FR factor has the effect of increasing the capital
rates. 49288), we estimated that total (special) Federal rate by 0.8 percent. The FY 2006
An adjustment for regular exception exceptions payments for FY 2005 would outlier adjustment factor has the effect of
payments is no longer necessary in equal 0.04 percent of aggregate payments increasing the capital Federal rate by 0.09
determining the FY 2006 capital Federal rate based on the capital Federal rate. Therefore, percent compared to the average FY 2005
because, in accordance with § 412.348(b), we applied an exceptions adjustment factor capital Federal rate, and the FY 2006
regular exception payments were only made of 0.9996 (1–0.0004) in determining the FY exceptions payment adjustment factor has
for cost reporting periods beginning on or 2005 capital Federal rate. As we stated above, the effect of increasing the capital Federal
after October 1, 1991 and before October 1, we estimate that exceptions payments in FY rate by 0.01 percent compared to the
2001. Accordingly, as we explained in the FY 2006 will equal 0.03 percent of aggregate exceptions payment adjustment factor for the
2002 IPPS final rule (66 FR 39949), in FY payments based on the FY 2006 capital FY 2005 capital Federal rate. The combined
2002 and subsequent fiscal years, no Federal rate. Therefore, we are applying an effect of all the changes is to increase the
payments will be made under the regular exceptions payment adjustment factor of capital Federal rate by 0.99 percent compared
exceptions provision. However, in 0.9997 to the capital Federal rate for FY 2006. to the average FY 2005 capital Federal rate.
COMPARISON OF FACTORS AND ADJUSTMENTS: FY 2005 CAPITAL FEDERAL RATE AND FY 2006 CAPITAL FEDERAL RATE
Percent
FY 2005 FY 2006 Change change
Update factor1 .................................................................................................. 1.0070 1.0080 1.0080 0.80

GAF/DRG Adjustment Factor1 ......................................................................... 1.0004 1.0008 1.0008 0.08
Outlier Adjustment Factor2 .............................................................................. 0.9506 0.9515 1.0009 0.09
COMPARISON OF FACTORS AND ADJUSTMENTS: FY 2005 CAPITAL FEDERAL RATE AND FY 2006 CAPITAL FEDERAL
RATE—Continued
Percent
FY 2005 FY 2006 Change change
Exceptions Adjustment Factor2 ....................................................................... 0.9996 0.9997 0.0001 0.01

Capital Federal Rate3 ...................................................................................... $416.53 $420.65 1.0099 0.99
1The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental
change from FY 2005 to FY 2006 resulting from the application of the 1.0008 GAF/DRG budget neutrality factor for FY 2006 is 1.0008. 2The
outlier reduction factor and the exceptions adjustment factor are not built permanently into the capital rates; that is, these factors are not applied
cumulatively in determining the capital rates. Thus, for example, the net change resulting from the application of the FY 2006 outlier adjustment
factor is 0.9515/0.9506, or 1.0009. 3The percent change in factors may not sum due to rounding.
We are also providing a chart that shows Federal rate presented in the FY 2006 IPPS
how the final FY 2006 capital Federal rate proposed rule (70 FR 23480).
differs from the proposed FY 2006 capital
COMPARISON OF FACTORS AND ADJUSTMENTS: PROPOSED FY 2006 CAPITAL FEDERAL RATE AND FINAL FY 2006
CAPITAL FEDERAL RATE
Proposed Final Percent
Change
FY 2006 FY 2006 Change
Update factor ................................................................................................... 1.0070 1.0080 1.0010 0.10

GAF/DRG Adjustment Factor .......................................................................... 1.0019 1.0008 0.9989 ¥0.11
Outlier Adjustment Factor ................................................................................ 0.9497 0.9515 1.0019 0.19
Exceptions Adjustment Factor ......................................................................... 0.9997 0.9997 0.0000 0.00
Capital Federal Rate ........................................................................................ $419.90 $420.65 1.0018 0.18
6. Special Capital Rate for Puerto Rico As we stated above in section III.A.4. of this • For the payment adjustments applicable
Hospitals Addendum, for Puerto Rico, the GAF budget to the hospital, by multiplying the hospital’s
Section 412.374 provides for the use of a neutrality factor is 1.0076, while the DRG GAF, disproportionate share adjustment
blended payment system for payments to adjustment is 0.9989, for a combined factor, and IME adjustment factor, when
Puerto Rico hospitals under the PPS for acute cumulative adjustment of 0.9959. appropriate.
care hospital inpatient capital-related costs. In computing the payment for a particular For purposes of calculating payments for
Accordingly, under the capital PPS, we Puerto Rico hospital, the Puerto Rico portion each discharge during FY 2006, the capital
compute a separate payment rate specific to of the capital rate (25 percent) is multiplied standard Federal rate is adjusted as follows:
Puerto Rico hospitals using the same by the Puerto Rico-specific GAF for the labor (Standard Federal Rate) × (DRG weight) ×
methodology used to compute the national market area in which the hospital is located, (GAF) × (Large Urban Add-on, if applicable)
Federal rate for capital-related costs. Under and the national portion of the capital rate × (COLA adjustment for hospitals located in
the broad authority of section 1886(g) of the (75 percent) is multiplied by the national Alaska and Hawaii) × (1 + Disproportionate
Act, as discussed in section VI. of the GAF for the labor market area in which the Share Adjustment Factor + IME Adjustment
preamble of this final rule, beginning with hospital is located (which is computed from Factor, if applicable). The result is the
discharges occurring on or after October 1, adjusted capital Federal rate.
national data for all hospitals in the United
2004, capital payments to hospitals in Puerto Hospitals also may receive outlier
States and Puerto Rico). In FY 1998, we
Rico are based on a blend of 25 percent of payments for those cases that qualify under
implemented a 17.78 percent reduction to the
the Puerto Rico capital rate and 75 percent the thresholds established for each fiscal
Puerto Rico capital rate as a result of Pub. L. year. Section 412.312(c) provides for a single
of the capital Federal rate. The Puerto Rico 105–33. In FY 2003, a small part of that
capital rate is derived from the costs of set of thresholds to identify outlier cases for
reduction was restored. both inpatient operating and inpatient
Puerto Rico hospitals only, while the capital
For FY 2005, before application of the capital-related payments. The outlier
Federal rate is derived from the costs of all
acute care hospitals participating in the IPPS GAF, the special capital rate for Puerto Rico thresholds for FY 2006 are in section II.A.4.c.
(including Puerto Rico). hospitals was $199.01 for discharges of this Addendum. For FY 2006, a case
To adjust hospitals’ capital payments for occurring on or after October 1, 2004 through qualifies as a cost outlier if the cost for the
geographic variations in capital costs, we September 30, 2005. With the changes we are case plus the IME and DSH payments is
apply a GAF to both portions of the blended making to the factors used to determine the greater than the prospective payment rate for
capital rate. The GAF is calculated using the capital rate, the FY 2006 special capital rate the DRG plus $23,600.
operating IPPS wage index and varies, for Puerto Rico is $201.93. An eligible hospital may also qualify for a
depending on the labor market area or rural special exceptions payment under
B. Calculation of Inpatient Capital-Related
area in which the hospital is located. We use § 412.348(g) for up through the 10th year
Prospective Payments for FY 2006
the Puerto Rico wage index to determine the beyond the end of the capital transition
GAF for the Puerto Rico part of the capital- Because the 10-year capital PPS transition period if it meets: (1) a project need
blended rate and the national wage index to period ended in FY 2001, all hospitals requirement described at § 412.348(g)(2),
determine the GAF for the national part of (except ‘‘new’’ hospitals under § 412.324(b) which in the case of certain urban hospitals
the blended capital rate. and under § 412.304(c)(2)) are paid based on includes an excess capacity test as described
Because we implemented a separate GAF 100 percent of the capital Federal rate in FY at § 412.348(g)(4); and (2) a project size
for Puerto Rico in FY 1998, we also apply 2006. The applicable capital Federal rate was requirement as described at § 412.348(g)(5).
separate budget neutrality adjustments for determined by making adjustments as Eligible hospitals include SCHs, urban
the national GAF and for the Puerto Rico follows: hospitals with at least 100 beds that have a
GAF. However, we apply the same budget • For outliers, by dividing the capital DSH patient percentage of at least 20.2
neutrality factor for DRG reclassifications and standard Federal rate by the outlier reduction percent or qualify for DSH payments under
recalibration nationally and for Puerto Rico. factor for that fiscal year; and § 412.106(c)(2), and hospitals that have a
combined Medicare and Medicaid inpatient 2. Forecast of the CIPI for FY 2006 paid based on a blend of reasonable cost-
utilization of at least 70 percent. Under Based on the latest forecast by Global based payment (subject to the TEFRA limit)
§ 412.348(g)(8), the amount of a special Insight, Inc. (second quarter of 2005), we are and the prospective per diem payment rate.
exceptions payment is determined by forecasting the CIPI to increase 0.8 percent in New IPFs are paid based on 100 percent of
comparing the cumulative payments made to FY 2006. This reflects a projected 1.4 percent the Federal per diem payment amount
the hospital under the capital PPS to the increase in vintage-weighted depreciation (§ 412.426). For cost reporting periods
cumulative minimum payment level. This prices (building and fixed equipment, and beginning on or after January l, 2008, IPFs
amount is offset by: (1) Any amount by movable equipment) and a 3.3 percent will be paid 100 percent of the Federal
which a hospital’s cumulative capital increase in other capital expense prices in FY prospective per diem payment amount.
payments exceed its cumulative minimum 2006, partially offset by a 2.3 percent decline Excluded psychiatric hospitals and units as
payment levels applicable under the regular in vintage-weighted interest expenses in FY well as LTCHs that are paid under a blended
exceptions process for cost reporting periods 2006. The weighted average of these three methodology will have the reasonable cost-
beginning during which the hospital has factors produces the 0.8 percent increase for based portion of their payment subject to a
been subject to the capital PPS; and (2) any the CIPI as a whole in FY 2006. hospital target amount.
amount by which a hospital’s current year B. Updated Caps for New Excluded Hospitals
operating and capital payments (excluding 75 IV. Changes to Payment Rates for Excluded
Hospitals and Hospital Units: Rate-of- and Units
percent of operating DSH payments) exceed
its operating and capital costs. Under Increase Percentages Section 1886(b)(7) of the Act established
§ 412.348(g)(6), the minimum payment level the method for determining the payment
A. Payments to Existing Excluded Hospitals amount for new rehabilitation hospitals and
is 70 percent for all eligible hospitals. and Units
During the transition period, new hospitals units, psychiatric hospitals and units, and
As discussed in section VII. of the LTCHs that first received payment as a
(as defined under § 412.300) were exempt
preamble of this final rule, in accordance hospital or unit excluded from the IPPS on
from the capital PPS for their first 2 years of
with section 1886(b)(3)(H)(i) of the Act and or after October 1, 1997. However, due to the
operation and were paid 85 percent of their
effective for cost reporting periods beginning implementation of the IRF PPS, effective for
reasonable costs during that period. Effective
on or after October 1, 2002, payments to cost reporting periods beginning on or after
with the third year of operation through the
existing psychiatric hospitals and units, October 1, 2002, this payment amount (or
remainder of the transition period, under
rehabilitation hospitals and units, and long- ‘‘new provider cap’’) no longer applies to any
§ 412.324(b), we paid the hospitals under the
term care hospitals (LTCHs) excluded from new rehabilitation hospital or unit because
appropriate transition methodology. If the
the IPPS are no longer subject to a cap on a they now are paid 100 percent of the adjusted
hold-harmless methodology were applicable,
hospital-specific target amount (expressed in Federal prospective rate under the IRF PPS.
the hold-harmless payment for assets in use
terms of the inpatient operating cost per In addition, LTCHs that meet the definition
during the base period would extend for 8 discharge under TEFRA) that was set for each of a new LTCH under § 412.23(e)(4) are paid
years, even if the hold-harmless payments hospital. The inpatient operating costs of 100 percent of the fully Federal prospective
extend beyond the normal transition period. children’s hospitals and cancer hospitals that payment rate. In contrast, those ‘‘new’’
Under § 412.304(c)(2), for cost reporting are excluded from the IPPS continue to be LTCHs that meet the criteria under
periods beginning on or after October 1, subject to the rate-of-increase limits § 413.40(f)(2)(ii) (that is, that were not paid
2002, we pay a new hospital 85 percent of established under the authority of section as an excluded hospital prior to October 1,
its reasonable costs during the first 2 years 1886(b) of the Act and § 413.40 of the 1997, but were paid as a LTCH before
of operation unless it elects to receive regulations. This target amount is applied as October 1, 2002), may be paid under the
payment based on 100 percent of the capital a ceiling on the allowable costs per discharge LTCH PPS transition methodology, with the
Federal rate. Effective with the third year of for the hospital’s cost reporting period. reasonable cost portion of the payment
operation, we pay the hospital based on 100 LTCHs and IPFs that have part of their subject to § 413.40(f)(2)(ii). Finally, LTCHs
percent of the capital Federal rate (that is, the payments based on reasonable costs also that existed prior to October 1, 1997, may
same methodology used to pay all other have the reasonable cost portion subject to also be paid under the LTCH PPS transition
hospitals subject to the capital PPS). the rate of increase limits in § 413.40. methodology, with the reasonable cost
C. Capital Input Price Index Effective for cost reporting periods portion subject to § 413.40(c)(4)(ii). (The last
beginning on or after October 1, 2002, LTCHs that were subject to the payment
1. Background rehabilitation hospitals and units are paid amount limitation for ‘‘new’’ LTCHs were
Like the operating input price index, the 100 percent of the adjusted Federal new LTCHs that had their first cost reporting
capital input price index (CIPI) is a fixed- prospective payment rate under the IRP PPS. period beginning on September 30, 2002. In
weight price index that measures the price Effective for cost reporting periods beginning that case, the payment amount limitation
changes associated with capital costs during on or after October 1, 2002, LTCHs also are remained applicable for the next 2 years—
a given year. The CIPI differs from the no longer paid on a reasonable cost basis, but September 30, 2002 through September 29,
operating input price index in one important are paid under a LTCH DRG-based PPS. In 2003, and September 30, 2003 through
aspect—the CIPI reflects the vintage nature of implementing the LTCH PPS for existing September 29, 2004. This is because, under
capital, which is the acquisition and use of LTCHs, we established a 5-year transition existing regulations at § 413.40(f)(2)(ii), the
capital over time. Capital expenses in any period from reasonable cost-based payments ‘‘new hospital’’ would be subject to the same
given year are determined by the stock of (subject to the TEFRA limit) to fully Federal payment (target amount) in its second cost
capital in that year (that is, capital that prospective payment amounts during which reporting period that was applicable to the
remains on hand from all current and prior a LTCH may receive a blended payment LTCH in its first cost reporting period.
capital acquisitions). An index measuring consisting of two payment components—one Accordingly, for this hospital, the updated
capital price changes needs to reflect this based on reasonable cost under the TEFRA payment amount limitation that we
vintage nature of capital. Therefore, the CIPI payment system, and the other based on the published in the FY 2003 IPPS final rule (67
was developed to capture the vintage nature standard Federal prospective payment rate. FR 50103) applied through September 29,
of capital by using a weighted-average of past However, an existing LTCH may elect to be 2004. Consequently, there is no longer a need
capital purchase prices up to and including paid based on 100 percent of the standard to publish updated payment amounts for new
the current year. Federal prospective payment rate during the (§ 413.40(f)(2)(ii)) LTCHs. A discussion of
We periodically update the base year for transition period. how the payment limitations were calculated
the operating and capital input prices to IPFs that have their first cost reporting can be found in the August 29, 1997 final
reflect the changing composition of inputs for period beginning on or after January 1, 2005, rule with comment period (62 FR 46019); the
operating and capital expenses. The CIPI was are not paid on a reasonable cost basis but May 12, 1998 final rule (63 FR 26344); the
last rebased to FY 1997 in the FY 2003 IPPS paid under a prospective per diem payment July 31, 1998 final rule (63 FR 41000); and
final rule (67 FR 50044). (We note that we are system. As part of the PPS for existing IPFs, the July 30, 1999 final rule (64 FR 41529).
rebasing to FY 2002 in section IV. of the we have established a 3-year transition With the implementation of the LTCH PPS,
preamble of this final rule.) period during which existing IPFs will be payment limitations under § 413.40(f)(2)(ii)
do not apply to any new LTCHs that meet the not subject to the payment amount Medicare Part B drugs to price blood clotting
definition at § 412.23(e)(4) because they are limitation. Therefore, since the last IPFs factors administered to inpatients who have
paid 100 percent of the Federal prospective eligible for a blended payment have a cost hemophilia under Medicare Part A. Section
payment rate. reporting period beginning on December 31, 303 of Pub. L. 108–173 amended the Act by
A freestanding inpatient rehabilitation 2004, the payment limitation published for adding section 1847A, which changed the
hospital, an inpatient rehabilitation unit of FY 2005 remains applicable for these IPFs, drug pricing system under Medicare Part B.
an acute care hospital, and an inpatient and publication of the updated payment Effective January 1, 2005, section 1847A of
rehabilitation unit of a CAH are referred to amount limitation is no longer needed. We the Act established a payment methodology
as IRFs. Effective for cost reporting periods note that IPFs that existed prior to October based on average sales price (ASP) under
beginning on or after October 1, 2002, this 1, 1997, may also be paid under the IPF
which almost all Medicare Part B drugs and
payment limitation is also no longer transition methodology with the reasonable
biologicals not paid on a cost or prospective
applicable to new rehabilitation hospitals cost portion of the payment subject to
§ 413.40(c)(4)(ii). basis are paid at 106 percent of the ASP.
and units because they are paid 100 percent In the FY 2005 IPPS final rule (69 FR
of the adjusted Federal prospective rate The payment limitations for new hospitals
under TEFRA do not apply to new LTCHs, 49292), we had instructed the fiscal
under the IRF PPS. Therefore, it is also no intermediaries for FY 2005 to continue to use
longer necessary to update the payment IRFs, or IPFs, that is, these hospitals with
their first cost reporting period beginning on the Single Drug Pricer (SDP) to establish the
limitation for new rehabilitation hospitals or pricing limits for the blood clotting factor
units. or after the date that the particular class of
hospitals implemented the respective PPS. administered to hemophilia inpatients at 95
Under the IPF PPS, there is a 3-year
Therefore, for the reasons noted above, we percent of the AWP. We did not use the new
transition period during which existing IPFs
are discontinuing the publication of Tables ASP pricing methodology for Part A blood
will receive a blended payment of the
4G and 4H (Pre-Reclassified Wage Index for clotting factor in FY 2005 because the IPPS
Federal per diem payment amount and the
Urban and Rural Areas, respectively) in the final rule was published in advance of final
reasonable cost-based payment amount
annual proposed and final IPPS rules. regulations implementing the ASP payment
TEFRA. IPFs that were ‘‘new’’ under
§ 413.40(f)(2)(ii) (that is, that were not paid V. Payment for Blood Clotting Factor methodology for Part B drugs and biologicals.
as an excluded hospital prior to October 1, Administered to Hemophilia Inpatients Final regulations establishing the ASP
1997, but were paid as an IPF prior to methodology and the furnishing fee for blood
As discussed in section VIII. of the clotting factor under Medicare Part B were
January 1, 2005), would have the reasonable preamble to this final rule, section 1886(a)(4)
cost portion of the transition period payment published on November 15, 2004 (69 FR
of the Act excludes the costs of administering 66299). Therefore, we believe that a
subject to the payment amount limitation as blood clotting factors to individuals with
determined according to § 413.40(f)(2)(ii). consistent methodology should be used to
hemophilia from the definition of ‘‘operating
The last ‘‘new’’ IPFs that were subject to the pay for blood clotting factor administered
costs of inpatient hospital services.’’ Section
payment amount limitation were IPFs that 6011(b) of Pub. L. 101–239 (the Omnibus under both Medicare Part A and Part B. For
had their first cost reporting period beginning Budget Reconciliation Act of 1989) provides this reason, as we proposed in the FY 2006
on December 31, 2004. For these hospitals, that the Secretary shall determine the IPPS proposed rule, we are providing that,
the payment amount limitation that was payment amount made to hospitals under for FY 2006, the fiscal intermediaries make
published in the FY 2005 IPPS final rule (69 Part A of Title XVIII of the Act for the costs payment for blood clotting factor using 106
FR 49189) for cost reporting periods of administering blood clotting factors to percent of ASP (that is ASP+ 6 percent) and
beginning on or after October 1, 2004, and individuals with hemophilia by multiplying make payment for the furnishing fee at $0.14
before January 1, 2005, remains applicable a predetermined price per unit of blood per individual unit (I.U.) that is currently
for the IPF’s first two cost reporting periods. clotting factor by the number of units used for Medicare Part B drugs. The ASP will
IPFs with a first cost reporting period provided to the individual. Currently, we use be updated quarterly. The furnishing fee will
beginning on or after January 1, 2005, are the average wholesale price (AWP) be updated annually based on the consumer
paid 100 percent of the Federal rate and are methodology used to determine rates paid for price index.
VI. Tables Table 3A—FY 2006 and 3-Year Average Stay [FY 2004 MedPAR Update March
This section contains the tables referred to Hourly Wage for Urban Areas by CBSA 2005 GROUPER V22.0]
throughout the preamble to this final rule Table 4A—Wage Index and Capital Table 7B—Medicare Prospective Payment
and in this Addendum. Tables 1A, 1B, 1C, Geographic Adjustment Factor (GAF) for System Selected Percentile Lengths of
Urban Areas by CBSA Stay [FY 2004 MedPAR Update March
1D, 2, 3A, 3B, 4A, 4B, 4C, 4F, 4J, 5, 6A, 6B,
Table 4B—Wage Index and Capital 2005 GROUPER V23.0]
6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, 8B, 9A,
Geographic Adjustment Factor (GAF) for Table 8A—Statewide Average Operating
9B, 9C, 10, and 11 are presented below. The
Rural Areas by CBSA Cost-to-Charge Ratios—July 2005
tables presented below are as follows:
Table 4C—Wage Index and Capital Table 8B—Statewide Average Capital Cost-to-
Table 1A—National Adjusted Operating Geographic Adjustment Factor (GAF) for
Standardized Amounts, Labor/Nonlabor Charge Ratios—July 2005
Hospitals That ARe Reclassified by
(69.7 Percent Labore Share/30.3 Percent Table 9A—Hospital Reclassifications and
CBSA
Nonlabor Share If Wage Index Is Greater Redesignations by Individual Hospital
Table 4F—Puerto Rico Wage Index and
Than 1) and CBSA—FY 2006
Capital Geographic Adjustment Factor
Table 1B—National Adjusted Operating Table 9B—Hospital Reclassifications and
(GAF) by CBSA
Standardized Amounts, Labor/Nonlabor Redesignations by Individual Hospital
Table 4J—Out-Migration Adjustment—FY
(62 Percent Labor Share/38 Percent 2006 Under Section 508 of Pub. L. 108–173—
Nonlabor Share If Wage Index Is Less Table 5—List of Diagnosis-Related Groups FY 2006
Than or Equal To 1) (DRGs), Relative Weighting Factors, and Table 9C—Hospitals Redesignated as Rural
Table 1C—Adjusted Operating Standardized Geometric and Arithmetic Mean Length under Section 1886(d)(8)(E) of the Act—
Amounts for Puerto Rico, Labor/ of Stay (LOS) FY 2006
Nonlabor Table 6A—New Diagnosis Codes Table 10—Geometric Mean Plus the Lesser of
Table 1D—Capital Standard Federal Payment Table 6B—New Procedure Codes .75 of the National Adjusted Operating
Rate Table 6C—Invalid Diagnosis Codes Standardized Payment Amount
Table 2—Hospital Case-Mix Indexes for Table 6D—Invalid Procedure Codes (Increased to Reflect the Difference
Discharges Occurring in Federal Fiscal Table 6E—Revised Diagnosis Code Titles Between Costs and Charges) or .75 of
Year 2004; Hospital Wage Indexes for Table 6F—Revised Procedure Code Titles One Standard Deviation of Mean Charges
Federal Fiscal Year 2006; Hospital Table 6G—Additions to the CC Exclusions by Diagnosis-Related Groups (DRGs)—
Average Hourly Wage for Federal Fiscal List July 2005
Years 2004 (2000 Wage Data), 2005 (2001 Table 6H—Deletions from the CC Exclusions Table 11—FY 2006 LTC–DRGs, Relative
Wage Data), and 2006 (2002 Wage Data); List Weights, Geometric Average Length of
Wage Indexes and 3-Year Average of Table 7A—Medicare Prospective Payment Stay, and 5/6ths of the Geometric
Hospital Average Hourly Wages System Selected Percentile Lengths of Average Length of Stay
TABLE 1A.—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR

[69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Greater Than 1]
Full update (3.7 percent) Reduced update (3.3 percent)
Labor-related Nonlabor-related Labor-related Nonlabor-related
$3,297.84 $1,433.63 $3,285.12 $1,428.10
TABLE 1B.—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR

[62 percent labor share/38 percent nonlabor share if wage index less than or equal to 1]
Full update (3.7 percent) Reduced update (3.3 percent)

Labor-related Nonlabor-related Labor-related Nonlabor-related
$2,933.52 $1,797.95 $2,922.20 $1,791.02
TABLE 1C.—ADJUSTED OPERATING STANDARDIZED AMOUNTS FOR PUERTO RICO, LABOR/NONLABOR

Rates if wage index greater than 1 Rates if wage index less than or equal to 1
Labor Nonlabor Labor Nonlabor
National $3,297.84 $1,433.63 $2,933.52 $1,797.95

Puerto Rico $1,402.46 $859.57 $1,327.81 $934.22
TABLE 1D.—CAPITAL STANDARD

FEDERAL PAYMENT RATE
Rate
National ................................. $420.65

Puerto Rico ........................... $201.93
TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2004; HOSPITAL WAGE
INDEXES FOR FEDERAL FISCAL YEAR 2006; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2004
(2000 WAGE DATA), 2005 (2001 WAGE DATA), AND 2006 (2002 WAGE DATA); WAGE INDEXES AND 3-YEAR AVER-
AGE OF HOSPITAL AVERAGE HOURLY WAGES
Average Average Average Average

Case-mix FY 2006
Provider No. hourly wage hourly wage hourly wage hourly wage
index 3 wage index FY 2004 FY 2005 FY 2006 1 ** (3 years)
010001 ............................................................................. 1.4738 0.7757 $19.4061 $20.6563 $21.6546 $20.5970

010004 ............................................................................. *** * $22.2674 $22.7585 * $22.4801
010005 h ........................................................................... 1.1467 0.9379 $19.6063 $20.4937 $22.4906 $20.9007
010006 ............................................................................. 1.4559 0.8297 $19.0976 $21.0241 $23.4823 $21.1655
010007 ............................................................................. 1.0885 0.7463 $17.5462 $16.8811 $18.2430 $17.5458
010008 ............................................................................. 1.0025 0.8300 $19.6573 $23.8333 $20.4591 $21.3782
010009 ............................................................................. 0.9852 0.8601 $20.4309 $21.6422 $23.2229 $21.7690
010010 h ........................................................................... 1.0269 0.9379 $19.2644 $22.3021 $21.4974 $21.0618
010011 ............................................................................. 1.5830 0.8959 $25.8231 $24.8166 $27.4850 $26.0626
010012 ............................................................................. 1.2324 0.9089 $20.0896 $21.7622 $22.7020 $21.5233
010015 ............................................................................. 0.9730 0.7463 $18.8890 $20.4732 $21.5111 $20.4315
010016 ............................................................................. 1.3312 0.8959 $21.7918 $23.0414 $25.1502 $23.3217
010018 ............................................................................. 1.2538 0.8959 $19.2071 $20.5888 $22.2990 $20.6865
010019 ............................................................................. 1.2330 0.8297 $18.9177 $20.1336 $22.0906 $20.4039
010021 h ........................................................................... 1.2024 0.7757 $17.7596 $20.7108 $18.6785 $19.0123
010022 ............................................................................. 0.9447 0.9405 $22.2267 $25.8797 $24.5670 $24.2502
010023 ............................................................................. 1.8563 0.8630 $20.4901 $23.7791 $27.6174 $23.7666
010024 ............................................................................. 1.6214 0.8630 $18.5942 $20.0067 $20.7265 $19.7702
010025 ............................................................................. 1.3289 0.8394 $19.3649 $19.8561 $21.2674 $20.1430
010027 ............................................................................. 0.7679 0.7463 $14.0975 $14.9585 $15.3704 $14.7992
010029 ............................................................................. 1.5563 0.8394 $20.9868 $21.6724 $22.6976 $21.8061
010031 ............................................................................. *** * $21.0176 $20.9463 * $20.9818
010032 ............................................................................. 0.8874 0.7463 $16.4713 $18.5073 $19.1555 $18.1219
010033 ............................................................................. 2.0404 0.8959 $24.5088 $25.5165 $26.3784 $25.4860
010034 ............................................................................. 0.9689 0.8630 $14.9333 $17.1625 $16.9686 $16.3417
010035 ............................................................................. 1.2590 0.8959 $21.6182 $23.1319 $22.2870 $22.3532
010036 ............................................................................. 1.1539 0.7463 $19.2501 $20.5125 $22.9747 $20.9446
010038 ............................................................................. 1.3348 0.7779 $18.6578 $20.3935 $21.4509 $20.2189
010039 ............................................................................. 1.6434 0.9120 $23.0339 $23.4151 $25.8820 $24.1525
010040 ............................................................................. 1.4704 0.7966 $20.7779 $21.6708 $22.8851 $21.7864
010043 ............................................................................. 1.0652 0.8959 $19.9012 $19.5422 $22.5945 $20.7320
010044 ............................................................................. 1.0535 0.8959 $25.8560 $23.0220 $21.4036 $23.2608
010045 ............................................................................. 1.0943 0.8959 $22.7713 $20.5658 $19.8803 $20.8779
010046 ............................................................................. 1.4623 0.7966 $19.6754 $20.8935 $21.6965 $20.8067
010047 ............................................................................. 0.8851 0.7618 $16.1695 $19.5937 $21.0604 $18.8438
010049 ............................................................................. 1.0914 0.7463 $16.2973 $17.7801 $20.2413 $18.1494
010050 ............................................................................. 1.0423 0.8959 $20.7398 $21.5625 $22.1584 $21.5077
010051 ............................................................................. 0.9034 0.8648 $14.3006 $14.7053 $15.2208 $14.7351
010052 ............................................................................. 0.8752 0.7463 $11.9019 $21.3673 $16.4959 $15.4174
010053 ............................................................................. 1.0186 0.7463 $17.3238 $17.4160 $19.0108 $17.9166
010054 ............................................................................. 1.0675 0.8601 $20.6382 $23.1894 $22.5554 $22.1149
010055 ............................................................................. 1.5040 0.7757 $18.9664 $19.1847 $22.3800 $20.1389
010056 ............................................................................. 1.5304 0.8959 $21.1104 $22.7183 $23.7144 $22.5773
010058 ............................................................................. 0.8812 0.8959 $17.7800 $20.3182 $18.5537 $18.9295
010059 ............................................................................. 1.0579 0.8509 $20.5534 $23.6963 $21.3237 $21.8874
010061 ............................................................................. 0.9745 0.7969 $17.0447 $20.5683 $21.9370 $19.8088
010062 ............................................................................. 1.0751 0.7757 $17.1786 $18.1323 $18.3435 $17.8796
010064 ............................................................................. 1.7028 0.8959 $22.2280 $25.4345 $26.1110 $24.2542
010065 ............................................................................. 1.4305 0.8300 $17.2698 $20.0108 $21.3785 $19.6007
010066 ............................................................................. 0.8403 0.7463 $14.8696 $17.0935 $17.6152 $16.5083
010068 ............................................................................. 1.2166 0.8959 $18.3308 $17.5690 $19.0789 $18.3440
010069 ............................................................................. 1.0532 0.7463 $17.0957 $19.6317 $21.3608 $19.4027
010072 ............................................................................. 1.1497 0.7717 $18.8807 $21.5419 $21.8169 $20.7331
010073 ............................................................................. 0.9378 0.7463 $14.9826 $16.4043 $16.4168 $15.9303
010078 ............................................................................. 1.3765 0.7779 $20.1447 $21.0633 $21.6857 $20.9549
010079 ............................................................................. 1.1745 0.9120 $20.7401 $20.4254 $21.8199 $21.0143
010083 h ........................................................................... 1.2054 0.8081 $19.8524 $20.2166 $22.3041 $20.7945
010084 ............................................................................. 1.5407 0.8959 $21.6522 $22.5219 $24.7127 $22.9810
010085 ............................................................................. 1.2286 0.8601 $22.5282 $23.7007 $24.4710 $23.5499
010086 ............................................................................. 1.0940 0.7463 $18.0122 $19.4332 $18.6081 $18.6721
010087 ............................................................................. 1.9263 0.7898 $19.7620 $21.6226 $22.5225 $21.2536
010089 ............................................................................. 1.2383 0.8959 $19.5783 $22.2508 $22.8448 $21.5236
010090 ............................................................................. 1.6654 0.7898 $20.0287 $21.4322 $23.6948 $21.7237
010091 ............................................................................. 0.9268 0.7463 $17.4672 $19.4222 $18.6912 $18.5367
010092 ............................................................................. 1.5091 0.8648 $19.9351 $22.0709 $24.4592 $22.1357
010095 ............................................................................. 0.8679 0.8648 $12.5243 $13.4426 $13.9326 $13.3037
010097 ............................................................................. 0.7797 0.8630 $15.1593 $17.1735 $16.7548 $16.2912
AGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued

Case-mix FY 2006
010098 ............................................................................. 1.1057 0.7463 $15.1629 $19.6717 $14.3076 $16.0844

010099 ............................................................................. 0.9928 0.7463 $16.3307 $18.1849 $18.7909 $17.7973
010100 h ........................................................................... 1.6620 0.8081 $19.8146 $20.0027 $21.2915 $20.4113
010101 ............................................................................. 1.1183 0.7717 $19.0718 $21.0085 $21.6593 $20.5878
010102 ............................................................................. 0.9035 0.7463 $16.4637 $19.9196 $21.0903 $19.1526
010103 ............................................................................. 1.8583 0.8959 $22.5709 $24.2201 $26.1163 $24.2529
010104 ............................................................................. 1.7367 0.8959 $20.9391 $24.1929 $24.7394 $23.1972
010108 ............................................................................. 1.0869 0.8630 $20.7787 $23.7803 $28.4624 $24.2639
010109 ............................................................................. 0.9573 0.7914 $18.2235 $21.7128 $21.6194 $20.4648
010110 ............................................................................. 0.7413 0.7463 $16.0015 $19.2706 $17.5957 $17.7893
010112 ............................................................................. 0.9711 0.7463 $17.9243 $17.2963 $16.8902 $17.3960
010113 ............................................................................. 1.6497 0.7898 $19.4106 $20.4181 $21.4121 $20.4357
010114 ............................................................................. 1.3236 0.8959 $20.1763 $21.5319 $22.3752 $21.3396
010115 ............................................................................. 0.8303 0.7556 $15.7872 $17.5985 $21.7478 $17.8278
010118 ............................................................................. 1.2532 0.8300 $19.5302 $18.8560 $19.7673 $19.4467
010119 ............................................................................. *** * $20.5245 $21.8215 * $21.1743
010120 ............................................................................. 0.9549 0.7898 $19.4368 $20.5855 $20.9450 $20.3424
010121 ............................................................................. *** * $17.1640 $17.0329 $24.0867 $18.5589
010125 ............................................................................. 1.0390 0.7463 $16.8622 $16.8419 $18.4114 $17.3762
010126 ............................................................................. 1.1100 0.8300 $19.9647 $23.1856 $23.1381 $22.1149
010128 ............................................................................. 0.8402 0.7463 $14.7646 $17.9354 $21.4201 $18.0579
010129 h ........................................................................... 0.9911 0.8019 $16.4905 $18.7821 $21.3555 $19.1436
010130 ............................................................................. 0.9505 0.8959 $18.7190 $18.4944 $23.2488 $20.0658
010131 ............................................................................. 1.3400 0.9120 $22.9969 $24.2197 $25.7837 $24.4029
010134 ............................................................................. *** * $17.7717 * * $17.7717
010137 ............................................................................. 1.2752 0.8959 $28.9402 $29.7665 $24.7366 $27.6545
010138 ............................................................................. 0.6239 0.7463 $14.2025 $13.5082 $13.8475 $13.8713
010139 ............................................................................. 1.5213 0.8959 $22.8390 $24.9410 $25.3014 $24.4108
010143 ............................................................................. 1.1690 0.8959 $20.5639 $22.1312 $22.0215 $21.5734
010144 ............................................................................. 1.5618 0.7898 $19.1497 $20.6425 $20.8209 $20.2306
010145 ............................................................................. 1.2807 0.8648 $22.1394 $23.1976 $24.9531 $23.4608
010146 ............................................................................. 1.0363 0.7779 $21.3083 $19.9944 $20.8917 $20.7213
010148 ............................................................................. 0.8816 0.7463 $17.6829 $18.5309 $20.5589 $19.0324
010149 ............................................................................. 1.3313 0.8630 $21.0086 $3.1593 $26.5854 $23.4663
010150 ............................................................................. 1.0526 0.8394 $21.2360 $20.6738 $21.6377 $21.1783
010152 ............................................................................. 1.2065 0.7898 $21.6038 $22.1626 $22.6202 $22.1446
010157 ............................................................................. 1.1281 0.8297 $19.6977 $21.3574 $24.3560 $21.7462
010158 ............................................................................. 1.0829 0.8509 $18.5464 $22.4440 $24.3531 $21.6528
010161 ............................................................................. *** * * $27.5119 * $27.5119
010162 ............................................................................. 1.8283 0.8959 * * * *
010163 ............................................................................. 1.2761 0.7757 * * * *
010164 ............................................................................. 1.0870 0.7717 * * * *
010165 ............................................................................. 1.7531 0.9120 * * * *
020001 ............................................................................. 1.6984 1.1965 $30.1452 $31.6091 $32.8120 $31.6051
020004 ............................................................................. 1.1704 1.1965 $27.3516 $29.9926 $32.0966 $29.8229
020005 ............................................................................. 0.9519 * $32.7936 * * $32.7936
020006 ............................................................................. 1.2203 1.1965 $31.2673 $33.4210 $36.0540 $33.6428
020008 ............................................................................. 1.2317 1.2828 $33.4543 $34.5856 $35.9236 $34.6652
020010 ............................................................................. *** * $20.7929 * * $20.7929
020012 ............................................................................. 1.3442 1.1965 $27.9955 $29.3419 $31.8995 $29.8198
020013 ............................................................................. *** * $30.6423 * * $30.6423
020014 ............................................................................. 1.0326 1.1965 $29.6805 $32.1233 $32.0893 $31.3377
020017 ............................................................................. 1.9353 1.1965 $30.3017 $32.9281 $33.5852 $32.3606
020018 ............................................................................. 0.9338 1.1965 * * * *
020019 ............................................................................. 0.8198 1.9343 * * * *
020020 ............................................................................. 0.8449 * * * * *
020021 ............................................................................. 0.9569 * * * * *
020024 ............................................................................. 1.1394 1.1965 $28.0930 $27.9799 $33.0644 $29.9221
020026 ............................................................................. 1.5552 1.9343 * * * *
020027 ............................................................................. 0.9166 1.9343 * * * *
030001 ............................................................................. 1.3883 1.0129 $25.7513 $27.7572 $29.9840 $27.8499
030002 ............................................................................. 2.0946 1.0129 $25.6038 $27.9628 $29.0519 $27.5075
030003 ............................................................................. *** * $22.1436 * * $22.1436
030004 ............................................................................. 0.8735 * * * * *
030006 ............................................................................. 1.6926 0.9027 $23.2881 $24.0169 $25.8872 $24.4719
030007 ............................................................................. 1.3598 1.1382 $26.1551 $26.9442 $29.6174 $27.6578
030009 ............................................................................. 0.8941 0.9027 $19.9131 $21.4065 $22.3992 $21.1294

Case-mix FY 2006
030010 ............................................................................. 1.3563 0.9027 $20.7204 $22.8647 $24.8275 $22.8055

030011 ............................................................................. 1.4714 0.9027 $21.0028 $22.8422 $25.1361 $23.0075
030012 ............................................................................. 1.3007 0.9422 $24.2366 $25.5205 $26.3859 $25.4550
030013 ............................................................................. 1.3461 0.9179 $21.9766 $23.5229 $25.7050 $23.8047
030014 ............................................................................. 1.4729 1.0129 $23.3663 $25.1189 $25.6259 $24.7232
030016 ............................................................................. 1.2676 1.0129 $24.3380 $27.1583 $26.7003 $26.0910
030017 ............................................................................. 2.0460 1.0129 $21.8792 $24.4055 $26.2452 $24.0378
030018 ............................................................................. 1.2271 1.0129 $24.9216 $24.4308 $28.9476 $25.9371
030019 ............................................................................. 1.3599 1.0129 $23.2973 $28.4917 $27.3156 $26.2053
030022 ............................................................................. 1.5548 1.0129 $24.9941 $25.1461 $26.4404 $25.5437
030023 ............................................................................. 1.6260 1.2082 $28.6627 $28.4112 $33.8333 $30.2808
030024 ............................................................................. 2.0251 1.0129 $26.7641 $28.3470 $31.6658 $28.9293
030027 ............................................................................. 0.9336 0.9007 $19.4583 $21.0527 $20.4031 $20.3074
030030 ............................................................................. 1.6760 1.0129 $25.2425 $24.6005 $30.2712 $26.5838
030033 ............................................................................. 1.2098 1.1382 $26.3814 $26.6009 $26.6531 $26.5511
030036 ............................................................................. 1.3281 1.0129 $24.9432 $26.5708 $30.3521 $27.3868
030037 ............................................................................. 2.2386 1.0129 $23.0542 $30.3907 $28.6453 $27.0409
030038 ............................................................................. 1.6056 1.0129 $25.2632 $26.5178 $29.5509 $27.6724
030040 ............................................................................. 0.9548 0.9007 $21.2717 $22.5130 $24.8145 $22.8703
030043 ............................................................................. 1.3515 0.9007 $23.5172 $26.0825 $24.7932 $24.8113
030044 ............................................................................. 0.9107 * $21.9503 $19.5714 * $20.6512
030055 h ........................................................................... 1.3655 1.1404 $22.8612 $23.1837 $24.5202 $23.5684
030059 ............................................................................. *** * * $24.7676 * $24.7676
030060 ............................................................................. 1.1098 0.9007 $21.7685 $22.3551 $24.3523 $22.7950
030061 ............................................................................. 1.6175 1.0129 $22.9706 $23.4722 $25.5529 $24.0363
030062 ............................................................................. 1.1767 0.9007 $21.1639 $21.9849 $23.8068 $22.3433
030064 ............................................................................. 1.9148 0.9027 $22.8009 $24.6732 $25.4922 $24.2954
030065 ............................................................................. 1.5739 1.0129 $24.6064 $25.6738 $27.1646 $25.8836
030067 ............................................................................. 1.0119 0.9007 $18.4003 $19.1332 $20.4376 $19.2370
030068 ............................................................................. 1.1175 0.9007 $19.7097 $19.7030 $20.8846 $20.1346
030069 h ........................................................................... 1.3479 1.1404 $24.5432 $25.6243 $26.3518 $25.5167
030071 ............................................................................. 0.9121 1.4448 * * * *
030073 ............................................................................. 1.0619 1.4448 * * * *
030074 ............................................................................. 1.3283 1.4448 * * * *
030077 ............................................................................. 0.8892 1.4448 * * * *
030078 ............................................................................. 1.2973 1.4448 * * * *
030080 ............................................................................. 1.5280 0.9027 $22.8953 $24.3573 $25.2077 $24.1500
030083 ............................................................................. 1.3085 1.0129 $24.3273 $24.9269 $27.5353 $25.6343
030084 ............................................................................. 0.9817 1.4448 * * * *
030085 ............................................................................. 1.5277 0.9027 $21.8196 $23.2070 $24.5792 $23.3008
030087 ............................................................................. 1.5910 1.0129 $25.6351 $26.3878 $26.6594 $26.2197
030088 ............................................................................. 1.3843 1.0129 $23.5761 $23.2478 $26.6796 $24.5472
030089 ............................................................................. 1.5441 1.0129 $24.5055 $26.2166 $27.1835 $26.0965
030092 ............................................................................. 1.3900 1.0129 $24.0515 $25.4127 $27.3203 $25.7452
030093 ............................................................................. 1.2317 1.0129 $23.2485 $23.5623 $25.8955 $24.3686
030094 ............................................................................. 1.3602 1.0129 $24.5992 $26.9985 $29.5948 $27.0516
030099 ............................................................................. 0.9027 0.9007 $20.3310 $26.7996 $26.3236 $24.0344
030100 ............................................................................. 2.0028 0.9027 $27.6299 * $29.0691 $28.4177
030101 h ........................................................................... 1.4076 1.1404 $23.7661 $25.0077 $26.1927 $25.0150
030102 ............................................................................. 2.5592 1.0129 $27.9419 * $29.0942 $28.5553
030103 ............................................................................. 1.6685 1.0129 $29.1105 $28.2832 $30.1994 $29.2117
030104 ............................................................................. *** * $34.6028 * * $34.6028
030105 ............................................................................. 2.4472 1.0129 * $27.6900 $31.3094 $29.8084
030106 ............................................................................. 1.5550 1.0129 * $30.4791 $34.7222 $32.1177
030107 ............................................................................. 2.2261 1.0129 * * * *
030108 ............................................................................. 1.9023 1.0129 * * * *
030109 ............................................................................. 2.1680 1.0129 * * * *
030110 ............................................................................. 1.0957 1.0129 * * * *
030111 ............................................................................. 0.8225 0.9027 * * * *
030112 ............................................................................. 1.8096 1.0129 * * * *
040001 ............................................................................. 1.0611 0.8707 $18.7141 $23.1475 $23.7718 $21.8056
040002 ............................................................................. 1.1352 0.7493 $18.0776 $19.3429 $20.1384 $19.2037
040003 ............................................................................. 1.0582 * $16.3918 $18.5000 * $17.3854
040004 ............................................................................. 1.5440 0.8707 $21.2335 $23.3504 $25.0286 $23.2843
040007 ............................................................................. 1.6746 0.8759 $23.3992 $23.4565 $25.7142 $24.1728
040010 ............................................................................. 1.3668 0.8707 $20.7114 $22.0984 $23.0274 $21.9856
040011 ............................................................................. 1.0105 0.7493 $18.8346 $19.0319 $20.3970 $19.4802

Case-mix FY 2006
040014 ............................................................................. 1.3837 0.8558 $22.4970 $24.0846 $25.3451 $23.9535

040015 ............................................................................. 1.0508 0.7493 $18.8513 $18.0793 $19.2831 $18.7435
040016 ............................................................................. 1.7065 0.8759 $21.2198 $22.7219 $22.1228 $22.0244
040017 ............................................................................. 1.0997 0.8242 $17.7545 $19.4365 $21.9875 $19.7066
040018 ............................................................................. 0.9918 0.8247 $22.0408 $23.8515 $23.6044 $23.2404
040019 ............................................................................. 1.1532 0.9148 $21.1711 $21.5316 $23.7328 $22.1722
040020 ............................................................................. 1.5108 0.9148 $18.6419 $20.9136 $21.6603 $20.4199
040021 ............................................................................. 1.2519 0.8759 $23.5620 $24.7771 $25.6917 $24.7363
040022 ............................................................................. 1.6253 0.8707 $21.4194 $23.7462 $25.4052 $23.5017
040024 ............................................................................. 1.0583 * $17.5750 $20.1101 * $18.8371
040026 ............................................................................. 1.5143 0.9020 $22.7699 $24.3053 $25.4072 $24.2169
040027 ............................................................................. 1.3588 0.8242 $19.3388 $19.9348 $21.1412 $20.1077
040029 ............................................................................. 1.5605 0.8759 $22.1882 $22.8770 $24.0704 $23.0869
040032 ............................................................................. 0.9574 * $16.2781 $18.5171 * $17.4291
040035 ............................................................................. 0.9191 * $11.8237 $13.4265 * $12.6475
040036 ............................................................................. 1.5893 0.8759 $21.6742 $24.2851 $26.3226 $24.0976
040039 ............................................................................. 1.3470 0.7784 $15.9673 $17.7976 $19.5998 $17.8170
040041 ............................................................................. 1.1930 0.8558 $20.4646 $22.0188 $22.1531 $21.5535
040042 ............................................................................. 1.3638 0.9402 $16.2285 $18.9550 $19.9627 $18.3286
040045 ............................................................................. 0.9454 0.7493 $19.5572 $18.7952 $17.2280 $18.4644
040047 ............................................................................. 1.0852 0.7919 $21.6323 $21.5334 $21.9163 $21.6924
040050 ............................................................................. 1.0870 0.7493 $15.1428 $15.4782 $16.3930 $15.6589
040051 ............................................................................. 0.9253 0.7493 $17.6964 $18.8943 $19.1401 $18.6103
040053 ............................................................................. 1.0125 0.7493 $19.2586 $20.8153 $20.7824 $20.2863
040054 ............................................................................. 1.0370 0.7493 $16.5573 $16.7370 $18.2684 $17.1740
040055 ............................................................................. 1.5720 0.8247 $19.7336 $22.2237 $23.3156 $21.7960
040062 ............................................................................. 1.5986 0.8247 $21.9336 $21.6403 $23.3083 $22.3231
040066 ............................................................................. 1.0416 * $21.7766 $23.4616 * $22.6592
040067 ............................................................................. 1.0257 0.7493 $16.0516 $15.1441 $16.8799 $16.0038
040069 ............................................................................. 1.0526 0.9148 $20.5968 $21.7607 $24.4662 $22.2668
040071 ............................................................................. 1.5315 0.8733 $19.4324 $22.9350 $24.3824 $22.1870
040072 ............................................................................. 1.0802 0.8558 $19.3079 $20.8269 $19.9009 $19.9951
040074 ............................................................................. 1.2035 0.8759 $22.0800 $22.6147 $25.2423 $23.2187
040075 ............................................................................. 0.9612 0.7493 $15.7875 $16.2583 $18.3254 $16.7901
040076 ............................................................................. 1.0330 0.8842 $23.5947 $21.0442 $20.6272 $21.6458
040077 ............................................................................. 0.9696 0.7493 $16.7832 $18.3261 $18.2082 $17.7537
040078 ............................................................................. 1.5651 0.9020 $21.4854 $24.4589 $24.5378 $23.4806
040080 ............................................................................. 0.9900 0.7784 $18.4470 $21.3483 $22.3392 $20.6867
040081 ............................................................................. 0.8227 0.7493 $13.2797 $13.7148 $15.1081 $14.0348
040084 ............................................................................. 1.0802 0.8759 $20.1163 $22.6441 $24.7225 $22.5619
040085 ............................................................................. 1.0020 0.7493 $15.5811 $18.0756 $29.8444 $19.6100
040088 ............................................................................. 1.3134 0.8758 $20.0032 $21.2974 $22.6183 $21.3215
040091 ............................................................................. 1.1579 0.8285 $20.6688 $23.0252 $23.1320 $22.2743
040100 ............................................................................. 1.3499 0.8558 $17.8889 $19.3560 $20.0460 $19.1639
040105 ............................................................................. 1.0187 0.7493 $15.4697 $15.8171 $18.2182 $16.4079
040107 ............................................................................. 0.7355 * $17.6695 * * $17.6695
040109 ............................................................................. 1.0950 0.7493 $17.1706 $18.8624 $22.8801 $19.5134
040114 ............................................................................. 1.7269 0.8759 $21.6849 $23.5628 $24.8992 $23.4046
040118 ............................................................................. 1.4172 0.7960 $21.7913 $24.2547 $24.7363 $23.6447
040119 ............................................................................. 1.4440 0.8558 $19.9013 $20.1631 $21.0103 $20.3637
040126 ............................................................................. 0.8734 0.7493 $13.3832 $12.5944 $14.0701 $13.3074
040132 ............................................................................. *** * $29.2343 $36.5525 $28.1390 $31.3524
040134 ............................................................................. 2.4871 0.8759 $24.4646 * $27.3412 $25.9794
040137 ............................................................................. 1.2240 0.8759 $24.7813 $23.4672 $25.2907 $24.5263
040138 ............................................................................. 1.2558 0.8707 $22.3523 $23.3615 $25.7513 $23.9295
040140 ............................................................................. *** * * $25.1224 * $25.1224
040141 ............................................................................. 0.7865 0.8707 * * $24.0901 $24.0901
040142 ............................................................................. 1.2881 0.9020 * * $27.9695 $27.9695
040144 ............................................................................. 1.8281 0.8247 * * * *
040145 ............................................................................. 1.6490 0.7960 * * * *
040146 ............................................................................. 1.5160 0.8707 * * * *
050002 ............................................................................. 1.3838 1.5463 $30.9729 $31.9709 $34.1948 $32.4064
050006 ............................................................................. 1.6406 1.1897 $25.4604 $27.6176 $30.5373 $27.9248
050007 ............................................................................. 1.4970 1.4974 $34.1406 $37.5804 $38.7033 $36.8959
050008 ............................................................................. 1.3604 1.5000 $32.4067 $36.9371 $39.1539 $36.3445
050009 ............................................................................. 1.8013 1.3972 $30.2740 $35.5384 $39.6393 $35.2947
050013 ............................................................................. 2.0861 1.3972 $29.8401 $31.7637 $31.9837 $31.2570

Case-mix FY 2006
050014 ............................................................................. 1.1355 1.2949 $27.7646 $29.5726 $33.0373 $30.2311

050015 ............................................................................. 1.2876 1.1042 $27.5652 $30.1398 $30.7940 $29.4852
050016 ............................................................................. 1.2303 1.1449 $25.5508 $25.5735 $26.2162 $25.7788
050017 ............................................................................. 1.9469 1.2949 $28.4911 $30.5863 $36.6593 $31.9215
050018 ............................................................................. 1.1836 1.1793 $17.9621 $20.3179 $22.3472 $20.1629
050022 ............................................................................. 1.5996 1.1296 $28.1312 $28.2773 $29.8632 $28.8610
050024 ............................................................................. 1.1356 1.1406 $25.1425 $26.9378 $27.5587 $26.6747
050025 ............................................................................. 1.8361 1.1406 $29.8262 $31.7242 $36.1622 $32.6605
050026 ............................................................................. 1.5525 1.1406 $24.2564 $26.6406 $28.3027 $26.5474
050028 ............................................................................. 1.2414 1.1042 $18.7866 $21.5448 $26.6160 $21.9931
050029 ............................................................................. *** * $30.2538 $34.3934 * $31.9320
050030 ............................................................................. 1.2356 1.1042 $21.9251 $22.9148 $24.9707 $23.2719
050032 ............................................................................. *** * $28.8046 * * $28.8046
050036 ............................................................................. 1.6046 1.1042 $25.3885 $27.4915 $32.7929 $28.6943
050038 ............................................................................. 1.4838 1.5088 $36.1619 $35.0441 $38.7527 $36.6692
050039 ............................................................................. 1.6104 1.1042 $26.8993 $29.8179 $31.6734 $29.4369
050040 ............................................................................. 1.2146 1.1793 $30.7426 $31.8983 $34.3279 $32.3366
050042 ............................................................................. 1.3842 1.1897 $27.6765 $29.8062 $33.9415 $30.4516
050043 ............................................................................. 1.6433 1.5463 $37.3217 $39.6054 $43.1589 $40.0134
050045 ............................................................................. 1.2820 1.1042 $22.1691 $22.7051 $23.8408 $22.8906
050046 ............................................................................. 1.2229 1.1769 $25.5490 $25.2786 $25.6875 $25.5104
050047 ............................................................................. 1.7071 1.5000 $34.4427 $39.3993 $40.9874 $38.4201
050054 ............................................................................. 1.1951 1.1296 $21.3495 $27.1437 $24.1262 $24.0051
050055 ............................................................................. 1.2558 1.5000 $36.1182 $36.9386 $37.5879 $36.9364
050056 ............................................................................. 1.3730 1.1793 $27.1458 $29.4829 $27.9330 $28.1647
050057 ............................................................................. 1.6271 1.1042 $24.2759 $26.2099 $29.4351 $26.6650
050058 ............................................................................. 1.5543 1.1793 $25.9389 $27.3584 $33.8215 $29.0264
050060 ............................................................................. 1.5154 1.1042 $22.9491 $26.5515 $27.3282 $25.6824
050061 ............................................................................. 0.8661 1.1681 $25.3042 * $32.2172 $28.5425
050063 ............................................................................. 1.3437 1.1793 $28.6093 $32.0515 $33.3039 $31.3845
050065 ............................................................................. 1.7814 1.1687 $28.8369 $33.8223 $34.0280 $32.3405
050067 ............................................................................. 1.2547 1.1960 $27.8867 $29.6982 $31.9597 $29.7844
050068 ............................................................................. *** * $21.9031 * * $21.9031
050069 ............................................................................. 1.6333 1.1687 $27.2744 $28.6752 $31.2172 $29.0770
050070 ............................................................................. 1.3101 1.4974 $39.5178 $40.5645 $45.3382 $41.9509
050071 ............................................................................. 1.3143 1.5463 $40.1344 $41.1036 $44.9464 $42.2000
050072 ............................................................................. 1.3841 1.5463 $39.2529 $40.8108 $44.2651 $41.6223
050073 ............................................................................. 1.3621 1.5463 $38.6763 $41.3430 $45.9765 $42.1975
050075 ............................................................................. 1.2741 1.5463 $40.2265 $43.7101 $47.2356 $44.0053
050076 ............................................................................. 2.0222 1.5463 $40.8075 $43.0845 $46.4990 $43.5903
050077 ............................................................................. 1.6862 1.1406 $27.1234 $29.6264 $32.0245 $29.6181
050078 ............................................................................. 1.3018 1.1793 $24.1091 $25.6814 $31.1425 $26.6955
050079 ............................................................................. 1.4490 1.5463 $38.8981 $42.7385 $47.8597 $43.4884
050082 ............................................................................. 1.6915 1.1769 $27.5022 $28.9139 $37.7783 $31.5037
050084 ............................................................................. 1.5652 1.1884 $26.0607 $28.2664 $33.0179 $29.0525
050088 ............................................................................. *** * $27.1103 $26.4093 $25.7385 $26.4472
050089 ............................................................................. 1.4042 1.1687 $24.7857 $29.4884 $33.5323 $29.3416
050090 ............................................................................. 1.2979 1.4740 $27.4193 $31.1774 $32.9584 $30.4520
050091 ............................................................................. 1.1111 1.1793 $29.2522 $30.1534 $30.8560 $30.1209
050093 ............................................................................. 1.5182 1.1042 $29.2642 $31.1083 $33.4119 $31.3614
050095 ............................................................................. 1.9620 1.5463 * * * *
050096 ............................................................................. 1.3470 1.1793 $23.0525 $24.2277 $24.6680 $23.9648
050097 ............................................................................. *** * $24.6726 $26.6788 * $25.5991
050099 ............................................................................. 1.5364 1.1687 $27.1282 $28.7711 $31.0437 $29.0188
050100 ............................................................................. 1.7257 1.1406 $25.6798 $28.0303 $29.6949 $27.8627
050101 ............................................................................. 1.3034 1.5194 $32.9866 $35.4655 $40.3195 $36.3932
050102 ............................................................................. 1.3335 1.1296 $25.5763 $24.9381 $29.1364 $26.2832
050103 ............................................................................. 1.5518 1.1793 $27.8079 $28.7375 $34.2529 $30.2688
050104 ............................................................................. 1.4289 1.1793 $26.1592 $29.1240 $29.7326 $28.3301
050107 ............................................................................. 1.3995 1.1681 $22.6900 $27.6002 $33.1358 $27.7768
050108 ............................................................................. 1.9705 1.2949 $28.5244 $31.4271 $35.5711 $32.0693
050110 ............................................................................. 1.2808 1.1681 $21.9297 $20.0769 $26.1453 $22.5312
050111 ............................................................................. 1.2956 1.1793 $23.7715 $26.6345 $28.1588 $26.1803
050112 ............................................................................. 1.5575 1.1793 $31.9797 $34.0258 $36.8026 $34.4310
050113 ............................................................................. 1.2863 1.4974 $32.6932 $34.2851 $33.8064 $33.6092
050114 ............................................................................. 1.4206 1.1793 $28.1938 $29.2858 $31.1294 $29.5973
050115 ............................................................................. 1.4425 1.1406 $24.1481 $27.5207 $30.9288 $27.6106

Case-mix FY 2006
050116 ............................................................................. 1.5310 1.1793 $28.2924 $28.8193 $34.5110 $30.5901

050117 ............................................................................. 1.2695 1.1575 $24.7555 $28.2227 $32.4414 $28.3268
050118 ............................................................................. 1.1749 1.1960 $28.9358 $33.0650 $35.4044 $32.6634
050121 ............................................................................. 1.3421 1.1042 $25.0858 $25.5962 $27.9537 $26.3210
050122 ............................................................................. 1.5329 1.1884 $29.1534 $29.7629 $34.2416 $31.1709
050124 ............................................................................. 1.2574 1.1793 $23.0843 $26.7065 $28.0288 $25.9680
050125 ............................................................................. 1.3697 1.5088 $35.6573 $40.9218 $41.7020 $39.5040
050126 ............................................................................. 1.4092 1.1793 $27.7126 $29.6203 $29.3360 $28.8881
050127 ............................................................................. 1.3547 1.2949 $21.8719 $23.6208 $26.1222 $23.7516
050128 ............................................................................. 1.5401 1.1406 $28.7668 $28.3278 $31.0662 $29.4553
050129 ............................................................................. 1.7891 1.1687 $25.2780 $27.8488 $32.2680 $28.7272
050131 ............................................................................. 1.3037 1.4974 $37.7845 $38.6834 $40.5321 $39.0707
050132 ............................................................................. 1.4510 1.1793 $27.8805 $29.4317 $35.1544 $30.7495
050133 ............................................................................. 1.5036 1.1212 $25.1948 $27.6030 $31.3530 $28.2112
050135 ............................................................................. 1.0272 1.1793 * $24.9415 $24.3927 $24.6796
050136 ............................................................................. 1.2278 1.4740 $31.6146 $35.2834 $37.4560 $34.8123
050137 ............................................................................. 1.3314 1.1793 $35.0503 $36.5409 $38.4827 $36.7225
050138 ............................................................................. 1.9543 1.1793 $43.0858 $43.8671 $46.9557 $44.6742
050139 ............................................................................. 1.3297 1.1793 $33.8749 $35.1013 $37.6217 $35.5604
050140 ............................................................................. 1.3938 1.1687 $36.1708 $37.5473 $39.6269 $37.8550
050144 ............................................................................. 1.4278 1.1793 $30.3679 $32.4042 $33.5109 $32.1636
050145 ............................................................................. 1.3157 1.4126 $37.5722 $39.5676 $42.3134 $39.8846
050146 ............................................................................. 1.6530 * * * * *
050148 ............................................................................. 1.1183 1.1042 $17.3908 $24.7063 $27.3005 $22.6027
050149 ............................................................................. 1.4274 1.1793 $28.0500 $30.1596 $33.2270 $30.4737
050150 ............................................................................. 1.1828 1.2949 $26.7728 $31.5333 $31.7560 $29.9321
050152 ............................................................................. 1.4073 1.5000 $34.5694 $40.3464 $43.6487 $39.6060
050153 ............................................................................. 1.5356 1.5088 $34.5870 $40.4446 $43.3190 $39.3912
050155 ............................................................................. 0.9853 1.1793 $21.2068 $21.8829 $21.8550 $21.6128
050158 ............................................................................. 1.2548 1.1793 $30.6598 $33.6400 $35.1326 $33.3121
050159 ............................................................................. 1.3195 1.1769 $27.4051 $30.8069 $31.3199 $29.8120
050167 ............................................................................. 1.3716 1.1884 $23.2022 $25.9850 $28.5179 $25.9911
050168 ............................................................................. 1.6387 1.1687 $27.5313 $30.8036 $33.2506 $30.5684
050169 ............................................................................. 1.4440 1.1793 $25.6896 $26.2864 $27.4644 $26.5104
050170 ............................................................................. *** * $29.4075 * * $29.4075
050172 ............................................................................. 1.2976 1.1042 $24.5849 $27.1497 $28.5604 $26.7638
050173 ............................................................................. 1.2683 1.1687 $27.7070 $27.6097 $30.3582 $28.5541
050174 ............................................................................. 1.6685 1.4740 $33.5204 $36.3117 $40.1747 $36.7717
050175 ............................................................................. 1.3257 1.1793 $26.9627 $31.5615 $30.5733 $29.6977
050177 ............................................................................. 1.2560 1.1769 $23.1575 $24.7531 $25.1442 $24.3743
050179 ............................................................................. 1.2062 1.1960 $23.0583 $25.8072 $27.1155 $25.4092
050180 ............................................................................. 1.5936 1.5463 $36.9905 $40.8101 $40.2504 $39.4196
050186 ............................................................................. *** * $27.6638 * * $27.6638
050188 ............................................................................. 1.3728 1.5088 $34.1503 $39.3507 $39.5110 $37.7827
050189 ............................................................................. 0.9950 1.4126 $32.3513 $20.0709 $29.1280 $26.2226
050191 ............................................................................. 1.4576 1.1793 $28.1689 * $34.2091 $31.2052
050192 ............................................................................. 0.9922 1.1042 $19.5327 $21.2448 $27.0424 $22.7189
050193 ............................................................................. 1.2105 1.1687 $24.6307 $30.7341 $29.6421 $28.4881
050194 ............................................................................. 1.3143 1.5144 $28.1413 $38.6750 $40.9096 $35.6972
050195 ............................................................................. 1.5288 1.5463 $42.1735 $43.9696 $48.4358 $44.9294
050196 ............................................................................. 1.0813 1.1042 $20.7257 $25.2168 $32.1933 $25.8088
050197 ............................................................................. 1.9485 1.4974 * $40.8832 $48.9052 $44.8389
050204 ............................................................................. 1.4278 1.1793 $24.9458 $25.2512 $28.6423 $26.2829
050205 ............................................................................. 1.2423 1.1793 $25.2841 $28.0504 $27.8611 $27.0700
050207 ............................................................................. 1.2722 1.1042 $25.1863 $27.0216 $29.5215 $27.2272
050211 ............................................................................. 1.2769 1.5463 $34.3396 $38.3319 $41.2166 $37.8840
050214 ............................................................................. *** * $22.4773 $24.4785 $23.9972 $23.6229
050215 ............................................................................. 1.6360 1.5088 $36.6063 $41.6886 $43.7985 $40.7257
050217 ............................................................................. 1.1523 * $22.2055 $23.6286 * $22.9187
050219 ............................................................................. 1.1203 1.1793 $21.8649 $22.9226 $22.4065 $22.4391
050222 ............................................................................. 1.6451 1.1406 $25.2922 $26.3882 $29.1094 $27.0242
050224 ............................................................................. 1.7382 1.1687 $26.2108 $26.7916 $29.3143 $27.4653
050225 ............................................................................. 1.5374 1.1042 $25.0219 $29.5184 $29.9656 $28.1785
050226 ............................................................................. 1.6099 1.1687 $26.0826 $29.2259 $30.5867 $28.6690
050228 ............................................................................. 1.3576 1.5463 $38.6751 $40.1362 $42.4226 $40.4482
050230 ............................................................................. 1.3869 1.1687 $30.0380 $34.1417 $32.9555 $32.4641
050231 ............................................................................. 1.6526 1.1793 $27.8896 $30.1298 $30.9607 $29.7082

Case-mix FY 2006
050232 ............................................................................. 1.4450 1.1449 $25.3439 $24.4383 $27.4099 $25.6865

050234 ............................................................................. 1.1731 1.1406 $24.0754 $29.2421 $29.6560 $27.4243
050235 ............................................................................. 1.5444 1.1793 $27.2838 $27.8965 $29.2979 $28.1654
050236 ............................................................................. 1.3994 1.1769 $27.0687 $28.1969 $32.1647 $29.0012
050238 ............................................................................. 1.4564 1.1793 $26.0312 $29.1481 $31.1764 $28.8569
050239 ............................................................................. 1.5849 1.1793 $27.0866 $28.2327 $31.0963 $28.8857
050240 ............................................................................. 1.6565 1.1793 $32.8542 $35.2284 $35.5735 $34.6528
050242 ............................................................................. 1.3410 1.5144 $34.4412 $39.7629 $44.3130 $39.6054
050243 ............................................................................. 1.6534 1.1296 $28.5626 $31.8153 $31.4883 $30.6830
050245 ............................................................................. 1.3548 1.1687 $25.7585 $27.0949 $28.6527 $27.2127
050248 ............................................................................. 1.0461 1.4126 $29.1192 $31.6240 $35.3864 $32.0261
050251 ............................................................................. 1.0047 1.1042 $24.4552 $26.5021 $27.2675 $26.0899
050253 ............................................................................. *** * $23.9246 $22.2450 $24.0044 $23.3808
050254 ............................................................................. 1.2205 1.2949 $23.3358 $24.1512 $27.0041 $24.9056
050256 ............................................................................. 1.5793 1.1793 $26.8618 $28.4728 $29.8194 $28.4077
050257 ............................................................................. 1.0004 1.1042 $17.4909 $20.8367 $21.3216 $19.7770
050261 ............................................................................. 1.3301 1.1042 $21.4693 $25.3005 $27.3234 $24.7145
050262 ............................................................................. 2.1454 1.1793 $33.0425 $36.1162 $44.0256 $37.8981
050264 ............................................................................. 1.3258 1.5463 $37.4742 $41.3478 $41.1211 $39.9496
050267 ............................................................................. *** * $26.6558 $26.7060 * $26.6806
050270 ............................................................................. 1.3557 1.1406 $27.9871 $30.0540 $32.4812 $30.2697
050272 ............................................................................. 1.3855 1.1687 $24.0921 $25.9103 $27.1989 $25.7666
050276 ............................................................................. 1.1976 1.5463 $34.7422 $41.2251 $39.3778 $38.5361
050277 ............................................................................. 1.0670 1.1793 $35.6323 $35.8246 $32.5213 $34.3014
050278 ............................................................................. 1.5957 1.1793 $26.0331 $28.0351 $29.9244 $28.0988
050279 ............................................................................. 1.2401 1.1687 $23.5145 $25.5299 $27.6573 $25.5685
050280 ............................................................................. 1.6713 1.2195 $28.5504 $30.6723 $35.2030 $31.5494
050281 ............................................................................. 1.5109 1.1793 $25.7832 $26.2623 $27.3824 $26.5030
050283 ............................................................................. 1.5342 1.5463 $35.1831 $38.5600 $43.0638 $39.0754
050286 ............................................................................. *** * $19.7352 $19.4973 * $19.6057
050289 ............................................................................. 1.5684 1.4974 $34.9645 $38.6875 $41.1774 $38.2497
050290 ............................................................................. 1.6298 1.1793 $31.9510 $32.6388 $34.5482 $33.0758
050291 ............................................................................. 1.8266 1.4740 $28.3451 $29.6162 $35.3653 $31.1027
050292 ............................................................................. 1.0060 1.1296 $27.6114 $27.0775 $26.8879 $27.1685
050295 ............................................................................. 1.5315 1.1042 $25.4332 $31.5960 $36.1950 $30.7774
050296 ............................................................................. 1.1543 1.5088 $33.5948 $34.9952 $39.0061 $36.0343
050298 ............................................................................. 1.1432 1.1687 $26.1707 $25.8232 $27.7416 $26.6026
050299 ............................................................................. 1.2359 1.1793 $26.9870 $27.7535 $31.5435 $28.9060
050300 ............................................................................. 1.5896 1.1687 $26.3182 $28.3862 $30.7148 $28.5022
050301 ............................................................................. 1.2259 1.1042 $25.7167 $28.5769 $31.9995 $28.7858
050305 ............................................................................. 1.4554 1.5463 $38.7597 $40.9978 $44.8630 $41.5654
050308 ............................................................................. 1.4708 1.5088 $31.6790 $38.0564 $43.0691 $37.5162
050309 ............................................................................. 1.3967 1.2949 $25.5367 $28.9181 $34.4145 $29.9035
050312 ............................................................................. 1.4897 1.2195 $28.2557 $32.6846 $33.9022 $31.7615
050313 ............................................................................. 1.2490 1.1884 $25.3372 $27.5321 $31.8003 $28.5358
050315 ............................................................................. 1.3108 1.1042 $23.6638 $26.1224 $28.5933 $26.1591
050320 ............................................................................. 1.2329 1.5463 $31.4570 $36.3252 $40.2352 $36.0082
050324 ............................................................................. 1.9659 1.1406 $28.4931 $30.9958 $32.9792 $30.9355
050325 ............................................................................. 1.1941 1.1218 $26.6325 $30.2280 $30.6117 $29.1581
050327 ............................................................................. 1.6830 1.1687 $33.0549 $29.8327 $33.0087 $31.8986
050329 ............................................................................. 1.2877 1.1296 $26.6341 $26.8021 $26.2120 $26.5339
050331 ............................................................................. 1.1730 1.4740 $21.5193 $20.9847 $20.2692 $20.9637
050333 ............................................................................. 1.0827 1.1042 $15.6929 $15.3119 $23.4009 $17.5306
050334 ............................................................................. 1.7039 1.4126 $37.2336 $38.7635 $40.7467 $38.9455
050335 ............................................................................. 1.4400 1.1218 $24.9274 $27.4046 $28.9403 $27.1683
050336 ............................................................................. 1.1812 1.1884 $23.2687 $25.3062 $28.5659 $25.7519
050342 ............................................................................. 1.2397 1.1042 $23.0282 $24.7654 $26.8507 $24.9581
050348 ............................................................................. 1.7148 1.1687 $28.9864 $33.2676 $37.7898 $33.4975
050349 ............................................................................. 0.9544 1.1042 $15.6043 $16.9251 $17.4791 $16.6299
050350 ............................................................................. 1.3733 1.1793 $27.2573 $29.4262 $31.1833 $29.2715
050351 ............................................................................. 1.5221 1.1793 $27.4042 $29.3082 $30.8661 $29.2314
050352 ............................................................................. 1.2426 1.2949 $32.6572 $24.2931 $33.9362 $30.0053
050353 ............................................................................. 1.5760 1.1793 $25.4309 $26.6332 $31.8291 $27.9376
050355 ............................................................................. *** * * $11.2498 * $11.2498
050357 ............................................................................. 1.4534 1.1681 $25.2126 $26.7265 $32.3095 $27.5322
050359 ............................................................................. 1.1458 1.1042 $22.9175 $23.6030 $25.7739 $24.1671
050360 ............................................................................. 1.4790 1.4974 $35.9032 $38.8658 $37.0769 $37.3332

Case-mix FY 2006
050366 ............................................................................. 1.2339 1.1042 $23.4696 $25.7692 $31.1854 $26.8679

050367 ............................................................................. 1.4231 1.5194 $32.6760 $34.4959 $38.7727 $35.6827
050369 ............................................................................. 1.4460 1.1793 $28.0909 $27.1327 $29.5697 $28.2751
050373 ............................................................................. 1.5312 1.1793 $30.7301 $32.2315 $31.9271 $31.6344
050376 ............................................................................. 1.4749 1.1793 $30.3530 $30.7562 $32.9393 $31.3430
050377 ............................................................................. *** * $14.3892 $20.2484 * $16.9896
050378 ............................................................................. 1.0130 1.1793 $30.4937 $33.9087 $34.2417 $32.8674
050379 ............................................................................. *** * $27.5151 $31.7645 $32.9575 $30.5157
050380 ............................................................................. 1.5551 1.5088 $35.8014 $39.1098 $42.0782 $38.9514
050382 ............................................................................. 1.4416 1.1793 $26.8950 $26.0927 $29.4323 $27.5053
050385 ............................................................................. 1.3604 1.4740 * $25.5735 $34.5184 $29.9098
050390 ............................................................................. 1.2081 1.1296 $25.7881 $28.7761 $26.0066 $26.7871
050391 ............................................................................. 1.3574 1.1793 $20.2887 $21.3012 $18.1004 $19.7304
050392 ............................................................................. 1.0336 * $21.8139 $22.7209 * $22.2790
050393 ............................................................................. 1.3444 1.1793 $26.4918 $28.2369 $30.0661 $28.2139
050394 ............................................................................. 1.5114 1.1769 $25.1869 $26.0074 $27.5061 $26.2967
050396 ............................................................................. 1.5986 1.1681 $28.4161 $30.5470 $33.5699 $30.9065
050397 ............................................................................. 0.8430 1.1042 $24.7279 $27.4716 $28.1640 $26.7356
050407 ............................................................................. 1.2038 1.5000 $33.2894 $35.6035 $37.9066 $35.6609
050410 ............................................................................. 0.9582 1.1042 $19.8436 $19.4995 $21.3814 $20.2094
050411 ............................................................................. 1.4367 1.1793 $35.5207 $37.3817 $37.8064 $36.9551
050414 ............................................................................. 1.3118 1.2949 $28.2381 $28.8561 $34.6672 $30.6054
050417 ............................................................................. 1.3035 1.1042 $24.5360 $25.2930 $29.5031 $26.5285
050419 ............................................................................. 1.3417 1.1897 $26.4357 $28.4471 $33.3125 $29.3954
050420 ............................................................................. 1.1580 1.1793 $26.7537 $26.1838 $24.9401 $25.8686
050423 ............................................................................. 0.9647 1.1296 $26.5188 $28.5944 $30.6416 $28.6936
050424 ............................................................................. 1.9964 1.1406 $27.5273 $29.9133 $31.0730 $29.4697
050425 ............................................................................. 1.3918 1.2949 $37.7347 $38.5317 $42.4177 $39.7789
050426 ............................................................................. 1.3428 1.1687 $30.9610 $30.0077 $30.6899 $30.5313
050430 ............................................................................. 0.9530 1.1042 $31.5170 $24.6684 $25.0607 $26.4412
050432 ............................................................................. 1.5243 1.1793 $28.1105 $30.3547 $30.8030 $29.8170
050433 ............................................................................. 0.9295 1.1042 $14.3846 $20.7565 $23.0806 $19.1896
050434 ............................................................................. 1.1531 1.1042 * $25.9506 $26.1621 $26.0550
050435 ............................................................................. 1.1069 1.1406 $22.6618 $32.2183 $28.0306 $27.3138
050438 ............................................................................. 1.5308 1.1793 $26.5535 $26.4668 $27.2662 $26.7804
050441 ............................................................................. 1.9818 1.5088 $36.6680 $38.2823 $42.9765 $39.2937
050444 ............................................................................. 1.3397 1.1575 $23.5299 $27.6971 $30.5504 $27.3177
050447 ............................................................................. 0.9222 1.1406 $25.7274 $21.8552 $25.2573 $24.1974
050448 ............................................................................. 1.1545 1.1042 $26.6967 $25.0983 $27.9759 $26.6380
050454 ............................................................................. 1.8872 1.5000 $34.4813 $36.8383 $43.5311 $38.4458
050455 ............................................................................. 1.6960 1.1042 $24.1694 $24.5314 $22.7235 $23.7347
050456 ............................................................................. 1.2406 1.1793 $23.7594 $22.1675 $22.5630 $22.8117
050457 ............................................................................. 1.6228 1.5000 $37.4570 $40.2725 $45.5829 $41.0011
050464 ............................................................................. 1.6633 1.1960 $31.4768 $37.1342 $37.3692 $35.4838
050468 ............................................................................. 1.4897 1.1793 $17.8128 $29.4280 $29.5448 $24.3346
050469 ............................................................................. 1.1011 1.1042 $25.7995 $27.3281 $28.9079 $27.4122
050470 ............................................................................. 1.1024 1.1042 $21.6981 $18.4689 $24.6755 $21.6205
050471 ............................................................................. 1.7973 1.1793 $32.3570 $34.5484 $34.5211 $33.8184
050476 ............................................................................. 1.3677 1.1299 $26.0482 $30.9974 $34.6585 $30.3567
050477 ............................................................................. 1.5014 1.1793 $32.1676 $34.6400 $34.6995 $33.8960
050478 ............................................................................. 0.9911 1.1681 $28.3894 $30.9865 $33.3998 $30.9361
050481 ............................................................................. 1.4449 1.1793 $30.3890 $31.9177 $33.7446 $32.0928
050485 ............................................................................. 1.6093 1.1793 $27.1437 $28.8459 $31.4233 $29.1407
050488 ............................................................................. 1.3372 1.5463 $37.2438 $40.5313 $42.9904 $40.3037
050491 ............................................................................. *** * $29.2987 $30.6461 $32.1379 $30.5664
050492 ............................................................................. 1.4155 1.1042 $23.7384 $27.4933 $27.1540 $26.2639
050494 ............................................................................. 1.3645 1.3467 $30.8706 $35.1457 $35.9909 $33.9880
050496 ............................................................................. 1.7942 1.5463 $35.7115 $38.2871 $42.2672 $38.6931
050497 ............................................................................. *** * $14.4481 $15.9501 * $15.1581
050498 ............................................................................. 1.2896 1.2949 $28.2196 $28.2667 $33.0298 $29.9964
050502 ............................................................................. 1.7506 1.1793 $28.0102 $28.7200 $29.5615 $28.8118
050503 ............................................................................. 1.4553 1.1406 $26.7924 $29.2001 $31.6418 $29.3049
050506 ............................................................................. 1.7275 1.1449 $30.4731 $32.4509 $36.0164 $33.1455
050510 ............................................................................. 1.2221 1.5463 $39.6005 $44.3883 $47.5510 $44.1129
050512 ............................................................................. 1.3790 1.5463 $39.0767 $41.8921 $46.9233 $42.8915
050515 ............................................................................. 1.3588 1.1406 $36.3131 $37.4251 $38.9978 $37.6365
050516 ............................................................................. 1.4661 1.2949 $30.0985 $29.4936 $36.2772 $31.8725

Case-mix FY 2006
050517 ............................................................................. 1.0856 1.1687 $23.4131 $23.6034 $23.9007 $23.6377

050522 ............................................................................. *** * $38.9157 * * $38.9157
050523 ............................................................................. 1.2555 1.5463 $33.8053 $34.7491 $35.5452 $34.7574
050526 ............................................................................. 1.2399 1.1687 $29.0004 $29.9495 $31.3744 $30.1287
050528 ............................................................................. 1.1417 1.1042 $23.9177 $28.6273 $29.6838 $27.7337
050531 ............................................................................. 1.1058 1.1793 $22.7311 $25.0157 $26.9420 $24.9597
050534 ............................................................................. 1.2857 1.1296 $26.7941 $29.7546 $29.8603 $28.8863
050535 ............................................................................. 1.3768 1.1687 $29.7904 $32.3646 $32.3723 $31.6438
050537 ............................................................................. 1.3916 1.2949 $25.1291 $27.4196 $31.3844 $28.1091
050539 ............................................................................. 1.2510 * $25.3328 $28.0586 $29.8242 $27.8112
050541 ............................................................................. 1.6070 1.5463 $41.1980 $43.7765 $46.1121 $43.8355
050542 ............................................................................. 1.1241 * $21.2846 * * $21.2846
050543 ............................................................................. 0.7293 1.1687 $24.0334 $25.7161 $26.1103 $25.3298
050545 ............................................................................. 0.7134 1.1793 $33.4322 $42.9451 $30.5554 $35.4562
050546 ............................................................................. 0.7307 1.1042 $42.8052 $52.7180 $30.2329 $41.5266
050547 ............................................................................. 0.8543 1.4740 $40.6483 $45.1842 $33.2205 $39.9154
050548 ............................................................................. 0.7266 1.1687 $32.3944 $37.1314 $30.3775 $33.5849
050549 ............................................................................. 1.5502 1.3467 $31.8525 $33.8288 $34.9818 $33.6342
050550 ............................................................................. 1.4030 1.1687 $29.0938 $31.1918 $30.2302 $30.2108
050551 ............................................................................. 1.3078 1.1687 $28.6834 $31.6782 $31.6165 $30.7425
050552 ............................................................................. 1.1266 1.1793 $24.9755 $26.8274 $27.1744 $26.5471
050557 ............................................................................. 1.5569 1.1960 $25.8719 $28.3111 $31.8048 $28.8575
050559 ............................................................................. *** * $25.3299 $26.9662 * $26.0948
050561 ............................................................................. 1.2622 1.1793 $35.9611 $37.5863 $38.8651 $37.5449
050567 ............................................................................. 1.5993 1.1687 $27.8475 $30.1167 $32.9829 $30.4114
050568 ............................................................................. 1.2479 1.1104 $20.8324 $22.5008 $24.4061 $22.5795
050569 ............................................................................. 1.3416 1.3467 $27.7955 $30.4874 $33.0259 $30.5066
050570 ............................................................................. 1.5225 1.1687 $29.9470 $32.6896 $34.0171 $32.2949
050571 ............................................................................. 1.3109 1.1793 $29.1716 $32.1656 $33.6156 $31.7338
050573 ............................................................................. 1.7313 1.1296 $27.2328 $30.5249 $34.1991 $30.6886
050575 ............................................................................. 1.2700 1.1793 $23.1358 $23.2447 $25.2513 $23.9658
050577 ............................................................................. 1.2292 1.1793 $26.4806 $28.7060 $30.8841 $28.7176
050578 ............................................................................. 1.7728 1.1793 $30.4934 $31.5953 $33.8825 $31.9512
050579 ............................................................................. 1.4467 1.1793 $34.9794 $40.2740 $39.4976 $38.3190
050580 ............................................................................. 1.2914 1.1687 $27.2431 $29.4337 $31.6256 $29.3950
050581 ............................................................................. 1.4899 1.1793 $28.9696 $32.0823 $32.1801 $31.1581
050583 ............................................................................. 1.5944 1.1406 $30.0427 $33.5209 $33.3697 $32.3610
050584 ............................................................................. 1.3233 1.1687 $24.5544 $24.5757 $24.8180 $24.6565
050585 ............................................................................. 1.1560 1.1687 $26.0595 $27.2982 $22.7121 $24.9986
050586 ............................................................................. 1.1733 1.1687 $25.7172 $25.3551 $27.4173 $26.0841
050588 ............................................................................. 1.3510 1.1793 $30.5453 $32.3603 $32.8212 $31.9715
050589 ............................................................................. 1.2707 1.1687 $27.9845 $30.6273 $30.9547 $29.9199
050590 ............................................................................. 1.2858 1.2949 $27.0620 $31.5987 $32.2142 $30.2046
050591 ............................................................................. 1.1589 1.1793 $28.6151 $28.5915 $28.8549 $28.6959
050592 ............................................................................. 1.1853 1.1687 $25.9545 $32.5000 $24.4542 $27.4073
050594 ............................................................................. 2.0368 1.1687 $30.8028 $34.6747 $34.7946 $33.5328
050597 ............................................................................. 1.2589 1.1793 $24.5542 $25.4868 $27.5691 $25.8776
050598 ............................................................................. *** * $24.6875 * * $24.6875
050599 ............................................................................. 1.8974 1.2949 $27.7684 $30.8420 $38.1975 $32.3121
050601 ............................................................................. 1.5294 1.1793 $32.3033 $35.0325 $34.7409 $34.0841
050603 ............................................................................. 1.4068 1.1687 $25.0996 $28.6982 $30.2464 $28.0787
050604 ............................................................................. 1.2727 1.5088 $42.0018 $45.4433 $49.9429 $45.9484
050608 ............................................................................. 1.4179 1.1042 $20.7955 $22.1999 $23.3630 $22.1922
050609 ............................................................................. 1.3791 1.1687 $37.4563 $38.4561 $41.1797 $39.1280
050613 ............................................................................. 0.8939 1.4974 * * * *
050615 ............................................................................. 1.3236 1.1793 $29.4323 $32.8786 $33.2909 $31.8903
050616 ............................................................................. 1.3870 1.1769 $23.1748 $28.5636 $36.9017 $29.6253
050618 ............................................................................. 1.0253 1.1042 $22.3481 $25.4500 $27.4539 $25.0614
050623 ............................................................................. *** * $29.9553 $29.6550 $32.0627 $30.4768
050624 ............................................................................. 1.2788 1.1793 $23.3492 $28.1941 $32.2907 $27.6796
050625 ............................................................................. 1.7550 1.1793 $30.8013 $33.5137 $36.3631 $33.6260
050630 ............................................................................. *** * $27.7051 $28.0726 $30.9410 $28.9666
050633 ............................................................................. 1.2323 1.1449 $30.2883 $33.4771 $35.3734 $33.1070
050636 ............................................................................. 1.3270 1.1406 $23.2573 $27.2360 $30.5156 $27.0926
050641 ............................................................................. 1.2310 1.1793 $21.5030 $20.4720 $21.4612 $21.1520
050644 ............................................................................. 0.9036 1.1793 $28.4054 $25.6614 $27.6547 $27.1915
050660 ............................................................................. 1.4561 * * * * *

Case-mix FY 2006
050662 ............................................................................. 0.7908 1.5088 $40.9242 $47.5065 $32.6362 $40.4932

050663 ............................................................................. 1.0382 1.1793 $22.9161 $25.1493 $25.7747 $24.4728
050667 ............................................................................. 0.9090 1.3972 $31.4906 $25.9250 $26.3937 $27.9100
050668 ............................................................................. 1.0144 1.5463 $55.9594 * $31.8065 $41.1707
050674 ............................................................................. 1.3172 1.2949 $36.8871 $38.4454 $42.6866 $39.5960
050677 ............................................................................. 1.4866 1.1793 $36.2702 $37.3389 $38.7984 $37.5511
050678 ............................................................................. 1.2681 1.1687 $27.1337 $29.1159 $30.7220 $29.1295
050680 ............................................................................. 1.2141 1.5194 $32.7065 $35.6614 $38.3946 $35.9028
050681 ............................................................................. 1.5453 1.1793 * * * *
050682 ............................................................................. 0.8883 1.1042 $23.0984 $21.7264 $21.7791 $22.0865
050684 ............................................................................. 1.1340 1.1296 $23.7443 $25.2575 $26.4234 $25.2119
050686 ............................................................................. 1.3399 1.1296 $37.3033 $38.5595 $40.9486 $39.0574
050688 ............................................................................. 1.2165 1.5088 $36.5555 $41.3305 $41.9325 $39.9230
050689 ............................................................................. 1.5667 1.5463 $37.5449 $40.3815 $42.2018 $40.1932
050690 ............................................................................. 1.2618 1.4740 $41.1385 $43.9228 $47.2769 $44.3743
050693 ............................................................................. 1.2877 1.1687 $32.6638 $34.8040 $35.0621 $34.2547
050694 ............................................................................. 1.2058 1.1296 $25.8298 $26.7041 $28.9544 $27.1978
050695 ............................................................................. 1.1260 1.1884 $27.8742 $30.1226 $35.6549 $31.4872
050696 ............................................................................. 2.0831 1.1793 $29.9410 $36.9314 $35.9220 $34.4812
050697 ............................................................................. 1.0591 1.2195 $18.6962 $19.2603 $25.1984 $20.8006
050699 ............................................................................. *** * $26.0909 $25.6818 $26.8210 $26.1958
050701 ............................................................................. 1.2963 1.1296 $28.4650 $29.6896 $29.6253 $29.3536
050704 ............................................................................. 1.0586 1.1793 $24.6072 $24.6609 $25.3488 $24.8998
050707 ............................................................................. 1.3365 1.4974 $27.7366 $32.4877 $34.0550 $31.4563
050708 ............................................................................. 1.6893 1.1042 $22.1606 $21.2163 $22.5034 $21.9751
050709 ............................................................................. 1.2235 1.1687 $22.7897 $21.9079 $25.6119 $23.3937
050710 ............................................................................. 1.3958 1.1042 $33.7204 $34.8311 $39.9858 $36.4647
050713 ............................................................................. 1.1982 1.1793 $19.0071 $20.7448 $20.2803 $19.9969
050714 ............................................................................. 1.3705 1.5144 $30.3263 $32.4491 $33.6676 $32.2064
050717 ............................................................................. 1.0677 1.1793 $33.0719 $34.5519 $38.0796 $35.2375
050718 ............................................................................. 1.0244 1.1296 $21.7835 $15.4037 $21.4996 $18.9377
050719 ............................................................................. *** * $22.0998 * * $22.0998
050720 ............................................................................. 0.9271 1.1687 $26.1941 $24.8117 $30.0812 $27.1452
050722 ............................................................................. 0.9675 1.1406 * * * *
050723 ............................................................................. 1.2891 1.1793 $33.0797 $34.9814 $35.0119 $34.4384
050724 ............................................................................. 2.1500 1.1042 $23.7567 * $34.4267 $28.5323
050725 ............................................................................. 1.0001 1.1793 $20.6592 $22.0946 $21.7816 $21.6358
050726 ............................................................................. 1.6871 1.1960 $25.8742 $27.0928 $27.8433 $27.0367
050727 ............................................................................. 1.3105 1.1793 * $23.7179 $24.3026 $24.0102
050728 ............................................................................. 1.3521 1.4740 * $31.4768 $36.0820 $33.6891
050729 ............................................................................. 1.4726 1.1793 * * $34.2580 $34.2580
050730 ............................................................................. 1.2831 1.1793 * * $51.5425 $51.5425
050731 ............................................................................. 1.7945 1.1194 * * * *
050732 ............................................................................. 2.6180 1.1042 * * * *
050733 ............................................................................. 1.4289 1.2195 * * * *
050734 ............................................................................. 1.5908 1.1793 * * * *
060001 ............................................................................. 1.5846 1.0507 $23.1548 $24.9410 $26.8470 $25.0779
060003 ............................................................................. 1.4167 1.0507 $23.0807 $24.7856 $24.2224 $24.0730
060004 ............................................................................. 1.2436 1.0699 $25.0037 $28.0656 $29.9649 $27.8289
060006 ............................................................................. 1.3607 0.9369 $21.8609 $22.7493 $24.5704 $23.0964
060007 ............................................................................. 1.0268 * $21.4244 $21.4792 * $21.4535
060008 ............................................................................. 1.1218 0.9369 $19.8803 $21.8037 $23.3859 $21.7601
060009 ............................................................................. 1.4811 1.0699 $24.7920 $27.0511 $28.7645 $26.9116
060010 ............................................................................. 1.7203 1.0136 $25.8475 $27.2290 $28.9850 $27.4402
060011 ............................................................................. 1.4799 1.0699 $25.8919 $26.1958 $27.2833 $26.4630
060012 ............................................................................. 1.5002 0.9369 $22.6374 $24.1557 $26.2469 $24.3434
060013 ............................................................................. 1.3908 0.9369 $23.3954 $24.9708 $24.5994 $24.0758
060014 ............................................................................. 1.7944 1.0699 $27.0326 $29.6744 $31.2588 $29.2315
060015 ............................................................................. 1.7610 1.0699 $27.6338 $30.1158 $30.4533 $29.4109
060016 ............................................................................. 1.1757 0.9369 $22.9300 $23.9655 $25.6527 $24.2479
060018 ............................................................................. 1.2207 0.9369 $21.0581 $23.6620 $25.7628 $23.4747
060020 ............................................................................. 1.6221 0.9369 $20.9025 $22.2052 $22.6748 $21.9753
060022 ............................................................................. 1.6261 0.9447 $24.7928 $25.7832 $26.5238 $25.7483
060023 ............................................................................. 1.6527 0.9581 $24.3749 $26.7285 $27.7644 $26.3625
060024 ............................................................................. 1.7646 1.0699 $25.2409 $28.7231 $29.0130 $27.7028
060027 ............................................................................. 1.5906 1.0507 $25.1480 $26.6348 $28.0909 $26.7085
060028 ............................................................................. 1.4101 1.0699 $27.1303 $27.9686 $30.0448 $28.4352

Case-mix FY 2006
060029 ............................................................................. *** * $19.7379 * * $19.7379

060030 ............................................................................. 1.3890 1.0136 $22.8309 $26.0011 $26.6251 $25.3046
060031 ............................................................................. 1.5600 0.9447 $23.8781 $25.6207 $26.3650 $25.3306
060032 ............................................................................. 1.5456 1.0699 $27.1783 $28.2234 $30.4247 $28.6396
060033 ............................................................................. 0.9940 * $16.7266 * * $16.7266
060034 ............................................................................. 1.6440 1.0699 $26.1602 $28.4604 $29.8445 $28.2231
060036 ............................................................................. 1.1229 0.9369 $19.4144 $20.4635 $20.7131 $20.1878
060041 ............................................................................. 0.9282 0.9369 $20.8746 $22.7123 $23.4978 $22.3670
060043 ............................................................................. 0.9500 0.9369 $19.1085 $20.0939 $18.7896 $19.3418
060044 ............................................................................. 1.1611 1.0507 $25.6112 $25.2471 $25.0360 $25.3737
060049 ............................................................................. 1.2730 1.0136 $25.3425 $26.8089 $29.0598 $27.1748
060050 ............................................................................. 1.1992 * $20.4386 $21.9108 * $21.1679
060054 ............................................................................. 1.4317 0.9581 $21.1281 $23.5803 $22.3490 $22.3633
060057 ............................................................................. 1.0678 * $24.3982 $26.9891 * $25.7472
060064 ............................................................................. 1.4920 1.0699 $29.1806 $30.0963 $31.3105 $30.2470
060065 ............................................................................. 1.3196 1.0699 $29.2377 $28.5282 $31.1987 $29.6323
060070 ............................................................................. *** * $22.6894 * * $22.6894
060071 ............................................................................. 1.1349 0.9369 $20.1385 $20.2706 $25.7248 $22.1931
060075 ............................................................................. 1.2191 1.1697 $27.7835 $30.7835 $32.7563 $30.4907
060076 ............................................................................. 1.2865 0.9369 $23.6266 $25.5406 $26.8236 $25.4496
060096 ............................................................................. 1.4740 1.0507 $26.4167 $27.4085 $30.0602 $27.9908
060100 ............................................................................. 1.7163 1.0699 $28.0561 $29.7690 $32.1537 $30.0220
060103 ............................................................................. 1.1819 1.0507 $26.6863 $28.8063 $30.3002 $28.6961
060104 ............................................................................. 1.3833 1.0699 $26.7683 $30.8625 $32.0889 $29.9703
060107 ............................................................................. 1.3856 1.0699 * $26.8267 $26.1883 $26.4984
060108 ............................................................................. *** * $19.0011 * * $19.0011
060110 ............................................................................. *** * $29.8561 * * $29.8561
060111 ............................................................................. *** * * $31.2571 * $31.2571
060112 ............................................................................. 1.5129 1.0699 * * * *
060113 ............................................................................. 1.2985 1.0699 * * * *
060114 ............................................................................. 1.1972 1.0699 * * * *
070001 ............................................................................. 1.6462 1.2739 $29.9592 $32.2718 $34.0302 $32.0467
070002 ............................................................................. 1.8219 1.1726 $28.1101 $29.0663 $31.1530 $29.4722
070003 ............................................................................. 1.0941 1.1726 $29.8684 $31.3716 $32.4197 $31.2543
070004 ............................................................................. 1.1910 1.1726 $25.7207 $27.3004 $29.2544 $27.3780
070005 ............................................................................. 1.3868 1.2739 $29.8173 $29.3265 $32.1668 $30.4848
070006 2 ........................................................................... 1.3201 1.3194 $33.3814 $33.9310 $36.8469 $34.7695
070007 ............................................................................. 1.2960 1.1726 $29.0336 $30.3648 $31.7125 $30.4064
070008 ............................................................................. 1.2616 1.1726 $24.3907 $24.9176 $26.4806 $25.2986
070009 ............................................................................. 1.2064 1.1726 $25.6072 $28.8649 $30.2706 $28.2076
070010 ............................................................................. 1.8394 1.3194 $30.4192 $33.1535 $32.5798 $32.0648
070011 ............................................................................. 1.3775 1.1726 $24.9457 $27.5391 $29.9105 $27.3901
070012 ............................................................................. 1.1898 1.1726 $34.9099 $40.3337 $44.1424 $39.6372
070015 ............................................................................. 1.4436 1.3194 $30.0614 $30.9728 $33.4595 $31.5141
070016 ............................................................................. 1.3613 1.2739 $29.7505 $29.6662 $31.0903 $30.2000
070017 ............................................................................. 1.3930 1.2739 $29.2978 $30.3951 $31.7223 $30.4949
070018 2 ........................................................................... 1.3416 1.3194 $33.8654 $35.7189 $37.6081 $35.8796
070019 ............................................................................. 1.2639 1.2739 $27.9838 $29.6290 $31.8148 $29.8448
070020 ............................................................................. 1.3495 1.1799 $28.4084 $29.9507 $31.0935 $29.8423
070021 ............................................................................. 1.2785 1.1726 $30.3254 $31.4397 $33.2357 $31.7179
070022 ............................................................................. 1.7912 1.2739 $29.7376 $32.3625 $35.4120 $32.5068
070024 ............................................................................. 1.3856 1.1726 $28.3460 $31.0243 $32.0430 $30.5001
070025 ............................................................................. 1.8602 1.1726 $28.3017 $29.2540 $30.9938 $29.5451
070027 ............................................................................. 1.3063 1.1726 $36.9700 $27.3487 $31.8018 $31.4568
070028 ............................................................................. 1.6215 1.3194 $28.2078 $29.5653 $31.5036 $29.7843
070029 ............................................................................. 1.2918 1.1726 $25.8107 $26.3871 $27.7213 $26.6692
070031 ............................................................................. 1.2501 1.2739 $25.5880 $27.2359 $28.9190 $27.3126
070033 ............................................................................. 1.2736 1.3194 $34.3904 $35.5355 $37.1929 $35.7524
070034 2 ........................................................................... 1.3886 1.3194 $32.8074 $35.6831 $36.3899 $34.9826
070035 ............................................................................. 1.3067 1.1726 $26.1693 $27.1816 $27.5585 $26.9760
070036 ............................................................................. 1.6645 1.2913 $35.0701 $34.0555 $36.1610 $35.1155
070038 ............................................................................. 1.1829 1.1910 * $31.1133 $25.7516 $26.9407
070039 ............................................................................. 0.9507 1.2739 $32.6059 $35.0164 $31.2269 $32.9340
080001 ............................................................................. 1.6806 1.0579 $28.0859 $30.2463 $30.0242 $29.4815
080002 ............................................................................. *** * $23.7309 $26.4192 $27.7932 $25.9827
080003 ............................................................................. 1.5960 1.0579 $24.8199 $27.1131 $29.2266 $26.9651
080004 ............................................................................. 1.3844 1.0325 $24.2251 $26.0092 $27.4921 $25.9420

Case-mix FY 2006
080006 ............................................................................. 1.2825 0.9579 $23.6838 $24.4204 $25.6160 $24.5955

080007 ............................................................................. 1.4048 1.0279 $23.4964 $24.6485 $27.0074 $25.0565
090001 ............................................................................. 1.7144 1.0928 $29.5432 $31.3552 $35.0413 $32.0128
090002 ............................................................................. *** * $23.5158 $29.6780 * $25.5760
090003 ............................................................................. 1.2860 1.0928 $22.7014 $27.0514 $29.2660 $26.1789
090004 ............................................................................. 1.9621 1.0928 $28.7417 $29.9785 $32.2021 $30.4513
090005 ............................................................................. 1.3773 1.0928 $28.6142 $30.2504 $30.7728 $29.9417
090006 ............................................................................. 1.4103 1.0928 $23.7241 $25.9086 $29.5590 $26.3083
090007 ............................................................................. *** * $25.8430 $30.1419 * $27.7359
090008 ............................................................................. 1.4931 1.0928 $19.3212 $29.6744 $29.1059 $25.7761
090011 ............................................................................. 2.0232 1.0928 $31.7710 $32.4412 $34.0693 $32.7262
100001 ............................................................................. 1.6183 0.9294 $22.6150 $25.2381 $24.4060 $24.0790
100002 ............................................................................. 1.3562 1.0051 $22.5982 $22.1269 $25.3389 $23.3729
100004 ............................................................................. 0.9452 0.8584 $15.6306 $16.2637 $16.5974 $16.2012
100006 ............................................................................. 1.6269 0.9450 $23.3745 $26.2372 $26.3789 $25.3884
100007 ............................................................................. 1.6462 0.9450 $24.3305 $25.4333 $26.5378 $25.5049
100008 ............................................................................. 1.6518 0.9747 $22.7706 $25.7377 $27.4314 $25.4374
100009 ............................................................................. 1.4445 0.9747 $24.7811 $24.4666 $25.9381 $25.0983
100010 ............................................................................. *** * $25.5614 $26.9486 * $26.2759
100012 ............................................................................. 1.6553 0.9323 $24.2602 $24.5762 $26.3788 $25.1063
100014 ............................................................................. 1.3001 0.9416 $21.7566 $22.3054 $24.5862 $22.8508
100015 ............................................................................. 1.3184 0.9328 $22.1272 $22.5781 $24.6038 $23.0946
100017 ............................................................................. 1.5242 0.9416 $21.1905 $22.9545 $26.1580 $23.5300
100018 ............................................................................. 1.6293 1.0114 $24.1885 $27.8582 $28.1481 $26.7680
100019 ............................................................................. 1.6455 0.9830 $24.2888 $25.5566 $27.6179 $25.9118
100020 ............................................................................. 1.3148 0.9747 $23.5303 $23.6106 $23.9414 $23.7036
100022 ............................................................................. 1.7585 1.0497 $27.9072 $29.0519 $29.9345 $29.0212
100023 ............................................................................. 1.4527 0.9450 $21.8111 $21.4015 $23.0074 $22.0889
100024 ............................................................................. 1.2489 0.9747 $24.4070 $27.6476 $30.2395 $27.3189
100025 ............................................................................. 1.6924 0.8584 $21.2568 $21.1174 $22.1580 $21.5429
100026 ............................................................................. 1.6201 0.8584 $20.1602 $21.3533 $21.4703 $20.9953
100027 ............................................................................. 1.1975 0.8584 $23.8982 $12.0314 $16.1223 $16.3797
100028 ............................................................................. 1.3007 0.9830 $21.8879 $23.7818 $26.8661 $24.1693
100029 ............................................................................. 1.1782 0.9747 $24.6814 $26.9307 $27.5844 $26.4439
100030 ............................................................................. 1.2924 0.9450 $21.8567 $22.4887 $24.0943 $22.9211
100032 ............................................................................. 1.7231 0.9328 $21.6415 $23.0174 $25.2450 $23.3565
100034 ............................................................................. 1.8273 0.9747 $23.1111 $24.4064 $25.9415 $24.5360
100035 ............................................................................. 1.5876 0.9634 $22.6349 $25.3590 $26.9407 $24.9239
100038 ............................................................................. 1.8898 1.0497 $25.7948 $27.4422 $29.8583 $27.7714
100039 ............................................................................. 1.4212 1.0497 $23.8060 $26.6016 $28.4627 $26.3398
100040 ............................................................................. 1.6882 0.9294 $22.4679 $23.5372 $23.6443 $23.2382
100043 ............................................................................. 1.2798 0.9328 $21.7738 $22.8963 $25.2273 $23.3549
100044 ............................................................................. 1.4261 1.0151 $23.9952 $26.3208 $28.3596 $26.2570
100045 ............................................................................. 1.3178 0.9450 $25.2285 $23.0520 $26.9641 $25.0756
100046 ............................................................................. 1.2409 0.9328 $24.2746 $26.6169 $26.3673 $25.8723
100047 ............................................................................. 1.7017 0.9286 $24.3522 $24.4212 $25.0404 $24.6186
100048 ............................................................................. 0.9446 0.8584 $17.5533 $18.3767 $18.8771 $18.2575
100049 ............................................................................. 1.2006 0.8925 $21.8679 $22.9532 $22.9810 $22.6230
100050 ............................................................................. 1.1817 0.9747 $20.0405 $20.6893 $19.8713 $20.2035
100051 ............................................................................. 1.3167 0.9450 $20.0231 $22.3311 $23.1940 $22.0077
100052 ............................................................................. 1.3612 0.8925 $20.5916 $20.9078 $22.3920 $21.3174
100053 ............................................................................. 1.2414 0.9747 $23.7837 $27.3383 $27.3224 $26.2170
100054 ............................................................................. 1.2242 0.8868 $22.0352 $25.7279 $28.0512 $25.3241
100055 ............................................................................. 1.3567 0.9328 $19.6350 $22.1051 $23.5332 $21.7040
100056 ............................................................................. *** * $25.9245 $25.7945 * $25.8574
100057 ............................................................................. 1.4902 0.9450 $24.6417 $22.6038 $25.3897 $24.1823
100061 ............................................................................. 1.5568 0.9747 $26.1273 $26.7673 $29.2565 $27.4077
100062 ............................................................................. 1.7188 0.9006 $24.9807 $24.1413 $25.2340 $24.7789
100063 ............................................................................. 1.2226 0.9328 $21.5620 $21.5566 $24.7026 $22.5862
100067 ............................................................................. 1.4372 0.9328 $23.8892 $23.9333 $26.1213 $24.6500
100068 ............................................................................. 1.7322 0.9416 $23.7840 $24.9025 $25.9202 $25.2289
100069 ............................................................................. 1.3222 0.9328 $19.6037 $22.4386 $24.7442 $22.2985
100070 ............................................................................. 1.6777 0.9634 $23.5524 $23.7746 $24.8883 $24.0603
100071 ............................................................................. 1.2323 0.9328 $21.7675 $23.4176 $24.9682 $23.4234
100072 ............................................................................. 1.3707 0.9416 $23.5362 $24.2934 $26.0459 $24.7023
100073 ............................................................................. 1.6999 1.0497 $23.5843 $25.3685 $30.3358 $26.4443
100075 ............................................................................. 1.4873 0.9328 $22.3890 $23.3503 $25.1691 $23.6907

Case-mix FY 2006
100076 ............................................................................. 1.2488 0.9747 $19.6444 $21.0777 $21.9483 $20.8673

100077 ............................................................................. 1.4270 0.9286 $22.3755 $24.3478 $26.0347 $24.2410
100079 ............................................................................. 1.6927 * * * * *
100080 ............................................................................. 1.7700 1.0051 $22.8704 $26.3596 $27.0126 $25.4415
100081 ............................................................................. 1.0416 0.8584 $16.8087 $16.9168 $15.6662 $16.4022
100084 ............................................................................. 1.8066 0.9450 $24.1122 $25.4140 $26.3393 $25.2629
100086 ............................................................................. 1.2304 1.0497 $25.2375 $26.4817 $28.2641 $26.6950
100087 ............................................................................. 1.8903 0.9634 $26.5915 $25.9909 $27.1531 $26.5891
100088 ............................................................................. 1.6794 0.9294 $23.6270 $24.8729 $25.9182 $24.8465
100090 ............................................................................. 1.4786 0.9294 $22.5894 $24.0501 $24.2422 $23.6608
100092 ............................................................................. 1.5155 0.9830 $25.4630 $26.0856 $28.4789 $26.7319
100093 ............................................................................. 1.7097 0.8584 $20.2949 $21.1547 $21.3524 $20.9431
100098 ............................................................................. 1.1058 * $20.0639 $21.2505 * $20.6613
100099 ............................................................................. 1.0234 0.8925 $18.5287 $20.4328 $21.3036 $20.1035
100102 ............................................................................. 1.0598 0.8709 $21.6772 $22.8850 $23.8596 $22.8413
100103 ............................................................................. 0.9719 * $20.3633 $21.7494 * $21.0705
100105 ............................................................................. 1.3731 0.9448 $24.5464 $24.9503 $26.8091 $25.4381
100106 ............................................................................. 0.9559 0.8584 $20.3417 $20.2882 $24.0389 $21.6406
100107 ............................................................................. 1.1536 0.9323 $23.3789 $24.4484 $26.1337 $24.6951
100108 ............................................................................. 0.7740 0.8584 $14.8039 $16.3757 $22.0750 $17.7359
100109 ............................................................................. 1.2577 0.9450 $23.0779 $23.8836 $24.9951 $24.0208
100110 ............................................................................. 1.5362 0.9450 $24.4533 $28.3699 $29.1494 $27.5406
100113 ............................................................................. 1.9395 0.9375 $24.3614 $25.0067 $26.3806 $25.2830
100114 ............................................................................. 1.3730 0.9747 $25.3699 $27.7413 $29.2195 $27.4364
100117 ............................................................................. 1.2013 0.9294 $23.9134 $26.0451 $26.4536 $25.5634
100118 ............................................................................. 1.3382 0.9294 $24.1104 $23.6669 $28.0569 $25.5448
100121 ............................................................................. 1.0774 0.8925 $23.1100 $24.0937 $24.8579 $24.0497
100122 ............................................................................. 1.2284 0.8868 $24.1820 $21.2597 $23.4751 $22.8811
100124 ............................................................................. 1.1728 0.8584 $24.3048 $21.6483 $22.7023 $22.7933
100125 ............................................................................. 1.1907 0.9747 $22.4185 $25.3532 $26.7452 $24.9756
100126 ............................................................................. 1.4150 0.9328 $21.7977 $23.2996 $24.4515 $23.2342
100127 ............................................................................. 1.6611 0.9328 $21.0153 $21.3223 $24.4485 $22.2652
100128 ............................................................................. 2.1526 0.9328 $24.4104 $25.6763 $29.4979 $26.6451
100130 ............................................................................. 1.2025 1.0051 $20.2478 $22.8324 $24.2046 $22.4252
100131 ............................................................................. 1.2751 0.9747 $25.4811 $25.8316 $29.2462 $26.9103
100132 ............................................................................. 1.2231 0.9328 $21.1538 $23.0428 $24.3293 $22.8670
100134 ............................................................................. 0.9566 0.8584 $18.3391 $19.5337 $20.9244 $19.6271
100135 ............................................................................. 1.6045 0.8703 $20.4915 $22.3071 $24.0024 $22.2526
100137 ............................................................................. 1.1709 0.8925 $20.4007 $23.3692 $25.1974 $23.1447
100139 ............................................................................. 0.8583 0.9375 $18.2204 $14.5046 $17.5489 $16.8211
100140 ............................................................................. 1.1864 0.9294 $22.5124 $24.8165 $26.4720 $24.7189
100142 ............................................................................. 1.2277 0.8584 $20.0689 $20.7219 $22.9577 $21.2432
100147 ............................................................................. *** * $17.1045 * * $17.1045
100150 ............................................................................. 1.4017 0.9747 $22.9194 $25.7122 $26.1990 $24.9706
100151 ............................................................................. 1.7883 0.9294 $26.6470 $26.1848 $28.1322 $27.0891
100154 ............................................................................. 1.5421 0.9747 $23.0820 $26.3703 $27.6127 $25.8181
100156 ............................................................................. 1.1045 0.8709 $20.6928 $22.2757 $26.7092 $23.2451
100157 ............................................................................. 1.5973 0.9328 $23.1045 $25.9133 $27.3851 $25.4671
100160 ............................................................................. 1.1995 0.8584 $23.4877 $27.2019 $26.9851 $25.9544
100161 ............................................................................. 1.5798 0.9450 $24.6268 $28.3607 $28.8077 $27.4143
100162 ............................................................................. *** * $23.8001 * * $23.8001
100166 ............................................................................. 1.4927 0.9634 $23.7419 $24.4251 $27.9618 $25.2885
100167 ............................................................................. 1.3172 1.0497 $26.4517 $26.8584 $30.3694 $27.8827
100168 ............................................................................. 1.3915 1.0051 $24.6276 $26.0864 $27.1292 $25.9577
100169 ............................................................................. *** * $23.4575 * * $23.4575
100172 ............................................................................. 1.2906 0.9747 $17.6051 $18.4651 $18.2735 $18.1344
100173 ............................................................................. 1.7474 0.9328 $19.7190 $22.4866 $24.8721 $22.4023
100175 ............................................................................. 1.0032 0.8815 $21.0474 $22.0666 $23.5455 $22.2224
100176 ............................................................................. 1.9043 1.0151 $26.8740 $29.8326 $31.2694 $29.3692
100177 ............................................................................. 1.3333 0.9830 $24.5078 $25.3973 $26.6781 $25.6089
100179 ............................................................................. 1.7758 0.9294 $24.1801 $26.6537 $29.5619 $26.9037
100180 ............................................................................. 1.3821 0.9328 $24.9433 $26.3299 $27.1804 $26.1924
100181 ............................................................................. 1.1077 0.9747 $18.1320 $19.5022 $21.8540 $19.8108
100183 ............................................................................. 1.1819 0.9747 $24.4575 $26.7893 $27.4951 $26.3276
100187 ............................................................................. 1.2915 0.9747 $23.4760 $26.1394 $27.3653 $25.7401
100189 ............................................................................. 1.3226 1.0497 $26.6846 $26.5763 $28.4136 $27.3048
100191 ............................................................................. 1.3178 0.9328 $24.1911 $24.3553 $26.6340 $25.0785

Case-mix FY 2006
100200 ............................................................................. 1.3861 1.0497 $24.8120 $28.0926 $29.8963 $27.6635

100204 ............................................................................. 1.5308 0.9375 $22.2613 $24.4697 $25.7537 $24.2423
100206 ............................................................................. 1.3026 0.9328 $22.8782 $23.0340 $25.2196 $23.7228
100208 ............................................................................. *** * $24.1482 $24.9854 * $24.5807
100209 ............................................................................. 1.3649 0.9747 $23.8502 $25.0778 $26.6246 $25.2683
100210 ............................................................................. 1.5495 1.0497 $26.0933 $28.6449 $28.9486 $27.9114
100211 ............................................................................. 1.1990 0.9328 $24.3243 * $24.7095 $24.5352
100212 ............................................................................. 1.4656 0.9006 $22.6584 $24.2669 $24.7566 $23.9351
100213 ............................................................................. 1.6219 0.9634 $24.4467 $25.1893 $27.1936 $25.6138
100217 ............................................................................. 1.1882 1.0151 $24.0291 $25.2635 $25.2907 $24.8791
100220 ............................................................................. 1.6567 0.9323 $24.9733 $25.0154 $26.0905 $25.3692
100223 ............................................................................. 1.5971 0.8868 $21.2434 $23.4556 $24.7015 $23.2004
100224 ............................................................................. 1.2332 1.0497 $23.0804 $23.3593 $24.8077 $23.7932
100225 ............................................................................. 1.2993 1.0497 $23.9971 $27.9473 $28.4316 $26.8326
100226 ............................................................................. 1.2785 0.9294 $23.8701 $27.8003 $29.3317 $27.1288
100228 ............................................................................. 1.3238 1.0497 $26.2593 $27.2873 $29.8952 $28.0013
100229 ............................................................................. *** * $21.0038 * * $21.0038
100230 ............................................................................. 1.3172 1.0497 $25.0518 $26.3690 $28.1703 $26.6050
100231 ............................................................................. 1.6896 0.8584 $23.5418 $24.6994 $25.5175 $24.6455
100232 h ........................................................................... 1.2414 0.9722 $21.8105 $23.9405 $24.9322 $23.5285
100234 ............................................................................. 1.3194 1.0051 $24.9141 $25.2574 $26.3601 $25.5144
100236 ............................................................................. 1.3721 0.9286 $23.9781 $25.9282 $26.6585 $25.5663
100237 ............................................................................. 1.9760 1.0497 $26.7664 $25.6112 $31.3543 $27.7849
100238 ............................................................................. 1.5274 0.9328 $24.6513 $27.1748 $28.4302 $26.8154
100239 ............................................................................. 1.2798 0.9634 $25.0509 $26.9668 $27.7592 $26.6605
100240 ............................................................................. 0.8844 0.9747 $23.0650 $23.4830 $25.3265 $24.0024
100242 ............................................................................. 1.3721 0.8584 $20.4681 $21.5130 $24.0990 $22.0856
100243 ............................................................................. 1.5526 0.9328 $23.2812 $25.2987 $26.1131 $24.9766
100244 ............................................................................. 1.3600 0.9323 $23.4876 $24.1515 $25.2584 $24.3502
100246 ............................................................................. 1.6200 1.0151 $26.7630 $27.6382 $28.9894 $27.8151
100248 ............................................................................. 1.5168 0.9328 $23.8742 $25.9170 $27.7797 $25.9263
100249 ............................................................................. 1.2673 0.8946 $21.3942 $23.4021 $23.2084 $22.6697
100252 ............................................................................. 1.2047 1.0151 $22.6475 $24.9860 $25.8540 $24.5257
100253 ............................................................................. 1.3828 1.0051 $23.6939 $24.4051 $25.7121 $24.6472
100254 ............................................................................. 1.5903 0.8703 $23.2794 $25.0192 $25.7338 $24.6995
100255 ............................................................................. 1.2022 0.9328 $22.9793 $22.2341 $24.4808 $23.2508
100256 ............................................................................. 2.0016 0.9328 $24.1969 $26.0629 $28.8856 $26.4333
100258 ............................................................................. 1.4996 1.0051 $24.5699 $31.8772 $31.2482 $29.0443
100259 ............................................................................. 1.2301 0.9328 $24.1148 $24.9404 $26.0175 $25.0705
100260 ............................................................................. 1.3611 1.0151 $23.5164 $25.2630 $27.5188 $25.5518
100262 ............................................................................. *** * $23.8006 $26.3954 * $25.1412
100264 ............................................................................. 1.2614 0.9328 $22.4800 $25.0250 $25.5489 $24.4115
100265 ............................................................................. 1.2982 0.9328 $21.0688 $23.4758 $24.1454 $23.0219
100266 ............................................................................. 1.4044 0.8584 $21.5258 $22.6614 $23.2340 $22.5196
100267 ............................................................................. 1.2892 0.9634 $23.3760 $26.5059 $27.3768 $25.7444
100268 ............................................................................. 1.1552 1.0051 $26.0297 $29.8289 $29.2898 $28.4053
100269 ............................................................................. 1.3013 1.0051 $24.9002 $25.3228 $26.7450 $25.7303
100271 ............................................................................. 2.2234 * * * * *
100275 ............................................................................. 1.2960 1.0051 $23.1419 $24.3059 $26.0361 $24.5544
100276 ............................................................................. 1.2393 1.0497 $25.4557 $27.2589 $30.0576 $27.6322
100277 ............................................................................. 1.3788 0.9747 $25.2985 $47.3905 $16.5427 $24.0477
100279 ............................................................................. 1.2480 0.9323 $24.8484 $25.4909 $26.8606 $25.7747
100281 ............................................................................. 1.2803 1.0497 $25.3382 $27.0864 $28.6660 $27.1929
100284 ............................................................................. 1.0961 0.9747 $22.3046 $22.5927 $23.8170 $22.9628
100286 ............................................................................. 1.5763 1.0114 * $27.1051 $29.4284 $28.3288
100287 ............................................................................. 1.3767 1.0051 * $28.2229 $28.3427 $28.2858
100288 ............................................................................. 1.5086 1.0051 * $37.4785 $33.8141 $35.4781
100289 ............................................................................. 1.8008 1.0497 * $28.4504 $29.2915 $28.8970
100290 ............................................................................. 1.1344 0.9166 * * $23.5080 $23.5080
100291 ............................................................................. 1.2572 0.9830 * * * *
100292 ............................................................................. 1.2330 0.8584 * * * *
100294 ............................................................................. 2.6620 0.9450 * * * *
100295 ............................................................................. 2.0078 0.9747 * * * *
100296 ............................................................................. 1.3342 0.9747 * * * *
100297 ............................................................................. 1.9333 0.8584 * * * *
100298 ............................................................................. 0.6963 0.8703 * * * *
100299 ............................................................................. 1.3082 0.9634 * * * *

Case-mix FY 2006
110001 ............................................................................. 1.2397 0.9782 $24.0561 $25.1164 $25.3102 $24.8284

110002 ............................................................................. 1.2464 0.9782 $20.4502 $21.8616 $25.3897 $22.5380
110003 ............................................................................. 1.3086 0.9294 $19.7061 $20.0968 $21.4002 $20.4029
110004 ............................................................................. 1.2230 0.9089 $21.8791 $22.7929 $23.9911 $22.8563
110005 ............................................................................. 1.1638 0.9782 $23.6146 $22.3645 $22.9000 $22.9401
110006 ............................................................................. 1.4890 0.9826 $23.8762 $25.0719 $28.6090 $25.8225
110007 ............................................................................. 1.6071 0.8634 $28.2025 $30.7430 $23.8729 $27.0966
110008 ............................................................................. 1.3988 0.9782 $22.6308 $23.4662 $27.1711 $24.4777
110010 ............................................................................. 2.1369 0.9782 $27.2029 $28.7690 $29.7142 $28.5850
110011 ............................................................................. 1.1924 0.9782 $23.2149 $25.4620 $26.0899 $24.9213
110015 ............................................................................. 1.1494 0.9782 $23.2280 $25.5661 $26.6610 $25.2080
110016 ............................................................................. 1.1984 0.7679 $18.8228 $18.8376 $21.7610 $19.7802
110018 ............................................................................. 1.1923 0.9782 $24.7007 $25.6485 $28.2431 $26.2640
110020 ............................................................................. 1.2822 0.9782 $23.3004 $24.8735 $26.8501 $25.0177
110023 ............................................................................. 1.3719 0.9782 $23.5673 $25.3746 $27.3029 $25.5307
110024 ............................................................................. 1.3944 0.9464 $22.1471 $23.8091 $25.7205 $23.8901
110025 ............................................................................. 1.4489 0.9294 $29.0965 $31.5253 $26.1311 $28.6493
110026 ............................................................................. 1.1044 0.7679 $19.3201 $20.5740 $21.2826 $20.4005
110027 ............................................................................. 1.0675 0.8066 $19.8351 $19.2323 $20.2175 $19.7328
110028 ............................................................................. 1.7446 0.9751 $25.9474 $25.1836 $28.1619 $26.4128
110029 ............................................................................. 1.6684 0.9782 $22.7981 $25.2335 $24.8893 $24.3542
110030 ............................................................................. 1.2123 0.9782 $22.2341 $25.0842 $26.4770 $24.7162
110031 ............................................................................. 1.2695 0.9782 $22.8695 $24.1711 $24.7874 $23.9912
110032 ............................................................................. 1.1708 0.7679 $18.0744 $20.7211 $21.9407 $20.2437
110033 ............................................................................. 1.4050 0.9782 $24.1447 $25.2326 $28.3210 $25.8930
110034 ............................................................................. 1.7124 0.9751 $24.0791 $24.4141 $26.9986 $25.1766
110035 ............................................................................. 1.5056 0.9782 $24.2581 $25.7562 $27.4583 $25.9197
110036 ............................................................................. 1.8079 0.9464 $24.4788 $25.4854 $26.8789 $25.6507
110038 ............................................................................. 1.5737 0.8385 $20.1710 $20.5880 $21.2138 $20.6802
110039 ............................................................................. 1.4151 0.9751 $17.0608 $19.4032 $24.7248 $20.0879
110040 ............................................................................. 1.1196 0.9782 $17.3095 $18.8744 $19.7509 $18.6568
110041 ............................................................................. 1.2605 0.9694 $20.8080 $21.5402 $23.4074 $21.9417
110042 ............................................................................. 1.1045 0.9782 $25.5588 $26.8321 $28.6873 $27.1121
110043 ............................................................................. 1.7587 0.9464 $22.7589 $25.2788 $26.6323 $24.8956
110044 ............................................................................. 1.1685 0.7679 $19.2562 $19.6940 $20.9654 $19.9819
110045 ............................................................................. 1.1544 0.9782 $19.7746 $21.3922 $24.9821 $22.1119
110046 ............................................................................. 1.1621 0.9782 $21.6201 $24.0022 $23.8292 $23.2190
110049 ............................................................................. 0.9856 * $18.9096 $19.8706 * $19.4074
110050 ............................................................................. 1.1084 0.9067 * $25.6020 $26.1320 $25.8647
110051 ............................................................................. 1.1338 0.7679 $17.6816 $19.0995 $19.4276 $18.7634
110054 ............................................................................. 1.4998 0.9782 $20.5387 $22.2250 $25.7085 $22.7254
110056 ............................................................................. 0.9527 * $21.7608 $23.0080 * $22.3710
110059 ............................................................................. 1.0870 0.7679 $19.9802 $18.7097 $20.5565 $19.6943
110061 ............................................................................. *** * $18.6696 * * $18.6696
110063 ............................................................................. 1.1145 * $19.4401 $20.3760 * $19.9198
110064 ............................................................................. 1.5138 0.8562 $21.7636 $23.8739 $24.2739 $23.3486
110069 ............................................................................. 1.2779 0.9078 $21.0518 $22.3006 $24.1669 $22.5324
110071 ............................................................................. 0.9789 0.7679 $15.2336 $13.3731 $18.0224 $15.4555
110073 ............................................................................. 1.0915 0.7679 $15.2711 $16.3610 $18.6336 $16.6863
110074 ............................................................................. 1.5001 0.9826 $24.4094 $27.5836 $27.1207 $26.3724
110075 ............................................................................. 1.2651 0.9300 $20.4634 $20.9973 $22.0935 $21.2149
110076 ............................................................................. 1.4712 0.9782 $23.8211 $25.2424 $26.3506 $25.1774
110078 ............................................................................. 2.0531 0.9782 $28.2149 $27.8627 $29.5779 $28.5704
110079 ............................................................................. 1.4257 0.9782 $22.8017 $24.5255 $23.1024 $23.4646
110080 ............................................................................. 1.2797 0.9782 $24.1958 $21.5482 $22.3213 $22.5788
110082 ............................................................................. 1.9279 0.9782 $27.2931 $28.9731 $29.8366 $28.7072
110083 ............................................................................. 1.9347 0.9782 $24.6460 $26.2604 $27.8245 $26.3029
110086 ............................................................................. 1.4411 0.7679 $18.8751 $20.8557 $21.1509 $20.2673
110087 ............................................................................. 1.4167 0.9782 $25.7908 $26.2872 $28.0471 $26.7332
110089 ............................................................................. 1.1500 0.7679 $20.6757 $21.2013 $21.9509 $21.2887
110091 ............................................................................. 1.2959 0.9782 $24.3354 $26.3857 $26.5523 $25.8218
110092 ............................................................................. 1.0183 0.7679 $16.9116 $18.7397 $18.5527 $18.0853
110095 ............................................................................. 1.4222 0.8701 $20.1024 $21.8709 $23.4846 $21.8636
110096 ............................................................................. 0.9833 * $18.5513 $19.4498 * $19.0000
110100 ............................................................................. 0.9748 0.7679 $15.1316 $16.5833 $16.5600 $16.0845
110101 ............................................................................. 1.0811 0.7679 $13.3943 $14.4630 $16.4270 $14.7428
110104 ............................................................................. 1.0702 0.7679 $17.9805 $19.5575 $18.7951 $18.8040

Case-mix FY 2006
110105 ............................................................................. 1.3296 0.7679 $19.2156 $20.6270 $21.1077 $20.3365

110107 ............................................................................. 1.8825 0.9475 $21.8167 $26.0763 $26.2526 $24.6977
110109 ............................................................................. 1.0145 0.7679 $18.7397 $20.4726 $21.4280 $20.2690
110111 ............................................................................. 1.1472 0.9751 $20.9535 $20.5577 $29.2190 $22.9282
110112 ............................................................................. 0.9453 0.7679 $20.4565 $21.0612 $24.2463 $21.7104
110113 ............................................................................. 1.0690 0.9751 $18.0770 $16.7641 $19.1753 $18.0155
110115 ............................................................................. 1.7318 0.9782 $26.3274 $29.8699 $32.0197 $29.3454
110118 ............................................................................. *** * $17.7344 * * $17.7344
110120 ............................................................................. *** * $20.3098 * * $20.3098
110121 ............................................................................. 1.0471 0.7679 $19.5230 $21.2534 $21.6637 $20.8173
110122 ............................................................................. 1.5383 0.8864 $20.4184 $22.0210 $23.7589 $22.1314
110124 ............................................................................. 1.0894 0.8107 $19.7004 $20.9334 $22.7058 $21.1178
110125 ............................................................................. 1.2347 0.9078 $19.8695 $22.1458 $22.4238 $21.5044
110128 ............................................................................. 1.2275 0.9300 $28.4943 $23.2576 $24.4596 $24.9779
110129 ............................................................................. 1.5326 0.8562 $21.8204 $22.4202 $23.3631 $22.5595
110130 ............................................................................. 0.9572 0.7679 $17.5272 $17.6529 $18.7549 $18.0115
110132 ............................................................................. 1.0434 0.7679 $17.2924 $18.9927 $19.2307 $18.5224
110135 ............................................................................. 1.2819 0.7679 $18.5125 $20.0057 $20.4411 $19.6750
110136 ............................................................................. 1.0906 0.7940 $21.1235 $22.7715 $15.8573 $19.9782
110142 ............................................................................. 0.9682 0.7679 $16.3359 $17.3328 $18.1980 $17.2921
110143 ............................................................................. 1.3817 0.9782 $24.3898 $25.4932 $27.7055 $25.9154
110146 ............................................................................. 1.0617 0.7679 $17.2250 $19.9221 $23.9067 $20.1122
110149 ............................................................................. 1.3423 0.9782 $25.3619 $24.7686 $27.1477 $25.8232
110150 ............................................................................. 1.2819 0.9078 $22.7366 $23.8157 $22.6624 $23.0726
110153 ............................................................................. 1.1438 0.9078 $21.5300 $22.8660 $24.5368 $22.9872
110155 ............................................................................. *** * $16.1785 * * $16.1785
110161 ............................................................................. 1.5043 0.9782 $26.4200 $27.4435 $29.3201 $27.7967
110163 ............................................................................. 1.4067 0.8634 $21.9411 $25.5461 $26.0764 $24.4314
110164 ............................................................................. 1.5286 0.9475 $23.7801 $26.4450 $27.0600 $25.7931
110165 ............................................................................. 1.4137 0.9782 $23.4071 $24.3897 $26.8378 $24.9170
110166 ............................................................................. *** * $23.6665 $25.2264 $26.8070 $25.1758
110168 ............................................................................. 1.8519 0.9782 $23.3426 $24.6321 $27.0022 $25.0628
110169 ............................................................................. *** * $24.7083 * * $24.7083
110171 ............................................................................. *** * $32.6386 * * $32.6386
110172 ............................................................................. 1.2169 0.9782 $25.2396 $27.0240 $29.1703 $27.1002
110177 ............................................................................. 1.6728 0.9751 $24.0700 $25.0129 $26.7504 $25.3590
110179 ............................................................................. *** * $26.0365 $26.1173 $26.0759 $26.0760
110183 ............................................................................. 1.2387 0.9782 $26.4248 $27.6020 $29.6133 $28.0105
110184 ............................................................................. 1.2066 0.9782 $24.3379 $25.5420 $26.5240 $25.5354
110186 ............................................................................. 1.3917 0.8562 $21.1176 $23.2348 $25.0299 $23.1796
110187 ............................................................................. 1.2286 0.9782 $23.2571 $22.5730 $24.2933 $23.3967
110188 ............................................................................. *** * $24.4785 * * $24.4785
110189 ............................................................................. 1.0968 0.9782 $21.4255 $23.9404 $26.7653 $24.1143
110190 ............................................................................. 1.0217 0.7861 $21.9008 $19.1054 $14.2517 $17.7557
110191 ............................................................................. 1.3090 0.9782 $24.0572 $25.8409 $26.8277 $25.5872
110192 ............................................................................. 1.3254 0.9782 $24.3823 $25.7406 $26.7852 $25.7103
110193 ............................................................................. 1.4091 0.9782 $25.1779 $27.8223 $27.3341 $26.8213
110194 ............................................................................. 0.9413 0.7679 $16.8075 $16.3148 $18.4776 $17.2529
110198 ............................................................................. 1.4037 0.9782 $28.0634 $30.8014 $31.7748 $30.3084
110200 ............................................................................. 1.8513 0.8562 $20.1816 $21.2177 $22.3249 $21.2486
110201 ............................................................................. 1.4094 0.9475 $24.1171 $27.0388 $28.2232 $26.3653
110203 ............................................................................. 0.9953 0.9782 $30.2609 $25.8951 $26.8768 $27.4232
110205 ............................................................................. 1.0813 0.9782 $23.1969 $20.6150 $19.7409 $21.0203
110209 ............................................................................. 0.5664 0.7679 $17.4145 $19.1000 $19.0450 $18.5793
110212 ............................................................................. 1.0529 0.8864 $18.7651 $20.9365 $40.5120 $27.9394
110215 ............................................................................. 1.2763 0.9782 $22.5679 $23.9657 $25.7886 $24.2458
110218 ............................................................................. *** * * $26.1073 * $26.1073
110219 ............................................................................. 1.4347 0.9782 * $27.1880 $27.0362 $27.1115
110220 ............................................................................. 1.3633 0.8562 * * * *
110221 ............................................................................. 2.1187 0.9782 * * * *
110222 ............................................................................. 2.6522 0.9751 * * * *
110223 ............................................................................. 1.2880 0.9782 * * * *
110224 ............................................................................. 1.3977 0.9475 * * * *
110225 ............................................................................. 1.1917 0.9782 * * * *
120001 ............................................................................. 1.7844 1.1213 $30.0871 $31.7108 $34.7715 $32.1848
120002 ............................................................................. 1.2199 1.0587 $24.2715 $26.9900 $29.9913 $27.2572
120004 ............................................................................. 1.2647 1.1213 $26.8010 $28.3569 $28.6527 $27.9367

Case-mix FY 2006
120005 ............................................................................. 1.3002 1.0587 $23.0113 $26.9053 $29.3405 $26.3828

120006 ............................................................................. 1.2367 1.1213 $28.1562 $29.6751 $31.2285 $29.7168
120007 ............................................................................. 1.6704 1.1213 $27.8497 $28.7964 $30.4247 $29.0434
120010 ............................................................................. 1.6900 1.1213 $25.4050 $27.1265 $30.1659 $27.2823
120011 ............................................................................. 1.4781 1.1213 $30.9308 $31.7447 $34.1643 $32.3199
120014 ............................................................................. 1.2116 1.0587 $25.3682 $28.0786 $28.6416 $27.3772
120016 ............................................................................. 1.5918 1.0587 $39.1173 $52.1034 $19.6034 $33.6763
120019 ............................................................................. 1.1922 1.0587 $24.4036 $28.9661 $30.3809 $27.8836
120022 ............................................................................. 1.8675 1.1213 $22.4951 $24.7875 $26.6100 $24.7024
120024 ............................................................................. 0.8789 1.0587 * * * *
120025 ............................................................................. *** * $40.2473 $48.7148 $30.2358 $39.7283
120026 ............................................................................. 1.2789 1.1213 $26.3653 $28.5048 $30.3293 $28.4200
120027 ............................................................................. 1.2385 1.1213 $24.9464 $26.4630 $28.6717 $26.5704
120028 ............................................................................. 1.2824 1.1213 $29.5070 $31.3195 $30.3794 $30.4272
120029 ............................................................................. 1.9790 1.1213 * * * *
130002 ............................................................................. 1.3652 0.9039 $20.1143 $21.6626 $23.6078 $21.8876
130003 ............................................................................. 1.3678 1.0095 $23.9403 $25.4904 $27.6345 $25.7287
130005 ............................................................................. *** * $24.4844 $25.2550 $25.7523 $25.1326
130006 ............................................................................. 1.7997 0.9039 $22.8567 $24.3982 $25.3221 $24.2894
130007 ............................................................................. 1.7373 0.9039 $22.8475 $24.8764 $24.9562 $24.2827
130011 ............................................................................. 1.2278 * $23.1120 $22.9336 * $23.0196
130013 ............................................................................. 1.2951 0.9039 $23.5316 $26.3118 $27.9209 $25.9669
130014 ............................................................................. 1.1868 0.9039 $21.6495 $23.4789 $24.3884 $23.2115
130018 ............................................................................. 1.5966 0.9394 $22.2249 $23.9798 $26.4125 $24.2860
130021 ............................................................................. *** * $18.0006 $18.9400 $16.1658 $17.7607
130022 ............................................................................. 1.1928 * $21.5602 * * $21.5602
130024 ............................................................................. 1.1376 0.8964 $22.1610 $21.7853 $23.3347 $22.4344
130025 ............................................................................. 1.2091 0.8689 $18.7814 $19.7066 $20.1452 $19.5513
130026 ............................................................................. 1.1154 * $24.4976 $25.4020 * $24.9502
130028 ............................................................................. 1.3724 0.9394 $21.1492 $25.2938 $26.3443 $24.2492
130036 ............................................................................. *** * $18.5921 $16.7907 * $17.6689
130045 ............................................................................. *** * $19.0270 * * $19.0270
130049 ............................................................................. 1.4577 1.0711 $23.7212 $24.5841 $26.9749 $25.1364
130060 ............................................................................. *** * $24.6773 $26.7516 * $25.7861
130062 ............................................................................. *** * $24.0494 $16.7951 $20.6642 $20.3051
130063 ............................................................................. 1.4722 0.9039 $18.8782 $20.9502 $22.5904 $20.7967
130065 ............................................................................. 1.8387 0.8689 * * * *
130066 ............................................................................. 1.9247 0.9982 * * * *
130067 ............................................................................. 0.6317 0.8689 * * * *
140001 ............................................................................. 1.0975 0.8279 $20.0247 $21.4779 $22.3170 $21.3141
140002 ............................................................................. 1.2742 0.8958 $23.0207 $24.4908 $24.6954 $24.0687
140003 ............................................................................. 1.0219 * $19.2097 $22.6230 * $20.9305
140005 ............................................................................. *** * $13.2365 * * $13.2365
140007 ............................................................................. 1.3190 1.0787 $25.1836 $26.7943 $28.3482 $26.7800
140008 ............................................................................. 1.5155 1.0787 $26.3287 $27.2211 $28.5297 $27.3790
140010 ............................................................................. 1.4537 1.0787 $29.0224 $31.5774 $35.1024 $32.1200
140011 ............................................................................. 1.1584 0.8279 $19.0903 $20.6338 $22.4091 $20.7429
140012 ............................................................................. 1.2419 1.0646 $24.4070 $24.3675 $28.6564 $25.7920
140013 ............................................................................. 1.4287 0.8845 $19.9800 $22.6022 $23.3065 $21.9604
140015 ............................................................................. 1.3914 0.8958 $21.4328 $22.2266 $23.0600 $22.2778
140016 ............................................................................. 1.0254 0.8279 $16.3417 $17.1372 $18.1242 $17.2195
140018 ............................................................................. 1.4356 1.0787 $24.3285 $27.3334 $27.7548 $26.4350
140019 ............................................................................. 0.9686 0.8279 $17.4206 $18.4554 $18.9228 $18.2432
140024 ............................................................................. 1.0049 * $15.6616 $16.9672 $17.5249 $16.7192
140026 ............................................................................. 1.1678 0.8625 $20.4084 $21.6847 $23.0470 $21.6994
140027 ............................................................................. 1.1697 * $20.9855 $22.6208 * $21.8225
140029 ............................................................................. 1.5538 1.0787 $25.0485 $27.7304 $28.6565 $27.2604
140030 ............................................................................. 1.7218 1.0787 $26.5733 $28.7623 $29.7771 $28.4275
140032 ............................................................................. 1.1810 0.8958 $20.6273 $22.8157 $24.0574 $22.5257
140033 ............................................................................. 1.2358 1.0581 $23.4279 $26.1553 $25.6068 $25.0497
140034 ............................................................................. 1.2428 0.8958 $20.9635 $22.1003 $23.0034 $21.9987
140037 ............................................................................. 0.8642 * $15.5578 * * $15.5578
140040 ............................................................................. 1.2197 0.8743 $19.2160 $20.0269 $22.2969 $20.4819
140043 ............................................................................. 1.2416 0.9664 $23.3751 $26.0330 $26.7996 $25.3939
140045 ............................................................................. 1.0450 * $18.9587 $21.0042 $20.6548 $20.2345
140046 ............................................................................. 1.4795 0.8958 $21.7969 $22.5022 $23.2127 $22.5567
140048 ............................................................................. 1.2945 1.0787 $25.9122 $27.0874 $28.2222 $27.0819

Case-mix FY 2006
140049 ............................................................................. 1.5948 1.0787 $21.9546 $26.6533 $27.4009 $25.3465

140051 ............................................................................. 1.5185 1.0787 $24.2472 $27.9935 $27.7901 $26.6740
140052 ............................................................................. 1.2078 0.8958 $21.8161 $22.2588 $23.5662 $22.5560
140053 ............................................................................. 1.8710 0.8787 $22.6099 $23.5477 $24.8455 $23.6468
140054 ............................................................................. 1.4602 1.0787 $35.5659 $31.7265 $31.8564 $32.8769
140058 ............................................................................. 1.2598 0.8958 $20.5089 $22.1269 $22.8423 $21.8133
140059 ............................................................................. 1.0851 0.8958 $19.9777 $22.7121 $22.4651 $21.7552
140061 ............................................................................. 0.9901 0.8958 $22.7515 $30.9925 $20.8063 $24.6734
140062 ............................................................................. 1.2163 1.0787 $30.7005 $31.2359 $34.7704 $32.2360
140063 ............................................................................. 1.3737 1.0787 $30.5430 $26.5584 $27.8306 $28.2367
140064 ............................................................................. 1.1693 0.8743 $20.6505 $21.7470 $22.0407 $21.4911
140065 ............................................................................. 1.3953 1.0787 $26.3521 $26.1904 $29.4678 $27.3858
140066 ............................................................................. 1.1355 0.8958 $18.0915 $20.4353 $21.9771 $20.1053
140067 ............................................................................. 1.8342 0.8845 $21.9579 $23.5906 $25.3986 $23.6801
140068 ............................................................................. 1.2364 1.0787 $24.1316 $25.8963 $27.3956 $25.8156
140070 ............................................................................. *** * $25.2960 * * $25.2960
140075 ............................................................................. 1.3361 1.0787 $26.5350 $26.9257 $27.9325 $27.1256
140077 ............................................................................. 0.9621 0.8958 $18.0487 $19.0922 $19.1363 $18.7657
140079 ............................................................................. *** * $25.7090 $29.3040 * $27.5634
140080 ............................................................................. 1.4435 1.0787 $24.4056 $26.0109 $23.2575 $24.4826
140082 ............................................................................. 1.4014 1.0787 $25.0474 $26.8077 $25.6645 $25.8332
140083 ............................................................................. 1.0694 1.0787 $23.2822 $24.6491 $26.2972 $24.7955
140084 ............................................................................. 1.2159 1.0581 $25.4818 $27.6819 $29.2515 $27.5306
140088 ............................................................................. 1.8214 1.0787 $28.4219 $31.0364 $32.4978 $30.6729
140089 ............................................................................. 1.1983 0.8279 $20.7632 $22.1227 $23.3401 $22.0452
140090 ............................................................................. *** * $35.0300 * * $35.0300
140091 ............................................................................. 1.7746 0.9582 $23.7560 $26.1075 $26.8518 $25.6285
140093 ............................................................................. 1.1579 0.9262 $21.5376 $22.1540 $25.3127 $22.9099
140094 ............................................................................. 1.0608 1.0787 $24.2166 $25.3678 $27.9273 $25.8494
140095 ............................................................................. 1.2411 1.0787 $24.7706 $29.9746 $27.6799 $27.5947
140100 ............................................................................. 1.2328 1.0581 $27.1868 $32.8743 $37.0819 $32.5610
140101 ............................................................................. 1.1378 1.0787 $24.6106 $25.4784 $28.5365 $26.3107
140102 ............................................................................. 1.0470 * $19.8678 $21.2278 * $20.5493
140103 ............................................................................. 1.3191 1.0787 $21.2404 $21.7512 $23.3258 $22.1297
140105 ............................................................................. 1.2587 1.0787 $27.3323 $26.3054 $27.4531 $27.0018
140109 ............................................................................. 1.1459 0.8279 $16.4261 $17.8103 $19.5675 $17.9602
140110 ............................................................................. 1.0552 1.0646 $21.9880 $25.6561 $27.9844 $25.2166
140113 ............................................................................. 1.5847 0.9582 $25.6621 $23.5337 $26.7969 $25.2477
140114 ............................................................................. 1.4787 1.0787 $24.1926 $25.7968 $28.3014 $26.1695
140115 ............................................................................. 1.1789 1.0787 $25.3410 $26.3677 $25.1498 $25.6313
140116 ............................................................................. 1.2924 1.0787 $26.8924 $30.5166 $31.9902 $29.9696
140117 ............................................................................. 1.5169 1.0787 $23.3531 $25.6314 $26.8802 $25.3065
140118 ............................................................................. 1.7320 1.0787 $26.7350 $27.7392 $29.7570 $28.1023
140119 ............................................................................. 1.7467 1.0787 $31.3486 $33.6302 $36.1419 $33.6518
140120 ............................................................................. 1.2682 0.8845 $20.3237 $22.5795 $22.7375 $21.8812
140121 ............................................................................. 1.6616 * $17.6019 * * $17.6019
140122 ............................................................................. 1.4446 1.0787 $26.8595 $26.4991 $28.4188 $27.2710
140124 ............................................................................. 1.2587 1.0787 $30.9648 $35.2798 $36.1327 $34.0784
140125 ............................................................................. 1.2383 0.8958 $19.5359 $20.7189 $20.4014 $20.2151
140127 ............................................................................. 1.5857 0.9074 $21.3102 $22.8172 $24.1658 $22.7988
140129 ............................................................................. *** * $21.6495 * * $21.6495
140130 ............................................................................. 1.2726 1.0581 $25.7324 $26.3518 $29.5247 $27.3008
140132 ............................................................................. *** * $23.0595 * * $23.0595
140133 ............................................................................. 1.2932 1.0787 $24.0458 $26.1599 $28.0339 $25.9998
140135 ............................................................................. 1.4186 0.8279 $19.7919 $21.2104 $22.3264 $21.1811
140137 ............................................................................. 1.0401 0.8958 $21.6017 $20.5053 $21.4700 $21.1955
140140 ............................................................................. 1.0197 * $19.1636 $21.4710 * $20.3063
140141 ............................................................................. 1.0211 * $20.3706 $23.0515 $21.7871 $21.7302
140143 ............................................................................. 1.1551 0.8743 $22.0009 $23.8255 $26.2954 $24.0154
140144 ............................................................................. 0.9634 * $26.9258 $27.8046 * $27.3474
140145 ............................................................................. 1.1271 0.8958 $19.6429 $21.6168 $23.4608 $21.6090
140147 ............................................................................. 1.1178 0.8279 $18.2692 $19.5896 $19.8541 $19.2467
140148 ............................................................................. 1.7094 0.8787 $21.5777 $23.0022 $24.7031 $23.0546
140150 ............................................................................. 1.6139 1.0787 $32.9291 $33.9013 $35.2711 $34.0702
140151 ............................................................................. 0.8241 1.0787 $21.5167 $22.4842 $23.4879 $22.5018
140152 ............................................................................. 1.2404 1.0787 $28.5468 $29.6882 $27.6086 $28.6011
140155 ............................................................................. 1.2756 1.0765 $25.2034 $27.6610 $28.9724 $27.2937

Case-mix FY 2006
140158 ............................................................................. 1.4203 1.0787 $22.5638 $23.8542 $27.0986 $24.2703

140160 ............................................................................. 1.2385 0.9664 $20.9986 $22.7002 $24.5373 $22.7502
140161 ............................................................................. 1.1279 1.0646 $22.2191 $24.1071 $23.1647 $23.1691
140162 ............................................................................. 1.6229 0.9074 $22.6426 $26.0312 $27.4472 $25.4182
140164 ............................................................................. 1.7657 0.8958 $19.7774 $22.0424 $23.7457 $21.8696
140165 ............................................................................. 1.0651 * $17.0666 $15.9312 $16.6304 $16.5175
140166 ............................................................................. 1.1824 0.8279 $20.7849 $21.7776 $23.1005 $21.8859
140167 ............................................................................. 1.0499 0.8279 $19.5959 $19.7610 $22.8911 $20.7477
140168 ............................................................................. 1.1726 * $18.7504 $20.0225 * $19.4021
140170 ............................................................................. 0.9358 * $17.0665 $17.1608 * $17.1147
140171 ............................................................................. *** * $17.3214 * * $17.3214
140172 ............................................................................. 1.3752 1.0787 $27.3372 $27.1121 $29.8568 $28.4878
140174 ............................................................................. 1.4729 1.0787 $23.6893 $24.7011 $27.8131 $25.3970
140176 ............................................................................. 1.2141 1.0787 $25.6824 $28.9378 $31.3490 $28.8390
140177 ............................................................................. 0.9529 1.0787 $20.8526 $19.3328 $22.5610 $20.9656
140179 ............................................................................. 1.3721 1.0787 $24.1539 $26.3200 $27.6376 $26.0525
140180 ............................................................................. 1.2667 1.0787 $25.4022 $27.4366 $28.3629 $27.0710
140181 ............................................................................. 1.2082 1.0787 $23.7308 $23.6034 $25.0100 $24.1182
140182 ............................................................................. 1.5193 1.0787 $32.1969 $28.0337 $28.2211 $28.8901
140184 ............................................................................. 1.2187 0.8279 $20.6499 $20.1279 $21.1802 $20.6885
140185 ............................................................................. 1.4330 0.8958 $20.0903 $22.0222 $23.8531 $22.0093
140186 ............................................................................. 1.5107 1.0765 $26.0970 $28.1977 $30.6951 $28.4624
140187 ............................................................................. 1.5026 0.8958 $20.5829 $22.0674 $23.2892 $21.9710
140189 ............................................................................. 1.1505 0.9262 $22.5875 $25.6954 $23.7198 $24.0159
140190 ............................................................................. 1.0728 * $17.9193 $18.8530 $19.8297 $18.8585
140191 ............................................................................. 1.3122 1.0787 $24.5446 $25.2817 $25.8678 $25.2409
140193 ............................................................................. 0.9701 * $20.5958 $22.9443 * $21.7731
140197 ............................................................................. 1.3542 1.0787 $19.2980 $21.8060 $23.0684 $21.2577
140199 ............................................................................. 1.0548 0.8279 $19.7888 $21.3464 $22.0315 $21.0597
140200 ............................................................................. 1.4946 1.0787 $24.1358 $24.9217 $26.3379 $25.1308
140202 ............................................................................. 1.5604 1.0581 $26.2460 $27.4336 $29.7870 $27.9702
140203 ............................................................................. 1.0839 * $26.5789 $28.2212 * $27.4338
140205 ............................................................................. 0.5759 1.0128 $25.1010 * * $25.1010
140206 ............................................................................. 1.1417 1.0787 $24.7616 $27.5481 $30.6561 $27.6301
140207 ............................................................................. 1.4242 1.0787 $23.3197 $25.7331 $24.1048 $24.4812
140208 ............................................................................. 1.6608 1.0787 $27.4671 $27.6586 $29.4708 $28.2131
140209 ............................................................................. 1.5477 0.8845 $22.0813 $23.3886 $24.5376 $23.3577
140210 ............................................................................. 1.0896 0.8279 $15.5339 $16.6729 $19.2639 $17.1406
140211 ............................................................................. 1.3172 1.0787 $25.8556 $29.5114 $29.7054 $28.4947
140213 ............................................................................. 1.1697 1.0787 $27.4607 $29.1649 $30.2945 $29.0178
140215 ............................................................................. *** * $18.6962 $22.3097 * $20.4262
140217 ............................................................................. 1.4497 1.0787 $24.7146 $29.3711 $31.5324 $28.5274
140223 ............................................................................. 1.4386 1.0787 $27.4355 $29.2540 $30.4923 $29.0769
140224 ............................................................................. 1.3999 1.0787 $27.1725 $29.0350 $28.2177 $28.1560
140228 ............................................................................. 1.5463 0.9965 $22.9899 $25.0074 $25.6419 $24.5738
140231 ............................................................................. 1.4877 1.0787 $25.5536 $28.3545 $30.6410 $28.2754
140233 ............................................................................. 1.5789 1.0646 $24.7103 $27.3379 $28.6305 $26.9841
140234 ............................................................................. 1.0500 0.8743 $20.8676 $23.2604 $23.6928 $22.6766
140239 ............................................................................. 1.5620 0.9965 $23.9205 $24.2112 $29.0092 $25.6976
140240 ............................................................................. 1.4134 1.0787 $25.0325 $27.2654 $28.7310 $26.9902
140242 ............................................................................. 1.4982 1.0787 $28.8686 $30.4005 $32.0522 $30.5576
140245 ............................................................................. 0.9917 * $15.2537 $16.0772 * $15.6642
140246 ............................................................................. *** * $16.1305 * * $16.1305
140250 ............................................................................. 1.2339 1.0787 $25.5501 $27.4628 $28.5971 $27.2294
140251 ............................................................................. 1.2951 1.0787 $24.8256 $26.7266 $27.1687 $26.2377
140252 ............................................................................. 1.4213 1.0787 $28.3479 $30.2656 $33.3351 $30.8078
140258 ............................................................................. 1.5301 1.0787 $27.5741 $27.9478 $30.2639 $28.6430
140271 ............................................................................. 0.8940 * $17.5174 $18.8535 * $18.2163
140275 ............................................................................. 1.2853 0.8709 $23.1871 $25.2824 $26.1473 $24.8583
140276 ............................................................................. 1.8142 1.0787 $25.3222 $27.5936 $29.8325 $27.5408
140280 ............................................................................. 1.4671 0.8709 $21.7004 $21.9302 $23.4447 $22.3667
140281 ............................................................................. 1.7032 1.0787 $27.9115 $29.2602 $30.4838 $29.2416
140285 ............................................................................. *** * * $17.7824 $20.7576 $19.1679
140286 ............................................................................. 1.1142 1.0787 $25.5805 $28.4378 $29.1543 $27.7906
140288 ............................................................................. 1.5423 1.0787 $26.3572 $26.9581 $29.3988 $27.5648
140289 ............................................................................. 1.3270 0.8958 $20.7506 $22.3274 $22.6211 $21.9308
140290 ............................................................................. 1.3299 1.0787 $29.9098 $28.6926 $31.7341 $30.1371

Case-mix FY 2006
140291 ............................................................................. 1.2633 1.0646 $27.6675 $28.2338 $29.8958 $28.6610

140292 ............................................................................. 1.1590 1.0787 $26.4077 $26.1781 $27.6285 $26.7692
140294 ............................................................................. 1.1328 0.8279 $21.7473 $22.6123 $23.4504 $22.6034
140300 ............................................................................. 1.2322 1.0787 $30.5172 $33.3983 $34.8568 $32.8808
140301 ............................................................................. 1.1673 1.0787 * * $31.7073 $31.7073
140303 ............................................................................. 2.1093 1.0787 * * * *
150001 ............................................................................. 1.1882 0.9912 $25.4897 $27.1021 $29.6844 $27.4774
150002 ............................................................................. 1.4225 1.0646 $22.3327 $23.3804 $25.0063 $23.5866
150003 ............................................................................. 1.6821 0.8721 $21.0944 $23.3196 $25.3458 $23.2610
150004 ............................................................................. 1.5573 1.0646 $23.6169 $24.8884 $26.8458 $25.1066
150005 ............................................................................. 1.2087 0.9912 $23.8818 $25.4443 $27.2369 $25.6152
150006 ............................................................................. 1.3215 0.9775 $23.1779 $24.8976 $26.4061 $24.8616
150007 ............................................................................. 1.3254 0.9546 $22.1098 $23.5841 $26.6073 $24.2353
150008 ............................................................................. 1.4227 1.0646 $23.8916 $23.6953 $26.6928 $24.7814
150009 ............................................................................. 1.3828 0.9254 $19.4763 $20.4993 $22.2147 $20.7473
150010 ............................................................................. 1.3579 0.9546 $22.5445 $23.9740 $26.8524 $24.4792
150011 ............................................................................. 1.1670 0.9766 $22.1559 $23.2249 $24.3490 $23.2593
150012 ............................................................................. 1.5500 0.9775 $23.1644 $22.9314 $27.3029 $24.2924
150013 ............................................................................. 0.9904 * $19.8564 $19.7689 $21.8465 $20.4949
150014 ............................................................................. 1.3341 0.9912 $24.3754 $26.5785 * $25.4309
150015 ............................................................................. 1.3287 1.0646 $23.1616 $24.3015 $26.2434 $24.6064
150017 ............................................................................. 1.8334 0.9787 $22.7979 $23.7180 $25.2342 $23.9446
150018 ............................................................................. 1.6441 0.9606 $24.6138 $24.7048 $26.3289 $25.2344
150019 ............................................................................. 1.0496 * $17.3170 * * $17.3170
150020 ............................................................................. 1.1215 * $18.4689 * * $18.4689
150021 ............................................................................. 1.7451 0.9787 $24.3658 $27.8168 $29.6967 $27.2581
150022 ............................................................................. 1.0786 0.8875 $22.2973 $22.8035 $22.6773 $22.6089
150023 ............................................................................. 1.5291 0.8626 $20.6926 $23.1253 $23.7159 $22.4697
150024 ............................................................................. 1.4380 0.9912 $21.7593 $24.7879 $27.1589 $24.7582
150026 ............................................................................. 1.2837 0.9606 $23.2169 $23.7185 $28.1127 $25.1166
150027 ............................................................................. 1.0264 0.9912 $21.5766 $21.2855 $17.4862 $19.9164
150029 ............................................................................. 1.4385 0.9775 $25.2067 $23.4103 $26.9680 $25.0754
150030 ............................................................................. 1.2127 0.9766 $23.0196 $24.4361 $26.9533 $24.8565
150031 ............................................................................. 1.0638 * $18.9180 * * $18.9180
150033 ............................................................................. 1.7015 0.9912 $24.1701 $25.8851 $27.9995 $26.0913
150034 ............................................................................. 1.5097 1.0646 $22.8812 $23.9388 $26.0465 $24.3610
150035 ............................................................................. 1.4639 0.9473 $23.5468 $26.0952 $26.6620 $25.4702
150037 ............................................................................. 1.3136 0.9912 $24.4997 $27.7009 $28.5451 $26.8949
150038 ............................................................................. 1.1135 0.9912 $21.6608 $24.4188 $28.8054 $24.9650
150042 ............................................................................. 1.4015 0.8626 $23.7838 $21.9917 $23.0102 $22.8781
150044 ............................................................................. 1.3418 0.9254 $20.5156 $23.1200 $23.7065 $22.4683
150045 h ........................................................................... 1.0611 1.0203 $23.0361 $24.2899 $25.2225 $24.2205
150046 ............................................................................. 1.4435 0.8626 $20.3453 $21.0417 $21.9369 $21.1254
150047 ............................................................................. 1.7099 0.9787 $24.8786 $24.5455 $25.8349 $25.1035
150048 ............................................................................. 1.3290 0.9595 $22.5181 $24.5864 $27.1817 $24.7509
150049 ............................................................................. 1.1302 0.8626 $18.4942 $20.2178 $22.3370 $20.2342
150051 ............................................................................. 1.5723 0.8626 $21.4009 $22.6866 $23.7061 $22.5941
150052 h ........................................................................... 1.0456 0.9254 $19.1070 $19.6073 $20.6339 $19.7871
150056 ............................................................................. 1.8501 0.9912 $24.7841 $27.6754 $28.2842 $26.9368
150057 ............................................................................. 1.9981 0.9912 $28.0884 $22.7804 $24.8605 $24.9551
150058 ............................................................................. 1.5717 0.9775 $24.9479 $26.9753 $27.5341 $26.5322
150059 ............................................................................. 1.5913 0.9912 $25.6738 $27.0792 $28.5715 $27.1975
150060 ............................................................................. 1.0914 * $19.8990 $23.2409 $24.8544 $22.6276
150061 ............................................................................. 1.1149 0.8626 $19.2826 $21.3640 $22.2822 $20.9919
150062 ............................................................................. 1.1174 0.8779 $22.9214 $23.5550 $24.6088 $23.7293
150063 ............................................................................. *** * $24.4091 $19.0377 * $21.8339
150064 ............................................................................. 1.1816 0.8626 $21.2512 $21.6370 $23.7707 $22.2400
150065 ............................................................................. 1.2407 0.9766 $23.0636 $24.4451 $25.9461 $24.5094
150067 ............................................................................. 1.0394 * $21.4374 * * $21.4374
150069 ............................................................................. 1.2003 0.9595 $23.8353 $25.3445 $25.2655 $24.8300
150070 ............................................................................. 0.9449 * $20.7413 $22.6260 * $21.7117
150072 ............................................................................. 1.2044 0.8626 $18.5447 $20.3191 $20.5111 $19.8274
150073 ............................................................................. *** * $14.8287 * * $14.8287
150074 ............................................................................. 1.4325 0.9912 $22.9598 $24.4374 $25.2586 $24.2433
150075 ............................................................................. 1.0887 0.9787 $20.1119 $24.2085 $24.0745 $22.8038
150076 ............................................................................. 1.2419 0.9775 $25.4519 $24.1434 $28.1874 $25.9085
150078 ............................................................................. 0.9482 * $20.1259 $21.2476 * $20.7180

Case-mix FY 2006
150079 ............................................................................. 1.0979 0.9254 $19.3860 $20.6486 $21.4067 $20.5165

150082 ............................................................................. 1.7386 0.8727 $21.0651 $22.2054 $25.5860 $22.9776
150084 ............................................................................. 1.8008 0.9912 $27.8354 $28.7722 $29.3905 $28.6939
150086 ............................................................................. 1.2204 0.9595 $21.5815 $22.4471 $23.9404 $22.7151
150088 ............................................................................. 1.2877 0.9766 $22.2627 $23.0998 $23.6253 $23.0168
150089 ............................................................................. 1.4776 0.8943 $21.6806 $22.6545 $25.0449 $23.0977
150090 ............................................................................. 1.5045 1.0646 $24.9021 $24.6758 $26.2899 $25.3163
150091 h ........................................................................... 1.0899 1.0360 $26.4248 $27.8087 $30.6209 $28.2762
150096 ............................................................................. 0.9793 * $19.7975 $21.9091 * $20.8347
150097 ............................................................................. 1.0695 0.9912 $22.4564 $24.4179 $25.0367 $24.0346
150100 ............................................................................. 1.7186 0.8727 $21.2980 $22.2687 $24.3530 $22.6387
150101 ............................................................................. 1.0362 0.9787 $26.1271 $27.9745 $29.1657 $27.6430
150102 ............................................................................. 1.1050 0.9390 $21.3313 $22.6870 $24.5923 $22.8112
150104 ............................................................................. 1.0587 0.9912 $21.0799 $21.8172 $25.5871 $22.8454
150106 h ........................................................................... 1.0532 0.9787 $19.1976 $20.9955 $20.9387 $20.4063
150109 ............................................................................. 1.4302 0.8721 $23.4642 $24.3786 $23.5865 $23.8124
150112 ............................................................................. 1.4431 0.9766 $23.5151 $24.7455 $26.5643 $24.9478
150113 ............................................................................. 1.2063 0.9766 $21.2412 $23.0450 $24.8760 $23.1460
150115 ............................................................................. 1.3456 0.8626 $20.3863 $20.5215 $19.3411 $20.0486
150122 ............................................................................. 1.1236 0.8825 $22.2752 $24.2471 $26.0173 $24.2508
150123 ............................................................................. *** * $15.5997 $15.3050 * $15.4580
150124 ............................................................................. 1.1255 0.8626 $17.9063 $18.8218 $21.3933 $19.4269
150125 ............................................................................. 1.5069 1.0646 $23.1464 $24.3872 $26.7666 $24.8140
150126 ............................................................................. 1.4223 1.0646 $24.1917 $25.5585 $26.9887 $25.6255
150128 ............................................................................. 1.3965 0.9912 $20.9869 $23.1660 $26.4976 $23.5710
150129 ............................................................................. 1.2019 0.9912 $34.3166 $35.4311 $29.9099 $32.9368
150130 ............................................................................. 1.0268 * $18.5578 $21.5678 $21.7399 $20.5294
150132 ............................................................................. 1.4086 1.0646 $22.2707 $24.2559 $25.6257 $24.1021
150133 ............................................................................. 1.2666 0.9787 $21.8807 $21.8839 $22.7293 $22.1682
150134 ............................................................................. 1.1176 0.9254 $20.7680 $22.1085 $23.8526 $22.2228
150136 ............................................................................. *** * $25.8467 $25.7004 $26.2703 $25.9403
150146 ............................................................................. 1.0225 0.9787 $25.1827 $26.1168 $29.3383 $26.7878
150147 ............................................................................. 1.1926 1.0646 * $32.3336 $22.8456 $26.0420
150148 ............................................................................. *** * $26.2188 $27.2081 * $26.7661
150149 ............................................................................. 0.9715 0.8727 * $23.8554 $23.6361 $23.7419
150150 ............................................................................. 1.2769 0.9787 * $26.5138 $25.5331 $26.0172
150151 ............................................................................. *** * * * $38.1446 $38.1446
150152 ............................................................................. *** * * * $44.7143 $44.7143
150153 ............................................................................. 2.4699 0.9912 * * * *
150154 ............................................................................. 2.5955 0.9912 * * * *
150156 ............................................................................. 1.8815 0.9390 * * * *
150157 ............................................................................. 1.6131 0.9912 * * * *
160001 ............................................................................. 1.2088 0.9272 $22.8426 $23.8657 $25.1220 $23.9155
160002 ............................................................................. *** * $19.9607 * * $19.9607
160003 ............................................................................. 0.9701 * $17.5050 $19.0037 * $18.2436
160005 ............................................................................. 1.1966 0.8553 $20.3313 $21.1745 $21.8950 $21.1337
160008 ............................................................................. 1.0690 0.8553 $17.9463 $19.8066 $20.7200 $19.4883
160013 ............................................................................. 1.2076 0.8771 $21.0541 $23.0163 $23.7163 $22.5118
160014 ............................................................................. 0.9968 * $18.3097 $19.2447 $20.5882 $19.3912
160016 ............................................................................. 1.5950 0.9430 $21.8400 $21.2785 $23.3619 $22.1755
160020 ............................................................................. 1.0680 0.8553 $16.6092 $19.0043 $19.5554 $18.4145
160024 ............................................................................. 1.5950 0.9668 $22.4256 $24.2385 $26.2392 $24.3248
160026 ............................................................................. 0.9887 0.9272 $22.8967 $24.2045 $24.7424 $23.9779
160028 ............................................................................. 1.3174 0.9546 $25.1998 $26.0052 $26.2948 $25.8671
160029 ............................................................................. 1.6190 0.9741 $23.7268 $24.9493 $27.9277 $25.5651
160030 ............................................................................. 1.2758 0.9577 $23.3687 $24.9920 $26.7068 $25.0247
160031 ............................................................................. 0.9697 0.8553 $17.8994 $18.5281 $19.7368 $18.7354
160032 ............................................................................. 1.0590 0.8825 $20.5024 $22.3837 $23.4727 $22.1329
160033 ............................................................................. 1.7424 0.8709 $22.2660 $23.4148 $24.6768 $23.4865
160034 ............................................................................. 0.9421 0.8553 $19.0684 $19.4837 $19.3503 $19.3060
160039 ............................................................................. 0.9342 0.8553 $19.8851 $20.9623 $22.1180 $20.9879
160040 ............................................................................. 1.2439 0.8813 $20.0567 $21.8187 $23.9053 $21.9454
160043 ............................................................................. *** * $15.5765 * * $15.5765
160044 ............................................................................. 1.1315 * $19.0956 $19.5635 * $19.3281
160045 ............................................................................. 1.6942 0.8813 $22.1285 $24.4957 $25.4153 $24.0445
160047 ............................................................................. 1.3730 0.9546 $22.1550 $24.5000 $25.2072 $23.9813
160048 ............................................................................. 1.0536 0.8553 $18.1174 $19.5701 $19.5832 $19.1110

Case-mix FY 2006
160050 ............................................................................. 1.1034 0.8553 $21.6247 $23.8830 $24.5403 $23.3364

160057 ............................................................................. 1.2602 0.9556 $20.8345 $22.0472 $23.0937 $21.9969
160058 ............................................................................. 1.8406 0.9741 $23.5663 $25.5244 $27.1646 $25.4595
160064 ............................................................................. 1.6054 1.0218 $23.8367 $27.6301 $28.6139 $26.8350
160066 ............................................................................. 1.0906 0.8553 $20.4609 $21.4631 $22.7709 $21.6117
160067 ............................................................................. 1.3672 0.8813 $19.9422 $21.9418 $23.4060 $21.8952
160069 ............................................................................. 1.4498 0.9005 $21.7197 $22.7514 $25.3402 $23.2842
160072 ............................................................................. *** * $15.8236 * * $15.8236
160074 ............................................................................. 1.0213 * $22.2988 $20.2418 * $21.1624
160076 ............................................................................. 0.9957 * $20.1603 $20.9749 * $20.5825
160079 ............................................................................. 1.5094 0.8813 $21.6562 $22.5299 $23.7234 $22.6640
160080 ............................................................................. 1.3139 0.9664 $21.1713 $23.5721 $23.1837 $22.6302
160081 ............................................................................. 1.1943 * $20.4415 $21.3614 $23.1930 $21.6437
160082 ............................................................................. 1.7485 0.9668 $21.6230 $23.8181 $26.4398 $23.8972
160083 ............................................................................. 1.6640 0.9668 $23.4670 $25.0617 $28.2193 $25.6738
160089 ............................................................................. 1.2859 0.9430 $19.9688 $21.5693 $22.6551 $21.4092
160090 ............................................................................. 0.9952 * $19.6767 $21.2753 * $20.4851
160091 ............................................................................. 0.9580 * $16.1660 $18.0630 $17.9862 $17.3974
160092 ............................................................................. 0.9609 * $20.4731 $22.0841 * $21.2805
160093 ............................................................................. *** * $22.8553 * * $22.8553
160101 ............................................................................. 1.1027 0.9668 $22.1741 $24.2309 $25.1000 $23.8100
160104 ............................................................................. 1.3950 0.8709 $23.2832 $24.0075 $24.9134 $24.0516
160106 ............................................................................. 1.1265 * $19.8905 $21.4912 * $20.6919
160107 ............................................................................. 1.0451 * $19.5111 $21.3754 * $20.4402
160110 ............................................................................. 1.6682 0.8813 $21.9299 $24.1762 $24.9434 $23.7256
160112 ............................................................................. 1.2599 0.8553 $20.4038 $21.8901 $23.0672 $21.8008
160113 ............................................................................. 0.9661 * $16.7574 $18.6599 * $17.7162
160114 ............................................................................. 0.9810 * $19.1743 * * $19.1743
160115 ............................................................................. 1.0985 * $17.6815 $19.5764 * $18.5763
160116 ............................................................................. 1.0398 * $19.6923 $22.2019 * $20.9445
160117 ............................................................................. 1.2805 0.9005 $22.3228 $23.4250 $25.0278 $23.6002
160118 ............................................................................. 1.0326 0.8553 $16.9466 $18.3322 $19.7764 $18.4025
160122 ............................................................................. 1.0846 0.8553 $21.2843 $22.9565 $22.5872 $22.2853
160124 ............................................................................. 1.1237 0.8553 $21.2279 $22.7223 $23.1690 $22.3848
160126 ............................................................................. 1.0433 0.8553 $20.0149 $20.3748 $19.8323 $20.0754
160131 ............................................................................. 0.9408 * $18.0486 * * $18.0486
160140 ............................................................................. 1.0209 * $22.1666 $22.5230 * $22.3471
160143 ............................................................................. 1.0157 * $19.0623 * * $19.0623
160146 ............................................................................. 1.4086 0.9365 $20.6638 $20.9583 $22.9897 $21.5377
160147 ............................................................................. 1.2192 0.9430 $22.7993 $26.6577 $26.6438 $25.4406
160153 ............................................................................. 1.6067 0.9365 $23.5212 $26.3671 $28.9881 $26.3386
170001 ............................................................................. 1.1627 0.8076 $19.8149 $20.9837 $21.9131 $20.9143
170006 ............................................................................. 1.2468 0.8450 $19.4488 $20.6460 $21.9019 $20.7240
170008 ............................................................................. *** * $18.2352 * * $18.2352
170009 ............................................................................. 1.0640 0.9463 $25.8246 $29.1979 $29.2588 $28.1227
170010 ............................................................................. 1.2408 0.8569 $20.6294 $21.2131 $24.0008 $21.9435
170012 ............................................................................. 1.6234 0.8977 $21.8587 $22.6869 $24.7392 $23.0750
170013 ............................................................................. 1.6094 0.8977 $21.4954 $23.1159 $25.0419 $23.1862
170014 ............................................................................. 0.9839 0.9463 $21.3416 $22.9772 $23.5960 $22.6522
170015 ............................................................................. 1.0552 * $18.0485 $19.1902 $20.2367 $19.1620
170016 ............................................................................. 1.6375 0.8912 $22.9479 $24.2336 $25.9482 $24.4090
170017 ............................................................................. 1.1078 0.9168 $21.6323 $23.3030 $24.7771 $23.3226
170018 ............................................................................. 0.8965 * $16.9169 $17.9497 * $17.4623
170019 ............................................................................. 1.2271 0.8076 $18.7916 $20.3243 $22.0251 $20.4068
170020 ............................................................................. 1.5762 0.8977 $20.6658 $22.2571 $23.1800 $22.0586
170022 ............................................................................. 1.0981 0.9463 $21.1947 $22.9313 $22.2878 $22.1486
170023 ............................................................................. 1.4687 0.8977 $21.6273 $23.2690 $23.9808 $22.9706
170024 ............................................................................. *** * $16.1196 * * $16.1196
170025 ............................................................................. *** * $19.2123 * * $19.2123
170026 ............................................................................. *** * $17.0836 * * $17.0836
170027 ............................................................................. 1.4017 0.8076 $20.7776 $21.4678 $22.5103 $21.6098
170033 ............................................................................. 1.3937 0.8977 $20.0627 $20.0801 $20.7865 $20.2914
170034 ............................................................................. 0.8608 * $18.1074 * * $18.1074
170039 ............................................................................. 0.9591 0.9168 $18.4473 $20.1983 $21.5203 $20.0407
170040 ............................................................................. 1.9183 0.9463 $24.5234 $27.1771 $28.2856 $26.8014
170041 ............................................................................. 0.6109 * $13.9709 * * $13.9709
170049 ............................................................................. 1.5134 0.9463 $22.9404 $24.1208 $24.7895 $23.9996

Case-mix FY 2006
170052 ............................................................................. 1.1936 0.8076 $15.8809 $17.3794 $18.5291 $17.3370

170054 ............................................................................. 0.9997 * $18.5239 $17.5500 * $18.0250
170056 ............................................................................. *** * $17.1872 * * $17.1872
170058 ............................................................................. 1.0822 0.9463 $23.0648 $22.0398 $23.3398 $22.8013
170068 ............................................................................. 1.2035 0.9156 $20.5512 $20.8771 $22.6087 $21.3531
170070 ............................................................................. 1.0815 0.8076 $15.0539 $16.4767 $16.0162 $15.8428
170074 ............................................................................. 1.2512 0.8076 $18.5446 $20.4936 $21.0565 $20.0516
170075 ............................................................................. 0.8352 0.8076 $15.6809 $16.2047 $16.5444 $16.1586
170077 ............................................................................. *** * $14.6377 * * $14.6377
170080 ............................................................................. 0.9108 * $15.0079 * * $15.0079
170082 ............................................................................. *** * $15.9973 * * $15.9973
170085 ............................................................................. 0.9571 * $17.2585 $18.4867 * $17.8616
170086 ............................................................................. 1.5689 0.8912 $22.1067 $22.7737 $24.0812 $23.0117
170090 ............................................................................. 0.9555 * $16.3550 $15.9807 * $16.1812
170093 ............................................................................. 0.8272 0.8076 $15.0307 $16.8710 $16.5553 $16.1514
170094 ............................................................................. 0.9999 0.8076 $20.1253 $20.3678 $21.3887 $20.6420
170097 ............................................................................. 0.8994 * $18.9865 $20.3391 * $19.6594
170098 ............................................................................. 1.0088 0.8076 $18.6676 $20.0078 $20.1242 $19.5946
170099 ............................................................................. 1.0382 * $15.8117 * * $15.8117
170101 ............................................................................. *** * $17.9291 * * $17.9291
170103 ............................................................................. 1.2477 0.9168 $20.1263 $21.4985 $22.8707 $21.5590
170104 ............................................................................. 1.5175 0.9463 $23.6589 $26.1866 $26.9671 $25.6385
170105 ............................................................................. 1.0793 0.8076 $18.3824 $19.6687 $21.4422 $19.8723
170109 ............................................................................. 0.9870 0.9463 $20.7580 $22.7166 $23.2626 $22.2703
170110 ............................................................................. 0.9756 0.8076 $16.5883 $21.8904 $22.9195 $20.4004
170113 ............................................................................. 1.0265 * $19.9957 * * $19.9957
170114 ............................................................................. 0.8632 0.8076 $17.4688 $18.1610 $18.9158 $18.1987
170116 ............................................................................. 1.0105 * $20.8800 $23.1127 * $21.9980
170120 ............................................................................. 1.2735 0.8450 $18.5895 $19.8723 $21.0499 $19.8632
170122 ............................................................................. 1.6272 0.9168 $22.2681 $24.6532 $25.3981 $24.1333
170123 ............................................................................. 1.6884 0.9168 $25.0073 $26.4676 $27.2239 $26.2255
170133 ............................................................................. 1.0703 0.9463 $20.0593 $21.7748 $22.9309 $21.5574
170137 ............................................................................. 1.2393 0.8076 $21.4394 $22.7676 $23.8863 $22.7099
170142 ............................................................................. 1.3477 0.8776 $19.8269 $22.4095 $22.5778 $21.6027
170143 ............................................................................. 1.1298 0.8076 $18.0308 $19.7643 $20.4459 $19.4072
170144 ............................................................................. *** * $23.9180 $24.4259 $24.6260 $24.3634
170145 ............................................................................. 1.0677 0.8076 $20.5143 $21.4472 $21.5756 $21.1869
170146 ............................................................................. 1.5459 0.9463 $27.0312 $28.1965 $29.1358 $28.2094
170147 ............................................................................. 1.2323 0.9168 $18.2480 $23.1610 $21.4753 $20.9339
170148 ............................................................................. *** * $26.3491 * * $26.3491
170150 ............................................................................. 1.1267 0.8076 $16.3724 $17.4916 $18.5744 $17.4967
170151 ............................................................................. 1.0276 * $15.7242 * * $15.7242
170152 ............................................................................. 1.0618 * * * * *
170166 ............................................................................. 0.9449 0.8076 $17.8131 $18.5978 $19.2842 $18.5319
170171 ............................................................................. *** * $14.7251 * * $14.7251
170175 ............................................................................. 1.3487 0.8977 $22.5605 $23.6262 $23.9304 $23.3714
170176 ............................................................................. 1.3432 0.9463 $25.5404 $24.2283 $26.2366 $25.2863
170180 ............................................................................. *** * $25.0935 * $25.1366 $25.1166
170182 ............................................................................. 1.4280 0.9463 $23.2115 $24.3820 $25.7443 $24.4497
170183 ............................................................................. 1.9727 0.9168 $19.6919 $22.8633 $24.5539 $22.4468
170185 ............................................................................. 1.3253 0.9463 $26.8307 $24.8478 $26.7797 $26.1506
170186 ............................................................................. 2.9322 0.9168 $28.5602 $30.5157 $31.7896 $30.4381
170187 ............................................................................. 1.1537 0.8076 $20.8289 $21.0780 $23.3702 $21.8354
170188 ............................................................................. 2.0471 0.9463 $25.2504 $27.2225 $29.9751 $27.6756
170189 ............................................................................. *** * $28.1996 * * $28.1996
170190 ............................................................................. 1.0582 0.8076 * $22.4865 $22.8729 $22.6685
170191 ............................................................................. 1.1279 0.8076 * $24.9599 $21.3069 $23.1771
170192 ............................................................................. 2.0907 0.9168 * * $27.9704 $27.9704
170193 ............................................................................. 1.2176 0.8076 * * $24.7430 $24.7430
170194 ............................................................................. 1.7132 0.9463 * * $27.9904 $27.9904
170195 ............................................................................. 2.2634 0.9463 * * * *
170196 ............................................................................. 2.4484 0.9168 * * * *
180001 ............................................................................. 1.2743 0.9595 $22.2674 $24.7647 $25.4217 $24.1342
180002 ............................................................................. 1.0566 0.7780 $20.5135 $21.6843 $22.9727 $21.7424
180004 ............................................................................. 1.1137 0.7780 $19.8552 $19.0834 $19.5437 $19.4871
180005 ............................................................................. 1.1545 0.9110 $22.6704 $22.8871 $24.5561 $23.3888
180006 ............................................................................. 0.9171 0.7780 $14.4066 $15.7136 $14.8011 $14.9439

Case-mix FY 2006
180007 ............................................................................. 1.4243 0.9051 $21.3545 $21.8724 $22.7606 $21.9873

180009 ............................................................................. 1.6411 0.9473 $22.4450 $24.0971 $25.3837 $24.0052
180010 ............................................................................. 1.9593 0.9051 $22.6846 $26.4116 $24.7256 $24.5688
180011 ............................................................................. 1.3606 0.8732 $18.8056 $22.3183 $22.7364 $21.2726
180012 ............................................................................. 1.5066 0.9254 $20.2758 $22.9096 $24.6642 $22.6125
180013 ............................................................................. 1.4556 0.9450 $21.0512 $21.4728 $22.9512 $21.8902
180016 ............................................................................. 1.3161 0.9254 $20.5203 $22.2148 $23.1832 $22.0005
180017 ............................................................................. 1.2474 0.8278 $18.0329 $19.0694 $20.8630 $19.3296
180018 ............................................................................. 1.3343 0.8732 $17.5670 $18.3314 $19.0992 $18.3166
180019 ............................................................................. 1.1920 0.9595 $20.8416 $22.0379 $24.1342 $22.3292
180020 ............................................................................. 1.0412 0.7780 $20.9964 $22.3477 $21.9494 $21.7537
180021 ............................................................................. 1.0484 0.7780 $17.6331 $17.9346 $18.5966 $18.0522
180024 ............................................................................. 1.1385 0.9254 $22.3922 $23.6826 $32.1824 $25.9352
180025 ............................................................................. 1.0658 0.9254 $18.3306 $17.4781 $19.1543 $18.3232
180026 ............................................................................. 1.1076 0.7780 $15.5354 $15.8431 $18.2120 $16.5328
180027 ............................................................................. 1.2142 0.8084 $20.5017 $22.1072 $23.8763 $22.1722
180028 ............................................................................. 0.9014 0.9110 $20.6324 $21.4766 $24.7968 $22.1418
180029 ............................................................................. 1.2921 0.8087 $20.4262 $21.2110 $23.0536 $21.5776
180035 ............................................................................. 1.5475 0.9595 $24.3874 $26.7702 $29.8438 $27.1206
180036 ............................................................................. 1.1732 0.9473 $22.2389 $23.1636 $25.1154 $23.5250
180037 ............................................................................. 1.2870 0.9254 $22.7893 $24.4451 $25.7361 $24.4985
180038 ............................................................................. 1.3647 0.8797 $20.6888 $22.2750 $24.6348 $22.4970
180040 ............................................................................. 2.1017 0.9254 $23.2341 $24.5590 $26.2125 $24.7248
180041 ............................................................................. 1.0818 * $19.1325 $18.5483 * $18.8494
180043 ............................................................................. 1.2068 0.7780 $20.6498 $18.8436 $19.0617 $19.4791
180044 ............................................................................. 1.5212 0.9110 $21.8163 $21.6837 $23.0971 $22.1791
180045 ............................................................................. 1.3293 0.9595 $22.1027 $24.5856 $25.8349 $24.1325
180046 ............................................................................. 1.0574 0.9051 $23.1139 $24.7562 $27.2244 $25.0514
180047 ............................................................................. 0.8551 0.7780 $17.8574 $20.4768 $21.8037 $20.0588
180048 ............................................................................. 1.2811 0.9254 $20.0114 $22.3601 $21.6571 $21.3621
180049 h ........................................................................... 1.3932 0.9051 $18.5188 $19.4488 $23.3407 $20.4067
180050 ............................................................................. 1.1398 0.7780 $19.9082 $21.7150 $22.6473 $21.3727
180051 ............................................................................. 1.4278 0.8264 $18.8186 $19.2100 $21.3312 $19.7863
180053 ............................................................................. 1.0413 0.7780 $17.6239 $18.6610 $19.1578 $18.5083
180054 ............................................................................. 0.9767 * $19.1340 $19.0657 * $19.0979
180055 h ........................................................................... 1.1334 0.9051 $17.8704 $21.1989 $20.7237 $19.9661
180056 ............................................................................. 1.0730 0.8727 $19.4072 $21.4695 $22.8910 $21.2490
180063 ............................................................................. 1.1816 0.7780 $15.5078 $15.9185 $17.9741 $16.5674
180064 ............................................................................. 1.2331 0.7780 $21.1067 $15.3819 $16.2638 $17.3349
180066 ............................................................................. 1.0540 0.9450 $21.1884 $24.6359 $24.9543 $23.6588
180067 ............................................................................. 1.9820 0.9051 $22.0056 $24.0551 $25.4080 $23.7960
180069 ............................................................................. 1.0535 0.9110 $20.3982 $20.8797 $22.3674 $21.2166
180070 ............................................................................. 1.1278 0.7780 $16.9892 $17.4266 $20.1308 $18.1917
180072 ............................................................................. *** * $17.5411 * * $17.5411
180078 ............................................................................. 1.0926 0.9110 $23.4616 $25.4196 $26.2636 $25.0479
180079 ............................................................................. 1.1273 0.7780 $18.0472 $19.5783 $19.7791 $19.1405
180080 ............................................................................. 1.3148 0.8732 $18.9582 $20.1651 $21.7380 $20.2813
180087 ............................................................................. 1.1773 0.7780 $16.4726 $17.7758 $18.4331 $17.6017
180088 ............................................................................. 1.5731 0.9254 $23.7217 $24.6053 $27.5767 $25.3642
180092 ............................................................................. 1.1351 0.9051 $19.6790 $22.4864 $22.5679 $21.6047
180093 ............................................................................. 1.4508 0.8499 $18.8469 $19.2748 $20.5422 $19.5520
180094 ............................................................................. 0.9639 * $15.7640 * * $15.7640
180095 ............................................................................. 1.0535 0.7780 $15.9881 $17.1354 $17.9677 $17.0401
180099 ............................................................................. *** * $14.0115 * * $14.0115
180101 ............................................................................. 1.1363 0.9051 $22.4094 $24.2242 $25.4796 $24.0981
180102 ............................................................................. 1.5634 0.8084 $20.1885 $19.1136 $18.4388 $19.1595
180103 ............................................................................. 2.2314 0.9051 $21.3867 $25.1577 $26.9407 $24.4722
180104 ............................................................................. 1.6311 0.8084 $21.3866 $22.8911 $24.9441 $23.1113
180105 ............................................................................. 0.8503 0.7780 $18.3521 $19.5364 $19.7615 $19.2381
180106 ............................................................................. 0.9842 0.7780 $15.4937 $15.7851 $17.8020 $16.4485
180108 ............................................................................. *** * $16.7327 * * $16.7327
180115 ............................................................................. 0.9674 0.7780 $19.2396 $19.9316 $20.9831 $20.0578
180116 ............................................................................. 1.2126 0.8279 $20.5453 $21.8698 $22.7353 $21.7465
180117 ............................................................................. 0.9872 0.7780 $17.7885 $20.5952 $21.1854 $19.7909
180120 ............................................................................. 0.7900 * $20.4507 * * $20.4507
180121 ............................................................................. 0.9689 * $16.9881 * * $16.9881
180124 ............................................................................. 1.3234 0.9450 $20.5369 $21.4270 $23.1917 $21.6877

Case-mix FY 2006
180126 ............................................................................. 1.0467 * $14.5644 $15.1776 * $14.8844

180127 ............................................................................. 1.2802 0.9254 $20.0059 $21.4633 $23.4765 $21.6735
180128 ............................................................................. 0.9517 0.8062 $19.8502 $20.5575 $20.8406 $20.4307
180129 ............................................................................. *** * $14.1861 * * $14.1861
180130 ............................................................................. 1.6476 0.9254 $23.4982 $24.8441 $26.0278 $24.8066
180132 ............................................................................. 1.3469 0.8732 $19.9358 $22.2101 $23.7652 $21.9796
180134 ............................................................................. 1.0734 0.7780 * $17.3449 $18.6779 $18.0324
180138 ............................................................................. 1.2131 0.9254 $23.0996 $25.1789 $27.3400 $25.1767
180139 ............................................................................. 1.0857 0.8732 $20.6287 $21.3797 $23.5363 $21.8425
180141 ............................................................................. 1.7853 0.9254 $22.6722 $24.3140 $25.3042 $24.1450
180143 ............................................................................. 1.5170 0.9051 $20.1309 $23.9125 $25.1613 $23.2370
180146 ............................................................................. 1.9117 0.9595 * * * *
180147 ............................................................................. 1.3564 0.8214 * * * *
180148 ............................................................................. 1.6098 0.7780 * * * *
190001 ............................................................................. 1.0919 0.8993 $20.4946 $19.5680 $19.7516 $19.8963
190002 ............................................................................. 1.7582 0.8420 $20.7172 $21.7000 $22.0056 $21.4744
190003 ............................................................................. 1.4846 0.8420 $20.7505 $21.8156 $23.4977 $22.0368
190004 ............................................................................. 1.3144 0.7895 $20.5272 $22.1835 $23.3290 $21.9727
190005 ............................................................................. 1.4478 0.8993 $20.0551 $20.7987 $22.3208 $21.0635
190006 ............................................................................. 1.2800 0.8420 $18.8115 $19.4573 $22.2467 $20.1618
190007 ............................................................................. 1.1307 0.7438 $17.9392 $18.7854 $19.7528 $18.8587
190008 ............................................................................. 1.6652 0.7895 $20.3278 $21.4137 $24.0111 $21.9572
190009 ............................................................................. 1.2108 0.8040 $17.5144 $18.8295 $19.8404 $18.6932
190010 ............................................................................. 1.1459 0.7839 $18.1797 $19.9788 $21.6889 $19.9508
190011 ............................................................................. 1.0389 0.8036 $15.4699 $18.1525 $19.7319 $17.7235
190013 ............................................................................. 1.3473 0.7839 $18.7538 $19.6346 $20.8626 $19.7509
190014 ............................................................................. 1.1833 0.7438 $17.0630 $17.4740 $22.4596 $18.7727
190015 ............................................................................. 1.3085 0.8993 $20.6167 $22.1046 $22.8875 $21.9289
190017 h ........................................................................... 1.3500 0.8655 $18.3528 $18.6962 $21.5033 $19.4006
190018 ............................................................................. *** * $19.2055 * * $19.2055
190019 ............................................................................. 1.7107 0.8040 $20.8193 $23.0704 $23.7168 $22.5353
190020 ............................................................................. 1.1470 0.8596 $18.5659 $19.8505 $21.6136 $19.9828
190025 ............................................................................. 1.2413 0.7438 $19.9969 $20.4651 $20.8950 $20.4776
190026 ............................................................................. 1.5333 0.8040 $19.9229 $21.3386 $22.5087 $21.3125
190027 ............................................................................. 1.6874 0.7839 $19.4057 $21.2449 $21.2526 $20.6470
190034 ............................................................................. 1.1882 0.7438 $16.8439 $17.5002 $19.6943 $18.0127
190036 ............................................................................. 1.6697 0.8993 $23.3903 $23.7356 $24.8152 $23.9954
190037 ............................................................................. 0.9569 0.7839 $15.6062 $16.7629 $18.6393 $17.0499
190039 ............................................................................. 1.4777 0.8993 $20.4900 $23.3105 $25.6665 $23.2338
190040 ............................................................................. 1.3328 0.8993 $22.9262 $23.8076 $26.7428 $24.3506
190041 ............................................................................. 1.4983 0.8758 $21.9983 $23.9082 $24.6734 $23.4433
190043 ............................................................................. 1.0016 0.7438 $15.7333 $16.8944 $17.3477 $16.6784
190044 h ........................................................................... 1.2408 0.8420 $17.7460 $19.5304 $19.5567 $18.9595
190045 ............................................................................. 1.6136 0.8993 $22.8709 $24.0490 $25.3854 $24.1220
190046 ............................................................................. 1.4259 0.8993 $21.1019 $22.2884 $24.2128 $22.4847
190048 ............................................................................. 1.0721 0.7438 $18.1698 $18.6148 $19.6288 $18.7855
190049 ............................................................................. 1.0285 * $19.3768 $20.1229 * $19.7625
190050 ............................................................................. 1.0919 0.7438 $18.6663 $18.5287 $19.1076 $18.7685
190053 ............................................................................. 1.1396 0.7438 $13.8037 $15.7258 $16.4968 $15.3819
190054 ............................................................................. 1.3813 0.7545 $19.9370 $20.3525 $20.1108 $20.1339
190059 ............................................................................. 0.8461 * $18.3334 $19.2396 * $18.7888
190060 ............................................................................. 1.5045 0.7839 $20.2207 $22.2517 $23.6278 $22.0195
190064 ............................................................................. 1.5825 0.8596 $21.1262 $21.5514 $23.3617 $22.0132
190065 ............................................................................. 1.5073 0.8596 $20.3583 $23.0523 $23.7450 $22.3992
190077 ............................................................................. 0.8561 0.8036 $17.0480 $18.4043 $18.8409 $18.0986
190078 h ........................................................................... 1.0179 0.8655 $19.8607 $21.5782 $21.3786 $20.9721
190079 ............................................................................. 1.2698 0.8993 $20.5000 $21.8158 $21.2546 $21.1972
190081 ............................................................................. 0.8933 0.7438 $11.4756 $14.9141 $15.6146 $13.9838
190083 ............................................................................. 0.8765 * $18.4954 $19.2683 * $18.9013
190086 ............................................................................. 1.2554 0.8758 $18.2005 $18.8306 $19.8823 $18.9783
190088 h ........................................................................... 1.0856 0.9463 $18.6738 $22.5045 $22.3480 $20.9939
190089 ............................................................................. 0.9661 * $15.5151 $16.2961 * $15.9103
190090 ............................................................................. 1.0976 0.7438 $19.0519 $20.0745 $20.2045 $19.8076
190095 ............................................................................. *** * $16.9519 $8.7302 $18.0174 $17.8930
190098 ............................................................................. 1.6297 0.8758 $20.7537 $23.0802 $24.6353 $22.7792
190099 ............................................................................. 1.0348 0.8461 $23.1606 $21.1657 $20.4597 $21.4552
190102 ............................................................................. 1.6431 0.8420 $22.0190 $23.4618 $25.2267 $23.6255

Case-mix FY 2006
190106 ............................................................................. 1.2127 0.8040 $20.3114 $21.5643 $21.7228 $21.2163

190109 ............................................................................. 1.1477 0.7895 $16.6515 $17.4842 $18.6524 $17.5941
190110 ............................................................................. 0.8711 * $16.5007 $19.0611 * $17.8105
190111 ............................................................................. 1.5859 0.8758 $24.4380 $25.2370 $24.4998 $24.7275
190114 ............................................................................. 1.0549 0.7438 $13.6101 $14.6258 $15.8031 $14.6821
190115 ............................................................................. 1.2024 0.8758 $25.4984 $26.0272 $26.6295 $26.0395
190116 ............................................................................. 1.2579 0.7438 $17.8297 $18.6074 $20.3844 $18.9443
190118 ............................................................................. 0.9498 0.8758 $17.5060 $19.0200 $19.7025 $18.7558
190122 ............................................................................. 1.1979 0.8596 $17.7811 $19.3131 $23.7082 $20.0706
190124 ............................................................................. 1.5411 0.8993 $23.3859 $23.4862 $24.6675 $23.8477
190125 ............................................................................. 1.6662 0.8036 $21.5692 $22.3976 $23.9649 $22.6514
190128 ............................................................................. 1.0876 0.8596 $23.8786 $24.7842 $27.9136 $25.5637
190130 ............................................................................. 0.9548 * $15.2678 $16.6910 * $15.9880
190131 ............................................................................. 1.2145 0.8993 $21.3154 $22.5032 $25.1917 $22.9740
190133 ............................................................................. 0.8962 0.7676 $13.4062 $14.3089 $13.6266 $13.7628
190135 ............................................................................. 1.4655 0.8993 $24.4908 $26.9920 $26.8238 $26.1247
190140 ............................................................................. 0.9978 0.7438 $15.4030 $17.0371 $17.6936 $16.7104
190144 h ........................................................................... 1.1534 0.9463 $21.3838 $21.1658 $21.7547 $21.4426
190145 ............................................................................. 0.9515 0.7438 $17.4407 $17.3361 $18.9678 $17.9319
190146 ............................................................................. 1.5597 0.8993 $22.1502 $23.7721 $26.1792 $24.0255
190147 ............................................................................. *** * $16.3596 * * $16.3596
190148 ............................................................................. 1.0428 * $19.3245 $20.8321 * $20.0526
190149 ............................................................................. 0.9282 0.7438 $18.4197 $17.1671 $18.8819 $18.1219
190151 ............................................................................. 1.0245 0.7438 $17.3402 $17.8741 $18.6293 $17.9597
190152 ............................................................................. 1.3603 0.8993 $25.1136 $27.4708 $27.6099 $26.7879
190156 ............................................................................. 0.8775 * $18.0528 $18.3702 * $18.2089
190158 ............................................................................. 1.3827 0.8993 $23.2361 $26.2352 $26.3042 $25.4140
190160 ............................................................................. 1.5036 0.8036 $19.8428 $20.0025 $21.6740 $20.5204
190161 ............................................................................. 1.1051 0.7839 $16.5322 $17.8794 $19.1022 $17.8227
190162 ............................................................................. *** * $20.7350 $22.1781 $25.0328 $22.6102
190164 ............................................................................. 1.1752 0.8040 $20.2791 $21.4247 $22.8599 $21.6241
190167 ............................................................................. 1.2233 0.7438 $17.2643 $17.8604 $24.3185 $19.7786
190175 ............................................................................. 1.3694 0.8993 $22.7574 $24.6790 $27.1531 $25.0038
190176 ............................................................................. 1.7655 0.8993 $25.2536 $25.8482 $25.6997 $25.6097
190177 ............................................................................. 1.5808 0.8993 $22.3318 $25.4769 $27.4621 $25.2171
190182 ............................................................................. 0.9407 0.8993 $23.6016 $25.0837 $28.4799 $25.6314
190183 ............................................................................. 1.1930 0.7895 $17.1805 $18.3151 $19.8084 $18.4205
190184 ............................................................................. 1.0092 0.7599 $20.6096 $21.3191 $23.9609 $21.8425
190185 ............................................................................. 1.3487 0.8993 $29.7870 $24.4176 $24.7912 $25.8807
190190 ............................................................................. 0.8782 0.7599 $16.2819 $14.0052 $16.1195 $15.4593
190191 h ........................................................................... 1.3706 0.8461 $21.9141 $22.3755 $23.5734 $22.6642
190196 ............................................................................. 0.8702 0.8420 $20.7601 $21.9355 $24.7135 $22.5497
190197 ............................................................................. 1.3549 0.8036 $21.6908 $22.9631 $24.3735 $23.0241
190199 ............................................................................. 1.1734 0.8596 $19.7776 $18.5317 $14.1410 $17.3575
190200 ............................................................................. 1.5774 0.8993 $24.1667 $26.4258 $27.5681 $25.9873
190201 ............................................................................. 1.2956 0.7839 $21.4335 $22.5588 $24.5877 $22.9165
190202 ............................................................................. 1.2769 0.8596 $22.4062 $21.8900 $24.7944 $23.0825
190203 ............................................................................. 1.5054 0.8993 $24.9518 $26.9099 $26.8795 $26.2979
190204 ............................................................................. 1.5090 0.8993 $26.1231 $28.8777 $28.3684 $27.8932
190205 ............................................................................. 1.7338 0.8420 $20.2374 $21.7696 $24.4540 $22.1979
190206 ............................................................................. 1.7022 0.8993 $24.2892 $26.9117 $26.0139 $25.7960
190207 ............................................................................. *** * $21.5325 * * $21.5325
190208 ............................................................................. 0.8593 0.7438 $23.0838 $24.8409 $24.2586 $24.0684
190218 ............................................................................. 1.1871 0.8758 $21.6206 $23.9182 $25.0356 $23.6192
190236 ............................................................................. 1.4525 0.8758 $24.4661 $23.8233 $23.6824 $23.9582
190240 ............................................................................. 0.9826 * $15.4026 $13.9888 * $14.7116
190241 ............................................................................. 1.2669 0.7895 $24.2462 $28.9620 $23.9700 $25.7012
190242 ............................................................................. 1.1361 0.8596 $18.6672 $20.5937 $23.0072 $20.7608
190243 ............................................................................. *** * * $30.6060 * $30.6060
190245 ............................................................................. 2.2150 0.8036 * * $27.1786 $27.1786
190246 ............................................................................. 1.5661 0.7599 * * * *
190249 ............................................................................. 1.5255 0.8596 * * * *
190250 ............................................................................. 2.4714 0.8993 * * * *
190251 ............................................................................. 1.6216 0.8596 * * * *
190252 ............................................................................. 0.9901 0.8596 * * * *
190253 ............................................................................. 1.0434 0.8993 * * * *
190254 ............................................................................. 1.4466 0.8596 * * * *

Case-mix FY 2006
190255 ............................................................................. 0.7772 0.8420 * * * *

190256 ............................................................................. 1.0194 0.8993 * * * *
190257 ............................................................................. 1.7195 0.7438 * * * *
190258 ............................................................................. 1.5399 0.8758 * * * *
190259 ............................................................................. 1.9052 0.8420 * * * *
190260 ............................................................................. 1.5277 0.8993 * * * *
190261 ............................................................................. 0.7151 0.8036 * * * *
190262 ............................................................................. 1.2664 0.8993 * * * *
190263 ............................................................................. 2.4990 0.8420 * * * *
200001 ............................................................................. 1.2994 0.9975 $21.6050 $23.2210 $25.1145 $23.3710
200002 ............................................................................. 1.1686 0.9874 $22.0700 $24.1446 $25.7478 $23.9468
200007 ............................................................................. 1.0815 * $21.0603 $22.3920 * $21.7470
200008 ............................................................................. 1.2589 1.0371 $25.1115 $25.1741 $27.4412 $25.9041
200009 ............................................................................. 1.9763 1.0371 $24.9041 $28.1409 $31.1056 $28.0391
200012 ............................................................................. 1.1397 0.8831 $21.8529 $24.1243 $25.7623 $23.9787
200013 ............................................................................. 1.1054 0.9017 $22.8909 $23.9048 $24.4131 $23.7685
200018 ............................................................................. 1.1830 0.8831 $21.1330 $24.3294 $23.6337 $23.0851
200019 ............................................................................. 1.2935 1.0371 $23.1114 $24.0926 $25.1367 $24.1296
200020 ............................................................................. 1.2570 1.0492 $27.0798 $28.7351 $31.7083 $29.2990
200021 ............................................................................. 1.1914 1.0371 $24.9925 $25.1027 $24.5519 $24.8792
200024 ............................................................................. 1.5273 0.9874 $22.9698 $24.6484 $26.0080 $24.6372
200025 ............................................................................. 1.0698 1.0371 $22.9023 $24.3646 $26.0573 $24.4151
200026 ............................................................................. 1.0477 * $19.7172 $21.9997 * $20.8927
200027 ............................................................................. 1.2293 0.8831 $21.0156 $23.2912 $26.3118 $23.4478
200028 ............................................................................. 1.0453 0.8831 $21.2180 $24.3061 $24.3271 $23.3297
200031 ............................................................................. 1.3580 0.8831 $18.8262 $20.6202 $21.9489 $20.4626
200032 ............................................................................. 1.2196 0.9297 $23.0487 $24.2221 $25.5227 $24.3050
200033 ............................................................................. 1.8626 0.9975 $25.1723 $26.8727 $28.6479 $26.9328
200034 ............................................................................. 1.3926 0.9874 $23.5415 $26.1150 $26.2926 $25.3574
200037 ............................................................................. 1.1984 0.8831 $22.6534 $23.3490 $23.2333 $23.0870
200039 ............................................................................. 1.2758 0.9874 $22.1333 $24.0474 $25.1196 $23.8217
200040 ............................................................................. 1.2300 1.0371 $21.8528 $23.6791 $25.5405 $23.6763
200041 ............................................................................. 1.1436 0.8831 $21.3816 $23.6797 $24.5532 $23.3316
200050 ............................................................................. 1.2576 0.9975 $23.4391 $25.5233 $26.4992 $25.2144
200052 ............................................................................. 1.0569 0.8831 $19.0535 $22.7763 $21.8726 $21.2769
200063 ............................................................................. 1.1958 0.9874 $23.0135 $24.7235 $25.0167 $24.2686
200066 ............................................................................. 1.2469 * $19.5890 $21.6354 * $20.6005
210001 ............................................................................. 1.4251 0.9647 $22.6614 $26.3144 $27.7561 $25.5750
210002 ............................................................................. 2.0200 0.9882 $25.6975 $25.2859 $26.4992 $25.8584
210003 ............................................................................. 1.6590 1.0928 $23.0790 $32.3042 $29.8684 $28.0698
210004 ............................................................................. 1.4471 1.1499 $29.4841 $29.4300 $34.2392 $31.0347
210005 ............................................................................. 1.2974 1.1459 $24.7185 $27.1276 $28.7557 $26.8963
210006 ............................................................................. 1.1056 0.9882 $24.7327 $25.6396 $25.4081 $25.2468
210007 ............................................................................. 1.9113 0.9882 $27.5104 $28.4496 $30.2548 $28.7829
210008 ............................................................................. 1.3194 0.9882 $24.6569 $26.3008 $25.2833 $25.4086
210009 ............................................................................. 1.7719 0.9882 $23.4889 $24.6332 $26.2360 $24.8136
210010 ............................................................................. *** * $23.7761 $24.5071 $25.7775 $24.7218
210011 ............................................................................. 1.4035 0.9882 $22.3262 $24.8373 $27.5031 $24.9589
210012 ............................................................................. 1.6057 0.9882 $25.2892 $25.7934 $27.4103 $26.2116
210013 ............................................................................. 1.2739 0.9882 $23.0151 $23.9875 $25.1348 $24.0450
210015 ............................................................................. 1.3351 0.9882 $23.8419 $25.8532 $28.2029 $25.9683
210016 ............................................................................. 1.7872 1.1499 $27.2632 $28.6992 $32.2081 $29.4293
210017 ............................................................................. 1.1676 0.9357 $19.0248 $21.3983 $23.2168 $21.2523
210018 ............................................................................. 1.2269 1.1499 $25.3112 $27.5431 $29.1870 $27.3837
210019 ............................................................................. 1.7512 0.9357 $23.5259 $24.9252 $26.1824 $24.9054
210022 ............................................................................. 1.4046 1.1499 $27.6680 $30.1470 $33.8015 $30.5481
210023 ............................................................................. 1.4601 1.0091 $26.7837 $29.0844 $30.4656 $28.8005
210024 ............................................................................. 1.6921 0.9882 $24.8939 $27.1756 $29.5579 $27.2560
210025 ............................................................................. 1.2415 0.9357 $22.8882 $23.8943 $26.0771 $24.3114
210027 ............................................................................. 1.4867 0.9357 $19.3517 $23.9255 $26.0111 $22.9283
210028 ............................................................................. 1.0874 0.9357 $22.4054 $24.1265 $25.9221 $24.1901
210029 ............................................................................. 1.2477 0.9882 $26.2082 $31.2888 $27.9741 $28.3176
210030 ............................................................................. 1.2689 0.9357 $20.7802 $27.5507 $29.5635 $25.7209
210032 ............................................................................. 1.1442 1.0516 $20.3407 $25.7138 $26.1829 $23.9925
210033 ............................................................................. 1.1745 0.9882 $25.0301 $26.6113 $29.0420 $26.9838
210034 ............................................................................. 1.2975 0.9882 $22.8827 $26.3896 $28.4308 $25.7800
210035 ............................................................................. 1.3293 1.0928 $21.6973 $24.5198 $26.1082 $24.1712

Case-mix FY 2006
210037 ............................................................................. 1.1871 0.9357 $23.5536 $24.1913 $27.0973 $24.9552

210038 ............................................................................. 1.2500 0.9882 $26.5696 $28.3414 $29.5980 $28.1851
210039 ............................................................................. 1.1125 1.0928 $24.0987 $25.8415 $27.6940 $25.8514
210040 ............................................................................. 1.2688 0.9882 $25.4729 $28.3723 $29.3514 $27.8674
210043 ............................................................................. 1.3169 1.0091 $22.2177 $24.3070 $27.5657 $24.7038
210044 ............................................................................. 1.3613 0.9882 $23.8101 $24.8083 $28.8700 $25.7966
210045 ............................................................................. 1.0532 0.9357 $11.8350 $15.0867 $15.6380 $14.3653
210048 ............................................................................. 1.3276 1.0169 $24.4328 $25.0617 $28.4638 $26.0370
210049 ............................................................................. 1.2425 0.9882 $24.7148 $25.9342 $26.9656 $25.9278
210051 ............................................................................. 1.3323 1.0928 $25.7103 $27.3692 $29.2998 $27.5052
210054 ............................................................................. 1.3523 1.0928 $27.3551 $24.6658 $26.2295 $26.0806
210055 ............................................................................. 1.2162 1.0928 $27.4218 $28.0014 $29.9708 $28.5097
210056 ............................................................................. 1.3306 0.9882 $23.5881 $26.6884 $28.6091 $26.3638
210057 ............................................................................. 1.4047 1.1499 $27.3520 $29.2233 $32.2883 $29.7939
210058 ............................................................................. 1.1672 0.9882 $22.0351 $24.8576 $29.7841 $25.5191
210060 ............................................................................. 1.1733 1.0928 $25.8377 $28.7531 $28.5087 $27.8143
210061 ............................................................................. 1.2516 0.9357 $22.5455 $24.1369 $23.6662 $23.5086
220001 ............................................................................. 1.2205 1.1274 $25.8030 $27.3238 $29.0014 $27.3878
220002 ............................................................................. 1.3882 1.1415 $26.3348 $28.9722 $30.3598 $28.5921
220003 ............................................................................. 1.1608 1.1274 $18.8150 $20.5790 $22.0549 $20.5049
220006 ............................................................................. 1.5147 1.1021 $27.1576 $29.5946 $30.8599 $29.3270
220008 ............................................................................. 1.2538 1.0954 $25.6647 $27.1675 $30.1043 $27.7253
220010 ............................................................................. 1.2902 1.1274 $24.5020 $27.4161 $29.7998 $27.3015
220011 ............................................................................. 1.1378 1.1415 $32.2266 $32.6624 $34.4064 $33.2336
220012 ............................................................................. 1.4927 1.2592 $32.0521 $32.9791 $35.7872 $33.6778
220015 ............................................................................. 1.1862 1.0715 $25.0272 $25.5449 $28.3397 $26.3904
220016 ............................................................................. 1.1279 1.0715 $25.7740 $26.8798 $28.0609 $26.8986
220017 ............................................................................. 1.3293 1.1551 $28.9024 $28.8264 $29.7108 $29.1461
220019 ............................................................................. 1.2167 1.1274 $21.6620 $22.2294 $23.2544 $22.3943
220020 ............................................................................. 1.2576 1.0954 $23.5737 $24.2279 $26.5305 $24.8270
220024 ............................................................................. 1.2616 1.0715 $24.1071 $25.5837 $27.3488 $25.6784
220025 ............................................................................. 1.1054 1.1274 $23.2374 $24.5186 $23.0637 $23.5753
220028 ............................................................................. 1.4583 1.1274 $31.4858 $31.3592 $32.0980 $31.6438
220029 ............................................................................. 1.1257 1.1274 $27.4792 $28.1432 $28.6970 $28.1288
220030 ............................................................................. 1.1225 1.0715 $20.0816 $23.6257 $24.4289 $22.7602
220031 ............................................................................. 1.5516 1.1551 $30.8324 $32.2660 $34.8183 $32.6251
220033 ............................................................................. 1.1970 1.1274 $25.4500 $26.8049 $28.2539 $26.9214
220035 ............................................................................. 1.3982 1.1274 $26.8486 $27.5533 $28.6238 $27.6997
220036 ............................................................................. 1.5239 1.1551 $28.2182 $29.6296 $31.5184 $29.8330
220041 ............................................................................. *** * $28.8184 $29.7464 * $29.2230
220046 ............................................................................. 1.3664 1.1274 $26.1955 $27.7726 $28.1396 $27.3951
220049 ............................................................................. 1.1613 1.1415 $26.7688 $27.0464 $27.7517 $27.2011
220050 ............................................................................. 1.1404 1.0715 $23.7326 $24.9945 $26.3768 $25.0718
220051 ............................................................................. 1.2220 1.0715 $22.2965 $26.5575 $29.8380 $26.3369
220052 ............................................................................. 1.1719 1.1551 $26.3043 $28.0925 $29.8577 $28.1429
220058 ............................................................................. 1.0134 1.1274 $22.4885 $25.0598 $24.9642 $24.1665
220060 ............................................................................. 1.1946 1.2303 $29.6960 $30.8242 $32.3362 $31.0565
220062 ............................................................................. 0.5902 1.1274 $22.6598 $21.9489 $24.2779 $22.9699
220063 ............................................................................. 1.2060 1.1415 $23.3704 $25.5840 $27.3967 $25.3936
220065 ............................................................................. 1.2350 1.0715 $22.4143 $24.8737 $26.5513 $24.6535
220066 ............................................................................. 1.3008 1.0715 $27.5575 $26.2561 $27.1317 $26.9786
220067 ............................................................................. 1.1875 1.1551 $22.4968 $28.5220 $29.8911 $26.7470
220070 ............................................................................. 1.1508 1.1415 $26.2697 $28.9100 $31.9283 $28.7436
220071 ............................................................................. 1.8769 1.1551 $27.7773 $31.8322 $32.2936 $30.6814
220073 ............................................................................. 1.2301 1.0954 $27.9309 $29.2399 $31.3566 $29.4912
220074 ............................................................................. 1.3075 1.1551 $25.7840 $27.5763 $28.4930 $27.3187
220075 ............................................................................. 1.4268 1.1551 $26.0527 $27.9503 $29.1588 $27.7387
220076 ............................................................................. *** * $24.8040 $27.2534 $29.7507 $27.1315
220077 ............................................................................. 1.7218 1.1075 $27.0946 $28.0935 $30.2684 $28.5352
220080 ............................................................................. 1.2205 1.1274 $24.7399 $27.1578 $28.9835 $27.0784
220082 ............................................................................. 1.2599 1.1415 $23.9542 $24.8060 $26.9841 $25.2609
220083 ............................................................................. 1.1206 1.1551 $28.3533 $29.9001 $32.9143 $30.3719
220084 ............................................................................. 1.2324 1.1415 $26.8596 $29.0505 $32.5711 $29.5958
220086 ............................................................................. 1.7352 1.1551 $29.4911 $31.7482 $34.3667 $31.8192
220088 ............................................................................. 1.8304 1.1551 $26.5849 $28.5711 $28.5462 $27.9606
220089 ............................................................................. 1.2531 1.1415 $28.9252 $32.4409 $31.1708 $30.8836
220090 ............................................................................. 1.2045 1.1274 $26.5552 $29.7945 $30.8685 $29.1558

Case-mix FY 2006
220095 ............................................................................. 1.1124 1.1274 $23.7629 $24.9871 $27.4273 $25.3894

220098 ............................................................................. 1.1795 1.1415 $26.2287 $26.8538 $28.8314 $27.2888
220100 ............................................................................. 1.2965 1.1551 $27.0265 $28.4848 $29.6912 $28.4369
220101 ............................................................................. 1.3346 1.1415 $26.9992 $31.0834 $33.1690 $30.4912
220105 ............................................................................. 1.2283 1.1415 $26.7570 $30.0892 $31.9421 $29.7099
220108 ............................................................................. 1.2295 1.1551 $26.0166 $29.0804 $30.6252 $28.5516
220110 ............................................................................. 2.0817 1.1551 $33.0445 $35.4242 $36.6084 $35.0926
220111 ............................................................................. 1.2101 1.1551 $27.7395 $28.9092 $31.1850 $29.2950
220116 ............................................................................. 2.0287 1.1551 $30.9871 $32.2337 $32.9988 $32.0845
220119 ............................................................................. 1.1583 1.1551 $25.9789 $27.8372 $30.1056 $28.0781
220126 ............................................................................. 1.1634 1.1551 $26.9853 $26.7660 $28.7805 $27.5408
220133 ............................................................................. *** * $33.0819 $31.2981 $33.6003 $32.6683
220135 ............................................................................. 1.3124 1.2592 $31.9159 $31.3246 $33.9866 $32.4440
220153 ............................................................................. 1.0242 1.0715 * $18.9267 * $18.9267
220154 ............................................................................. 0.9702 1.1551 $25.6069 $30.9009 $28.6462 $28.0721
220162 ............................................................................. 1.3910 * * * * *
220163 ............................................................................. 1.6274 1.1274 $29.9312 $30.5056 $33.6484 $31.2574
220171 ............................................................................. 1.7493 1.1415 $27.2647 $28.9733 $30.4036 $28.9007
220174 ............................................................................. 1.1913 1.1274 * $30.3356 $31.7572 $31.0464
230001 ............................................................................. 1.1136 * $22.0875 $24.3660 * $23.2049
230002 ............................................................................. 1.3022 1.0436 $23.7972 $27.0305 $29.1410 $26.7010
230003 ............................................................................. 1.2080 1.0393 $22.4322 $25.2596 $26.1278 $24.6604
230004 ............................................................................. 1.7070 1.0393 $23.0827 $25.5573 $26.7206 $25.1973
230005 h ........................................................................... 1.2383 1.0874 $20.3750 $22.1018 $24.1902 $22.4061
230006 ............................................................................. 1.1371 0.9788 $22.0733 $22.7656 $23.8835 $22.9495
230013 ............................................................................. 1.3752 1.0461 $20.4633 $22.7014 $23.7822 $22.3686
230015 ............................................................................. 1.0463 0.9325 $21.7640 $23.4512 $24.6570 $23.3267
230017 ............................................................................. 1.6296 1.0393 $26.1609 $27.3259 $29.5178 $27.7392
230019 ............................................................................. 1.5743 1.0461 $24.7472 $27.6563 $28.4575 $26.9496
230020 ............................................................................. 1.6919 1.0570 $25.8267 $26.8516 $29.2869 $27.3788
230021 ............................................................................. 1.5257 0.9102 $22.0757 $23.4663 $24.9551 $23.5352
230022 ............................................................................. 1.2333 1.0570 $22.2179 $22.2528 $23.3000 $22.6032
230024 ............................................................................. 1.5606 1.0570 $24.7364 $27.6555 $30.0813 $27.3385
230027 ............................................................................. 1.0877 0.9389 $21.2223 $22.5736 $23.5511 $22.4431
230029 ............................................................................. 1.6623 1.0461 $26.7646 $27.9012 $29.0935 $27.9121
230030 ............................................................................. 1.2630 0.8966 $19.9853 $20.9867 $22.3174 $21.1301
230031 ............................................................................. 1.3895 0.9868 $22.1874 $23.2910 $25.4678 $23.7275
230032 ............................................................................. *** * $23.8366 * * $23.8366
230034 ............................................................................. 1.2255 0.8966 $18.5768 $20.9195 $26.7967 $22.0680
230035 ............................................................................. 1.3094 0.9389 $18.0735 $20.9197 $21.2317 $19.9973
230036 ............................................................................. 1.3643 1.0461 $25.9801 $26.5854 $28.3622 $26.9984
230037 ............................................................................. 1.2368 1.0570 $24.4115 $24.7875 $26.2000 $25.1648
230038 ............................................................................. 1.6919 1.0393 $23.4685 $25.2499 $26.3480 $25.2371
230040 ............................................................................. 1.2081 0.9389 $21.8062 $21.9813 $24.2349 $22.7262
230041 ............................................................................. 1.4920 0.9624 $24.2297 $25.2518 $26.1760 $25.1852
230042 ............................................................................. 1.1974 0.8966 $21.8241 $24.3640 $26.2037 $24.1687
230046 ............................................................................. 1.8655 1.0874 $28.2320 $29.2683 $30.3591 $29.3515
230047 ............................................................................. 1.4049 1.0436 $24.3622 $26.2447 $28.1351 $26.3210
230053 ............................................................................. 1.6133 1.0570 $26.1415 $28.3030 $29.8703 $28.0492
230054 ............................................................................. 2.0488 0.9470 $23.0818 $24.0137 $24.9905 $24.0601
230055 ............................................................................. 1.2763 0.8966 $20.9350 $23.7671 $25.4143 $23.4450
230058 ............................................................................. 1.1537 0.8966 $22.4516 $21.9308 $24.0657 $22.7966
230059 ............................................................................. 1.4459 1.0393 $21.2743 $23.1451 $25.5350 $23.3695
230060 ............................................................................. 1.2928 0.8966 $22.3512 $24.5073 $25.5015 $24.1280
230065 ............................................................................. *** * $26.3217 $27.9179 $28.4631 $27.5421
230066 ............................................................................. 1.3207 1.0393 $23.9696 $25.8517 $27.4928 $25.8295
230069 ............................................................................. 1.1955 1.0461 $26.0438 $27.6815 $29.5556 $27.8051
230070 ............................................................................. 1.6029 0.9140 $22.8588 $25.1587 $24.2342 $24.0769
230071 ............................................................................. 0.9724 1.0461 $23.6674 $24.7707 $26.3907 $24.9681
230072 ............................................................................. 1.3973 1.0393 $22.9626 $24.1560 $24.4933 $23.9114
230075 ............................................................................. 1.3516 0.9635 $22.6799 $24.1482 $27.6193 $24.8869
230077 ............................................................................. 1.9571 1.0461 $29.2041 $27.3117 $27.6157 $27.9729
230078 ............................................................................. 1.0412 0.8966 $20.5427 $21.9200 $23.9901 $22.2077
230080 ............................................................................. 1.2788 0.8966 $20.2405 $21.2840 $21.2314 $20.9185
230081 ............................................................................. 1.2023 0.8966 $20.4289 $20.6777 $23.0788 $21.3975
230082 ............................................................................. 1.0277 0.8966 $21.3100 $23.1240 $22.2165 $22.1964
230085 ............................................................................. 1.2412 1.0393 $24.2802 $22.2569 $22.7314 $23.1872

Case-mix FY 2006
230086 ............................................................................. 1.1486 * $27.8923 $20.8759 * $24.2011

230087 ............................................................................. *** * $22.2688 * $16.9168 $19.0752
230089 ............................................................................. 1.3664 1.0570 $23.3847 $23.9486 $28.7015 $25.3973
230092 ............................................................................. 1.2812 0.9680 $22.3122 $24.3768 $26.3584 $24.3257
230093 ............................................................................. 1.1695 0.9389 $25.1213 $24.5055 $26.4967 $25.3702
230095 ............................................................................. 1.2598 0.8966 $19.1810 $19.2244 $21.3915 $19.9401
230096 ............................................................................. 1.1759 1.0393 $26.7156 $26.7578 $28.7681 $27.4077
230097 ............................................................................. 1.8168 1.0393 $22.9902 $25.2104 $26.5773 $24.9608
230099 ............................................................................. 1.2146 1.0570 $23.5490 $25.0390 $26.4882 $25.0486
230100 ............................................................................. 1.1053 0.8966 $19.8016 $20.4565 $21.8895 $20.6965
230101 ............................................................................. 1.0939 0.8966 $22.3310 $23.1349 $24.3772 $23.3147
230103 ............................................................................. 1.0133 0.9788 $19.4434 $18.4304 $21.6609 $19.7646
230104 ............................................................................. 1.5419 1.0570 $27.4119 $27.8864 $30.5570 $28.5801
230105 ............................................................................. 1.9466 0.9525 $23.9851 $24.6853 $27.2705 $25.3146
230106 ............................................................................. 1.1233 1.0393 $23.1962 $24.1128 $24.3980 $23.9236
230108 ............................................................................. 1.1591 0.8966 $19.9842 $22.4966 $18.4063 $20.1757
230110 ............................................................................. 1.2615 0.8966 $21.5523 $22.7621 $28.7704 $24.4693
230117 ............................................................................. 1.8928 1.0393 $28.1220 $29.6361 $29.4775 $29.0873
230118 ............................................................................. 1.0682 0.8966 $22.2208 $21.4886 $22.3636 $22.0278
230119 ............................................................................. 1.3259 1.0570 $25.3562 $29.2509 $30.2441 $27.9914
230120 h ........................................................................... 1.1166 1.0874 $22.7243 $21.7894 $24.1485 $22.9095
230121 ............................................................................. 1.2558 0.9788 $22.3708 $23.4394 $24.5220 $23.4095
230124 ............................................................................. 1.3249 * $22.0097 $23.0508 * $22.5308
230130 ............................................................................. 1.7417 1.0461 $23.7854 $26.9907 $26.6076 $25.8001
230132 ............................................................................. 1.4061 1.0644 $29.0292 $29.9106 $30.5318 $29.8191
230133 ............................................................................. 1.4148 0.8966 $20.4801 $21.2273 $24.3175 $22.0722
230135 ............................................................................. 1.1266 1.0570 $19.8290 $23.9000 $25.8406 $23.1673
230141 ............................................................................. 1.6549 1.0644 $23.9885 $30.4643 $28.6326 $27.6090
230142 ............................................................................. 1.2687 1.0436 $22.9036 $25.6044 $26.9433 $25.2019
230143 ............................................................................. 1.2616 0.8966 $19.5446 $19.5387 $21.4083 $20.1494
230144 ............................................................................. 2.1498 * $23.6959 * * $23.6959
230145 ............................................................................. 1.1530 * $15.8192 $17.2181 * $16.5158
230146 ............................................................................. 1.2683 1.0570 $21.3539 $24.3891 $26.3432 $24.1395
230149 ............................................................................. 0.9481 * $20.8933 $21.4753 * $21.1778
230151 ............................................................................. 1.3327 1.0461 $23.8527 $26.4669 $28.2243 $26.2186
230153 ............................................................................. 1.1020 0.9788 $22.8584 $22.3404 $22.8644 $22.6896
230155 ............................................................................. 1.0473 * $18.0743 $24.0404 * $20.6336
230156 ............................................................................. 1.5973 1.0874 $27.7164 $29.4855 $31.1909 $29.5181
230165 ............................................................................. 1.7254 1.0570 $25.9534 $27.3164 $28.9636 $27.4184
230167 ............................................................................. 1.6214 0.9788 $24.7935 $26.6828 $27.4562 $26.3153
230169 ............................................................................. *** * $24.9265 $27.1172 $31.8442 $27.6798
230171 ............................................................................. 1.0689 * $19.9097 $22.0635 * $20.9931
230172 ............................................................................. 1.2378 1.0393 $23.0023 $24.0236 $25.7402 $24.2756
230174 ............................................................................. 1.3643 1.0393 $24.4671 $26.2770 $27.6920 $26.1839
230175 ............................................................................. *** * $22.5964 * * $22.5964
230176 ............................................................................. 1.2540 1.0570 $24.6675 $25.6777 $27.3605 $26.1023
230180 ............................................................................. 1.0980 0.8966 $20.9832 $22.5454 $24.7358 $22.8206
230184 ............................................................................. 1.2060 0.9680 $21.4031 $21.9346 $23.6707 $22.3438
230186 ............................................................................. *** * $21.6147 $27.1126 $26.2282 $24.5338
230188 ............................................................................. 0.9386 * $18.8076 * * $18.8076
230189 ............................................................................. 1.0084 0.8966 $22.7783 $20.8605 $23.0099 $22.2035
230190 ............................................................................. 1.0096 1.0393 $27.3430 $28.7365 $29.9604 $28.6717
230193 ............................................................................. 1.2826 0.9868 $22.8916 $24.3181 $23.3565 $23.5189
230195 ............................................................................. 1.4454 1.0436 $25.3285 $27.1266 $28.2892 $26.9865
230197 ............................................................................. 1.5759 1.0644 $26.9840 $28.3439 $30.0367 $28.4836
230204 ............................................................................. 1.3229 1.0436 $24.4095 $25.9871 $29.1466 $26.3875
230207 ............................................................................. 1.3781 1.0461 $22.2848 $22.2854 $24.5201 $23.0106
230208 ............................................................................. 1.2059 0.9389 $20.3171 $20.9420 $21.9651 $21.0908
230212 ............................................................................. 1.0320 1.0874 $26.0656 $27.3686 $29.7980 $27.6833
230216 ............................................................................. 1.5747 0.9868 $23.4262 $26.1468 $27.5230 $25.7787
230217 ............................................................................. 1.2944 0.9788 $24.3650 $26.7929 $28.6075 $26.7623
230222 h ........................................................................... 1.3316 0.9368 $24.6101 $24.8925 $26.9724 $25.4947
230223 ............................................................................. 1.2948 1.0461 $28.5549 $27.1503 $29.2853 $28.3304
230227 ............................................................................. 1.5114 1.0436 $27.7510 $28.1105 $29.5798 $28.4993
230230 ............................................................................. 1.5119 0.9788 $23.9568 $25.4471 $27.9607 $25.8281
230235 ............................................................................. 1.0369 0.8966 $19.9118 $19.6046 $21.8777 $20.4653
230236 ............................................................................. 1.4349 1.0393 $25.7463 $26.3988 $28.4754 $26.9289

Case-mix FY 2006
230239 ............................................................................. 1.2193 0.8966 $19.8370 $21.1643 $22.1040 $21.0930

230241 ............................................................................. 1.1743 0.9868 $24.2063 $25.8671 $27.4890 $25.8668
230244 ............................................................................. 1.3568 1.0436 $23.9004 $25.3817 $26.4326 $25.2154
230254 ............................................................................. 1.3507 1.0461 $24.2594 $26.4431 $28.1216 $26.2901
230257 ............................................................................. 1.0361 1.0436 $24.8069 $25.4086 $27.8197 $25.8794
230259 ............................................................................. 1.2125 1.0874 $24.8598 $24.3067 $26.8677 $25.3750
230264 ............................................................................. 2.0733 1.0436 $17.4847 $19.9992 $19.2398 $19.0176
230269 ............................................................................. 1.3677 1.0461 $25.3367 $27.4732 $28.8187 $27.2692
230270 ............................................................................. 1.2712 1.0570 $22.8842 $26.1113 $27.8488 $25.6802
230273 ............................................................................. 1.4501 1.0570 $25.8466 $30.2209 $29.9307 $28.6762
230275 ............................................................................. 0.4648 0.9140 $29.4180 $30.2244 $23.1095 $27.7059
230276 ............................................................................. *** * $23.4928 * * $23.4928
230277 ............................................................................. 1.3829 1.0461 $25.3378 $26.9231 $29.1973 $27.2248
230279 ............................................................................. 0.5490 1.0461 $21.2467 $23.1636 $24.7673 $22.9663
230283 ............................................................................. 0.8715 1.0436 $25.0038 $24.9272 $26.2622 $25.3910
230288 ............................................................................. *** * $30.3422 * * $30.3422
230289 ............................................................................. *** * * * $29.7720 $29.7720
230290 ............................................................................. *** * * $29.4792 * $29.4792
230291 ............................................................................. *** * * * $30.9655 $30.9655
230292 ............................................................................. *** * * * $31.8943 $31.8943
230296 ............................................................................. 1.9453 0.9788 * * * *
240001 ............................................................................. 1.5150 1.1052 $28.2239 $29.9123 $31.5753 $29.9731
240002 ............................................................................. 1.8323 1.0226 $24.7674 $26.9608 $28.9860 $26.9851
240004 ............................................................................. 1.5506 1.1052 $26.8197 $27.8796 $30.8072 $28.5006
240006 ............................................................................. 1.0563 1.1116 $29.5789 $30.2330 $30.1950 $30.0237
240007 ............................................................................. 1.1570 * $21.4367 $23.7588 * $22.6144
240010 ............................................................................. 2.0308 1.1116 $29.0955 $30.4139 $31.3733 $30.3196
240011 ............................................................................. 1.0533 * $24.0364 $22.9561 * $23.3835
240013 ............................................................................. 1.2714 1.0900 $27.3855 $28.7202 $28.3860 $28.1704
240014 ............................................................................. 1.0255 1.1052 $26.5144 $28.3788 $29.8623 $28.2985
240016 ............................................................................. 1.2643 0.9132 $25.2629 $24.9211 $26.7814 $25.7376
240017 ............................................................................. 1.2581 0.9132 $21.6243 $23.3314 $24.4417 $23.1535
240018 ............................................................................. 1.2280 1.0900 $27.3634 $27.9218 $25.6236 $26.6208
240019 ............................................................................. 1.1515 1.0226 $25.1331 $27.5441 $28.6723 $27.1439
240020 ............................................................................. 1.0854 1.1052 $24.7516 $28.1568 $31.2443 $28.0203
240021 ............................................................................. 0.8740 1.0052 $23.9568 $23.7096 $27.1235 $24.8433
240022 ............................................................................. 1.1089 0.9132 $23.4702 $23.7368 $25.2066 $24.1392
240025 ............................................................................. 1.0799 * $21.2597 $27.8656 * $24.3444
240027 ............................................................................. 0.9514 0.9132 $18.3340 $20.2531 $18.2481 $18.8765
240029 ............................................................................. 1.0910 0.9132 $21.2342 $24.3017 $25.3568 $23.3870
240030 ............................................................................. 1.3509 0.9775 $22.0200 $23.3753 $24.7154 $23.4178
240031 ............................................................................. 0.9576 * $23.4389 $26.7242 $26.7778 $25.6303
240036 ............................................................................. 1.6930 1.0900 $23.4857 $27.0821 $28.0812 $26.3323
240037 ............................................................................. 1.0462 * $21.8392 $24.3986 * $23.1115
240038 ............................................................................. 1.5325 1.1052 $28.9676 $29.8465 $31.0779 $30.0073
240040 ............................................................................. 1.0971 1.0226 $21.3870 $26.3177 $27.4895 $24.8843
240043 ............................................................................. 1.1474 0.9132 $19.5532 $20.7155 $21.8685 $20.7481
240044 ............................................................................. 1.1223 1.0000 $22.7482 $24.3009 $22.0973 $22.9999
240045 ............................................................................. 1.1155 * $25.9223 $26.1743 * $26.0530
240047 ............................................................................. 1.5788 1.0226 $29.6184 $29.1211 $28.8288 $29.1562
240050 ............................................................................. 1.0371 1.1052 $24.7589 $26.6687 $26.4854 $26.0710
240052 ............................................................................. 1.2117 0.9132 $23.5898 $24.9870 $26.4256 $25.0236
240053 ............................................................................. 1.4271 1.1052 $26.7122 $28.4733 $29.5315 $28.3118
240056 ............................................................................. 1.2482 1.1052 $28.5169 $30.8619 $31.6623 $30.4153
240057 ............................................................................. 1.8689 1.1052 $27.7600 $29.4870 $30.6258 $29.3431
240059 ............................................................................. 1.0941 1.1052 $27.0517 $28.6340 $29.7916 $28.5358
240061 ............................................................................. 1.7548 1.1116 $28.7372 $30.0031 $30.6383 $29.8381
240063 ............................................................................. 1.5720 1.1052 $26.7960 $29.9603 $32.3487 $29.6692
240064 ............................................................................. 1.2696 1.0226 $24.9928 $26.6996 $29.9662 $27.5790
240066 ............................................................................. 1.3865 1.1052 $27.4066 $30.2716 $33.4532 $30.4657
240069 ............................................................................. 1.1509 1.1116 $25.6943 $27.4990 $28.9496 $27.4534
240071 ............................................................................. 1.1507 1.1116 $24.8036 $26.4780 $28.0585 $26.4808
240075 ............................................................................. 1.2095 0.9775 $24.4084 $26.6607 $26.1956 $25.7681
240076 ............................................................................. 1.1103 1.1052 $26.7112 $28.4519 $29.8562 $28.4067
240077 ............................................................................. *** * $18.9735 * * $18.9735
240078 ............................................................................. 1.6081 1.1052 $27.5066 $30.5339 $32.3235 $30.0485
240079 ............................................................................. 0.9659 * $20.6644 $20.9220 * $20.8010

Case-mix FY 2006
240080 ............................................................................. 1.7263 1.1052 $27.8807 $29.6274 $31.6828 $29.7638

240083 ............................................................................. 1.2421 0.9132 $24.4352 $25.0214 $26.6582 $25.4096
240084 ............................................................................. 1.1324 1.0226 $23.9942 $24.7856 $26.8142 $25.2047
240087 ............................................................................. 1.0337 * $20.1002 $24.8479 * $22.4032
240088 ............................................................................. 1.2796 0.9775 $25.5587 $27.6323 $28.0825 $27.1245
240089 ............................................................................. *** * $23.4028 * * $23.4028
240093 ............................................................................. 1.3386 1.0900 $22.3968 $23.7785 $25.5805 $23.9303
240094 ............................................................................. 1.0933 * $24.4166 $27.3974 * $25.9702
240097 ............................................................................. *** * $34.2810 * * $34.2810
240100 ............................................................................. 1.3081 0.9132 $24.7500 $25.3269 $27.6299 $25.9040
240101 ............................................................................. 1.1448 0.9132 $24.3455 $26.6078 $25.5355 $25.5132
240103 ............................................................................. 1.0756 0.9132 $20.2324 $22.5416 $22.7078 $21.8542
240104 ............................................................................. 1.1434 1.1052 $27.4946 $30.1392 $31.4306 $29.9577
240106 ............................................................................. 1.5040 1.1052 $25.5890 $27.5171 $29.3455 $27.5527
240107 ............................................................................. 0.9266 * $24.5583 $25.5199 * $25.0405
240109 ............................................................................. 0.9571 0.9132 $14.5892 $15.2076 $16.5051 $15.4279
240115 ............................................................................. 1.6254 1.1052 $27.0312 $29.0261 $31.3869 $29.1786
240117 ............................................................................. 1.1426 0.9132 $20.1436 $22.0463 $23.6230 $21.9434
240121 ............................................................................. 0.9181 * $24.5455 * * $24.5455
240122 ............................................................................. 0.9991 * $23.5331 * * $23.5331
240123 ............................................................................. 1.0632 0.9132 $20.0721 $20.5755 $21.7500 $20.8397
240124 ............................................................................. 0.9935 * $23.5139 $23.9297 * $23.7277
240127 ............................................................................. *** * $19.3857 $24.4824 * $21.5460
240128 ............................................................................. 1.0317 0.9132 $20.1960 $21.2638 $21.5791 $21.0226
240132 ............................................................................. 1.2709 1.1052 $26.7063 $29.5310 $31.7139 $29.3306
240133 ............................................................................. 1.1454 * $23.6068 $26.1836 * $24.8841
240135 ............................................................................. *** * $17.8573 $16.1837 * $16.9824
240137 ............................................................................. 1.2132 * $23.1752 $23.8666 * $23.5315
240139 ............................................................................. 1.0823 * $22.4473 $23.7898 * $23.1612
240141 ............................................................................. 1.0302 1.1052 $25.1597 $26.7173 $26.4016 $26.1666
240143 ............................................................................. 0.8573 0.9132 $18.9442 $21.1180 $21.7416 $20.6376
240145 ............................................................................. *** * $22.6063 * * $22.6063
240152 ............................................................................. 0.9381 * $25.4031 $27.3445 $29.6196 $27.5602
240154 ............................................................................. 1.0445 0.9270 $21.3809 $23.9643 * $22.6453
240162 ............................................................................. 1.1550 0.9132 $20.4807 $22.3136 $22.2721 $21.7043
240166 ............................................................................. 1.1188 0.9132 $21.5002 $23.4265 $25.7509 $23.5628
240179 ............................................................................. 0.8477 * $19.8249 $20.8449 * $20.3419
240187 ............................................................................. 1.2042 1.0900 $24.8879 $26.5129 $27.8811 $26.4667
240196 ............................................................................. 0.7590 1.1052 $27.2901 $28.9380 $30.7719 $29.0287
240205 ............................................................................. 0.9108 * * * * *
240206 ............................................................................. 0.9071 1.4448 * * * *
240207 ............................................................................. 1.2158 1.1052 $27.4330 $29.2395 $31.7665 $29.5904
240210 ............................................................................. 1.2547 1.1052 $26.6545 $29.7227 $32.1564 $29.5372
240211 ............................................................................. 0.9342 1.0900 $32.8801 $44.4214 $18.8503 $27.6876
240213 ............................................................................. 1.3162 1.1052 $27.5104 $31.3974 $32.7532 $30.8794
250001 ............................................................................. 1.8740 0.8304 $20.9338 $21.9176 $22.7827 $21.9287
250002 ............................................................................. 0.8830 0.8603 $21.6643 $20.1310 $23.3845 $21.6434
250004 ............................................................................. 1.8410 0.9148 $20.9295 $20.6828 $24.1065 $21.8737
250006 ............................................................................. 1.0537 0.9148 $20.3061 $21.4038 $24.0191 $21.9290
250007 ............................................................................. 1.2501 0.8913 $21.2226 $23.6933 $25.8710 $23.5817
250009 ............................................................................. 1.2499 0.8790 $19.7610 $20.4329 $22.2323 $20.8522
250010 ............................................................................. 0.9858 0.7688 $17.6204 $19.4130 $19.4403 $18.8097
250012 ............................................................................. 0.9474 0.9402 $15.6117 $20.0493 $20.2921 $18.4571
250015 ............................................................................. 1.0283 0.7688 $19.3794 $20.6931 $20.7555 $20.2702
250017 ............................................................................. 1.0990 0.7688 $19.0436 $18.1013 $21.3950 $19.5260
250018 ............................................................................. 0.9187 0.7688 $16.8783 $17.0689 $16.6294 $16.8678
250019 ............................................................................. 1.5751 0.8913 $22.9085 $22.8358 $23.9741 $23.2493
250020 ............................................................................. 0.9907 0.7688 $19.1877 $19.3390 $21.4019 $19.9847
250021 ............................................................................. *** * $15.8485 $15.1242 $20.3559 $16.0142
250023 ............................................................................. 0.8489 0.8603 $14.7355 $16.1820 $16.2418 $15.7024
250025 ............................................................................. 1.0467 0.7688 $21.2651 $20.6892 $20.5258 $20.8816
250027 ............................................................................. 0.9980 0.7688 $17.5937 $17.3313 $17.3481 $17.4314
250030 ............................................................................. *** * $27.2140 * * $27.2140
250031 ............................................................................. 1.3065 0.8174 $21.0894 $22.0850 $21.4326 $21.5380
250034 ............................................................................. 1.5522 0.9148 $20.3681 $20.6752 $24.3189 $21.8100
250035 ............................................................................. 0.8612 0.7688 $17.1071 $14.6149 $17.2045 $16.2933
250036 ............................................................................. 1.0134 0.8156 $17.0469 $17.8313 $19.1975 $18.0476

Case-mix FY 2006
250037 ............................................................................. 0.8781 0.7688 $16.6347 $17.4463 $17.4012 $17.1789

250038 ............................................................................. 0.9918 0.8304 $16.8610 $18.0209 $18.9050 $17.9032
250039 ............................................................................. 0.9235 0.8304 $16.8729 $15.2939 $17.3155 $16.4505
250040 ............................................................................. 1.4785 0.8603 $20.8178 $21.3451 $23.2285 $21.8161
250042 ............................................................................. 1.2257 0.9148 $19.4367 $21.4117 $23.4135 $21.3957
250043 ............................................................................. 1.0459 0.7688 $17.7554 $18.3322 $19.8098 $18.6971
250044 ............................................................................. 1.0268 0.7688 $20.3711 $21.1198 $23.3862 $21.6199
250045 ............................................................................. 1.0860 0.8955 $25.3236 $25.0863 $26.3831 $25.6144
250048 ............................................................................. 1.5885 0.8304 $19.3635 $21.6547 $22.9765 $21.3756
250049 ............................................................................. 0.8502 0.7688 $13.4396 $17.8154 $17.7005 $16.2411
250050 ............................................................................. 1.1938 0.7688 $16.6723 $18.3170 $19.1467 $18.0183
250051 ............................................................................. 0.8440 0.7688 $10.5027 $10.6908 $10.6095 $10.6008
250057 ............................................................................. 1.1364 0.7688 $19.0571 $19.6789 $20.1900 $19.6573
250058 ............................................................................. 1.2634 0.7688 $16.5565 $17.5160 $18.1704 $17.4280
250059 ............................................................................. 0.9887 0.7688 $19.0733 $17.7270 $19.2977 $18.6884
250060 ............................................................................. 0.7969 0.7688 $14.0155 $20.8115 $16.8247 $17.2475
250061 ............................................................................. 0.8471 0.7688 $11.4573 $15.2515 $12.8174 $12.9127
250065 ............................................................................. 0.8335 * $16.2010 $16.1984 * $16.1997
250066 ............................................................................. 0.7772 * $16.1044 * * $16.1044
250067 ............................................................................. 1.0575 0.7688 $20.0430 $20.1261 $21.6911 $20.6215
250068 ............................................................................. 0.7710 * $16.3759 $16.9585 * $16.6506
250069 ............................................................................. 1.5154 0.8648 $21.2224 $21.6617 $22.8162 $21.9460
250071 ............................................................................. 0.8510 * $13.7056 $17.7149 * $15.4400
250072 ............................................................................. 1.5086 0.8304 $20.7827 $22.9316 $24.6587 $22.7773
250077 ............................................................................. 0.9511 0.7688 $14.0318 $14.2271 $14.7632 $14.3259
250078 2 ........................................................................... 1.6194 0.8603 $17.5186 $18.6563 $20.9354 $19.1036
250079 ............................................................................. 0.8399 0.8174 $21.3506 $27.2549 $38.0031 $29.5848
250081 ............................................................................. 1.2491 0.8174 $20.4513 $21.3830 $24.7031 $21.9463
250082 ............................................................................. 1.2880 0.8091 $19.5962 $20.5212 $19.6966 $19.9404
250083 ............................................................................. 0.9197 * $19.5217 $19.9484 * $19.7505
250084 ............................................................................. 1.1778 0.7688 $22.4632 $21.8001 $18.5775 $20.7280
250085 ............................................................................. 0.9636 0.7688 $18.0473 $18.7367 $19.7007 $18.8283
250089 ............................................................................. 1.0566 * $16.0203 * * $16.0203
250093 ............................................................................. 1.2244 0.7688 $17.4413 $18.8001 $21.3237 $19.1985
250094 ............................................................................. 1.5974 0.8603 $19.9619 $22.3312 $22.7312 $21.7001
250095 ............................................................................. 1.0096 0.7688 $18.6616 $19.9553 $21.3511 $19.9748
250096 ............................................................................. 1.0813 0.8304 $20.7246 $22.7458 $22.6298 $22.0767
250097 ............................................................................. 1.4095 0.8461 $18.8399 $19.4534 $20.1687 $19.4858
250098 ............................................................................. *** * $17.9561 * * $17.9561
250099 ............................................................................. 1.2497 0.8174 $18.2504 $19.0333 $19.5797 $18.9671
250100 ............................................................................. 1.4599 0.8648 $18.8877 $22.0328 $24.2209 $21.7570
250101 ............................................................................. *** * * $21.2234 $19.3543 $20.1785
250102 ............................................................................. 1.5659 0.8304 $21.3213 $22.5518 $24.2868 $22.7655
250104 ............................................................................. 1.4476 0.8174 $20.5035 $21.4431 $22.6591 $21.5782
250105 ............................................................................. 0.9055 0.7688 $17.0136 $17.9468 $18.1196 $17.6992
250107 ............................................................................. 0.9099 0.7688 $16.7104 $16.5369 $17.8999 $17.0742
250112 ............................................................................. 0.9532 0.7688 $16.8696 $19.6172 $21.2824 $19.4217
250117 ............................................................................. 1.0427 0.8603 $18.8863 $19.9774 $23.3673 $20.6608
250119 ............................................................................. *** * $17.1373 * * $17.1373
250120 ............................................................................. 1.0523 0.7688 $22.9071 $22.7607 $23.4277 $23.0135
250122 ............................................................................. 1.0743 0.8603 $19.7966 $23.7230 $24.5854 $22.7156
250123 ............................................................................. 1.2646 0.8913 $22.2184 $22.0486 $24.5115 $22.9495
250124 ............................................................................. 0.8452 0.8304 $15.6866 $15.4343 $17.2181 $16.1302
250125 ............................................................................. 1.2941 0.8913 $25.3415 $26.8379 $27.7077 $26.6997
250126 ............................................................................. 0.9445 0.9402 $20.1118 $20.4085 $21.7111 $20.7174
250127 ............................................................................. 0.9410 1.4448 * * * *
250128 ............................................................................. 0.8891 0.7688 $15.8352 $15.9344 $17.6269 $16.4363
250131 ............................................................................. 0.8974 * $11.5396 * * $11.5396
250134 ............................................................................. 0.6463 0.8304 $22.0310 $23.5608 $25.8368 $23.6784
250136 ............................................................................. 0.9913 0.8304 $21.9977 $22.5832 $23.0637 $22.5479
250138 ............................................................................. 1.2713 0.8304 $21.2490 $22.7902 $23.8861 $22.6997
250141 ............................................................................. 1.5730 0.9402 $22.5187 $24.5772 $27.6158 $25.2301
250146 ............................................................................. 0.8892 0.7688 $16.9341 $17.2328 $18.6486 $17.5743
250149 ............................................................................. 0.9022 0.7688 $16.4228 $15.0367 $15.0641 $15.5315
250151 ............................................................................. 0.7349 0.7688 $20.4581 $21.8697 $17.2205 $18.4362
250152 ............................................................................. 1.5970 0.8304 * * $25.7837 $25.7837
250153 ............................................................................. *** * * * $29.0461 $29.0461

Case-mix FY 2006
250154 ............................................................................. 0.9022 * * * * *

250156 ............................................................................. 1.3430 0.7688 * * * *
250157 ............................................................................. 1.6672 0.7688 * * * *
250158 ............................................................................. 1.6049 0.7688 * * * *
250159 ............................................................................. 0.8412 * * * * *
260001 ............................................................................. 1.6402 0.8585 $22.6646 $25.3084 $25.9250 $24.6413
260002 ............................................................................. *** * $24.6812 $27.2329 $26.4879 $26.0819
260003 ............................................................................. 1.0295 * $16.5931 $17.6339 * $17.1135
260004 ............................................................................. 0.9660 0.7919 $16.4423 $16.7742 $16.9421 $16.7356
260005 ............................................................................. 1.4856 0.8958 $25.5927 $24.6142 $26.5773 $25.6220
260006 ............................................................................. 1.4373 0.7919 $24.1078 $26.4948 $26.7587 $25.8174
260008 ............................................................................. *** * $21.6256 $17.6040 $18.9522 $19.2926
260009 ............................................................................. 1.1870 0.9463 $20.1679 $21.2729 $22.1816 $21.2122
260011 ............................................................................. 1.3912 0.8388 $21.1625 $21.4409 $22.7061 $21.7937
260012 ............................................................................. 1.0557 0.7919 $17.7854 $19.3389 $20.3061 $19.2632
260013 ............................................................................. 1.0239 0.8585 $18.4857 $19.2065 $20.5007 $19.3903
260015 ............................................................................. 1.0966 0.7919 $21.7581 $22.4450 $22.5409 $22.2644
260017 ............................................................................. 1.3141 0.8958 $20.7837 $21.1359 $22.7022 $21.5787
260018 ............................................................................. 1.0604 0.7919 $14.3278 $14.8425 $17.0434 $15.4340
260020 ............................................................................. 1.7533 0.8958 $22.4709 $25.7898 $26.0407 $24.8648
260021 ............................................................................. 1.3869 0.8958 $27.2478 $27.8332 $27.6330 $27.5756
260022 ............................................................................. 1.2259 0.8553 $20.5417 $21.7707 $22.8085 $21.6784
260023 ............................................................................. 1.2848 0.8958 $19.6324 $21.2519 $21.2077 $20.7002
260024 ............................................................................. 1.1431 0.7919 $16.9968 $17.5351 $18.4829 $17.6819
260025 ............................................................................. 1.2731 0.8958 $19.3535 $20.0901 $22.4645 $20.6596
260027 ............................................................................. 1.6048 0.9463 $22.9973 $24.7605 $25.3348 $24.3810
260029 ............................................................................. 1.1007 * $22.0390 $22.2892 * $22.1651
260031 ............................................................................. *** * $24.3626 $24.2877 * $24.3260
260032 ............................................................................. 1.8231 0.8958 $21.8830 $23.1125 $23.9478 $22.9995
260034 ............................................................................. 0.9611 0.9463 $21.6108 $23.3034 $24.1143 $23.0518
260035 ............................................................................. 0.9500 * $15.0468 $16.8502 $17.8741 $16.5641
260036 ............................................................................. 0.9544 * $19.4559 $20.1324 $22.1912 $20.4830
260040 ............................................................................. 1.6840 0.8242 $20.0422 $21.9452 $23.3566 $21.8297
260044 ............................................................................. 0.9461 * $18.2413 $20.0686 * $19.1695
260047 ............................................................................. 1.5080 0.8357 $22.4585 $22.6169 $24.4185 $23.1892
260048 ............................................................................. 1.2627 0.9463 $26.6363 $25.8089 $24.3906 $25.5119
260050 ............................................................................. 1.1649 0.7919 $20.8510 $20.6364 $23.6849 $21.9007
260052 ............................................................................. 1.3280 0.8958 $21.1297 $22.5809 $24.5165 $22.8077
260053 ............................................................................. 1.0499 0.8585 $18.9606 $20.0051 $21.6607 $20.2038
260057 ............................................................................. 1.0425 0.9463 $15.8404 $16.4875 $19.3335 $17.1879
260059 ............................................................................. 1.1923 0.7919 $17.2807 $18.6379 $19.7243 $18.6135
260061 ............................................................................. 1.0980 0.7919 $18.7280 $19.6674 $21.5264 $19.9180
260062 ............................................................................. 1.1962 0.9463 $25.2958 $26.0439 $26.4539 $25.9705
260063 ............................................................................. 0.9748 * $21.1284 $22.0826 * $21.6180
260064 ............................................................................. 1.3701 0.8357 $17.5188 $19.1587 $19.0543 $18.5908
260065 ............................................................................. 1.7311 0.8242 $22.0058 $23.6969 $23.0015 $22.9155
260067 ............................................................................. 0.9016 0.7919 $14.9792 $16.5364 $17.6256 $16.4270
260068 ............................................................................. 1.7690 0.8357 $22.0951 $23.9340 $24.9504 $23.7077
260070 ............................................................................. 0.9649 0.7919 $11.2251 $14.3881 $18.4779 $14.0836
260073 ............................................................................. 1.0223 0.7919 $17.8185 $19.2744 $21.6214 $19.6354
260074 ............................................................................. 1.1765 0.8357 $18.7639 $23.9301 $24.8654 $22.4254
260077 ............................................................................. 1.6652 0.8958 $21.9947 $23.5466 $25.5782 $23.7347
260078 ............................................................................. 1.2201 0.7919 $16.9217 $18.4017 $19.0802 $18.1811
260080 ............................................................................. 0.9095 0.7919 $13.6815 $11.2817 $14.7774 $13.2210
260081 ............................................................................. 1.4955 0.8958 $22.6627 $23.7447 $26.3969 $24.2793
260085 ............................................................................. 1.5999 0.9463 $22.7394 $24.6046 $25.6302 $24.3659
260086 ............................................................................. 0.8794 0.7919 $17.2048 $17.1202 $19.1702 $17.8711
260091 ............................................................................. 1.5303 0.8958 $23.9975 $26.1149 $27.2407 $25.8446
260094 ............................................................................. 1.6494 0.8242 $20.1043 $20.6805 $23.2544 $21.4540
260095 ............................................................................. 1.3127 0.9463 $22.8156 $23.8671 $25.5668 $24.0702
260096 ............................................................................. 1.4324 0.9463 $23.5009 $25.9932 $27.5592 $25.8492
260097 ............................................................................. 1.1529 0.8344 $19.6203 $21.5077 $21.3957 $20.9049
260102 ............................................................................. 0.8644 0.9463 $24.1041 $22.9283 $24.2368 $23.7509
260103 ............................................................................. *** * $21.6192 $23.3175 * $22.4894
260104 ............................................................................. 1.4718 0.8958 $22.4769 $24.0038 $26.2867 $24.3941
260105 ............................................................................. 1.7289 0.8958 $24.6572 $28.4652 $28.8849 $27.3498
260107 ............................................................................. 1.3256 0.9463 $23.1564 $24.2001 $26.7782 $24.6444

Case-mix FY 2006
260108 ............................................................................. 1.8415 0.8958 $22.7975 $24.0936 $24.9880 $23.9815

260110 ............................................................................. 1.6342 0.8958 $22.0026 $22.2730 $23.7978 $22.7167
260113 ............................................................................. 1.0891 0.8279 $16.3440 $19.2467 $20.9644 $18.7740
260115 ............................................................................. 1.1612 0.8958 $20.4880 $21.7450 $21.9859 $21.4408
260116 ............................................................................. 1.1354 0.8279 $16.9807 $17.2698 $18.5076 $17.6168
260119 ............................................................................. 1.3457 0.7919 $18.7959 $22.1588 $24.9937 $22.8442
260120 ............................................................................. *** * $18.7651 * * $18.7651
260122 ............................................................................. 1.1399 0.9463 $16.1637 $17.3270 $20.8015 $18.1468
260123 ............................................................................. 1.0022 * $17.7996 $16.1169 * $17.0002
260127 ............................................................................. 0.9654 0.8077 $19.7946 $22.5328 $21.8534 $21.3553
260134 ............................................................................. 1.1531 * $18.4511 $18.1531 * $18.2845
260137 ............................................................................. 1.6787 0.8585 $20.7638 $21.3426 $22.7431 $21.6630
260138 ............................................................................. 1.9152 0.9463 $25.6579 $27.8229 $28.5610 $27.3740
260141 ............................................................................. 1.9311 0.8357 $21.0771 $21.1511 $22.4886 $21.5378
260142 ............................................................................. 1.0558 0.7919 $18.6412 $19.6582 $20.3993 $19.6104
260147 ............................................................................. 0.9412 0.7919 $16.1171 $17.2291 $18.5153 $17.2858
260159 ............................................................................. *** * $23.1093 $26.8924 $23.7427 $24.4817
260160 ............................................................................. 1.0924 0.7919 $18.8723 $19.4997 $21.0544 $19.7923
260162 ............................................................................. 1.3775 0.8958 $22.5705 $24.1246 $25.1423 $23.9984
260163 ............................................................................. 1.1555 0.7919 $18.1310 $19.2885 $20.1949 $19.2038
260164 ............................................................................. 1.0699 0.7919 $16.9403 $19.5539 $19.7068 $18.6878
260166 ............................................................................. 1.2047 0.9463 $22.8409 $25.5151 $27.0237 $25.1725
260172 ............................................................................. 0.9118 * $17.1504 $18.1438 * $17.6539
260175 ............................................................................. 1.1009 0.7919 $19.7939 $21.1257 $22.6171 $21.1462
260176 ............................................................................. 1.5984 0.8958 $25.7802 $29.2184 $27.4244 $27.5317
260177 ............................................................................. 1.2264 0.9463 $24.0550 $25.0724 $26.1178 $25.1274
260178 ............................................................................. 1.7950 0.8357 $21.7704 $21.4781 $22.2251 $21.8190
260179 ............................................................................. 1.5777 0.8958 $23.2824 $24.8541 $26.1419 $24.7933
260180 ............................................................................. 1.5476 0.8958 $21.8585 $21.9679 $26.7461 $23.4659
260183 ............................................................................. 1.6527 0.8958 $24.2330 $23.3924 $26.0418 $24.6030
260186 ............................................................................. 1.6276 0.8357 $21.6620 $23.4317 $25.3148 $23.5713
260190 ............................................................................. 1.1494 0.9463 $24.5014 $25.1653 $26.4505 $25.4095
260191 ............................................................................. 1.3231 0.8958 $21.1331 $22.4369 $23.3856 $22.3648
260193 ............................................................................. 1.2211 0.9463 $22.9556 $24.4705 $26.2979 $24.7042
260195 ............................................................................. 1.2806 0.7919 $20.0889 $20.1327 $22.3958 $20.9711
260198 ............................................................................. 1.1880 0.8958 $25.3390 $27.6116 $27.5996 $26.8633
260200 ............................................................................. 1.2239 0.8958 $22.3913 $25.1134 $24.8624 $24.2536
260207 ............................................................................. 1.0639 0.8242 $18.5247 $19.2467 $19.7294 $19.2332
260208 ............................................................................. *** * $28.3158 * * $28.3158
260209 ............................................................................. 1.0858 0.8381 * $21.8396 $23.2430 $22.5334
260210 ............................................................................. 1.2315 0.8958 * * $25.3782 $25.3782
260211 ............................................................................. 1.6081 0.9463 * * $33.9109 $33.9109
260213 ............................................................................. 2.4615 0.9463 * * * *
270002 2 ........................................................................... 1.2991 0.9526 $19.7588 $20.7620 $22.7322 $21.1317
270003 ............................................................................. 1.3122 0.9065 $23.0396 $24.2823 $26.4843 $24.5714
270004 ............................................................................. 1.6944 0.8846 $21.5577 $22.9081 $23.5454 $22.7035
270009 ............................................................................. 1.3205 * $21.5655 * * $21.5655
270011 ............................................................................. 0.9741 0.9065 $21.4031 $22.0710 $22.1394 $21.8739
270012 2 ........................................................................... 1.4543 0.9526 $21.7634 $23.1697 $25.2873 $23.4084
270014 ............................................................................. 1.8361 0.9526 $20.3456 $25.0650 $26.2025 $23.6425
270017 ............................................................................. 1.2834 0.9526 $23.2320 $24.6186 $27.5483 $25.1665
270021 ............................................................................. 1.0162 0.8846 $21.1624 $21.6758 $21.7056 $21.5330
270023 ............................................................................. 1.5384 0.8846 $23.7486 $25.5525 $26.7576 $25.3555
270032 ............................................................................. 1.0493 0.8846 $20.1801 $18.2377 $19.6212 $19.3552
270036 ............................................................................. 0.8049 * $18.8785 $21.8255 $20.4242 $20.3944
270040 ............................................................................. 1.1952 * $20.7240 * * $20.7240
270049 ............................................................................. 1.7898 0.8846 $22.9524 $24.6556 $26.3996 $24.7520
270050 ............................................................................. 1.0516 * $21.0901 $22.4195 * $21.7451
270051 ............................................................................. 1.5696 0.9526 $22.2580 $26.4457 $26.6619 $25.1119
270057 ............................................................................. 1.2393 0.8846 $21.9997 $22.6251 $24.2980 $23.0119
270060 ............................................................................. 0.8910 0.8752 * $16.6592 $17.7564 $17.1813
270074 ............................................................................. 0.8557 1.4448 * * * *
270075 ............................................................................. 0.9239 * * * * *
270079 ............................................................................. 0.8481 * * $21.6382 * $21.6382
270081 ............................................................................. 1.0142 0.8752 $15.6833 $17.3174 $17.4862 $16.8348
270082 ............................................................................. 1.0574 * $21.0150 $19.6173 * $20.3610
270084 2 ........................................................................... 1.0107 * $19.6104 $22.2340 * $21.0235

Case-mix FY 2006
270086 ............................................................................. 1.1183 0.9065 * * * *

270087 ............................................................................. 1.0295 0.8752 * * * *
280003 ............................................................................. 1.8656 1.0187 $26.0937 $27.2844 $29.3921 $27.8614
280005 ............................................................................. *** * $23.9753 * * $23.9753
280009 ............................................................................. 1.8585 0.9656 $23.8046 $25.3162 $26.7678 $25.2627
280010 ............................................................................. *** * $23.8325 $22.6516 * $23.2571
280013 ............................................................................. 1.8094 0.9546 $23.4920 $24.5214 $26.1908 $24.7334
280020 ............................................................................. 1.8480 1.0187 $23.4577 $25.7522 $26.5068 $25.3300
280021 ............................................................................. 1.1450 0.8658 $21.5215 $22.2864 $22.0489 $21.9595
280023 ............................................................................. 1.4143 0.9656 $19.6265 $22.7207 $22.3230 $21.6126
280030 ............................................................................. 1.9539 0.9546 $29.2221 $32.5601 $30.7481 $30.8807
280032 ............................................................................. 1.3432 0.9656 $21.5150 $22.6510 $23.6462 $22.6240
280040 ............................................................................. 1.6893 0.9546 $23.6597 $25.2965 $26.9827 $25.3499
280047 ............................................................................. 0.7859 * $19.5815 * * $19.5815
280054 ............................................................................. 1.1577 0.8795 $23.1191 $22.4241 $23.5665 $23.0380
280057 ............................................................................. 0.8226 0.9656 $22.5481 $23.6793 $20.4830 $22.0597
280060 ............................................................................. 1.6274 0.9546 $23.1128 $25.2288 $26.2139 $24.9273
280061 ............................................................................. 1.3744 0.9249 $21.2901 $23.9110 $24.9482 $23.4090
280065 ............................................................................. 1.2862 0.9587 $23.8128 $27.9937 $26.0135 $25.9591
280077 ............................................................................. 1.3374 0.9546 $22.7244 $24.0516 $25.5624 $24.1150
280081 ............................................................................. 1.6432 0.9546 $24.3199 $25.1973 $26.0541 $25.2026
280085 ............................................................................. *** * $21.8473 * * $21.8473
280105 ............................................................................. 1.3057 0.9546 $25.1401 $25.0445 $26.7555 $25.7137
280108 ............................................................................. 1.0428 0.8658 $20.9016 $22.5584 $23.2502 $22.2006
280111 ............................................................................. 1.2161 0.8658 $20.7398 $22.1424 $23.4770 $22.1827
280117 ............................................................................. 1.0657 0.8658 $20.5464 $22.0611 $24.1521 $22.2744
280118 ............................................................................. 0.9223 * $19.3466 * * $19.3466
280119 ............................................................................. 0.8238 1.4448 * * * *
280123 ............................................................................. 0.9746 0.8795 $24.3539 $27.5207 * $25.8965
280125 ............................................................................. 1.5209 0.8658 $20.0643 $21.8385 $21.7658 $21.2295
280126 ............................................................................. *** * $33.8918 * * $33.8918
280127 ............................................................................. 1.8510 1.0187 * * * *
280128 ............................................................................. 3.3466 1.0187 * * * *
280129 ............................................................................. 1.9562 0.9546 * * * *
280130 ............................................................................. 1.2105 0.9546 * * * *
290001 ............................................................................. 1.7842 1.0973 $25.9590 $27.3105 $31.1981 $28.2417
290002 ............................................................................. 0.8744 0.9776 $16.8363 $16.8433 $18.3469 $17.3909
290003 ............................................................................. 1.7886 1.1404 $27.4732 $27.1099 $28.1625 $27.5886
290005 ............................................................................. 1.3920 1.1404 $24.6877 $27.1531 $27.6697 $26.5417
290006 ............................................................................. 1.2847 1.0794 $24.2211 $26.3617 $27.9502 $26.1547
290007 ............................................................................. 1.6569 1.1404 $35.1020 $35.4193 $37.5559 $36.0546
290008 ............................................................................. 1.1784 1.1237 $27.0115 $26.4086 $27.9714 $27.1141
290009 ............................................................................. 1.8755 1.0973 $26.9020 $27.6011 $29.8019 $28.1837
290010 ............................................................................. 1.0905 1.1404 $25.4598 $23.8733 $23.9654 $24.4204
290012 ............................................................................. 1.3505 1.1404 $25.8036 $27.2675 $31.0843 $28.0502
290016 ............................................................................. 1.1558 * $22.5111 $25.1726 $26.1925 $24.6281
290019 ............................................................................. 1.4095 1.0794 $25.1684 $27.2484 $28.6158 $27.0192
290020 h ........................................................................... 0.9713 1.1404 $24.2373 $21.3094 $21.6993 $22.1469
290021 ............................................................................. 1.7615 1.1404 $26.2510 $28.3837 $33.2116 $29.2014
290022 ............................................................................. 1.5354 1.1404 $27.5364 $29.8144 $29.4422 $28.9634
290027 ............................................................................. 0.9199 0.9070 $13.5031 $17.8850 $15.1448 $15.3083
290032 ............................................................................. 1.3774 1.0973 $27.5425 $29.4164 $31.7105 $29.6070
290039 ............................................................................. 1.5330 1.1404 $28.7599 $29.6801 $31.2941 $30.0435
290041 ............................................................................. 1.3550 1.1404 $28.6294 $30.1346 $33.9878 $31.0661
290042 ............................................................................. 0.8016 1.1404 * * * *
290044 ............................................................................. 0.8476 1.1404 * * * *
290045 ............................................................................. 1.5027 1.1404 $26.5644 $26.9319 $30.9612 $28.4883
290046 ............................................................................. 1.3462 1.1404 * * * *
290047 ............................................................................. 1.2927 1.1404 * * * *
290048 ............................................................................. 0.8479 * * * * *
290049 ............................................................................. 1.2664 1.0245 * * * *
290050 ............................................................................. 1.0634 * * * * *
300001 ............................................................................. 1.5613 1.1561 $27.1312 $29.4130 $27.5032 $28.0073
300003 ............................................................................. 2.0882 1.1561 $26.7859 $27.8059 $33.3560 $29.3633
300005 ............................................................................. 1.4274 1.1561 $22.8163 $25.1869 $25.6699 $24.5947
300006 ............................................................................. 1.1183 * $22.0187 $20.6787 $23.3200 $21.9532
300007 ............................................................................. 1.2618 * $23.6919 $25.3125 * $24.5082

Case-mix FY 2006
300010 ............................................................................. 1.2996 * $24.6295 $26.9346 $27.5028 $26.4641

300011 ............................................................................. 1.3151 1.1561 $25.0979 $27.3325 $28.4044 $26.9920
300012 ............................................................................. 1.3958 1.1561 $26.3914 $28.4234 $30.5198 $28.4955
300013 ............................................................................. 1.0792 * $21.3397 $23.1529 * $22.1888
300014 ............................................................................. 1.2142 1.1561 $23.7144 $25.5059 $27.5151 $25.6846
300015 ............................................................................. 1.0999 * $24.4869 $24.0620 * $24.2732
300016 ............................................................................. *** * $18.9756 $24.5498 * $21.6922
300017 ............................................................................. 1.2296 1.1922 $26.1104 $28.3959 $29.6957 $28.0967
300018 ............................................................................. 1.4036 1.1561 $25.7851 $28.0308 $29.7209 $27.9654
300019 ............................................................................. 1.2296 1.1561 $23.8076 $25.3845 $25.9656 $25.1005
300020 ............................................................................. 1.2033 1.1561 $24.8189 $26.8402 $28.6723 $26.8622
300022 ............................................................................. 1.1157 * $22.3918 $23.5948 * $23.0102
300023 ............................................................................. 1.4320 1.1922 $24.9992 $25.4873 $28.6309 $26.4774
300024 ............................................................................. 1.2361 * $22.4883 $23.9205 * $23.2005
300029 ............................................................................. 1.7597 1.1922 $24.5772 $26.9484 $29.0806 $26.9920
300034 ............................................................................. 2.0835 1.1561 $26.9093 $28.5375 $29.7484 $28.4471
310001 ............................................................................. 1.7881 1.3194 $30.1786 $33.9360 $35.3612 $33.2483
310002 ............................................................................. 1.8499 1.3194 $33.9058 $35.4567 $37.3461 $35.5944
310003 ............................................................................. 1.2158 1.3194 $30.4234 $31.1040 $32.8935 $31.5180
310005 ............................................................................. 1.3325 1.1879 $26.0227 $27.5690 $29.0084 $27.5943
310006 ............................................................................. 1.2371 1.3194 $25.9000 $27.0436 $27.4545 $26.7958
310008 ............................................................................. 1.3135 1.3194 $28.0970 $29.5857 $31.2579 $29.6725
310009 ............................................................................. 1.2631 1.3194 $24.6353 $29.7760 $32.7384 $29.0885
310010 ............................................................................. 1.2926 1.1319 $26.7889 $25.3139 $28.5852 $26.9172
310011 ............................................................................. 1.2822 1.1342 $26.1586 $28.5241 $30.8612 $28.5543
310012 ............................................................................. 1.6929 1.3194 $31.1705 $33.1622 $34.6882 $33.0545
310013 ............................................................................. 1.3611 1.3194 $25.0951 $28.5016 $30.6248 $28.1586
310014 ............................................................................. 1.8368 1.1227 $29.1931 $32.7222 $29.7204 $30.4762
310015 ............................................................................. 1.8831 1.3194 $30.1767 $32.4980 $36.4776 $33.0707
310016 ............................................................................. 1.3521 1.3194 $25.7368 $28.9788 $33.9862 $29.9150
310017 ............................................................................. 1.3377 1.1879 $25.2636 $28.0930 $30.9233 $28.1646
310018 ............................................................................. 1.1436 1.3194 $25.9108 $26.9399 $30.3381 $27.8107
310019 ............................................................................. 1.6345 1.3194 $26.8663 $31.0524 $29.6592 $29.1388
310020 ............................................................................. 1.6071 1.3194 $25.0147 $29.3392 $30.6722 $28.2107
310021 ............................................................................. 1.6314 1.3194 $29.4003 $29.6308 $31.3410 $30.1313
310022 ............................................................................. 1.2376 1.1227 $26.7487 $26.1914 $28.2024 $27.0808
310024 ............................................................................. 1.3723 1.1879 $26.9499 $27.5278 $30.9171 $28.3714
310025 ............................................................................. 1.2711 1.3194 $26.8719 $27.7960 $31.1274 $28.7415
310026 ............................................................................. 1.2595 1.3194 $24.6697 $25.3970 $27.5171 $25.9064
310027 ............................................................................. 1.3032 1.1879 $22.1935 $27.0982 $28.8314 $26.4162
310028 ............................................................................. 1.2382 1.3194 $25.7246 $29.1101 $31.3849 $28.7946
310029 ............................................................................. 1.8875 1.1227 $25.9606 $29.1439 $30.7707 $28.6905
310031 ............................................................................. 3.0548 1.1290 $29.5581 $30.2345 $33.9685 $31.2972
310032 ............................................................................. 1.3038 1.1227 $25.7088 $27.8754 $27.5232 $27.0476
310034 ............................................................................. 1.3424 1.1290 $26.5224 $27.8517 $29.9162 $28.1036
310037 ............................................................................. 1.3214 1.3194 $30.1264 $32.1471 $35.0329 $32.5209
310038 ............................................................................. 1.9998 1.3194 $32.3865 $32.1977 $33.4822 $32.7188
310039 ............................................................................. 1.2576 1.1640 $24.6045 $27.1054 $28.8292 $26.9337
310040 ............................................................................. 1.3440 1.3194 $27.4041 $28.0068 $34.1113 $29.8744
310041 ............................................................................. 1.2776 1.1290 $26.8145 $29.7335 $32.8085 $29.8863
310042 ............................................................................. 1.1597 1.3194 $26.9695 $29.0207 $30.7358 $28.9101
310044 ............................................................................. 1.3350 1.1319 $25.1618 $27.7752 $31.3206 $28.1678
310045 ............................................................................. 1.5973 1.3194 $31.7376 $32.6359 $34.1060 $32.8838
310047 ............................................................................. 1.3157 1.1600 $26.1353 $28.3415 $32.7880 $29.2740
310048 ............................................................................. 1.3670 1.1879 $27.4050 $28.4715 $30.2025 $28.7345
310049 ............................................................................. *** * $26.5332 $32.7666 $27.8564 $27.2897
310050 ............................................................................. 1.2840 1.3194 $25.3772 $27.2276 $27.3033 $26.7397
310051 ............................................................................. 1.3861 1.3194 $29.2386 $32.0113 $33.7168 $31.6981
310052 ............................................................................. 1.3183 1.1290 $27.0324 $28.1498 $30.8036 $28.6341
310054 ............................................................................. 1.2891 1.3194 $28.1880 $30.6905 $34.1860 $31.0476
310057 ............................................................................. 1.3232 1.1227 $26.3903 $26.4606 $29.5221 $27.5782
310058 ............................................................................. 1.1046 1.3194 $28.1753 $26.4816 $28.0815 $27.5746
310060 ............................................................................. 1.2819 1.3194 $22.1914 $23.2146 $25.1575 $23.5782
310061 ............................................................................. 1.2681 1.1227 $24.9678 $27.5400 $28.2129 $26.9521
310063 ............................................................................. 1.3537 1.1879 $25.9868 $28.3457 $31.4884 $28.5345
310064 ............................................................................. 1.5668 1.1600 $27.8388 $29.5979 $33.4440 $30.4173
310067 ............................................................................. *** * $26.3624 $26.8068 * $26.5479

Case-mix FY 2006
310069 ............................................................................. 1.2704 1.1227 $25.7690 $27.9656 $28.1681 $27.3281

310070 ............................................................................. 1.3710 1.3194 $30.1917 $32.1806 $33.2310 $31.9325
310072 ............................................................................. *** * $25.3145 $26.3520 * $25.8709
310073 ............................................................................. 1.7905 1.1290 $28.8791 $29.6611 $32.0329 $30.2191
310074 ............................................................................. 1.3372 1.3194 $27.6789 $28.4361 $29.4834 $28.5348
310075 ............................................................................. 1.2812 1.1290 $25.7726 $26.2479 $31.6870 $27.8786
310076 ............................................................................. 1.6139 1.3194 $32.4533 $34.9428 $36.4280 $34.6292
310077 ............................................................................. 1.6620 1.3194 $28.7352 $30.7465 $32.6644 $30.7450
310078 ............................................................................. 1.2889 1.3194 $24.7753 $26.9589 $29.8014 $27.2209
310081 ............................................................................. 1.2546 1.1227 $24.6083 $26.4259 $26.6136 $25.9041
310083 ............................................................................. 1.3035 1.3194 $25.2465 $24.6563 $28.2392 $25.9836
310084 ............................................................................. 1.2321 1.1290 $27.3680 $29.9437 $32.9001 $30.0920
310086 ............................................................................. 1.2262 1.1227 $25.2751 $27.3601 $29.3058 $27.3522
310088 ............................................................................. 1.1801 1.1600 $23.7846 $25.5274 $26.4966 $25.2810
310090 ............................................................................. 1.2575 1.1879 $25.3640 $27.1661 $30.8941 $27.8574
310091 ............................................................................. 1.1983 1.1227 $25.6405 $27.1115 $27.7204 $26.8559
310092 ............................................................................. 1.3772 1.1319 $23.2226 $25.7071 $29.4999 $26.1525
310093 ............................................................................. 1.1945 1.3194 $24.6942 $25.8727 $28.0401 $26.2654
310096 ............................................................................. 2.1069 1.3194 $28.4705 $30.3675 $34.4275 $31.1262
310105 ............................................................................. 1.2141 1.3194 $28.7333 $30.9968 $31.9769 $30.6308
310108 ............................................................................. 1.3926 1.1640 $24.9090 $29.1548 $30.1002 $28.0512
310110 ............................................................................. 1.2919 1.1319 $26.4175 $27.8707 $31.2164 $28.8347
310111 ............................................................................. 1.2048 1.1290 $26.2496 $28.8692 $30.7475 $28.7020
310112 ............................................................................. 1.2411 1.1290 $27.8796 $28.9928 $30.4192 $29.1502
310113 ............................................................................. 1.2444 1.1290 $25.9143 $27.5203 $29.6079 $27.7501
310115 ............................................................................. 1.2750 1.3194 $24.5413 $26.2803 $29.6020 $26.9083
310116 ............................................................................. 1.2596 1.3194 $25.1189 $26.6287 $25.6976 $25.7970
310118 ............................................................................. 1.2916 1.3194 $28.0517 $28.1238 $28.8797 $28.3510
310119 ............................................................................. 1.8491 1.3194 $34.7468 $35.6786 $37.7876 $36.1340
310120 ............................................................................. 1.1631 1.3194 $24.7078 $27.2010 $31.4110 $27.6263
310122 ............................................................................. 2.3504 1.1290 * * * *
310123 ............................................................................. 1.7519 1.2230 * * * *
310124 ............................................................................. 1.6667 1.1640 * * * *
310125 ............................................................................. 2.0879 1.1879 * * * *
320001 ............................................................................. 1.4902 0.9686 $23.0290 $26.1962 $26.9434 $25.3673
320002 ............................................................................. 1.3977 1.0897 $26.7332 $28.6963 $30.5158 $28.6521
320003 ............................................................................. 1.1158 0.9269 $20.7939 $22.3911 $28.1402 $23.4549
320004 ............................................................................. 1.2784 0.8640 $19.4799 $24.0362 $24.9481 $23.1709
320005 ............................................................................. 1.4190 0.9548 $22.1677 $21.2164 $23.8264 $22.4376
320006 ............................................................................. 1.3263 1.0152 $21.1222 $22.5615 $24.2812 $22.6734
320009 ............................................................................. 1.5264 0.9686 $21.5870 $24.4237 $22.8293 $22.9608
320011 ............................................................................. 1.1800 0.9082 $20.7714 $23.1539 $24.2279 $22.7686
320013 ............................................................................. 1.1550 1.0152 $19.4487 $27.8671 $28.9276 $24.8284
320014 ............................................................................. 1.1314 0.8640 $19.7656 $26.7112 $24.5310 $23.5594
320016 ............................................................................. 1.1578 0.8640 $19.9326 $21.7001 $23.5040 $21.7285
320017 ............................................................................. 1.2944 0.9686 $22.5460 $23.6861 $25.0286 $23.7296
320018 ............................................................................. 1.4792 0.8703 $21.4650 $23.0915 $23.2360 $22.6002
320019 ............................................................................. 1.5611 0.9686 $26.6900 $31.2250 $31.5192 $29.7045
320021 ............................................................................. 1.6370 0.9686 $21.0913 $28.5620 $27.2357 $25.1851
320022 ............................................................................. 1.1035 0.8640 $20.7919 $22.1492 $23.7160 $22.2284
320030 ............................................................................. 1.0503 0.8640 $16.8696 $18.0990 $22.1971 $18.9458
320033 ............................................................................. 1.1604 1.0152 $24.2703 $24.1185 $27.6393 $25.3263
320037 ............................................................................. 1.1579 0.9686 $19.6466 $21.6080 $23.3999 $21.6108
320038 ............................................................................. 1.2492 0.8640 $19.2962 $21.2181 $20.1533 $20.2270
320046 ............................................................................. 1.1922 0.8640 $21.5915 $22.9114 $24.3534 $22.9610
320057 ............................................................................. 0.8993 1.4448 * * * *
320058 ............................................................................. 0.7493 1.4448 * * * *
320059 ............................................................................. 1.0334 1.4448 * * * *
320060 ............................................................................. 0.9956 1.4448 * * * *
320061 ............................................................................. 1.0533 1.4448 * * * *
320062 ............................................................................. 0.8317 1.4448 * * * *
320063 ............................................................................. 1.2977 0.9584 $20.7804 $24.9141 $24.4696 $23.4155
320065 ............................................................................. 1.1296 0.9584 $19.9012 $21.6189 $26.6603 $22.8070
320067 ............................................................................. 0.8447 0.8640 $13.9459 $20.4431 $23.7745 $19.8406
320069 ............................................................................. 1.0789 0.8640 $18.5375 $19.7296 $20.9167 $19.7352
320070 ............................................................................. 0.9077 1.4448 * * * *
320074 ............................................................................. 1.1720 0.9686 $28.3086 $35.5980 $22.2175 $28.2084

Case-mix FY 2006
320079 ............................................................................. 1.1219 0.9686 $21.9090 $23.8092 $25.2105 $23.6814

320083 ............................................................................. 2.6265 0.9686 $20.6771 * $28.2114 $23.7546
320084 ............................................................................. 1.1015 0.8640 * * $17.2511 $17.2511
320085 ............................................................................. 1.6312 0.8703 * * $24.8752 $24.8752
330001 ............................................................................. *** * $30.8509 $31.3735 $33.4718 $31.9148
330002 ............................................................................. 1.4714 1.3194 $28.0882 $29.3459 $31.1924 $29.5603
330003 ............................................................................. 1.2754 0.8607 $20.2744 $21.6506 $22.9945 $21.6443
330004 ............................................................................. 1.2891 1.0677 $24.3703 $23.9959 $26.0445 $24.8414
330005 ............................................................................. 1.6050 0.9503 $24.3578 $25.9287 $29.0124 $26.3013
330006 ............................................................................. 1.3144 1.3194 $28.3904 $29.7509 $31.5370 $29.8730
330008 ............................................................................. 1.1195 0.9503 $20.6816 $21.3269 $21.8198 $21.2850
330009 ............................................................................. 1.3259 1.3194 $33.3605 $35.8367 $35.4986 $34.8796
330010 ............................................................................. *** * $19.8211 $17.9178 $19.6920 $19.0804
330011 ............................................................................. 1.3109 0.8580 $19.8035 $20.3641 $21.8008 $20.6687
330013 ............................................................................. 2.1016 0.8607 $21.2063 $23.9070 $24.5162 $23.2224
330014 ............................................................................. 1.3670 1.3194 $32.0824 $35.4053 $38.8123 $35.4565
330016 ............................................................................. 0.9945 0.8217 $18.1603 $18.9388 $28.4392 $20.9735
330019 ............................................................................. 1.3013 1.3194 $31.9042 $32.3413 $34.8266 $33.0470
330023 2 ........................................................................... 1.5963 1.3194 $29.4538 $29.2669 $31.6208 $30.1574
330024 ............................................................................. 1.7371 1.3194 $35.3598 $36.5648 $37.8398 $36.5683
330025 ............................................................................. 1.0525 0.9503 $18.7663 $19.7561 $20.2775 $19.6152
330027 ............................................................................. 1.4762 1.3194 $34.1281 $35.1325 $39.0717 $36.0189
330028 ............................................................................. 1.4305 1.3194 $31.8452 $33.5312 $34.2709 $33.2330
330029 ............................................................................. 0.4479 0.9503 $18.4354 $18.6623 $19.1589 $18.7332
330030 ............................................................................. 1.2729 0.9123 $22.0574 $22.4368 $22.9937 $22.4866
330033 ............................................................................. 1.2661 0.8217 $18.6316 $21.3762 $22.5681 $20.8260
330036 ............................................................................. 1.1408 1.3194 $27.0970 $27.6813 $28.9409 $27.8674
330037 ............................................................................. 1.0939 0.9123 $18.3557 $19.6385 $20.6904 $19.5992
330041 ............................................................................. 1.1981 1.3194 $34.5461 $36.2481 $36.0286 $35.6239
330043 ............................................................................. 1.3182 1.2739 $31.7873 $34.1039 $34.7480 $33.5850
330044 ............................................................................. 1.2710 0.8378 $22.0465 $23.1450 $24.1907 $23.1415
330045 ............................................................................. 1.3384 1.2739 $30.9046 $34.4956 $36.1893 $33.9234
330046 ............................................................................. 1.4099 1.3194 $41.6759 $42.0900 $44.8494 $42.8629
330047 h ........................................................................... 1.2039 0.8607 $20.1646 $21.1244 $24.0678 $21.8925
330049 ............................................................................. 1.3530 1.3194 $24.7766 $25.7022 $29.2904 $26.5366
330053 ............................................................................. 1.0936 0.9123 $18.1728 $19.6807 $18.5290 $18.7942
330055 ............................................................................. 1.6595 1.3194 $34.9709 $35.1393 $38.4839 $36.2207
330056 ............................................................................. 1.4846 1.3194 $32.0982 $32.9295 $37.8444 $34.2883
330057 ............................................................................. 1.7122 0.8607 $20.9282 $22.6519 $24.4680 $22.6890
330058 ............................................................................. 1.3286 0.9123 $19.2916 $19.5520 $21.3727 $20.0924
330059 ............................................................................. 1.5373 1.3194 $36.4176 $38.1019 $39.7386 $38.0767
330061 ............................................................................. 1.2282 1.3194 $28.6725 $32.7427 $33.2848 $31.6301
330062 ............................................................................. 1.2015 0.9195 $20.0222 $21.4270 $21.0464 $20.8258
330064 ............................................................................. 1.1499 1.3194 $36.0976 $38.5719 $36.4276 $37.0304
330065 ............................................................................. 1.0337 0.9503 $20.5958 $21.9192 $23.9128 $22.1517
330066 ............................................................................. 1.3298 0.8607 $20.9990 $23.0916 $24.7941 $23.0025
330067 2 ........................................................................... 1.4233 1.3194 $24.8927 $34.8416 $26.4243 $28.0084
330072 ............................................................................. 1.4104 1.3194 $32.9665 $32.7905 $36.4336 $34.0607
330073 ............................................................................. 1.1359 0.9123 $18.4162 $19.0781 $20.1490 $19.1772
330074 ............................................................................. 1.3388 0.9123 $21.7299 $20.2874 $21.4274 $21.1093
330075 ............................................................................. 1.1708 0.9589 $19.9781 $22.0240 $22.4188 $21.4854
330078 ............................................................................. 1.4383 0.9503 $20.8379 $22.7762 $23.3981 $22.3650
330079 ............................................................................. 1.3107 0.8217 $21.1153 $22.1064 $22.5237 $21.9214
330080 ............................................................................. 1.1864 1.3194 $33.5537 $36.1171 $39.1724 $36.3260
330084 ............................................................................. 1.0874 0.8217 $19.2135 $22.6365 $21.5455 $21.1058
330085 ............................................................................. 1.2019 0.9318 $21.8271 $23.2927 $23.9568 $23.0352
330086 ............................................................................. 1.3273 1.3194 $27.1585 $28.8424 $29.1784 $28.3884
330088 ............................................................................. 1.0581 1.2739 $29.5181 $31.2631 $31.3973 $30.7659
330090 ............................................................................. 1.4589 0.8268 $20.9327 $22.7721 $23.6174 $22.4292
330091 ............................................................................. 1.3887 0.9503 $22.9396 $22.5796 $23.8063 $23.1125
330094 ............................................................................. 1.2635 0.8900 $21.3659 $22.1495 $23.0001 $22.1769
330095 ............................................................................. *** * $28.9794 $28.9914 $31.9872 $29.7944
330096 ............................................................................. 1.0741 0.8217 $21.1648 $22.4895 $22.0337 $21.9119
330097 ............................................................................. 1.1345 0.8217 $18.6291 $19.2233 $20.3189 $19.3571
330100 ............................................................................. 0.9578 1.3194 $31.5775 $32.8406 $34.4621 $32.9762
330101 ............................................................................. 1.8426 1.3194 $38.4810 $39.2601 $38.7503 $38.8324
330102 ............................................................................. 1.3592 0.9503 $23.5254 $23.6141 $24.8184 $23.9846

Case-mix FY 2006
330103 ............................................................................. 1.1027 0.8217 $17.9017 $18.8763 $21.1452 $19.3116

330104 ............................................................................. 1.3673 1.3194 $36.8451 $33.7556 $32.8818 $34.4566
330106 ............................................................................. 1.7553 1.4804 $38.7822 $39.8554 $41.4561 $40.0631
330107 ............................................................................. 1.2310 1.2739 $29.1958 $31.8528 $31.3888 $30.7790
330108 ............................................................................. 1.1202 0.8268 $20.2536 $21.4680 $22.2607 $21.3131
330111 ............................................................................. 1.0428 0.9503 $17.7020 $17.6185 $20.9387 $18.7250
330114 ............................................................................. *** * $19.2566 * * $19.2566
330115 ............................................................................. 1.1639 0.9589 $18.5544 $20.5101 $23.3043 $20.7157
330119 ............................................................................. 1.7652 1.3194 $34.6591 $36.5873 $39.1114 $36.7610
330121 ............................................................................. 0.9319 * $17.9757 $19.7388 * $18.8764
330122 ............................................................................. *** * $25.6500 $26.3849 * $26.0090
330125 ............................................................................. 1.7965 0.9123 $22.8078 $24.6945 $26.7118 $24.8603
330126 ............................................................................. 1.2876 1.3194 $27.7155 $28.8299 $31.6370 $29.4715
330127 ............................................................................. 1.2802 1.3194 $42.2836 $43.7479 $44.6103 $43.5622
330128 ............................................................................. 1.2008 1.3194 $32.7050 $34.5289 $37.7166 $35.0246
330132 ............................................................................. 1.0872 0.8217 $16.0311 $16.3088 $17.4946 $16.8474
330133 ............................................................................. 1.3209 1.3194 $35.3136 $44.0704 $36.6962 $38.2248
330135 ............................................................................. 1.2321 1.3194 $25.6504 $26.9969 $29.0837 $27.3649
330136 ............................................................................. 1.4834 0.9318 $21.4225 $22.5447 $24.2010 $22.7506
330140 ............................................................................. 1.8029 0.9589 $21.1787 $23.5774 $25.7573 $23.5011
330141 ............................................................................. 1.3062 1.2739 $29.3283 $30.6616 $34.8902 $31.6934
330144 ............................................................................. 1.0366 0.8217 $17.3920 $20.1805 $20.9935 $19.3948
330148 ............................................................................. 1.0270 * $17.6560 $18.5443 * $18.0744
330151 ............................................................................. 1.1181 0.8217 $16.4028 $17.6782 $19.1841 $17.7056
330152 ............................................................................. 1.3111 1.3194 $32.3332 $32.0616 $36.5136 $33.6447
330153 ............................................................................. 1.7109 0.8607 $21.2843 $21.9935 $24.5219 $22.5953
330154 ............................................................................. 1.7188 * * * * *
330157 ............................................................................. 1.3749 0.9318 $23.5522 $23.6939 $25.2312 $24.1798
330158 ............................................................................. 1.5749 1.3194 $32.7159 $33.0067 $32.2990 $32.6514
330159 ............................................................................. 1.4004 0.9589 $22.5580 $24.1916 $28.9094 $25.1161
330160 ............................................................................. 1.5746 1.3194 $32.1266 $34.0373 $34.1960 $33.4347
330162 ............................................................................. 1.2769 1.3194 $29.6042 $31.3812 $32.1783 $31.0913
330163 ............................................................................. 1.2220 0.9503 $21.1517 $22.4644 $24.0200 $22.5391
330164 ............................................................................. 1.4926 0.9123 $23.5427 $24.4306 $28.8481 $25.6753
330166 h ........................................................................... 1.0649 0.8217 $18.4262 $18.8777 $19.4360 $18.9008
330167 ............................................................................. 1.7998 1.2876 $30.9667 $33.7365 $34.4748 $33.1276
330169 ............................................................................. 1.4238 1.3194 $36.2725 $38.3498 $39.3361 $37.9349
330171 ............................................................................. 1.1784 1.3194 $25.9946 $27.7810 $30.0122 $27.7871
330175 ............................................................................. 1.1309 0.8217 $20.4628 $21.1944 $22.2067 $21.3007
330177 ............................................................................. 0.9502 0.8217 $19.0005 $20.1850 $19.6100 $19.6031
330180 ............................................................................. 1.2380 0.8607 $19.8951 $21.9641 $22.1920 $21.3178
330181 ............................................................................. 1.3214 1.3194 $37.1218 $35.9334 $38.5351 $37.1999
330182 ............................................................................. 2.3660 1.3194 $35.2416 $36.3831 $39.6038 $37.1311
330184 ............................................................................. 1.4168 1.3194 $30.7479 $33.2843 $34.4044 $32.7893
330185 ............................................................................. 1.2705 1.2739 $28.9787 $31.0179 $32.3466 $30.8714
330188 ............................................................................. 1.2509 0.9503 $21.1196 $22.6803 $23.9210 $22.6030
330189 ............................................................................. 0.9309 0.8607 $19.0726 $19.2538 $21.6229 $19.9266
330191 ............................................................................. 1.2962 0.8607 $20.9392 $22.3719 $24.0232 $22.4577
330193 ............................................................................. 1.2693 1.3194 $36.2427 $36.9866 $37.1807 $36.8214
330194 ............................................................................. 1.8239 1.3194 $38.5372 $39.9177 $43.9910 $40.8421
330195 ............................................................................. 1.7567 1.3194 $36.4249 $38.6867 $40.0206 $38.4696
330196 ............................................................................. 1.2876 1.3194 $31.1915 $32.5883 $33.2171 $32.3484
330197 ............................................................................. 1.1380 0.8217 $20.8386 $22.3117 $23.4291 $22.2164
330198 ............................................................................. 1.3590 1.2876 $25.3622 $29.5359 $30.5485 $28.5487
330199 ............................................................................. 1.1222 1.3194 $34.1354 $32.7870 $35.0059 $33.9687
330201 ............................................................................. 1.7233 1.3194 $29.3745 $33.3215 $39.3682 $33.7813
330202 ............................................................................. 1.2896 1.3194 $30.7990 $34.3545 $38.0129 $34.5293
330203 ............................................................................. 1.4869 0.9589 $24.7422 $26.2459 $26.5882 $25.8191
330204 ............................................................................. 1.3437 1.3194 $30.3699 $30.3273 $37.6849 $32.8372
330205 ............................................................................. 1.2623 1.3194 $29.0622 $30.0101 $32.1617 $30.4707
330208 ............................................................................. 1.1831 1.3194 $30.6158 $28.2667 $29.6282 $29.4819
330209 ............................................................................. 1.1850 1.2739 $27.7071 $28.7213 $29.7988 $28.7477
330211 ............................................................................. 1.1669 0.8217 $20.8224 $21.1094 $22.9966 $21.6469
330212 ............................................................................. *** * $24.9434 $27.0585 $27.2232 $26.1185
330213 ............................................................................. 1.1274 0.8217 $20.7967 $21.7208 $22.5191 $21.6931
330214 ............................................................................. 1.9195 1.3194 $32.7647 $33.7670 $37.8500 $34.8451
330215 ............................................................................. 1.3208 0.8378 $19.9226 $20.6343 $22.6744 $21.0901

Case-mix FY 2006
330218 ............................................................................. 1.0429 0.9589 $20.6012 $21.4095 $24.1106 $22.0618

330219 ............................................................................. 1.6506 0.9503 $28.7448 $27.7400 $29.3644 $28.6092
330221 ............................................................................. 1.4249 1.3194 $34.9345 $34.7033 $36.5539 $35.4233
330222 ............................................................................. 1.2936 0.8607 $23.5491 $25.9825 $23.9746 $24.4778
330223 ............................................................................. 1.0359 0.8217 $18.8253 $18.4291 $19.4229 $18.9058
330224 ............................................................................. 1.2946 1.0217 $22.7847 $23.9379 $25.7850 $24.1687
330225 ............................................................................. 1.1808 1.2876 $29.1744 $28.9952 $29.2719 $29.1527
330226 ............................................................................. 1.3168 0.9123 $23.5405 $23.4783 $21.8977 $22.8832
330229 h ........................................................................... 1.1793 0.8415 $18.5590 $19.5670 $20.6095 $19.5838
330230 ............................................................................. 1.0030 1.3194 $32.5997 $32.1101 $33.3175 $32.6586
330231 ............................................................................. 1.0147 1.3194 $30.2184 $33.9324 $36.9619 $33.7652
330232 ............................................................................. 1.2013 0.8607 $21.1277 $21.4765 $24.4531 $22.3535
330233 ............................................................................. 1.4520 1.3194 $39.5133 $41.9968 $45.5132 $42.4372
330234 ............................................................................. 2.2916 1.3194 $37.7135 $36.8500 $40.6314 $38.3961
330235 ............................................................................. 1.1373 0.9318 $21.4643 $22.1217 $23.3866 $22.3225
330236 ............................................................................. 1.4476 1.3194 $31.8491 $32.9391 $35.6347 $33.4921
330238 ............................................................................. 1.2736 0.9123 $18.3846 $19.2407 $20.8639 $19.5443
330239 h ........................................................................... 1.2341 0.8415 $19.7561 $20.4936 $21.5397 $20.5927
330240 ............................................................................. 1.2411 1.3194 $37.3866 $40.7478 $39.9450 $39.4043
330241 ............................................................................. 1.8693 0.9589 $26.7598 $27.7213 $29.0882 $27.8974
330242 ............................................................................. 1.3070 1.3194 $30.5172 $32.2178 $33.6926 $32.1583
330245 ............................................................................. 1.9330 0.8378 $20.2037 $21.6857 $22.8003 $21.6000
330246 ............................................................................. 1.3525 1.2739 $31.8857 $31.6763 $34.6329 $32.7279
330247 ............................................................................. 0.9562 1.3194 $25.6063 $32.1733 $32.2300 $29.8298
330249 ............................................................................. 1.2127 0.9589 $19.1469 $21.4345 $22.9834 $21.2588
330250 ............................................................................. 1.2932 0.9278 $22.1272 $23.0641 $25.1664 $23.4900
330259 ............................................................................. 1.4393 1.2876 $27.4131 $30.0488 $31.9152 $29.8816
330261 ............................................................................. 1.2766 1.3194 $30.4771 $30.9356 $30.7942 $30.7386
330263 ............................................................................. 0.9848 0.8217 $20.0831 $20.8456 $22.4675 $21.1560
330264 ............................................................................. 1.2498 1.2739 $26.3652 $28.1501 $30.0139 $28.1122
330265 ............................................................................. 1.2921 0.9123 $18.2547 $19.9414 $20.4635 $19.5583
330267 ............................................................................. 1.4718 1.3194 $29.0499 $30.3709 $31.5478 $30.3522
330268 ............................................................................. 0.9523 0.8217 $18.7991 $18.9142 $20.9720 $19.5863
330270 ............................................................................. 2.0223 1.3194 $36.5976 $38.2605 $42.2111 $39.0845
330273 ............................................................................. 1.4035 1.3194 $28.8548 $29.5106 $30.4720 $29.6353
330276 ............................................................................. 1.1215 0.8280 $20.7973 $21.7826 $22.2353 $21.6210
330277 ............................................................................. 1.1672 0.9195 $21.8866 $25.1438 $25.3582 $24.1682
330279 ............................................................................. 1.4644 0.9503 $23.8793 $23.4816 $25.2130 $24.2253
330285 ............................................................................. 1.9863 0.9123 $26.0446 $27.1260 $27.9018 $27.0364
330286 ............................................................................. 1.3792 1.2739 $31.1344 $32.3244 $33.3552 $32.3237
330290 ............................................................................. 1.7499 1.3194 $35.5617 $36.3764 $36.9981 $36.3009
330293 ............................................................................. *** * $17.6506 $19.0290 * $18.3452
330304 ............................................................................. 1.2859 1.3194 $31.1146 $33.4431 $34.5761 $33.1106
330306 ............................................................................. 1.4713 1.3194 $30.4426 $30.7551 $35.6640 $32.2831
330307 ............................................................................. 1.2230 0.9845 $23.8583 $25.4128 $27.5699 $25.6624
330314 ............................................................................. 1.2551 1.2739 $26.2954 $26.0150 $25.5597 $25.9594
330316 ............................................................................. 1.3011 1.3194 $33.7857 $33.1512 $34.8623 $33.9322
330327 ............................................................................. *** * $19.3465 * * $19.3465
330331 ............................................................................. 1.2271 1.2876 $34.6302 $34.7052 $36.1630 $35.1867
330332 ............................................................................. 1.2639 1.2876 $30.5104 $31.8389 $33.3050 $32.0164
330333 ............................................................................. *** * $29.7725 $33.7637 $26.1917 $29.6723
330336 ............................................................................. *** * $32.9548 * * $32.9548
330338 ............................................................................. *** * $25.4319 $27.3859 $31.3761 $27.9867
330339 ............................................................................. 0.8248 0.8607 $20.8424 $22.2812 $22.6569 $21.9390
330340 ............................................................................. 1.1787 1.2739 $29.8140 $31.4322 $33.9358 $31.7549
330350 ............................................................................. 1.5082 1.3194 $35.5656 $39.3541 $36.6250 $37.1672
330353 ............................................................................. 1.1647 1.3194 $35.6821 $38.6962 $37.6549 $37.3737
330354 ............................................................................. 1.8586 * * * * *
330357 ............................................................................. 1.2969 1.3194 $36.5461 $34.3965 $35.5975 $35.5017
330372 ............................................................................. 1.2646 1.2876 $28.2490 $30.1505 $32.6721 $30.3998
330385 ............................................................................. 1.1337 1.3194 $44.3387 $42.6671 $46.3221 $44.4556
330386 ............................................................................. 1.2201 1.0677 $25.2064 $25.9228 $27.9943 $26.4367
330389 ............................................................................. 1.8679 1.3194 $32.2112 $34.7552 $34.7669 $33.9210
330390 ............................................................................. 1.2873 1.3194 $32.7450 $33.2628 $36.0573 $33.8898
330393 ............................................................................. 1.7555 1.2739 $33.0953 $34.8213 $34.8095 $34.2742
330394 ............................................................................. 1.6386 0.8580 $21.3678 $23.3505 $25.2229 $23.3324
330395 ............................................................................. 1.3987 1.3194 $32.1089 $35.4619 $37.3096 $34.7722

Case-mix FY 2006
330396 ............................................................................. 1.3734 1.3194 $31.2429 $32.5345 $35.0297 $32.9828

330397 ............................................................................. 1.3696 1.3194 $40.0884 $34.5110 $38.4741 $37.5361
330399 ............................................................................. 1.1728 1.3194 $32.1248 $33.6753 $32.3688 $32.7392
330401 ............................................................................. 1.3252 1.2739 $33.8633 $35.7435 $40.6249 $36.8252
330402 ............................................................................. 0.8016 * * $21.3302 * $21.3302
330403 ............................................................................. *** * * * $23.1887 $23.1887
340001 ............................................................................. 1.4865 0.9707 $21.6113 $23.2436 $25.0041 $23.2441
340002 ............................................................................. 1.7550 0.9577 $24.0145 $25.1099 $27.3349 $25.5169
340003 ............................................................................. 1.1019 0.8544 $20.8205 $21.5562 $23.3066 $21.9251
340004 ............................................................................. 1.4225 0.9124 $23.3756 $24.2055 $25.4474 $24.3851
340005 ............................................................................. 1.0112 0.8544 $20.8150 $22.9830 $22.3814 $22.0177
340007 ............................................................................. *** * $19.5208 $21.1519 * $20.3174
340008 ............................................................................. 1.0967 0.9577 $22.7338 $24.2089 $26.6314 $24.5355
340010 ............................................................................. 1.3267 0.9411 $21.3024 $23.1349 $24.5666 $23.0280
340011 ............................................................................. 1.0555 0.8544 $18.1926 $18.1843 $19.9484 $18.7756
340012 ............................................................................. 1.2913 0.8544 $19.6350 $22.0583 $22.7189 $21.4818
340013 ............................................................................. 1.2464 0.9577 $21.0066 $22.4787 $23.0261 $22.1688
340014 ............................................................................. 1.5408 0.8951 $22.6757 $24.4831 $25.1872 $24.1069
340015 h ........................................................................... 1.3668 0.9974 $24.3410 $24.3870 $26.2276 $25.0387
340016 ............................................................................. 1.2189 0.8544 $20.2859 $22.7574 $23.0359 $22.0228
340017 ............................................................................. 1.2705 0.9303 $21.7083 $22.8879 $23.8229 $22.8228
340018 ............................................................................. 1.1437 0.9174 $17.3480 $20.3840 $23.7243 $20.2881
340019 ............................................................................. 0.9714 * $16.7901 $17.8768 * $17.3292
340020 ............................................................................. 1.2008 0.8751 $21.3385 $24.1955 $23.7995 $23.1233
340021 ............................................................................. 1.3123 0.9577 $22.9208 $23.6884 $26.0995 $24.2587
340022 ............................................................................. *** * $19.9078 * * $19.9078
340023 ............................................................................. 1.3810 0.9702 $22.3590 $23.2844 $24.4897 $23.4088
340024 ............................................................................. 1.1661 0.8544 $20.4906 $21.2671 $22.2521 $21.3515
340025 ............................................................................. 1.2517 0.9303 $20.2864 $20.9915 $21.2276 $20.8493
340027 ............................................................................. 1.1715 0.9404 $21.0975 $22.6107 $23.6326 $22.4564
340028 ............................................................................. 1.5576 0.9417 $22.2028 $24.6836 $26.3298 $24.3471
340030 ............................................................................. 2.0547 1.0200 $26.7753 $27.4664 $29.0122 $27.8175
340032 ............................................................................. 1.3999 0.9707 $23.2204 $24.8031 $26.7475 $25.0122
340035 ............................................................................. 1.0339 0.8544 $16.4821 $21.2407 $23.5476 $20.1377
340036 ............................................................................. 1.1813 0.9668 $20.8313 $22.2089 $25.2077 $22.9528
340037 ............................................................................. 1.0074 0.8760 $21.9524 $22.5089 $21.6411 $22.0344
340038 ............................................................................. 1.2006 0.8544 $13.9936 $14.0203 $14.0713 $14.0327
340039 ............................................................................. 1.2892 0.9577 $24.8246 $25.6605 $27.1275 $25.9204
340040 ............................................................................. 1.9383 0.9404 $22.4777 $24.1523 $26.3325 $24.3631
340041 ............................................................................. 1.2382 0.8930 $17.6319 $23.0497 $23.6600 $21.2911
340042 ............................................................................. 1.1026 0.8544 $21.1107 $22.1107 $23.0236 $22.0702
340044 ............................................................................. 0.9463 * $18.2154 $21.7089 * $19.7398
340045 ............................................................................. 0.9932 * $17.4066 $14.5004 $23.1918 $18.0750
340047 ............................................................................. 1.9018 0.8951 $22.5199 $25.3727 $25.0605 $24.3496
340049 ............................................................................. 2.0187 1.0200 $21.2734 $22.3082 $30.4827 $24.7548
340050 ............................................................................. 1.1060 0.9183 $20.3262 $21.4511 $24.2533 $22.0481
340051 ............................................................................. 1.2486 0.8930 $20.3057 $21.9069 $23.4091 $21.9456
340053 ............................................................................. 1.6016 0.9707 $24.9768 $26.9361 $27.7261 $26.5947
340055 ............................................................................. 1.2426 0.8930 $23.2990 $24.3728 $24.1057 $23.9407
340060 ............................................................................. 1.0677 0.9124 $20.8077 $22.4303 $22.8657 $22.0570
340061 ............................................................................. 1.8016 1.0200 $25.1081 $26.6657 $27.5594 $26.4994
340064 ............................................................................. 1.0923 0.8544 $19.4523 $22.3631 $22.9143 $21.5916
340065 ............................................................................. 1.1839 * $20.3296 $20.8413 * $20.5941
340067 ............................................................................. *** * $22.2565 * * $22.2565
340068 ............................................................................. 1.2128 0.9384 $19.4487 $20.8600 $21.8830 $20.7420
340069 ............................................................................. 1.8902 0.9944 $24.4650 $27.5045 $27.4473 $26.5163
340070 ............................................................................. 1.2747 0.9341 $22.2605 $23.6045 $24.9033 $23.6142
340071 ............................................................................. 1.1357 0.9411 $19.9561 $22.1854 $25.4537 $22.5747
340072 ............................................................................. 1.1901 0.8544 $19.2773 $21.3320 $23.1163 $21.1853
340073 ............................................................................. 1.3885 0.9944 $26.6829 $29.4189 $30.2061 $28.9141
340075 ............................................................................. 1.2198 0.8930 $23.2904 $24.1297 $26.0225 $24.4391
340084 ............................................................................. 1.1791 0.9707 $20.8175 $21.3227 $21.2580 $21.1447
340085 h ........................................................................... 1.1632 0.9501 $21.7112 $23.0890 $23.9793 $22.8869
340087 ............................................................................. 1.1851 0.8544 $17.8215 $18.4202 $22.0070 $19.3351
340088 ............................................................................. 1.3435 * $22.8687 $24.3299 * $23.5994
340090 ............................................................................. 1.2399 0.9668 $20.3261 $21.7173 $23.4542 $21.9222
340091 ............................................................................. 1.5409 0.9124 $23.1430 $24.9411 $25.8266 $24.6682

Case-mix FY 2006
340096 h ........................................................................... 1.2085 0.9501 $22.1174 $23.6345 $25.2169 $23.6523

340097 ............................................................................. 1.1856 0.8544 $20.8690 $22.5775 $24.2127 $22.5886
340098 ............................................................................. 1.4560 0.9707 $24.2262 $25.4823 $27.3308 $25.7030
340099 ............................................................................. 1.1870 0.8544 $17.5114 $20.0178 $20.3683 $19.3181
340104 ............................................................................. 0.8501 0.8760 $12.9949 $14.3252 $15.7521 $14.3947
340106 ............................................................................. 1.0879 0.8544 $20.1076 $22.6979 $22.4894 $21.8047
340107 ............................................................................. 1.2195 0.8915 $21.0960 $22.5583 $22.9698 $22.2242
340109 ............................................................................. 1.3280 0.8832 $20.4341 $22.3826 $23.4419 $22.1467
340113 ............................................................................. 1.8763 0.9707 $25.0729 $26.0776 $28.2568 $26.5148
340114 ............................................................................. 1.6302 0.9944 $19.9142 $25.4533 $26.6813 $23.7911
340115 ............................................................................. 1.6059 0.9944 $23.8284 $25.1907 $25.0212 $24.7040
340116 ............................................................................. 1.7294 0.8930 $23.9643 $26.1641 $25.3213 $25.1777
340119 ............................................................................. 1.1322 0.9707 $21.2239 $22.4821 $24.2287 $22.6894
340120 ............................................................................. 1.0480 0.8544 $19.9860 $21.8548 $23.0916 $21.7078
340121 ............................................................................. 1.0504 0.9570 $19.9409 $20.3701 $21.7576 $20.7129
340123 ............................................................................. 1.1938 0.9124 $22.3711 $23.1879 $26.1083 $23.9306
340124 ............................................................................. 1.0787 0.9411 $17.5691 $18.3866 $20.8018 $18.8482
340126 h ........................................................................... 1.2300 0.9411 $21.4271 $23.5405 $25.0189 $23.3764
340127 ............................................................................. 1.1727 0.9944 $22.9672 $24.6096 $25.7831 $24.5262
340129 ............................................................................. 1.2525 0.9577 $22.3260 $24.1356 $25.4902 $24.1365
340130 ............................................................................. 1.3763 0.9707 $22.7687 $23.0937 $25.2941 $23.7854
340131 ............................................................................. 1.5307 0.9404 $24.1370 $25.2989 $27.9358 $25.8415
340132 ............................................................................. 1.2002 0.8544 $17.8771 $20.4222 $21.3521 $19.8892
340133 ............................................................................. 1.0161 0.8852 $23.1444 $22.1588 $22.5558 $22.6188
340137 ............................................................................. 1.0101 0.8930 $33.1751 $29.9903 $21.0642 $28.4915
340138 ............................................................................. 0.8487 0.9944 $29.5286 $27.4767 $21.3670 $26.2644
340141 ............................................................................. 1.6488 0.9570 $24.2033 $24.8132 $27.3355 $25.5266
340142 ............................................................................. 1.1830 0.8544 $20.4320 $22.1298 $22.9907 $21.8836
340143 ............................................................................. 1.4873 0.8930 $23.0416 $24.8904 $25.3633 $24.4002
340144 ............................................................................. 1.2457 0.9577 $25.4598 $25.6538 $27.2686 $26.1330
340145 ............................................................................. 1.2943 0.9577 $21.8120 $23.7028 $23.7131 $23.0768
340146 ............................................................................. 1.0635 * $20.7252 $18.8354 * $19.6880
340147 ............................................................................. 1.2141 0.9411 $22.6057 $23.9998 $25.4534 $24.0568
340148 ............................................................................. 1.3490 0.8951 $20.8156 $22.4205 $23.5880 $22.2985
340151 ............................................................................. 1.1115 0.8544 $19.2593 $22.2613 $22.0052 $21.1161
340153 ............................................................................. 1.8758 0.9707 $23.7426 $25.7078 $26.4896 $25.3204
340155 ............................................................................. 1.4344 1.0200 $26.3663 $28.8758 $30.4940 $28.6096
340156 ............................................................................. 0.8242 1.4448 * * * *
340158 ............................................................................. 1.1147 0.9570 $21.7489 $23.4724 $26.4849 $23.8953
340159 ............................................................................. 1.1662 1.0200 $21.2983 $22.1872 $23.2991 $22.2743
340160 ............................................................................. 1.2859 0.8544 $18.7569 $19.1330 $20.7525 $19.5589
340166 ............................................................................. 1.3711 0.9707 $22.8349 $25.7398 $26.0557 $24.9254
340168 ............................................................................. 0.3956 * $16.8278 $16.8076 $17.3249 $17.0046
340171 ............................................................................. 1.1940 0.9707 $25.9603 $27.2074 $28.2734 $27.2246
340173 ............................................................................. 1.2567 0.9944 $23.7037 $26.6128 $27.5072 $26.0994
340176 ............................................................................. *** * $26.5277 * * $26.5277
340177 ............................................................................. 1.0581 0.8544 * * $24.7471 $24.7471
340178 ............................................................................. *** * * * $28.7219 $28.7219
340181 ............................................................................. 2.1149 0.9303 * * * *
340182 ............................................................................. 2.7404 1.0200 * * * *
350002 ............................................................................. 1.7344 0.8769 $20.4398 $20.6474 $22.0283 $21.0339
350003 ............................................................................. 1.1648 0.8769 $21.0585 $25.3076 $21.8061 $22.5764
350004 ............................................................................. *** * $28.3773 $27.5891 * $28.0246
350006 ............................................................................. 1.6936 0.8769 $19.7577 $19.5870 $19.4985 $19.5737
350009 ............................................................................. 1.0850 0.8769 $20.2558 $20.7014 $23.0873 $21.3437
350010 ............................................................................. 1.0994 0.8769 $17.2489 $18.5682 $19.1965 $18.3109
350011 ............................................................................. 1.9994 0.8769 $21.9111 $22.3896 $23.1947 $22.5594
350014 ............................................................................. 0.9136 0.8769 $16.1718 $18.5360 $17.7565 $17.4777
350015 ............................................................................. 1.7120 0.8769 $18.5437 $18.6381 $20.1161 $19.1124
350017 ............................................................................. 1.4490 0.8769 $19.1952 $20.1943 $21.0243 $20.1512
350019 2 ........................................................................... 1.6909 0.8769 $21.3589 $24.2382 $22.1960 $22.5332
350027 ............................................................................. 1.0607 * $17.6731 $14.2262 * $15.5713
350030 ............................................................................. 0.9611 0.8769 $18.8822 $19.2282 $18.9978 $19.0373
350043 ............................................................................. *** * $18.8378 $20.9732 * $19.9618
350058 ............................................................................. 0.9761 * $15.0196 * * $15.0196
350061 ............................................................................. 1.0550 * $18.8494 $18.6546 $22.0515 $19.8387
350063 ............................................................................. 0.9163 1.4448 * * * *

Case-mix FY 2006
350064 ............................................................................. 0.8946 1.4448 * * * *

350070 ............................................................................. 1.9464 0.8769 * $24.4464 $25.2836 $24.8833
360001 ............................................................................. 1.3631 0.9595 $22.2387 $23.7750 $23.9101 $23.2970
360002 ............................................................................. 1.2126 0.8826 $20.7586 $22.6923 $24.5789 $22.7274
360003 ............................................................................. 1.8536 0.9595 $24.4144 $26.3180 $27.5029 $26.0650
360006 ............................................................................. 2.0518 0.9857 $24.0814 $25.7041 $28.1698 $26.0230
360007 ............................................................................. *** * $19.1315 * * $19.1315
360008 ............................................................................. 1.3213 0.9110 $21.3795 $23.2545 $24.5714 $23.1202
360009 ............................................................................. 1.6004 0.9271 $22.4076 $23.2659 $23.1012 $22.9250
360010 ............................................................................. 1.2000 0.8970 $20.6290 $22.0262 $23.1178 $21.9858
360011 ............................................................................. 1.3439 0.9857 $21.4293 $22.4482 $25.5340 $23.0257
360012 ............................................................................. 1.3892 0.9857 $24.3618 $25.5913 $27.5470 $25.9629
360013 ............................................................................. 1.1054 0.9271 $24.4232 $25.1588 $26.8129 $25.4875
360014 ............................................................................. 1.1501 0.9857 $22.9372 $23.8305 $25.3861 $24.0832
360016 ............................................................................. 1.4438 0.9595 $22.8430 $24.6587 $26.1283 $24.5377
360017 ............................................................................. 1.7459 0.9857 $23.6181 $25.4969 $27.2910 $25.5905
360018 ............................................................................. *** * $29.9085 * * $29.9085
360019 ............................................................................. 1.3001 0.9207 $23.3006 $24.1105 $25.5926 $24.3472
360020 ............................................................................. 1.6459 0.9207 $21.5085 $22.3795 $24.4343 $22.8262
360024 ............................................................................. *** * $22.5356 $24.0612 $23.5793 $23.3219
360025 ............................................................................. 1.4264 0.9207 $21.6676 $23.6574 $25.5633 $23.7829
360026 ............................................................................. 1.2976 0.9060 $20.8825 $22.3303 $23.5898 $22.2676
360027 ............................................................................. 1.6880 0.9207 $23.5907 $24.7093 $25.4894 $24.6187
360029 ............................................................................. 1.0971 0.9564 $20.4924 $20.8778 $22.7785 $21.4073
360031 ............................................................................. *** * $24.3482 $24.4324 * $24.3900
360032 h ........................................................................... 1.1348 0.9271 $21.1743 $22.9759 $23.2638 $22.4807
360034 ............................................................................. 1.1011 * $21.5621 $25.1366 * $23.3553
360035 ............................................................................. 1.7292 0.9857 $24.2433 $25.6895 $27.5220 $25.8774
360036 ............................................................................. 1.2246 0.9207 $22.3567 $25.0910 $27.6094 $25.0649
360037 ............................................................................. 1.3805 0.9207 $32.6245 $25.1615 $24.3982 $26.6839
360038 ............................................................................. 1.4223 0.9595 $23.4855 $24.8294 $22.8009 $23.7144
360039 ............................................................................. 1.4979 0.9857 $23.4642 $22.5921 $24.0218 $23.3755
360040 ............................................................................. 1.1570 0.8826 $21.3307 $22.8729 $24.0942 $22.7498
360041 ............................................................................. 1.4614 0.9207 $22.1352 $23.2625 $24.1080 $23.2048
360044 ............................................................................. 1.0733 0.8826 $19.7212 $20.4724 $21.8411 $20.6845
360046 ............................................................................. 1.2105 0.9595 $22.8425 $23.8918 $25.0775 $23.9800
360047 ............................................................................. 0.9609 0.8826 $17.5885 $17.1973 $21.7248 $18.9388
360048 ............................................................................. 1.7734 0.9564 $24.7150 $27.2274 $28.8107 $26.8831
360049 ............................................................................. 1.1590 0.9207 $22.4939 $24.2605 $25.8367 $24.2864
360051 ............................................................................. 1.6784 0.9060 $23.0658 $25.1785 $25.7556 $24.7297
360052 ............................................................................. 1.5709 0.9060 $22.5005 $23.3285 $24.5405 $23.5101
360054 ............................................................................. 1.2960 0.8826 $19.2884 $20.3176 $23.0376 $20.9178
360055 ............................................................................. 1.4051 0.8826 $23.5586 $25.1475 $26.3112 $24.9991
360056 ............................................................................. 1.5598 0.9595 $22.4475 $23.4638 $23.1024 $22.9631
360058 ............................................................................. 1.1320 0.8826 $21.0768 $22.7943 $23.4429 $22.4519
360059 ............................................................................. 1.4973 0.9207 $23.0775 $25.5222 $25.3516 $24.6433
360062 ............................................................................. 1.5523 0.9857 $24.5746 $26.8091 $28.6518 $26.7475
360064 ............................................................................. 1.5736 0.8826 $21.3424 $22.8729 $22.2393 $22.1811
360065 ............................................................................. 1.2094 0.9207 $22.9727 $24.0868 $26.3036 $24.5445
360066 ............................................................................. 1.5723 0.9271 $24.6806 $25.2316 $27.3362 $25.7779
360068 ............................................................................. 1.8628 0.9564 $22.1110 $23.7895 $25.8414 $23.9678
360069 ............................................................................. 1.1368 0.9564 $20.5349 $25.7032 $24.2444 $23.4234
360070 ............................................................................. 1.6666 0.8976 $21.8228 $23.1687 $24.8863 $23.3191
360071 h ........................................................................... 1.2226 0.9271 $21.4478 $21.6176 $22.0786 $21.6950
360072 ............................................................................. 1.4007 0.9857 $21.3736 $23.0464 $24.4332 $23.0100
360074 ............................................................................. 1.2667 0.9564 $22.2368 $23.6172 $24.9055 $23.6214
360075 ............................................................................. 1.2223 0.9207 $23.8492 $24.7610 $26.8453 $25.2573
360076 ............................................................................. 1.4070 0.9595 $22.5863 $22.5943 $25.9369 $23.7285
360077 ............................................................................. 1.5522 0.9207 $23.3686 $24.7086 $25.6505 $24.5864
360078 ............................................................................. 1.2933 0.9207 $23.3799 $24.6821 $26.1313 $24.7447
360079 ............................................................................. 1.7728 0.9595 $25.9623 $25.8762 $26.0935 $25.9804
360080 ............................................................................. 1.0799 0.8826 $18.7213 $19.5436 $20.8309 $19.7267
360081 ............................................................................. 1.3290 0.9564 $22.1973 $25.1439 $27.5695 $24.8761
360082 ............................................................................. 1.4058 0.9207 $25.2254 $27.4264 $27.1197 $26.6255
360084 ............................................................................. 1.5637 0.8976 $23.3257 $25.2059 $25.8415 $24.8445
360085 ............................................................................. 2.0948 0.9857 $24.6618 $27.5792 $29.0081 $27.1579
360086 ............................................................................. 1.5369 0.9060 $21.5983 $22.3005 $22.1859 $22.0265

Case-mix FY 2006
360087 ............................................................................. 1.4204 0.9207 $23.9638 $25.9131 $25.4040 $25.0901

360089 ............................................................................. 1.1248 0.8826 $21.0229 $21.0253 $22.7951 $21.6142
360090 ............................................................................. 1.4961 0.9564 $22.6236 $24.4291 $26.7717 $24.5859
360091 ............................................................................. 1.2239 0.9207 $23.5759 $26.0541 $27.5067 $25.7352
360092 ............................................................................. 1.2370 0.9857 $21.9732 $23.5100 $25.6618 $23.7647
360093 ............................................................................. 1.0538 * $21.4623 $24.1238 * $22.7886
360094 ............................................................................. *** * $22.6440 $27.1864 $26.6348 $24.9723
360095 ............................................................................. 1.3015 0.9271 $23.6518 $24.6984 $26.1275 $24.8802
360096 ............................................................................. 1.0962 0.8826 $22.0673 $22.2333 $24.6317 $22.9802
360098 ............................................................................. 1.4207 0.9207 $22.7644 $23.6413 $24.8447 $23.7933
360099 ............................................................................. *** * $20.8524 * * $20.8524
360100 ............................................................................. 1.2206 0.8976 $21.5911 $19.0616 $23.0561 $21.0569
360101 ............................................................................. 1.4001 0.9207 $26.2875 $27.7584 $26.6208 $26.9092
360102 ............................................................................. 1.0721 0.9207 * * * *
360106 ............................................................................. 1.0956 * $19.8658 $21.6450 $24.1588 $21.9428
360107 ............................................................................. 1.0610 0.9207 $23.6880 $24.5365 $25.9697 $24.7438
360109 ............................................................................. 1.1010 0.8826 $23.0178 $24.3236 $25.4184 $24.2613
360112 ............................................................................. 2.0624 1.0570 $25.5910 $26.7880 $28.6784 $26.9982
360113 ............................................................................. 1.2545 0.9595 $22.3348 $23.5138 $25.6493 $23.7408
360115 ............................................................................. 1.2688 0.9207 $22.3926 $24.0232 $24.0052 $23.4857
360116 ............................................................................. 1.2736 0.9595 $21.3809 $23.4049 $18.0655 $20.9510
360118 ............................................................................. 1.5074 0.9902 $23.0070 $24.2526 $27.7289 $25.0968
360121 ............................................................................. 1.2399 1.0570 $23.2515 $25.2037 $24.5592 $24.3452
360123 ............................................................................. 1.4309 0.9207 $23.1310 $24.1761 $22.6523 $23.2730
360125 ............................................................................. 1.1911 0.9207 $21.1408 $22.6871 $22.1096 $21.9849
360126 ............................................................................. *** * $22.2409 * * $22.2409
360128 ............................................................................. 1.0897 * $18.0356 $18.5954 $21.0066 $19.1903
360129 ............................................................................. 0.9502 * $17.9151 $19.5336 * $18.7493
360130 ............................................................................. 1.4589 0.9207 $20.1257 $21.7015 $22.9762 $21.5955
360131 ............................................................................. 1.2615 0.8976 $21.7838 $23.1730 $24.0495 $23.0299
360132 ............................................................................. 1.2590 0.9595 $23.4179 $25.7991 $25.9453 $25.1258
360133 ............................................................................. 1.6363 0.9060 $22.0958 $23.9457 $24.6208 $23.6001
360134 ............................................................................. 1.7249 0.9595 $23.6817 $25.3013 $29.2975 $26.0944
360137 ............................................................................. 1.7024 0.9207 $23.8947 $25.7647 $26.9522 $25.5442
360141 ............................................................................. 1.6707 0.8826 $25.1442 $31.0127 $27.7085 $27.9618
360142 ............................................................................. 0.9787 0.8826 $20.6728 $21.2084 $22.1610 $21.3780
360143 ............................................................................. 1.3313 0.9207 $22.2275 $23.8938 $24.6306 $23.6169
360144 ............................................................................. 1.3548 0.9207 $24.7973 $26.7160 $25.7079 $25.7641
360145 ............................................................................. 1.7973 0.9207 $22.4813 $23.4743 $25.8268 $23.9319
360147 ............................................................................. 1.3819 0.8826 $20.0409 $22.7172 $24.1953 $22.4020
360148 ............................................................................. 1.0643 0.8826 $21.3211 $24.4873 $26.1946 $24.0470
360150 ............................................................................. 1.2073 0.9207 $24.8485 $25.8703 $24.7667 $25.1568
360151 ............................................................................. 1.5213 0.8976 $21.7215 $22.2179 $24.8629 $22.8949
360152 ............................................................................. 1.5274 0.9857 $22.9352 $24.9894 $27.9147 $25.0211
360153 ............................................................................. 0.9727 0.8826 $17.3367 $19.0844 $19.0226 $18.4206
360154 ............................................................................. 0.9978 * $16.2416 $17.1274 * $16.6874
360155 ............................................................................. 1.5088 0.9207 $23.0020 $23.9466 $25.3909 $24.1471
360156 ............................................................................. 1.1585 0.9039 $21.2853 $22.6709 $24.0510 $22.6856
360159 ............................................................................. 1.2447 0.9857 $23.3359 $25.7108 $33.1613 $27.1828
360161 ............................................................................. 1.3756 0.8826 $21.5114 $22.6005 $24.3792 $22.8785
360163 ............................................................................. 1.9069 0.9595 $23.1500 $25.7966 $26.9728 $25.2619
360170 ............................................................................. 1.2023 0.9857 $22.2815 $22.9359 $24.3620 $23.3031
360172 ............................................................................. 1.4108 0.9207 $22.7104 $23.4727 $26.3501 $24.1960
360174 ............................................................................. 1.2246 0.9060 $21.7129 $22.8167 $24.9990 $23.2230
360175 ............................................................................. 1.2182 0.9857 $22.7887 $24.6152 $26.5949 $24.7311
360177 ............................................................................. 1.1637 0.8826 $20.8194 $23.4256 $24.4712 $22.9543
360178 ............................................................................. *** * $18.2393 * * $18.2393
360179 ............................................................................. 1.5758 0.9595 $23.0678 $25.9429 $28.8645 $26.0273
360180 ............................................................................. 2.2433 0.9207 $25.1499 $26.8720 $26.1514 $26.0861
360185 ............................................................................. 1.1997 0.8826 $21.1245 $21.8641 $23.7173 $22.2403
360187 ............................................................................. 1.5882 0.9060 $21.9499 $23.8362 $24.8173 $23.5639
360189 ............................................................................. 1.1305 0.9857 $20.0275 $24.2512 $24.2136 $22.8164
360192 ............................................................................. 1.3344 0.9207 $24.9995 $26.2976 $26.7577 $26.0512
360194 ............................................................................. 1.1621 * $20.3677 $22.3297 * $21.3611
360195 ............................................................................. 1.0805 0.9207 $23.1897 $25.8043 $26.1280 $25.1222
360197 ............................................................................. 1.1010 0.9857 $23.1378 $24.7539 $27.0896 $25.0381
360203 ............................................................................. 1.1587 0.8826 $19.3642 $21.5564 $22.1414 $21.0862

Case-mix FY 2006
360210 ............................................................................. 1.1833 0.9857 $25.0811 $26.5665 $27.8415 $26.5578

360211 ............................................................................. 1.5671 0.8832 $22.4529 $23.0884 $22.5449 $22.6945
360212 ............................................................................. 1.3858 0.9207 $22.8041 $24.5310 $25.2756 $24.2166
360218 ............................................................................. 1.1880 0.9857 $22.8060 $24.4720 $27.4288 $25.0106
360230 ............................................................................. 1.6262 0.9207 $24.7681 $26.6444 $27.0223 $26.1931
360234 ............................................................................. 1.3217 0.9595 $22.1787 $23.3325 $24.3625 $23.2666
360236 ............................................................................. 1.1633 0.9595 $22.8821 $21.3795 $35.8144 $24.3729
360239 ............................................................................. 1.3270 0.9060 $23.5802 $24.4398 $25.2474 $24.5362
360241 ............................................................................. *** * $23.4061 $24.8089 $24.7001 $24.1133
360242 ............................................................................. 1.9421 * * * * *
360245 ............................................................................. 0.5583 0.9207 $18.1015 $18.7966 $19.1885 $18.7327
360247 ............................................................................. 0.3956 0.9857 * $25.1083 $19.8892 $22.3390
360253 ............................................................................. 2.2766 0.9060 $31.3006 $28.2555 $30.4276 $29.8452
360254 ............................................................................. *** * $30.0792 * * $30.0792
360255 ............................................................................. *** * $15.0963 * * $15.0963
360257 ............................................................................. 1.0823 * * $17.9652 * $17.9652
360259 ............................................................................. 1.2034 0.9564 * * $25.1338 $25.1338
360260 ............................................................................. *** * * * $27.3903 $27.3903
360261 ............................................................................. 1.8245 0.9473 * * $22.5431 $22.5431
360262 ............................................................................. 1.3722 0.9564 * * $27.1680 $27.1680
360263 ............................................................................. 1.7091 0.9271 * * $20.8884 $20.8884
360264 ............................................................................. 2.2623 0.9595 * * * *
360265 ............................................................................. 2.0629 0.8826 * * * *
360266 ............................................................................. 2.0862 0.9857 * * * *
360267 ............................................................................. 2.5734 0.8976 * * * *
360268 ............................................................................. 1.1877 0.9060 * * * *
370001 ............................................................................. 1.7009 0.8569 $25.5838 $26.2391 $27.7245 $26.5391
370002 ............................................................................. 1.1857 0.7607 $18.9544 $19.7718 $20.1479 $19.6308
370004 ............................................................................. 1.1013 0.8450 $21.5041 $24.7694 $25.3919 $23.7972
370006 ............................................................................. 1.2175 0.7607 $15.6333 $16.9469 $20.1063 $17.6384
370007 ............................................................................. 1.0578 0.7607 $16.7598 $17.2084 $17.6547 $17.2160
370008 ............................................................................. 1.3926 0.9034 $22.1596 $22.7419 $24.2978 $23.1423
370011 ............................................................................. 1.0967 0.9034 $17.1458 $19.2266 $19.7821 $18.6737
370013 ............................................................................. 1.5307 0.9034 $21.1512 $22.6451 $24.9295 $22.9792
370014 ............................................................................. 1.0503 0.8962 $21.8473 $24.8138 $25.3576 $24.0194
370015 ............................................................................. 0.9755 0.8569 $20.3966 $21.1833 $23.6693 $21.7009
370016 h ........................................................................... 1.5144 0.8673 $20.4407 $24.2737 $25.4062 $23.3330
370018 ............................................................................. 1.4275 0.8569 $20.8357 $23.4286 $23.5336 $22.5984
370019 ............................................................................. 1.2367 0.7607 $18.1260 $19.6761 $21.4474 $19.7475
370020 ............................................................................. 1.2396 0.7607 $16.8631 $17.4835 $18.5046 $17.6368
370022 ............................................................................. 1.2026 0.7666 $20.2432 $18.4217 $19.6495 $19.4375
370023 ............................................................................. 1.2518 0.7691 $19.3386 $20.6002 $21.5762 $20.5441
370025 ............................................................................. 1.2688 0.8569 $20.2845 $22.0287 $23.5659 $21.9757
370026 h ........................................................................... 1.5389 0.8673 $21.9140 $22.5734 $23.0848 $22.5236
370028 ............................................................................. 1.8670 0.9034 $24.1009 $24.8661 $26.6153 $25.1976
370029 ............................................................................. 1.0497 0.7607 $19.5811 $22.1163 $23.9956 $21.8559
370030 ............................................................................. 1.0482 0.7607 $18.6541 $20.3315 $23.3037 $20.7201
370032 ............................................................................. 1.4610 0.9034 $20.0827 $21.6029 $23.4843 $21.7536
370034 ............................................................................. 1.2055 0.7998 $16.1540 $17.6247 $18.2341 $17.3349
370036 ............................................................................. 1.0269 0.7607 $16.5844 $16.9222 $17.7576 $17.1504
370037 ............................................................................. 1.6819 0.9034 $21.0719 $23.1256 $23.9685 $22.7803
370039 ............................................................................. 1.0974 0.8569 $20.3137 $21.0793 $21.8220 $21.0783
370040 ............................................................................. 1.0217 0.8247 $18.9981 $21.1061 $22.4048 $20.8291
370041 ............................................................................. 0.8941 0.8569 $19.0144 $22.0082 $22.3496 $21.1267
370042 ............................................................................. 0.9463 * $14.0899 $15.3613 * $14.7180
370043 ............................................................................. 0.9527 * $20.2929 $21.5588 * $20.9707
370045 ............................................................................. 0.9173 * $12.6613 $14.6370 * $13.6711
370047 ............................................................................. 1.4476 0.8962 $19.4856 $19.7112 $20.4657 $19.9082
370048 ............................................................................. 1.1085 0.7607 $15.4768 $17.7273 $19.2464 $17.4431
370049 ............................................................................. 1.3041 0.9034 $20.4826 $21.6878 $23.2171 $21.8100
370051 ............................................................................. 1.0513 0.7607 $12.0397 $14.6254 $17.2618 $14.4702
370054 ............................................................................. 1.2607 0.7607 $20.3788 $21.5521 $21.5043 $21.1653
370056 ............................................................................. 1.6327 0.7908 $20.4872 $21.7647 $22.0312 $21.4507
370057 ............................................................................. 0.9482 0.8569 $17.3020 $18.0426 $19.7284 $18.3749
370060 ............................................................................. 0.9366 0.8569 $23.1897 $23.8007 $18.7592 $21.7395
370064 ............................................................................. 0.9040 0.7607 $11.9044 $14.1879 $14.2053 $13.4809
370065 ............................................................................. 1.0317 0.7728 $18.3966 $20.6537 $20.0226 $19.6691

Case-mix FY 2006
370072 ............................................................................. 0.8151 0.7607 $12.5765 $14.6387 $9.9616 $11.8723

370076 ............................................................................. *** * $19.0230 $21.5461 * $20.2863
370078 ............................................................................. 1.6275 0.8569 $22.2318 $23.9507 $25.4068 $23.9046
370080 ............................................................................. 0.9012 0.7607 $16.1444 $17.4857 $18.0665 $17.2314
370082 ............................................................................. *** * $12.6060 * * $12.6060
370083 ............................................................................. 0.9426 0.7607 $18.5669 $15.3447 $16.8836 $16.8841
370084 ............................................................................. 0.9728 0.7607 $16.1278 $17.2735 $16.6514 $16.7384
370089 ............................................................................. 1.0828 0.7607 $18.0505 $19.9021 $20.4699 $19.4850
370091 ............................................................................. 1.7106 0.8569 $24.2117 $22.9893 $23.3357 $23.4867
370093 ............................................................................. 1.6481 0.9034 $23.5685 $25.7296 $26.9774 $25.3740
370094 ............................................................................. 1.4086 0.9034 $20.6507 $22.0591 $23.1191 $21.9907
370095 ............................................................................. 0.8962 * $14.3563 $16.5310 * $15.4277
370097 ............................................................................. 1.3020 0.7908 $20.3218 $21.7150 $22.3267 $21.5064
370099 ............................................................................. 1.0107 0.8569 $20.2001 $20.5217 $20.5075 $20.4227
370100 ............................................................................. 0.9798 0.7607 $13.0681 $14.1883 $14.7712 $14.0181
370103 ............................................................................. 0.9470 0.8053 $15.6110 $16.1408 $17.8018 $16.5505
370105 ............................................................................. 1.8538 0.9034 $22.4493 $22.1584 $23.8978 $22.8583
370106 ............................................................................. 1.3548 0.9034 $24.1115 $24.2393 $26.5867 $25.0105
370108 ............................................................................. *** * $13.8170 * * $13.8170
370112 ............................................................................. 0.9371 0.8247 $16.5965 $15.4941 $15.4471 $15.8101
370113 ............................................................................. 1.1531 0.8707 $21.4267 $23.3011 $25.3565 $23.3322
370114 ............................................................................. 1.5662 0.8569 $19.4933 $21.0603 $21.7880 $20.8230
370123 ............................................................................. *** * $20.5180 $22.8174 $25.4733 $22.7986
370125 ............................................................................. 0.8604 * $17.9240 $17.2013 $17.1361 $17.4038
370138 ............................................................................. 1.0236 0.7607 $19.0403 $19.8308 $18.3113 $19.0435
370139 ............................................................................. 0.9440 0.7607 $16.3224 $17.8900 $18.5225 $17.5400
370141 ............................................................................. *** * $24.7859 * * $24.7859
370148 ............................................................................. 1.4980 0.9034 $22.8526 $24.6194 $25.2348 $24.3075
370149 h ........................................................................... 1.2123 0.9390 $18.2260 $21.0608 $22.3537 $20.7832
370153 ............................................................................. 1.0538 0.7607 $17.9692 $18.5417 $19.8349 $18.7951
370154 ............................................................................. *** * $17.4760 * * $17.4760
370156 ............................................................................. 1.0073 0.7607 $15.9647 $16.6572 $19.4743 $17.3490
370158 ............................................................................. 1.0204 0.9034 $17.3412 $17.3161 $18.5578 $17.7592
370166 ............................................................................. 1.0006 0.8569 $21.3628 $21.9070 $23.1681 $22.1327
370169 ............................................................................. 0.9033 0.7607 $16.5607 $15.7686 $15.8002 $16.0704
370170 ............................................................................. 1.0221 1.4448 * * * *
370171 ............................................................................. 1.5204 1.4448 * * * *
370172 ............................................................................. 0.8692 1.4448 * * * *
370173 ............................................................................. 1.0681 1.4448 * * * *
370174 ............................................................................. 0.9191 1.4448 * * * *
370176 ............................................................................. 1.1146 0.8569 $22.1456 $23.0324 $25.0509 $23.4362
370177 ............................................................................. 1.0163 0.7607 $14.0279 $15.6723 $14.7193 $14.7923
370178 ............................................................................. 0.9012 0.7607 $12.9635 $14.9767 $14.6070 $14.1857
370179 ............................................................................. 0.9319 0.8569 $21.9673 $22.8322 $23.5794 $22.6918
370180 ............................................................................. 1.0669 1.4448 * * * *
370183 ............................................................................. 1.0219 0.8569 $17.9270 $20.5025 $21.8147 $20.0076
370186 ............................................................................. 0.9039 * $16.3879 * * $16.3879
370190 ............................................................................. 1.5509 0.8569 $22.3326 $24.9455 $33.1137 $27.0848
370192 ............................................................................. 1.8038 0.9034 $24.3832 $26.1338 $31.4930 $27.6466
370196 ............................................................................. 1.0637 0.9034 $23.6334 $29.4383 $22.6824 $25.4359
370199 ............................................................................. 0.9513 0.9034 $20.7075 $23.7340 $26.0451 $23.4652
370200 ............................................................................. 1.1695 0.7607 $16.7164 $18.1008 $17.6317 $17.5059
370201 ............................................................................. 1.7144 0.9034 $18.9906 $23.1240 $23.3550 $21.7730
370202 ............................................................................. 1.5408 0.8569 $24.0239 $24.4920 $25.1181 $24.5965
370203 ............................................................................. 1.3869 0.9034 $19.8772 $21.2426 $23.5190 $21.5182
370206 ............................................................................. 1.5811 0.9034 $22.3471 $27.4495 $26.0912 $25.5795
370207 ............................................................................. *** * $26.3746 * * $26.3746
370209 ............................................................................. *** * * $32.8278 * $32.8278
370210 ............................................................................. 2.2165 0.8569 * $20.0360 $21.2682 $20.6946
370211 ............................................................................. 0.9595 0.9034 * * $26.5344 $26.5344
370212 ............................................................................. 1.5535 0.9034 * * $21.0758 $21.0758
370213 ............................................................................. *** * * * $29.3777 $29.3777
370214 ............................................................................. 0.8997 0.7607 * * * *
370215 ............................................................................. 2.5045 0.9034 * * $32.3589 $32.3589
370216 ............................................................................. 2.5952 0.8569 * * * *
370217 ............................................................................. 1.0003 0.7607 * * * *
370218 ............................................................................. 2.3683 0.8569 * * * *

Case-mix FY 2006
380001 ............................................................................. 1.1917 1.1235 $20.9585 $27.8554 $30.0103 $26.2164

380002 ............................................................................. 1.2041 1.0431 $25.2629 $26.3348 $27.1861 $26.3148
380003 ............................................................................. *** * $24.6377 * * $24.6377
380004 ............................................................................. 1.7214 1.1235 $27.5184 $28.2466 $30.5172 $28.8120
380005 ............................................................................. 1.3710 1.0301 $26.3472 $28.0682 $30.2211 $28.3075
380006 ............................................................................. 1.1672 * $24.7492 $26.0475 * $25.3948
380007 ............................................................................. 1.9085 1.1235 $30.0497 $31.5207 $33.9969 $31.9322
380008 ............................................................................. 1.1295 1.0301 $24.6149 $25.4494 $25.8356 $25.3227
380009 ............................................................................. 1.9379 1.1235 $26.0012 $30.4198 $31.7042 $29.4616
380010 ............................................................................. 1.0337 1.1235 $25.5234 $27.5291 $30.2957 $27.8451
380011 ............................................................................. *** * $21.9382 * * $21.9382
380013 ............................................................................. *** * $24.1491 * * $24.1491
380014 ............................................................................. 1.8478 1.0700 $28.4536 $27.7255 $29.9648 $28.7806
380017 ............................................................................. 1.7770 1.1235 $29.2543 $31.7440 $32.2447 $31.1318
380018 ............................................................................. 1.8112 1.0301 $27.5171 $27.8952 $28.0701 $27.8359
380020 ............................................................................. 1.3781 1.0799 $23.7066 $25.8320 $28.3563 $26.0268
380021 ............................................................................. 1.4279 1.1235 $28.0334 $29.3001 $29.3295 $28.9428
380022 ............................................................................. 1.2258 1.0502 $26.4794 $27.8683 $29.2642 $27.9316
380023 ............................................................................. 1.1838 1.0301 $23.0079 $23.7073 $26.5439 $24.4358
380025 ............................................................................. 1.3001 1.1235 $28.8525 $30.2628 $33.2105 $30.8181
380026 ............................................................................. 1.1392 * $23.8666 $26.5217 * $25.2072
380027 ............................................................................. 1.2955 1.0419 $21.5822 $23.8758 $25.5161 $23.7359
380029 ............................................................................. 1.3050 1.0510 $24.2939 $26.2070 $26.9966 $25.9075
380033 ............................................................................. 1.6636 1.0799 $30.4783 $29.7995 $30.8767 $30.3883
380035 ............................................................................. 1.0501 * $26.2434 $26.4784 * $26.3599
380037 ............................................................................. 1.2406 1.1235 $25.0200 $27.1884 $30.5818 $27.7342
380038 ............................................................................. 1.2652 1.1235 $29.1804 $30.5903 $34.2303 $31.3814
380039 ............................................................................. 0.9848 1.1235 $27.5115 $30.1544 $32.3959 $30.0601
380040 ............................................................................. 1.1935 1.0301 $21.5958 $28.4373 $32.0103 $27.1504
380047 ............................................................................. 1.7995 1.0772 $26.5017 $27.8385 $29.8627 $28.1638
380050 ............................................................................. 1.4063 1.0301 $23.1332 $24.2416 $25.6190 $24.3627
380051 ............................................................................. 1.5965 1.0510 $26.2384 $28.1305 $29.7219 $28.0410
380052 ............................................................................. 1.1791 1.0301 $21.2567 $22.6799 $24.9476 $22.9567
380056 ............................................................................. 0.9470 1.0510 $22.3571 $25.0068 $25.1475 $24.2275
380060 ............................................................................. 1.3974 1.1235 $27.8551 $30.2507 $30.7041 $29.6593
380061 ............................................................................. 1.6520 1.1235 $27.3827 $29.5145 $29.8217 $28.9273
380066 ............................................................................. 1.2331 * $23.3581 $27.5412 * $25.5211
380070 ............................................................................. 1.1830 * $34.1039 * * $34.1039
380071 ............................................................................. 1.3513 1.1235 $27.9055 $29.5740 $30.2304 $29.2634
380072 ............................................................................. 0.8571 * $21.9516 $22.5275 * $22.2419
380075 ............................................................................. 1.3193 1.0301 $25.1930 $27.4795 $29.0368 $27.3082
380081 ............................................................................. 1.1378 1.0301 $22.1822 $21.0708 $21.8850 $21.7195
380082 ............................................................................. 1.2295 1.1235 $28.0668 $30.2721 $32.3002 $30.2952
380089 ............................................................................. 1.2844 1.1235 $29.6989 $30.8396 $33.4214 $31.3234
380090 ............................................................................. 1.2860 1.2303 $31.8702 $33.6822 $34.4536 $33.3615
380091 ............................................................................. 1.3349 1.1235 $31.2807 $35.7002 $33.8950 $33.5968
390001 ............................................................................. 1.6737 0.9834 $21.5154 $22.4407 $22.5309 $22.1581
390002 ............................................................................. 1.2774 0.8832 $22.0646 $23.0113 $22.4388 $22.5092
390003 h ........................................................................... 1.1761 0.9834 $19.1857 $21.3182 $21.6478 $20.7084
390004 ............................................................................. 1.5734 0.9308 $21.3475 $23.4063 $24.3249 $23.1020
390005 ............................................................................. 0.9917 * $19.0727 $19.0318 * $19.0497
390006 ............................................................................. 1.8416 0.9139 $23.0378 $23.3960 $25.1216 $23.8687
390008 h ........................................................................... 1.1617 0.8832 $19.9417 $21.0021 $22.2680 $21.0752
390009 ............................................................................. 1.7609 0.8737 $21.9459 $24.2789 $25.5482 $23.9471
390010 ............................................................................. 1.2015 0.8832 $19.4377 $21.6273 $23.5390 $21.5537
390011 ............................................................................. 1.3462 0.8352 $18.6548 $19.8602 $21.9279 $20.1129
390012 ............................................................................. 1.2234 1.1028 $28.5114 * $28.5076 $28.5093
390013 ............................................................................. 1.2242 0.9139 $22.1679 $23.3180 $24.0044 $23.1713
390016 h ........................................................................... 1.2089 0.8832 $18.1536 $19.9899 $21.9549 $20.1569
390017 h ........................................................................... *** * $19.1962 $20.6575 * $19.8788
390018 ............................................................................. *** * $19.9117 * * $19.9117
390019 ............................................................................. 1.2036 0.9834 $21.2806 $21.5137 $23.4636 $22.1361
390022 ............................................................................. 1.3229 1.1028 $27.5504 $31.0971 $29.0710 $29.1659
390023 ............................................................................. 1.2592 1.1028 $25.3767 $27.1600 $31.7149 $28.1614
390024 ............................................................................. 0.9502 1.1028 $25.9806 $37.4330 $35.3959 $29.4333
390025 ............................................................................. 0.5326 1.1028 $14.8690 $15.0282 $17.2977 $15.7085
390026 ............................................................................. 1.2514 1.1028 $24.0326 $27.0802 $29.5157 $26.9256

Case-mix FY 2006
390027 ............................................................................. 1.5554 1.1028 $33.2139 $28.9159 $35.8381 $32.5478

390028 ............................................................................. 1.6221 0.8832 $24.6796 $23.6616 $25.7246 $24.7268
390029 ............................................................................. *** * * $24.4276 * $24.4276
390030 ............................................................................. 1.1890 0.9834 $20.0598 $20.9859 $22.1581 $21.0867
390031 ............................................................................. 1.2121 0.9491 $20.3568 $21.2949 $22.6828 $21.4388
390032 ............................................................................. 1.1808 0.8832 $20.8450 $20.9971 $22.7205 $21.5225
390035 ............................................................................. 1.2294 1.1028 $23.2173 $24.7281 $26.2647 $24.7742
390036 ............................................................................. 1.4723 0.8832 $20.5751 $23.3858 $24.6032 $22.8336
390037 ............................................................................. 1.3526 0.8832 $20.1665 $22.9008 $24.7820 $22.6385
390039 h ........................................................................... 1.1584 0.8340 $18.4580 $17.8461 $20.3787 $18.9083
390040 ............................................................................. *** * $20.5371 $23.1807 * $21.7860
390041 ............................................................................. 1.3213 0.8832 $21.0074 $20.6789 $21.5925 $21.0799
390042 ............................................................................. 1.3558 0.8832 $22.2351 $23.9632 $25.6328 $23.9486
390043 ............................................................................. 1.1770 0.8289 $19.8641 $20.9835 $22.2549 $21.0509
390044 ............................................................................. 1.6846 0.9888 $22.4235 $24.2586 $27.1505 $24.6634
390045 ............................................................................. 1.6020 0.8355 $20.2082 $22.2582 $23.0712 $21.8774
390046 ............................................................................. 1.5586 0.9447 $23.1271 $25.0825 $27.2630 $25.1787
390048 ............................................................................. 1.0902 0.9139 $20.3523 $23.6622 $24.9759 $22.9112
390049 ............................................................................. 1.5998 0.9834 $24.0933 $25.4056 $27.1366 $25.5929
390050 ............................................................................. 2.0676 0.8832 $22.6951 $24.5424 $26.6931 $24.6339
390052 ............................................................................. 1.1861 0.8933 $22.1380 $21.6736 $23.3474 $22.4074
390054 ............................................................................. 1.2038 0.9706 $19.8602 $21.4983 $22.8087 $21.3801
390055 ............................................................................. *** * $23.5292 $25.5675 $25.6945 $24.9860
390056 ............................................................................. 1.0708 0.8331 $21.4239 * $19.5537 $20.4834
390057 ............................................................................. 1.3477 1.1028 $24.8235 $25.1901 $27.9583 $26.0368
390058 ............................................................................. 1.2896 0.9308 $22.0113 $25.3415 $27.4799 $24.8349
390061 ............................................................................. 1.5366 0.9706 $24.4550 $25.5012 $28.4538 $26.1704
390062 ............................................................................. 1.1215 0.8933 $17.6303 $19.0692 $21.4052 $19.4592
390063 ............................................................................. 1.7830 0.8737 $21.7120 $23.5469 $24.7614 $23.4097
390065 ............................................................................. 1.2190 1.0802 $23.1384 $23.4021 $25.2188 $23.9720
390066 ............................................................................. 1.2758 0.9139 $21.7717 $23.0891 $24.2087 $23.0471
390067 ............................................................................. 1.8416 0.9308 $23.5136 $25.4576 $26.3287 $25.0668
390068 ............................................................................. 1.3355 0.9706 $21.1177 $25.9890 $25.8291 $24.3019
390070 ............................................................................. 1.3629 1.1028 $24.4403 $26.9235 $30.9499 $27.4435
390071 ............................................................................. 0.9938 0.8289 $17.8117 $20.9443 $21.8366 $20.0802
390072 h ........................................................................... 1.0521 0.9834 $20.0561 $22.0155 $24.9388 $22.3043
390073 ............................................................................. 1.5860 0.8933 $22.7073 $24.8013 $26.3698 $24.6228
390074 ............................................................................. 1.1499 0.8832 $21.8456 $21.0941 $22.8545 $21.9412
390075 ............................................................................. *** * $19.9775 $22.6530 $24.6359 $22.3701
390076 ............................................................................. 1.3526 1.1028 $21.2039 $18.1276 $27.9004 $21.9007
390079 ............................................................................. 1.9205 0.8462 $19.9169 $21.4323 $23.3053 $21.5091
390080 ............................................................................. 1.2863 1.1028 $23.3742 $25.0921 $27.2616 $25.2851
390081 ............................................................................. 1.2261 1.1028 $28.1056 $28.7974 $30.3840 $29.1503
390084 ............................................................................. 1.2773 0.8289 $18.3551 $20.7799 $19.8605 $19.6630
390086 ............................................................................. 1.5753 0.8289 $19.6488 $20.7383 $22.5317 $20.9944
390090 ............................................................................. 1.8335 0.8832 $22.4688 $20.7474 $25.2014 $22.8601
390091 ............................................................................. 1.1481 0.8600 $19.7361 $20.8243 $21.5586 $20.7010
390093 ............................................................................. 1.1857 0.8832 $19.9209 $21.0427 $21.4401 $20.8186
390095 ............................................................................. 1.1983 0.9834 $18.3939 $21.0754 $23.6240 $20.9725
390096 ............................................................................. 1.5210 0.9888 $22.9502 $24.4145 $27.0763 $24.8874
390097 ............................................................................. 1.1981 1.1028 $24.5304 $25.3012 $25.6660 $25.2008
390100 ............................................................................. 1.7217 0.9706 $23.4155 $26.7267 $27.7208 $26.0717
390101 ............................................................................. 1.2600 0.9447 $20.1271 $20.1694 $21.9418 $20.7655
390102 ............................................................................. 1.3487 0.8832 $20.9807 $21.6629 $24.8898 $22.6239
390103 ............................................................................. 1.0148 0.8832 $21.0637 $18.6703 $20.6775 $20.1561
390104 ............................................................................. 1.0645 0.8289 $16.5081 $19.1803 $19.6428 $18.4897
390107 ............................................................................. 1.3834 0.8832 $21.5852 $23.1023 $24.1386 $23.0080
390108 ............................................................................. 1.2360 1.1028 $23.7842 $24.7486 $27.2661 $25.2833
390109 ............................................................................. 1.1285 0.9834 $17.2667 $18.7558 $19.9156 $18.6551
390110 ............................................................................. 1.6141 0.8832 $22.3968 $23.3355 $23.9808 $23.2737
390111 ............................................................................. 2.0277 1.1028 $30.5814 $30.6809 $32.6510 $31.3439
390112 h ........................................................................... 1.2130 0.8340 $15.6710 $16.6113 $19.2126 $17.1537
390113 ............................................................................. 1.3094 0.8600 $20.1160 $21.7729 $22.2591 $21.3940
390114 ............................................................................. 1.3657 0.8832 $23.6162 $22.6630 $24.0473 $23.4341
390115 ............................................................................. 1.4597 1.1028 $24.1951 $26.4751 $27.7333 $26.1536
390116 ............................................................................. 1.2968 1.1028 $24.9581 $28.5563 $30.2722 $28.0177
390117 ............................................................................. 1.1039 0.8289 $19.0983 $20.0040 $20.3946 $19.8418

Case-mix FY 2006
390118 ............................................................................. 1.1816 0.8289 $17.8460 $19.3332 $21.5001 $19.5328

390119 ............................................................................. 1.3011 0.9834 $20.3034 $21.2761 $22.2746 $21.3271
390121 ............................................................................. 1.6883 0.8933 $20.8017 $22.0556 $23.1408 $22.0024
390122 ............................................................................. 1.0995 0.8289 $18.5130 $21.6981 $22.5785 $20.8388
390123 ............................................................................. 1.2160 1.1028 $23.2232 $25.2209 $28.6269 $25.7365
390125 ............................................................................. 1.2682 0.8289 $18.2411 $19.4406 $20.9456 $19.5654
390127 ............................................................................. 1.3307 1.1028 $25.0836 $28.9238 $30.9374 $28.4999
390128 ............................................................................. 1.1938 0.8832 $21.3668 $21.8837 $23.1539 $22.1603
390130 ............................................................................. 1.2722 0.8352 $19.4835 $21.0694 $24.0685 $21.4556
390131 ............................................................................. 1.3078 0.8832 $19.5296 $21.2164 $22.6306 $21.1571
390132 ............................................................................. 1.4193 1.1028 $24.6889 $26.8153 $27.7250 $26.4427
390133 ............................................................................. 1.7317 1.1028 $25.2110 $26.1458 $28.7162 $26.7622
390135 ............................................................................. *** * $24.0445 * $24.4738 $24.2670
390136 ............................................................................. 1.1143 0.8832 $21.9531 $24.8042 $22.1415 $22.9715
390137 ............................................................................. 1.4923 0.9834 $19.5457 $21.8830 $23.4877 $21.5609
390138 ............................................................................. 1.1914 1.0802 $21.4705 $22.7210 $24.2769 $22.8713
390139 ............................................................................. 1.3319 1.1028 $26.3622 $28.2089 $30.4246 $28.3708
390142 ............................................................................. 1.4938 1.1028 $29.8874 $32.0827 $32.5786 $31.5029
390145 ............................................................................. 1.5150 0.8832 $20.6580 $22.4255 $23.8041 $22.3138
390146 ............................................................................. 1.2524 0.8342 $21.4580 $22.3260 $25.2460 $23.0540
390147 ............................................................................. 1.2394 0.8832 $22.3135 $23.6380 $25.0971 $23.6939
390150 ............................................................................. 1.1849 0.8832 $20.0261 $24.5256 $24.1855 $22.9524
390151 ............................................................................. 1.2851 1.0802 $24.7843 $25.1422 $27.1539 $25.7127
390152 ............................................................................. 1.0043 * $21.5474 $11.7774 * $15.1275
390153 ............................................................................. 1.3870 1.1028 $25.3391 $27.5167 $30.0586 $27.7812
390154 ............................................................................. 1.2514 0.8289 $19.1300 $20.4408 $20.6982 $20.0794
390156 ............................................................................. 1.3762 1.1028 $25.0801 $27.8096 $31.2571 $28.0054
390157 ............................................................................. 1.3060 0.8832 $20.6933 $22.0222 $22.7493 $21.8431
390160 ............................................................................. 1.1894 0.8832 $19.3598 $19.5942 $21.4877 $20.1709
390162 ............................................................................. 1.4816 1.0034 $24.0291 * $30.0900 $26.8901
390163 ............................................................................. 1.2734 0.8832 $18.8585 $19.8863 $22.1741 $20.2736
390164 ............................................................................. 2.1009 0.8832 $24.2334 $25.1277 $26.4971 $25.3882
390166 ............................................................................. 1.1601 0.8832 $19.8531 $20.9510 $24.9810 $21.8402
390168 ............................................................................. 1.4583 0.8832 $20.6777 $21.9344 $24.5820 $22.5085
390169 ............................................................................. 1.4280 0.9834 $22.7695 $24.1682 $27.2242 $24.7030
390173 ............................................................................. 1.1927 0.8289 $20.6958 $21.6562 $22.8220 $21.7639
390174 ............................................................................. 1.7358 1.1028 $28.4490 $30.3725 $32.6265 $30.5109
390176 ............................................................................. 1.1618 0.8832 $18.0752 $17.1387 * $17.5532
390178 ............................................................................. 1.3036 0.8600 $17.2384 $19.2731 $20.7270 $19.1018
390179 ............................................................................. 1.3742 1.1028 $24.0501 $24.8350 $27.2222 $25.3975
390180 ............................................................................. 1.4593 1.1028 $28.4842 $30.4264 $32.4375 $30.5043
390181 ............................................................................. 1.0430 0.8289 * $25.7357 $24.4573 $25.1039
390183 ............................................................................. 1.0924 0.8289 $21.6811 $22.0117 $25.6554 $23.0449
390184 ............................................................................. 1.0967 0.8832 $21.1962 $21.3407 $22.5519 $21.7060
390185 ............................................................................. 1.2794 0.9706 $20.4476 $21.8871 $23.0202 $21.7597
390189 ............................................................................. 1.1225 0.8289 $20.1365 $21.2711 $22.3722 $21.3477
390191 ............................................................................. 1.1066 0.8289 $18.5972 $19.2308 $20.8761 $19.5306
390192 ............................................................................. 1.0171 0.9834 $19.1883 $20.0395 $21.2620 $20.1833
390193 ............................................................................. *** * $18.9764 $18.5516 $20.1024 $19.2196
390194 ............................................................................. 1.1094 0.9834 $21.5850 $23.1814 $25.4235 $23.4479
390195 ............................................................................. 1.6530 1.1028 $26.2024 $28.3480 $31.0019 $28.5392
390196 ............................................................................. 1.6486 * * * * *
390197 ............................................................................. 1.4055 0.9834 $22.8349 $24.9234 $25.7739 $24.4854
390198 ............................................................................. 1.1833 0.8737 $17.3937 $16.8529 $18.7222 $17.6295
390199 ............................................................................. 1.2240 0.8289 $18.9787 $19.9653 $21.3157 $20.1079
390200 ............................................................................. *** * $19.4471 $23.1486 $23.7471 $21.9484
390201 ............................................................................. 1.3035 0.9416 $22.7849 $24.8222 $26.3658 $24.6735
390203 ............................................................................. 1.6417 1.1028 $26.9436 $28.2741 $28.9054 $28.0870
390204 ............................................................................. 1.2657 1.1028 $23.9673 $25.6342 $28.6829 $26.1129
390211 ............................................................................. 1.2873 0.8600 $21.0450 $22.4472 $23.1450 $22.2313
390215 ............................................................................. *** * $25.2617 $26.4180 $28.0402 $26.4046
390217 ............................................................................. 1.1598 0.8832 $21.4058 $21.3281 $24.3610 $22.3261
390219 ............................................................................. 1.3040 0.8832 $20.0594 $22.8559 $25.1705 $22.7113
390220 ............................................................................. 1.1030 1.1028 $23.4385 $24.7553 $41.6138 $28.9098
390222 ............................................................................. 1.2493 1.1028 $24.9345 $27.0954 $28.7488 $26.9594
390223 ............................................................................. 1.9327 1.1028 $22.8725 $28.2538 $27.6407 $26.2383
390224 ............................................................................. 0.8495 0.8462 $16.1289 $18.1226 $18.7624 $17.7120

Case-mix FY 2006
390225 ............................................................................. 1.2019 0.9706 $20.9232 $23.4945 $24.9391 $23.3545

390226 ............................................................................. 1.7580 1.1028 $25.6917 $27.0061 $28.5890 $27.1866
390228 ............................................................................. 1.3366 0.8832 $21.0164 $22.5999 $23.3078 $22.3536
390231 ............................................................................. 1.4457 1.1028 $24.7757 $27.0576 $29.2653 $27.1070
390233 ............................................................................. 1.3679 0.9447 $21.8043 $22.8667 $24.8690 $23.1907
390235 ............................................................................. *** * $23.7068 * * $23.7068
390236 ............................................................................. 1.1484 0.8289 $19.8687 $21.9199 $21.9169 $21.2652
390237 ............................................................................. 1.5801 0.9834 $23.2054 $24.6316 $26.9533 $24.9348
390238 ............................................................................. *** * $19.2171 $26.4748 * $22.5836
390246 ............................................................................. 1.1726 0.8289 $22.0687 $23.3275 $20.1581 $21.8667
390249 ............................................................................. 0.8825 * $14.7215 * * $14.7215
390256 ............................................................................. 1.8708 0.9308 $22.6146 $24.2331 $26.3619 $24.4523
390258 ............................................................................. 1.5526 1.1028 $25.0634 $27.2038 $29.4626 $27.3466
390262 ............................................................................. *** * $21.3264 * * $21.3264
390263 ............................................................................. 1.4528 0.9834 $22.0008 $23.4202 $26.0170 $23.9015
390265 ............................................................................. 1.4641 0.8832 $20.5948 $21.6751 $23.4836 $21.9520
390266 ............................................................................. 1.1857 0.8600 $18.2424 $19.2836 $20.3918 $19.3171
390267 ............................................................................. 1.1960 0.8832 $21.4801 $22.5464 $23.1051 $22.3821
390268 ............................................................................. 1.3183 0.8360 $23.1124 $24.2050 $25.0021 $24.1351
390270 ............................................................................. 1.4784 0.9706 $22.5258 $24.0837 $24.1496 $23.6565
390272 ............................................................................. 0.5215 1.1028 * * * *
390278 ............................................................................. 0.5505 1.1028 $21.1387 $21.6893 $23.6843 $22.1694
390279 ............................................................................. 1.1500 0.8360 $16.0510 $15.3569 $17.0012 $16.1304
390285 ............................................................................. 1.5470 1.1028 $30.6300 $33.5347 $35.0427 $33.0866
390286 ............................................................................. 1.1729 1.1028 $25.4499 $27.4090 $28.1761 $27.0003
390287 ............................................................................. 1.4347 1.1028 $32.9709 $35.7147 $37.6569 $35.5140
390288 ............................................................................. *** * $28.0957 $28.5267 $29.7287 $28.6956
390289 ............................................................................. 1.1071 1.1028 $25.1658 $28.4577 $28.8826 $27.4320
390290 ............................................................................. 1.9387 1.1028 $31.0967 $36.4991 $37.9040 $35.0787
390291 ............................................................................. *** * $21.0057 $21.3015 * $21.1542
390294 ............................................................................. *** * $33.3537 * * $33.3537
390295 ............................................................................. *** * $26.8862 * * $26.8862
390296 ............................................................................. *** * $25.6981 * * $25.6981
390297 ............................................................................. *** * $25.7318 * * $25.7318
390298 ............................................................................. *** * * $26.8290 * $26.8290
390299 ............................................................................. *** * * $31.9423 * $31.9423
390300 ............................................................................. *** * * $40.4697 * $40.4697
390301 ............................................................................. *** * * * $30.9838 $30.9838
390304 ............................................................................. 1.1794 1.1028 * * * *
390305 ............................................................................. 1.9433 0.8832 * * * *
390306 ............................................................................. 1.7325 0.8832 * * * *
390307 ............................................................................. 1.3440 0.8600 * * * *
390308 ............................................................................. 0.8223 1.1028 * * * *
390309 ............................................................................. 0.9254 1.1028 * * * *
390310 ............................................................................. 2.3639 0.8289 * * * *
400001 ............................................................................. 1.2690 0.4621 $11.7572 $16.1114 $13.1847 $13.4859
400002 ............................................................................. 1.7591 0.4939 $11.6804 $14.8607 $16.7583 $14.1458
400003 ............................................................................. 1.3684 0.4939 $10.5963 $13.0776 $12.8329 $12.1392
400004 ............................................................................. 1.1372 0.4621 $11.4041 $10.4716 $14.3108 $11.8780
400005 ............................................................................. 1.1239 0.4621 $10.5356 $10.2878 $10.7207 $10.5186
400006 ............................................................................. 1.1832 0.4621 $9.2852 $8.9919 $9.2265 $9.1710
400007 ............................................................................. 1.1869 0.4621 $8.6022 $8.7152 $9.2463 $8.8511
400009 ............................................................................. 1.1006 0.3183 $9.4413 $9.2007 $9.3116 $9.3159
400010 ............................................................................. 0.8274 0.4732 $9.2799 $10.9354 $10.0962 $10.0495
400011 ............................................................................. 1.0870 0.4621 $8.9111 $8.5868 $8.5534 $8.6726
400012 ............................................................................. 1.3561 0.4621 $9.0740 $8.3580 $8.3802 $8.5938
400013 ............................................................................. 1.3120 0.4621 $9.9905 $9.5584 $10.3347 $9.9727
400014 ............................................................................. 1.3286 0.4019 $11.4580 $11.7023 $12.2169 $11.7941
400015 ............................................................................. 1.3925 0.4621 * $15.6066 $15.6349 $15.6221
400016 ............................................................................. 1.3523 0.4621 $14.6491 $15.3497 $14.7607 $14.9193
400017 ............................................................................. 1.2103 0.4621 $10.7475 $10.1238 $10.2734 $10.3916
400018 ............................................................................. 1.2290 0.4621 $10.8254 $10.7948 $11.6165 $11.0939
400019 ............................................................................. 1.3287 0.4621 $13.7007 $14.9892 $12.8029 $13.7525
400021 ............................................................................. 1.3231 0.4641 $13.5224 $13.8643 $14.1533 $13.8469
400022 ............................................................................. 1.3548 0.4939 $15.2904 $16.0539 $15.9246 $15.7672
400024 ............................................................................. 0.8431 0.4019 $9.8650 $9.1316 $12.4649 $10.2156
400026 ............................................................................. 1.0668 0.3183 $5.9206 $5.2085 $5.8200 $5.6501

Case-mix FY 2006
400028 ............................................................................. 1.2118 0.4939 $9.5266 $10.3354 $10.9808 $10.2872

400032 ............................................................................. 1.2001 0.4621 $10.7100 $10.7195 $10.2652 $10.5650
400044 ............................................................................. 1.2951 0.4939 $9.0275 $10.7890 $13.7509 $11.4819
400048 ............................................................................. 1.1083 0.4621 $10.8618 $14.0887 $10.4266 $11.8488
400061 ............................................................................. 1.7198 0.4621 $16.5895 $15.1639 $18.9123 $16.8879
400079 ............................................................................. 1.1394 0.4732 $8.7218 $9.4218 $12.7825 $10.1505
400087 ............................................................................. 1.2148 0.4621 $10.7118 $9.5860 $10.6849 $10.3421
400094 ............................................................................. *** * $9.2871 $8.8646 * $9.1244
400098 ............................................................................. 1.5611 0.4621 $13.8036 $13.7938 $12.8230 $13.4850
400102 ............................................................................. 1.1411 0.4621 $10.9973 $10.1795 $10.2677 $10.4779
400103 ............................................................................. 1.7278 0.4019 $11.5797 $12.8288 $9.3859 $10.9876
400104 ............................................................................. 1.1614 0.4621 $7.1781 $8.2758 $9.3854 $8.1476
400105 ............................................................................. 1.1409 0.4621 $11.5608 $12.7725 $14.0219 $12.7229
400106 ............................................................................. 1.1978 0.4621 $10.1241 $9.6902 $11.4507 $10.3951
400109 ............................................................................. 1.4855 0.4621 $12.8921 $14.2169 $14.2111 $13.7444
400110 ............................................................................. 1.1119 0.4408 $12.0159 $11.8458 $12.3449 $12.0750
400111 ............................................................................. 1.0818 0.4732 $12.7701 $13.4777 $14.5029 $13.5496
400112 ............................................................................. 1.2190 0.4621 $12.2859 $8.9469 $19.3945 $12.3541
400113 ............................................................................. 1.2194 0.4939 $10.4416 $10.0830 $9.6778 $10.1179
400114 ............................................................................. 1.0966 0.4621 $9.7444 $12.1920 $11.5478 $11.0784
400115 ............................................................................. 1.1336 0.4621 $7.0411 $9.1132 $13.7392 $9.2213
400117 ............................................................................. 1.1139 0.4621 $9.7314 $10.2911 $12.7600 $10.8102
400118 ............................................................................. 1.2358 0.4621 $12.4590 $11.9324 $12.5743 $12.3218
400120 ............................................................................. 1.3171 0.4621 $11.8837 $11.9714 $12.7955 $12.2196
400121 ............................................................................. 1.0708 0.4621 $8.3575 $8.6665 $8.2197 $8.4118
400122 ............................................................................. 1.9324 0.4621 $9.6644 $9.6463 $11.2325 $10.1283
400123 ............................................................................. 1.2113 0.4019 $10.5643 $11.8135 $12.3041 $11.5735
400124 ............................................................................. 2.8401 0.4621 $14.3496 $17.2258 $16.1812 $15.8787
400125 ............................................................................. 1.1372 0.4156 $10.6642 $10.7425 $11.6386 $11.0069
400126 ............................................................................. 1.2124 0.4641 * $13.3932 $9.8008 $11.0632
400127 ............................................................................. 2.2229 0.4621 * * * *
410001 ............................................................................. 1.3175 1.1274 $24.0033 $27.0309 $28.0816 $26.3767
410004 ............................................................................. 1.2352 1.1274 $23.6409 $25.4578 $27.4209 $25.5908
410005 ............................................................................. 1.2881 1.1274 $24.6522 $27.1171 $30.1606 $27.3044
410006 ............................................................................. 1.2547 1.1274 $26.1372 $27.1842 $29.4395 $27.6190
410007 ............................................................................. 1.7162 1.1274 $27.7171 $30.1360 $31.8548 $30.0135
410008 ............................................................................. 1.2160 1.1274 $25.4183 $28.4245 $29.6092 $27.8277
410009 ............................................................................. 1.2898 1.1274 $26.9135 $27.7337 $29.4094 $28.0697
410010 ............................................................................. 1.1690 1.1734 $30.3860 $30.7826 $32.8599 $31.3979
410011 ............................................................................. 1.3123 1.1274 $29.7664 $28.5875 $30.3787 $29.5538
410012 ............................................................................. 1.7743 1.1274 $28.1791 $32.1679 $32.6009 $31.1120
410013 ............................................................................. 1.2336 1.1274 $28.9386 $31.7482 $35.4624 $32.1157
420002 ............................................................................. 1.5354 0.9707 $25.1067 $27.9312 $28.2848 $27.1910
420004 ............................................................................. 1.9995 0.9240 $23.4579 $26.0279 $27.2620 $25.6238
420005 ............................................................................. 1.0201 0.8660 $19.5521 $19.8167 $23.1943 $20.8182
420006 ............................................................................. 1.0887 0.9240 $22.7896 $22.8920 $24.0811 $23.2220
420007 ............................................................................. 1.5955 0.9175 $22.0228 $25.0395 $25.2650 $24.2318
420009 ............................................................................. 1.3854 0.9702 $18.6866 $23.8668 $25.5079 $22.5621
420010 ............................................................................. 1.1980 0.8971 $19.1746 $21.6478 $23.4562 $21.5057
420011 ............................................................................. 1.1292 1.0001 $17.7300 $20.8895 $21.4030 $20.0081
420014 ............................................................................. 0.9681 * $21.2045 $21.5658 * $21.3876
420015 ............................................................................. 1.2696 1.0001 $23.1274 $24.7383 $26.2154 $24.7258
420016 ............................................................................. 0.9673 0.8660 $17.0051 $17.3837 $17.1229 $17.1752
420018 ............................................................................. 1.7687 0.9067 $20.4649 $23.6356 $24.8024 $22.8926
420019 ............................................................................. 1.1234 0.8660 $19.6836 $20.5472 $22.5312 $20.8812
420020 ............................................................................. 1.2759 0.9240 $22.1616 $24.6592 $25.8883 $24.3667
420023 ............................................................................. 1.6656 1.0001 $23.2568 $25.1035 $26.7263 $25.0152
420026 ............................................................................. 1.8862 0.9067 $23.7406 $29.2961 $27.4814 $26.8241
420027 ............................................................................. 1.5766 0.9198 $21.0637 $22.8322 $25.1692 $23.0401
420030 ............................................................................. 1.2300 0.9240 $22.6766 $24.2847 $26.0079 $24.3704
420033 ............................................................................. 1.1298 1.0001 $26.2711 $27.5740 $31.8759 $28.5975
420036 ............................................................................. 1.2584 0.9577 $20.6649 $21.9641 $22.8294 $21.8110
420037 ............................................................................. 1.2615 1.0001 $25.5492 $26.8750 $29.4156 $27.3838
420038 ............................................................................. 1.2639 1.0001 $21.6133 $22.6741 $24.2259 $22.8531
420039 ............................................................................. 1.0432 0.9174 $21.9737 $24.0637 $25.1148 $23.7048
420043 h ........................................................................... 1.0874 0.9351 $21.8816 $22.9764 $23.0555 $22.6545
420048 ............................................................................. 1.2709 0.9067 $21.9517 $23.1515 $24.1923 $23.1348

Case-mix FY 2006
420049 ............................................................................. 1.2340 0.8929 $21.2604 $23.2156 $23.9722 $22.8399

420051 ............................................................................. 1.5014 0.8971 $20.6629 $23.9455 $24.8026 $23.1828
420053 ............................................................................. 1.1649 0.8660 $19.9013 $21.1177 $22.2825 $21.1778
420054 ............................................................................. 1.0290 0.8660 $20.8471 $24.0653 $24.8931 $23.2676
420055 ............................................................................. 1.0770 0.8660 $19.6817 $20.3599 $21.9764 $20.6871
420056 ............................................................................. 1.4078 0.8660 $20.0527 $21.1640 $21.6963 $20.9682
420057 ............................................................................. 1.0461 0.8971 $17.6727 $19.7653 $23.4311 $20.1207
420059 ............................................................................. 1.0686 * $20.2917 $21.4260 * $20.8684
420061 ............................................................................. 1.1331 * $19.9789 $20.8684 * $20.4341
420062 ............................................................................. 1.1085 0.8660 $17.4764 $25.6683 $25.9526 $22.5339
420064 ............................................................................. 1.2023 0.8929 $20.9057 $22.1290 $23.3610 $22.2043
420065 ............................................................................. 1.3680 0.9240 $22.0784 $22.8674 $24.5715 $23.1699
420066 ............................................................................. 0.9805 0.8971 $20.7782 $20.5893 $23.9048 $21.7523
420067 ............................................................................. 1.2989 0.9300 $22.8104 $24.6038 $25.0345 $24.2301
420068 ............................................................................. 1.3586 0.9240 $21.7257 $22.2638 $23.4248 $22.4620
420069 ............................................................................. 1.0761 0.8660 $17.6291 $19.6959 $20.5546 $19.3217
420070 ............................................................................. 1.2782 0.9067 $20.3664 $22.4370 $23.4355 $22.1331
420071 ............................................................................. 1.3654 0.9702 $21.8579 $23.1727 $24.9418 $23.3888
420072 ............................................................................. 1.1026 0.8660 $16.2578 $17.5899 $18.6742 $17.5511
420073 ............................................................................. 1.3501 0.9067 $21.4718 $24.0274 $24.5813 $23.3018
420074 ............................................................................. *** * $18.7010 * * $18.7010
420075 ............................................................................. 0.8901 * $15.9889 $16.4816 * $16.2328
420078 ............................................................................. 1.8173 1.0001 $24.3273 $25.3032 $28.9112 $26.1920
420079 ............................................................................. 1.171 0.9240 $23.3992 $25.2939 $25.4935 $24.7672
420080 ............................................................................. 1.3906 0.9300 $26.7489 $28.4569 $28.4734 $27.9158
420082 ............................................................................. 1.4934 0.9751 $23.6936 $26.1221 $29.8528 $26.5169
420083 ............................................................................. 1.3637 0.9175 $24.8508 $25.3043 $27.1322 $25.7973
420085 ............................................................................. 1.6439 0.9384 $24.4040 $25.3180 $26.8692 $25.5532
420086 ............................................................................. 1.4056 0.9067 $24.5760 $25.1372 $25.8869 $25.2138
420087 ............................................................................. 1.7921 0.9240 $22.4526 $23.2230 $24.3609 $23.3441
420088 ............................................................................. *** * $23.5174 $23.1273 * $23.4240
420089 ............................................................................. 1.3993 0.9240 $23.3240 $25.2729 $26.0074 $24.9015
420091 ............................................................................. 1.3155 0.8971 $23.7936 $23.4710 $26.9214 $24.8118
420093 ............................................................................. 0.9962 0.9175 $21.4678 $25.1457 $27.4766 $24.8258
420097 ............................................................................. *** * * $24.7809 * $24.7809
420098 ............................................................................. 1.1527 0.8695 * * * *
420099 ............................................................................. 1.5769 1.0001 * * * *
430005 ............................................................................. 1.2246 0.8993 $18.2647 $19.9454 $22.3272 $20.0877
430008 2 ........................................................................... 1.1187 0.9607 $20.0124 $20.9442 $23.3790 $21.4251
430011 ............................................................................. 1.2454 * $19.9835 $20.6597 * $20.3142
430012 ............................................................................. 1.2783 0.9607 $21.2588 $22.7530 $24.0850 $22.7129
430013 2 ........................................................................... 1.1798 0.9607 $21.3389 $22.9675 $25.1378 $23.1495
430014 ............................................................................. 1.2591 0.8769 $22.0285 $25.5387 $26.4964 $24.6896
430015 ............................................................................. 1.1287 0.9607 $20.5849 $23.2035 $22.7947 $22.1979
430016 ............................................................................. 1.5924 0.9607 $24.2450 $26.1495 $27.8453 $26.0153
430018 ............................................................................. *** * $17.9850 * * $17.9850
430023 ............................................................................. *** * $18.8816 * * $18.8816
430024 ............................................................................. *** * $18.8357 * * $18.8357
430027 ............................................................................. 1.7822 0.9607 $22.1807 $23.8477 $26.2139 $24.1495
430029 ............................................................................. 0.9023 * $18.9464 $20.2708 * $19.6526
430031 2 ........................................................................... 0.9381 0.9607 $15.2321 $15.6112 $16.0346 $15.6358
430033 ............................................................................. *** * $21.6254 * * $21.6254
430043 ............................................................................. 1.1653 * $17.9672 $17.2722 * $17.5904
430047 ............................................................................. 0.9900 0.8551 $18.2774 $21.9116 $18.8982 $19.7432
430048 ............................................................................. 1.2446 0.9607 $20.0607 $21.1718 $23.0783 $21.5127
430054 ............................................................................. 0.9435 * $17.8871 * * $17.8871
430060 ............................................................................. 0.8286 0.9607 $10.6492 $10.2704 * $10.4542
430064 ............................................................................. 1.0479 0.9607 $14.3407 $16.4314 $17.5376 $16.1075
430077 ............................................................................. 1.7069 0.9607 $21.6786 $23.4835 $25.1763 $23.4802
430081 ............................................................................. 0.8933 1.4448 * * * *
430082 ............................................................................. 0.7728 1.4448 * * * *
430083 ............................................................................. 0.8284 1.4448 * * * *
430084 ............................................................................. 0.7621 1.4448 * * * *
430085 ............................................................................. 0.8598 1.4448 * * * *
430089 ............................................................................. 1.6477 0.9365 $19.8572 $21.1109 $22.5625 $21.3078
430090 ............................................................................. 1.4231 0.9607 $25.6873 $26.0851 $25.8460 $25.8845
430091 ............................................................................. 2.6720 0.9607 $22.2824 $23.8897 $24.3021 $23.6064

Case-mix FY 2006
430092 ............................................................................. 1.8040 0.8551 $19.7354 $20.2570 $20.9486 $20.3194

430093 ............................................................................. 0.9288 0.8993 $23.8820 $23.1526 $29.5244 $25.7876
430094 ............................................................................. 1.8192 0.9249 $20.8743 $18.5429 $18.9099 $19.3880
430095 ............................................................................. 2.3466 0.9607 * $24.7074 $28.1749 $26.5823
430096 ............................................................................. 1.9928 0.8551 * * $21.6998 $21.6998
440001 ............................................................................. 1.1332 0.8003 $18.9833 $17.4802 $19.3100 $18.5533
440002 ............................................................................. 1.6950 0.8955 $22.0178 $23.2177 $24.6664 $23.3294
440003 ............................................................................. 1.2221 0.9731 $21.6336 $24.5168 $25.9209 $24.0777
440006 ............................................................................. 1.4174 0.9731 $24.3173 $26.7983 $28.5951 $26.6300
440007 ............................................................................. 0.9582 0.8003 $14.8015 $13.7042 $25.8236 $17.2437
440008 ............................................................................. 1.0035 0.8499 $20.9237 $22.1405 $23.4301 $22.0908
440009 ............................................................................. 1.1945 0.8003 $19.6564 $21.1274 $21.5970 $20.8327
440010 ............................................................................. 0.9504 0.8003 $16.7270 $16.9060 $17.1803 $16.9489
440011 ............................................................................. 1.3104 0.8456 $20.5036 $21.6861 $22.5068 $21.6145
440012 ............................................................................. 1.4955 0.8087 $21.1213 $21.4769 $22.3029 $21.6368
440015 ............................................................................. 1.8835 0.8456 $23.4485 $22.5583 $23.7422 $23.2495
440016 ............................................................................. 0.9765 0.8003 $20.1504 $20.0982 $22.1646 $20.8341
440017 ............................................................................. 1.8069 0.8087 $21.8033 $22.5313 $22.9364 $22.4333
440018 ............................................................................. 1.1381 0.8003 $21.2242 $21.7239 $23.3444 $22.1229
440019 ............................................................................. 1.8078 0.8456 $21.8854 $23.8802 $25.2553 $23.6676
440020 ............................................................................. 1.0621 0.9120 $21.1075 $23.1718 $23.9475 $22.7656
440023 ............................................................................. 0.9577 * $15.5410 $17.0335 * $16.3078
440024 ............................................................................. 1.2491 0.8544 $19.9751 $20.3658 $23.2716 $21.1545
440025 ............................................................................. 1.1929 0.8003 $19.1478 $19.5995 $20.6798 $19.8282
440026 ............................................................................. *** * $25.1655 $26.9149 $26.8986 $26.2876
440029 ............................................................................. 1.3437 0.9731 $24.1379 $25.8538 $28.0779 $26.0679
440030 ............................................................................. 1.2605 0.8059 $19.9056 $20.0586 $22.1217 $20.7764
440031 ............................................................................. 1.0756 0.8003 $17.0289 $18.0944 $19.6685 $18.2797
440032 ............................................................................. 1.0233 0.8087 $14.7683 $16.0734 $18.5277 $16.4708
440033 ............................................................................. 1.0557 0.8003 $17.2637 $18.7749 $20.7917 $19.0076
440034 ............................................................................. 1.5382 0.8456 $22.2478 $23.1121 $23.5403 $22.9348
440035 ............................................................................. 1.3499 0.9450 $21.4990 $22.3230 $24.3752 $22.7486
440039 ............................................................................. 2.0662 0.9731 $25.0874 $26.4647 $28.4678 $26.7675
440040 ............................................................................. 0.9282 0.8003 $16.9886 $17.7647 $17.8510 $17.5455
440041 ............................................................................. 0.9443 0.8157 $15.5784 $17.4074 $17.9409 $17.0933
440046 ............................................................................. 1.1465 0.9731 $22.3380 $25.5329 $26.1341 $24.7333
440047 ............................................................................. 0.8634 0.8502 $18.7962 $20.4812 $21.4280 $20.2387
440048 ............................................................................. 1.8493 0.9402 $23.1553 $24.3283 $27.7560 $24.7999
440049 ............................................................................. 1.5710 0.9402 $21.1930 $22.9755 $25.3043 $23.1991
440050 ............................................................................. 1.2761 0.9303 $21.1397 $21.8972 $23.1362 $22.0679
440051 ............................................................................. 0.9475 0.8003 $19.0165 $20.7948 $21.9108 $20.5095
440052 ............................................................................. 0.9672 0.8003 $18.1935 $20.1875 $21.1133 $19.9032
440053 ............................................................................. 1.2173 0.9731 $22.0345 $23.9083 $25.4345 $23.8916
440054 ............................................................................. 1.1288 0.8003 $15.4208 $20.5992 $21.4400 $18.6411
440056 ............................................................................. 1.1377 0.8324 $19.3108 $20.4088 $22.1068 $20.7270
440057 ............................................................................. 1.0437 0.8003 $14.1477 $14.6242 $16.4451 $15.0915
440058 ............................................................................. 1.1803 0.9089 $21.7512 $22.6014 $22.9263 $22.4470
440059 ............................................................................. 1.5233 0.9450 $22.4248 $23.9301 $26.3551 $24.2545
440060 ............................................................................. 1.0246 0.8790 $20.2189 $22.7133 $23.3014 $22.1119
440061 ............................................................................. 1.0985 0.8003 $19.5458 $21.2085 $21.8274 $20.8215
440063 ............................................................................. 1.6296 0.8014 $19.7468 $21.8578 $22.3256 $21.2848
440064 ............................................................................. 0.9994 0.9089 $19.4020 $20.9742 $22.0955 $20.8374
440065 ............................................................................. 1.2298 0.9731 $19.9099 $21.4794 $22.3247 $21.2895
440067 ............................................................................. 1.1868 0.8456 $19.5643 $22.1410 $23.1089 $21.6500
440068 ............................................................................. 1.1520 0.9089 $20.9188 $23.1705 $24.5971 $22.9451
440070 ............................................................................. 0.9587 0.8003 $18.3717 $19.0240 $19.4372 $18.9540
440072 ............................................................................. 1.2012 0.9148 $19.6579 $20.9294 $27.1443 $22.1374
440073 ............................................................................. 1.3695 0.9450 $20.7181 $22.2959 $23.9198 $22.3108
440081 h ........................................................................... 1.1519 0.8456 $18.3141 $19.0328 $19.7878 $19.0770
440082 ............................................................................. 2.1876 0.9731 $26.1497 $28.7828 $27.9724 $27.6484
440083 ............................................................................. 0.9129 0.8003 $15.7015 $16.0956 $17.3329 $16.4160
440084 ............................................................................. 1.1715 0.8003 $15.0510 $15.2825 $16.3738 $15.6128
440091 ............................................................................. 1.6425 0.9089 $23.0296 $26.1122 $25.6797 $24.9494
440102 ............................................................................. 1.1396 0.8003 $16.6548 $17.5140 $17.5261 $17.2560
440104 ............................................................................. 1.7869 0.9089 $21.9870 $23.3731 $25.3739 $23.6244
440105 ............................................................................. 1.0319 0.8014 $19.2902 $20.7821 $22.3438 $20.8223
440109 ............................................................................. 0.9845 0.8003 $17.3578 $18.2508 $18.6720 $18.1156

Case-mix FY 2006
440110 ............................................................................. 1.1814 0.8456 $19.9715 $20.9039 $21.3287 $20.7233

440111 ............................................................................. 1.2601 0.9731 $24.9883 $25.8821 $28.5705 $26.5016
440114 ............................................................................. 1.0019 0.8526 $20.1152 $21.4271 $24.0147 $21.9369
440115 ............................................................................. 0.9887 0.8502 $18.5389 $20.0642 $21.7830 $20.1587
440120 ............................................................................. 1.5911 0.8456 $22.4031 $23.9003 $25.5961 $24.0224
440125 ............................................................................. 1.5944 0.8456 $21.1018 $21.9337 $22.4196 $21.8367
440130 ............................................................................. 1.1680 0.8003 $20.6363 $21.6480 $23.4517 $21.9020
440131 ............................................................................. 1.2349 0.9402 $21.0640 $22.4119 $24.9598 $22.8950
440132 ............................................................................. 1.2816 0.8003 $18.9580 $20.5716 $21.5085 $20.3655
440133 ............................................................................. 1.5916 0.9731 $23.3600 $27.5019 $26.2422 $25.6963
440135 ............................................................................. 1.1005 0.8003 $23.9749 $25.3928 $26.6615 $25.3742
440137 ............................................................................. 1.0626 0.8003 $16.5529 $18.2073 $20.6663 $18.4329
440141 ............................................................................. 0.9580 0.8003 $19.2607 $19.4528 $21.3313 $20.0578
440142 ............................................................................. 0.8635 * $17.7587 * * $17.7587
440143 ............................................................................. 0.9934 * $19.2978 $21.0374 * $20.1684
440144 ............................................................................. 1.2202 0.8003 $19.7938 $22.3671 $23.3828 $21.8222
440145 ............................................................................. 0.9884 0.8003 $18.2019 $20.9863 $20.7875 $19.9424
440147 ............................................................................. *** * $25.0780 $28.9038 $31.4012 $28.2938
440148 ............................................................................. 1.1331 0.9450 $20.7693 $23.0697 $24.6412 $22.8692
440149 ............................................................................. 1.0249 * $18.1316 $19.8020 $20.4562 $19.4498
440150 ............................................................................. 1.3918 0.9731 $22.8733 $25.4952 $26.8308 $25.0868
440151 ............................................................................. 1.0949 0.9450 $21.1576 $23.3037 $23.9808 $22.8559
440152 ............................................................................. 1.8872 0.9402 $22.7498 $25.9495 $26.5513 $25.0265
440153 ............................................................................. 1.0214 0.8010 $19.9486 $22.7744 $22.2846 $21.7049
440156 ............................................................................. 1.5036 0.9089 $23.7799 $25.6333 $26.9689 $25.5243
440159 ............................................................................. 1.4437 0.9402 $20.5719 $21.1073 $22.8645 $21.5659
440161 ............................................................................. 1.8166 * $26.1354 $28.6774 * $27.4329
440162 ............................................................................. *** * $20.3909 $16.5305 $21.1418 $19.2406
440166 ............................................................................. 1.5652 0.9402 $23.1692 $27.1355 $31.0779 $26.9641
440168 ............................................................................. 0.9909 0.9402 $21.2113 $22.1764 $22.8768 $22.0809
440173 ............................................................................. 1.6518 0.8456 $20.8442 $20.8723 $22.8846 $21.5657
440174 ............................................................................. 0.8859 0.8375 $19.2201 $20.7960 $22.0974 $20.6472
440175 ............................................................................. 1.0647 0.9450 $22.3331 $24.0005 $22.7299 $23.0174
440176 ............................................................................. 1.3041 0.8087 $20.4861 $22.0079 $23.6659 $22.0556
440180 ............................................................................. 1.2186 0.8456 $21.2398 $21.9781 $23.3808 $22.2150
440181 ............................................................................. 0.9292 0.8410 $19.6133 $21.1406 $22.7150 $21.1984
440182 ............................................................................. 0.9320 0.8003 $19.3928 $20.2630 $22.3612 $20.6845
440183 ............................................................................. 1.5539 0.9402 $24.9282 $27.7769 $27.1515 $26.6633
440184 ............................................................................. 1.0116 0.8014 $21.4484 $20.8219 $22.3475 $21.5303
440185 ............................................................................. 1.1665 0.9089 $22.1845 $23.4172 $23.9052 $23.2612
440186 ............................................................................. 1.0410 0.9731 $23.0193 $24.6773 $25.7445 $24.4615
440187 ............................................................................. 1.0873 0.8003 $19.9478 $21.7637 $21.3252 $21.0131
440189 ............................................................................. 1.3710 0.8955 $23.2866 $24.7851 $27.5435 $25.2579
440192 ............................................................................. 1.0294 0.9450 $21.3228 $25.1119 $25.7495 $24.1386
440193 ............................................................................. 1.2635 0.9731 $22.0345 $24.3911 $24.4299 $23.6341
440194 ............................................................................. 1.3815 0.9731 $24.4508 $26.2498 $26.6527 $25.8291
440197 ............................................................................. 1.2847 0.9731 $24.2660 $26.4999 $27.1534 $25.9812
440200 ............................................................................. 0.9486 0.9731 $16.7752 $17.0633 $17.7491 $17.1850
440203 ............................................................................. 0.9834 0.8003 * $17.7639 $19.3864 $18.5423
440217 ............................................................................. 1.4086 0.9402 $23.3544 $25.9667 $28.5968 $26.1820
440218 ............................................................................. 0.8896 0.9731 $20.1377 $26.3741 $24.6465 $23.5719
440220 ............................................................................. *** * $21.9117 * * $21.9117
440222 ............................................................................. 0.9594 0.9402 * $28.3879 $29.7292 $29.0585
440225 ............................................................................. 0.8471 0.8456 * * * *
440226 ............................................................................. 1.5354 0.8456 * * * *
440227 ............................................................................. 1.1936 0.9731 * * * *
440228 ............................................................................. 1.1074 0.9402 * * * *
450002 ............................................................................. 1.4467 0.9007 $24.0411 $25.4975 $25.7171 $25.1126
450005 ............................................................................. 1.0676 0.8413 $21.7110 $23.4049 $23.5576 $22.9913
450007 ............................................................................. 1.3321 0.8978 $18.3738 $19.2875 $20.7321 $19.4904
450008 ............................................................................. 1.3155 0.8557 $20.1816 $22.0934 $22.9669 $21.7810
450010 ............................................................................. 1.5300 0.8936 $20.3023 $22.4133 $23.7529 $22.1525
450011 ............................................................................. 1.7085 0.8902 $22.1472 $24.1576 $24.8831 $23.7448
450014 ............................................................................. 1.0361 * $20.6936 $22.5001 * $21.5732
450015 ............................................................................. 1.5818 1.0222 $23.9526 $24.0730 $27.4012 $25.2046
450016 ............................................................................. *** * $20.1232 $22.1368 * $21.1548
450018 ............................................................................. 1.3937 0.9996 $22.9019 $24.6443 $26.7999 $24.7633

Case-mix FY 2006
450020 ............................................................................. 0.9512 0.9439 $19.1087 $17.7148 $18.3047 $18.3252

450021 ............................................................................. 1.8322 1.0222 $25.0769 $28.5578 $29.1350 $27.5806
450023 ............................................................................. 1.4131 0.8140 $19.1645 $20.9278 $22.0558 $20.7053
450024 ............................................................................. 1.3715 0.9007 $20.7727 $22.4178 $24.4195 $22.4300
450028 ............................................................................. 1.6020 0.9835 $22.7775 $25.6030 $26.8250 $25.1270
450029 ............................................................................. 1.5255 0.8093 $19.9198 $23.9709 $23.2995 $22.4069
450031 ............................................................................. 1.4886 1.0222 $21.7621 $27.0328 $27.9626 $25.5466
450032 ............................................................................. 1.2211 0.8758 $20.5217 $20.8306 $27.0748 $22.7202
450033 ............................................................................. 1.6042 0.9835 $26.5990 $29.0541 $28.4781 $28.0809
450034 ............................................................................. 1.5499 0.8413 $21.6097 $23.4615 $24.1589 $23.0888
450035 ............................................................................. 1.5349 0.9996 $24.1860 $25.4580 $26.2838 $25.3196
450037 ............................................................................. 1.5164 0.8732 $23.1179 $23.1176 $24.2684 $23.5229
450039 ............................................................................. 1.3931 0.9938 $22.0058 $23.3034 $24.7347 $23.3847
450040 ............................................................................. 1.7554 0.8781 $21.2990 $23.8047 $24.9590 $23.3165
450042 ............................................................................. 1.7420 0.8523 $21.8886 $22.6936 $24.1181 $22.9317
450044 ............................................................................. 1.6814 1.0222 $24.1127 $25.8403 $29.4308 $26.5654
450046 ............................................................................. 1.5707 0.8549 $20.9239 $22.0695 $23.4907 $22.1959
450047 ............................................................................. 0.8608 0.9835 $21.8840 $22.7242 $19.8221 $21.4269
450050 ............................................................................. 0.9394 0.8803 $19.5171 $21.6933 $23.3044 $21.3893
450051 ............................................................................. 1.7951 1.0222 $24.5533 $27.2523 $28.0411 $26.6907
450052 ............................................................................. 0.9735 0.8053 $17.6543 $19.7185 $19.7774 $19.2138
450053 ............................................................................. 0.9596 0.8053 $18.6556 $19.4978 $21.9082 $20.0823
450054 ............................................................................. 1.6766 0.8557 $23.2915 $25.1229 $24.2782 $24.2283
450055 ............................................................................. 1.1336 0.8053 $18.2235 $20.5235 $22.1979 $20.3131
450056 ............................................................................. 1.7962 0.9439 $24.4197 $25.6685 $27.0530 $25.7808
450058 ............................................................................. 1.5442 0.8978 $22.0158 $24.7442 $25.9653 $24.1658
450059 ............................................................................. 1.3265 0.9439 $22.8792 $26.8209 $26.6535 $25.4407
450064 ............................................................................. 1.4250 0.9938 $19.1271 $24.2920 $23.8748 $22.4752
450068 ............................................................................. 2.0373 0.9996 $24.0925 $26.2864 $27.9633 $26.1666
450072 ............................................................................. 1.1689 0.9996 $20.3683 $22.5010 $24.0166 $22.2336
450073 ............................................................................. 0.9446 0.8053 $19.2398 $20.0464 $21.7337 $20.3411
450076 ............................................................................. 1.6909 * * * * *
450078 ............................................................................. 0.9333 0.8053 $14.8285 $17.2196 $15.8968 $15.9697
450079 ............................................................................. 1.5644 1.0222 $24.0085 $27.0443 $28.1096 $26.3674
450080 ............................................................................. 1.1870 0.8612 $21.0353 $21.2482 $22.9835 $21.7735
450081 ............................................................................. 1.0552 * $19.2632 * * $19.2632
450082 ............................................................................. 1.1437 0.8053 $16.6566 $20.9113 $22.0442 $19.8834
450083 ............................................................................. 1.7669 0.9182 $22.5063 $24.9182 $25.8214 $24.4447
450085 ............................................................................. 1.0245 0.8053 $18.1922 $19.4524 $22.0840 $19.8958
450087 ............................................................................. 1.3515 0.9938 $24.5976 $26.4203 $29.1587 $26.8455
450090 ............................................................................. 1.1590 0.8053 $17.1073 $17.6506 $19.4244 $18.0792
450092 ............................................................................. 1.1484 0.8053 $16.0199 $20.4921 $23.2071 $19.7031
450094 ............................................................................. 1.1039 1.0222 $25.8313 $25.3618 $25.2434 $25.4570
450096 ............................................................................. 1.3896 0.8413 $19.8012 $22.8722 $24.1619 $22.3082
450097 ............................................................................. 1.4324 0.9996 $22.2467 $24.9380 $26.4965 $24.6105
450098 ............................................................................. 0.9304 0.8612 $20.4795 $22.9005 $22.6626 $21.9800
450099 ............................................................................. 1.1823 0.9156 $21.4482 $24.0293 $26.6796 $24.1168
450101 ............................................................................. 1.5906 0.8523 $20.1473 $20.6575 $23.6905 $21.4670
450102 ............................................................................. 1.7381 0.9182 $20.9900 $23.1773 $24.5503 $22.9587
450104 ............................................................................. 1.1789 0.8978 $19.7126 $22.5165 $23.8469 $22.0194
450107 ............................................................................. 1.4555 0.9007 $23.2209 $23.8770 $25.9326 $24.3252
450108 ............................................................................. 1.1169 0.8978 $18.8084 $19.3561 $19.4935 $19.2181
450109 ............................................................................. *** * $15.1459 * * $15.1459
450112 ............................................................................. *** * $20.2627 $22.5552 * $21.2999
450113 ............................................................................. *** * $37.8944 * $54.6681 $43.1390
450119 ............................................................................. 1.3114 0.8936 $20.8840 $24.1392 $25.7008 $23.6793
450121 ............................................................................. 1.4809 0.9938 $24.6090 $25.8826 $25.7051 $25.4063
450123 ............................................................................. 1.1197 0.8413 $17.8629 $19.5872 $21.2154 $19.5002
450124 ............................................................................. 1.7951 0.9439 $24.2788 $26.0280 $27.4198 $26.0262
450126 ............................................................................. 1.3686 0.9996 $24.1961 $27.3021 $28.3033 $26.6832
450128 ............................................................................. 1.2540 0.8936 * $21.4190 $23.3633 $22.3457
450130 ............................................................................. 1.1901 0.8978 $19.6199 $20.2777 $21.5226 $20.5273
450131 ............................................................................. 1.2257 0.8549 $20.0434 $23.2317 $23.7098 $22.3750
450132 ............................................................................. 1.5577 0.9883 $22.4680 $26.8476 $28.6954 $25.9595
450133 ............................................................................. 1.5553 0.9513 $25.3928 $25.0972 $26.8344 $25.8308
450135 ............................................................................. 1.6939 0.9938 $22.5673 $24.3858 $26.0755 $24.4084
450137 ............................................................................. 1.6171 0.9938 $24.9732 $27.0081 $30.4254 $27.6976

Case-mix FY 2006
450140 ............................................................................. 0.8931 * $18.3835 $22.4695 * $20.3190

450143 ............................................................................. 1.0532 0.9439 $18.4204 $19.7487 $21.8705 $20.0996
450144 ............................................................................. 1.1763 0.9584 $21.3896 $20.9599 $21.3289 $21.2289
450146 ............................................................................. *** * $16.6808 * * $16.6808
450147 ............................................................................. 1.4066 0.8140 $21.7248 $24.6203 $23.9771 $23.5121
450148 ............................................................................. 1.1628 0.9938 $22.1351 $23.5037 $25.3498 $23.7382
450151 ............................................................................. 1.1936 0.8053 $17.9127 $20.1356 $22.2915 $20.0948
450152 ............................................................................. 1.1967 0.8557 $20.0146 $21.6351 $22.7463 $21.4376
450154 ............................................................................. 1.2820 0.8053 $16.5204 $18.6058 $21.2021 $18.7210
450155 ............................................................................. 1.0357 0.8053 $18.4021 $17.9306 $18.0589 $18.1275
450157 ............................................................................. 1.0122 * $17.8764 $17.8812 * $17.8788
450160 ............................................................................. 0.9342 * $20.7736 $21.9118 * $21.3607
450162 ............................................................................. 1.3737 0.8781 $26.0570 $31.0645 $30.9903 $29.3951
450163 ............................................................................. 0.9859 0.8187 $19.8194 $20.3280 $23.1400 $21.0903
450165 ............................................................................. 1.1629 0.8978 $16.1632 $20.2414 $24.3242 $20.2279
450176 ............................................................................. 1.3413 0.8936 $19.1823 $20.9392 $20.9297 $20.4107
450177 ............................................................................. 1.2063 0.8053 $17.2637 $19.7657 $21.3322 $19.4690
450178 ............................................................................. 0.9765 0.8053 $19.1186 $20.2992 $24.7301 $21.2492
450184 ............................................................................. 1.5408 0.9996 $24.0596 $25.3935 $26.7821 $25.4743
450185 ............................................................................. 0.9850 * $14.3594 $15.5838 * $14.9644
450187 ............................................................................. 1.1679 0.9996 $22.6275 $24.2400 $25.6786 $24.2306
450188 ............................................................................. 0.9332 0.8053 $17.6158 $18.9586 $20.4070 $19.0169
450191 ............................................................................. 1.1357 0.9439 $23.2261 $25.9078 $26.0298 $25.1584
450192 ............................................................................. 1.0946 0.9938 $20.1718 $22.5118 $22.5880 $21.7848
450193 ............................................................................. 2.0472 0.9996 $26.6580 $29.2751 $32.2964 $29.4595
450194 ............................................................................. 1.3374 0.9938 $22.7310 $22.3348 $24.8972 $23.2572
450196 ............................................................................. 1.4229 0.9938 $20.1938 $23.6170 $24.7557 $23.2376
450200 ............................................................................. 1.4551 0.8285 $20.4656 $22.0923 $23.5344 $22.0868
450201 ............................................................................. 0.9302 0.8053 $19.5907 $20.3350 $20.9809 $20.3028
450203 ............................................................................. 1.1740 0.9491 $22.9226 $23.3953 $24.1675 $23.5222
450209 ............................................................................. 1.9039 0.9156 $23.4794 $24.4977 $26.0958 $24.6956
450210 ............................................................................. 0.9631 0.8053 $16.7851 $19.6340 $19.9832 $18.8463
450211 ............................................................................. 1.3504 0.9996 $20.0280 $20.7982 $23.8230 $21.4806
450213 ............................................................................. 1.7973 0.8978 $21.1280 $21.7930 $23.9676 $22.3693
450214 ............................................................................. 1.1786 0.9996 $22.4543 $23.9112 $25.9598 $24.1177
450219 ............................................................................. 0.9891 0.8053 $21.0691 $20.8255 $21.7934 $21.2690
450221 ............................................................................. 1.1410 0.8053 $19.6778 $20.6887 $20.3186 $20.2506
450222 ............................................................................. 1.5793 0.9996 $23.5033 $26.2975 $27.4426 $25.8797
450224 ............................................................................. 1.3957 0.9030 $20.4453 $22.2250 $24.1956 $22.3315
450229 ............................................................................. 1.6507 0.8053 $17.9811 $19.8279 $21.4459 $19.7433
450231 ............................................................................. 1.6179 0.9156 $21.3086 $23.9532 $25.2852 $23.5313
450234 ............................................................................. 0.9864 0.8053 $22.3954 $23.6695 $18.4451 $21.2354
450235 ............................................................................. 0.9187 0.8053 $18.7028 $19.1453 $21.5138 $19.8415
450236 ............................................................................. 1.0511 0.8053 $17.7373 $19.2987 $22.0788 $19.5556
450237 ............................................................................. 1.6849 0.8978 $22.4477 $25.1504 $24.8901 $24.1935
450239 ............................................................................. 0.9333 0.8557 $19.3655 $21.8595 $21.1945 $20.7705
450241 ............................................................................. 0.9526 0.8053 $17.4151 $18.1155 $18.7957 $18.0879
450243 ............................................................................. 1.0082 0.8053 $13.0790 $14.0589 $15.4636 $14.1605
450249 ............................................................................. 0.9883 * $13.1222 $16.5616 * $14.7712
450250 ............................................................................. *** * $13.3731 * * $13.3731
450253 ............................................................................. 0.9826 0.9996 $16.6523 $19.6379 $20.6124 $18.9496
450264 ............................................................................. 0.9237 * $13.5345 $15.4111 * $14.4829
450269 ............................................................................. 1.0284 * $12.6907 $14.8204 * $13.7206
450270 ............................................................................. 1.0833 0.8053 $13.9053 $15.0879 $14.4325 $14.4468
450271 ............................................................................. 1.1604 0.9491 $18.3659 $19.4299 $21.7719 $19.9620
450272 ............................................................................. 1.2055 0.9439 $21.4520 $23.7933 $25.7392 $23.6800
450276 ............................................................................. 0.9069 * $12.8895 $16.0264 $16.6319 $15.2952
450280 ............................................................................. 1.5459 1.0222 $23.1664 $27.4523 $28.7233 $26.4522
450283 ............................................................................. 1.0663 0.9938 $17.1013 $20.0069 $20.9680 $19.5520
450289 ............................................................................. 1.3250 0.9996 $23.7108 $27.3864 $28.5665 $26.5635
450292 ............................................................................. 1.3344 1.0222 $23.4257 $23.5330 $25.0411 $24.0121
450293 ............................................................................. 0.8831 0.8053 $17.7673 $20.0898 $21.3136 $19.7647
450296 ............................................................................. 1.0732 0.9996 $20.4483 $29.2006 $27.9690 $25.4406
450299 ............................................................................. 1.5904 0.8902 $22.9849 $25.8183 $26.4933 $25.0990
450303 ............................................................................. 0.8440 * $16.1330 * * $16.1330
450306 ............................................................................. 0.9365 0.8053 $17.6821 $14.6699 $15.9854 $15.8111
450315 ............................................................................. *** * $26.4677 $27.9780 * $27.2229

Case-mix FY 2006
450320 ............................................................................. *** * $26.8089 * * $26.8089

450324 ............................................................................. 1.5419 0.9509 $23.8523 $23.6362 $24.9128 $24.1611
450327 ............................................................................. *** * $14.3848 * * $14.3848
450330 ............................................................................. 1.2220 0.9996 $22.9947 $24.4310 $25.5820 $24.4245
450340 ............................................................................. 1.3912 0.8279 $20.0621 $22.7826 $24.0636 $22.3350
450346 ............................................................................. 1.4004 0.8413 $20.1921 $21.9717 $22.2469 $21.4909
450347 ............................................................................. 1.1459 0.9996 $21.7142 $22.8133 $27.2203 $23.9176
450348 ............................................................................. 0.9913 0.8053 $15.6324 $17.0198 $18.7675 $17.1642
450351 ............................................................................. 1.2263 0.9491 $22.2597 $23.5895 $25.6859 $23.9245
450352 ............................................................................. 1.1316 1.0222 $21.8138 $23.4297 $24.8012 $23.3447
450353 ............................................................................. 1.2847 0.8053 $19.5263 $20.9271 $24.4454 $21.5974
450358 ............................................................................. 2.0232 0.9996 $25.9105 $29.3408 $30.4280 $28.6741
450362 ............................................................................. 0.9914 0.8539 $20.6340 $22.0223 $25.4372 $22.7898
450369 ............................................................................. 1.0154 0.8053 $16.5636 $17.5360 $18.4848 $17.6077
450370 ............................................................................. 1.1827 0.8311 $19.0340 $22.6815 $20.0832 $20.4877
450371 ............................................................................. *** * $17.3415 * * $17.3415
450372 ............................................................................. 1.3217 1.0222 $22.9079 $26.8019 $28.3359 $26.0630
450373 ............................................................................. 0.9098 0.8053 $17.7955 $20.5789 $22.2213 $20.1017
450374 ............................................................................. 0.9226 0.8053 $15.0670 $17.4509 $23.2285 $18.2702
450378 ............................................................................. 1.3660 0.9996 $25.8048 $29.5108 $30.7684 $28.7797
450379 ............................................................................. 1.3962 1.0222 $29.0865 $31.1573 $30.6072 $30.3060
450381 ............................................................................. 0.9383 0.9439 $19.0584 $20.9200 $22.0482 $20.7572
450388 ............................................................................. 1.6677 0.8978 $22.4441 $24.1598 $25.8674 $24.3854
450389 ............................................................................. 1.1979 0.9938 $20.7160 $22.3803 $23.8764 $22.4221
450393 ............................................................................. *** * $23.8237 $24.6872 $18.4551 $22.6427
450395 ............................................................................. 1.0292 0.8537 $19.1938 $23.9689 $24.8656 $22.6314
450399 ............................................................................. 0.9450 0.8053 $19.1571 $19.5928 $18.2074 $18.9826
450400 ............................................................................. 1.2340 0.8523 $20.1376 $22.0103 $23.1739 $21.7697
450403 ............................................................................. 1.2939 1.0222 $24.6215 $27.8138 $29.3063 $27.2736
450411 ............................................................................. 0.9786 0.8053 $16.9558 $17.6570 $19.6086 $18.1139
450417 ............................................................................. 0.8798 0.9996 $16.1957 $17.8078 $20.0350 $18.0319
450418 ............................................................................. 1.2682 0.9996 $25.1306 $27.0283 $26.8434 $26.3230
450419 ............................................................................. 1.1829 0.9938 $26.7662 $28.4122 $31.0404 $28.7694
450422 ............................................................................. 0.9445 1.0222 $29.0032 $29.5592 $30.6659 $29.7888
450424 ............................................................................. 1.3043 0.9996 $22.0682 $23.1253 $28.3149 $24.8057
450431 ............................................................................. 1.5444 0.9439 $22.9545 $24.7346 $25.2477 $24.3602
450438 ............................................................................. 1.1526 0.9996 $19.2165 $22.0476 $21.9351 $21.1413
450446 ............................................................................. 0.6565 0.9996 $14.1684 $14.9983 $14.3132 $14.4984
450447 ............................................................................. 1.2118 0.9938 $21.0247 $22.5602 $23.5047 $22.3940
450451 ............................................................................. 1.1267 0.9491 $21.1046 $22.3834 $23.3042 $22.3121
450460 ............................................................................. 0.9508 0.8053 $17.9487 $19.5709 $20.5812 $19.4136
450462 ............................................................................. 1.6798 1.0222 $24.0081 $25.6952 $27.8923 $25.9496
450464 ............................................................................. *** * $16.1987 * * $16.1987
450465 ............................................................................. 1.1088 0.8488 $19.4486 $23.0130 $22.4183 $21.6303
450469 ............................................................................. 1.4831 0.9509 $24.0794 $26.6781 $28.7890 $26.6238
450473 ............................................................................. *** * $18.6002 * * $18.6002
450475 ............................................................................. 1.0070 0.8732 $20.9443 $20.7983 $23.5596 $21.7528
450484 ............................................................................. 1.3956 0.9996 $23.2881 $23.0604 $25.3527 $23.9206
450488 ............................................................................. 1.1147 0.8732 $22.5650 $22.3949 $23.9144 $22.9600
450489 ............................................................................. 1.0293 0.8053 $18.5941 $19.6884 $21.4771 $19.8409
450497 ............................................................................. 1.0383 0.8053 $17.1327 $17.6614 $18.8344 $17.8832
450498 ............................................................................. 0.8822 0.8053 $19.2984 $16.4358 $17.7822 $17.7509
450508 ............................................................................. 1.4234 0.9030 $20.8183 $23.5066 $23.9572 $22.7686
450514 ............................................................................. 1.1291 0.8413 $21.0116 $21.4034 $22.6552 $21.6987
450517 ............................................................................. 0.9315 * $14.4246 $15.2707 * $14.8080
450518 ............................................................................. 1.6511 0.8413 $21.1015 $22.2587 $24.1194 $22.4755
450523 ............................................................................. *** * $22.3034 $28.6387 * $25.2834
450530 ............................................................................. 1.1682 0.9996 $23.3005 $26.1998 $28.7451 $26.1850
450534 ............................................................................. 0.9008 * $22.5156 $20.4715 * $21.4079
450535 ............................................................................. *** * $23.7255 $29.4427 * $26.5477
450537 ............................................................................. 1.3614 1.0222 $22.5972 $23.9256 $27.5856 $24.8361
450539 ............................................................................. 1.2202 0.8053 $18.4299 $20.0343 $21.0442 $19.8677
450545 ............................................................................. *** * $21.7762 $22.8130 * $22.2858
450547 ............................................................................. 0.9664 0.9938 $22.6557 $21.8106 $21.6542 $22.0062
450558 ............................................................................. 1.7818 0.8053 $21.4201 $25.0837 $26.1551 $24.1840
450563 ............................................................................. 1.3796 0.9938 $27.5671 $27.9427 $28.7289 $28.1251
450565 ............................................................................. 1.2555 0.8539 $17.2171 $22.1971 $23.8847 $20.9966

Case-mix FY 2006
450571 ............................................................................. 1.5391 0.8279 $21.5688 $20.9651 $22.7703 $21.7784

450573 ............................................................................. 1.1304 0.8053 $18.6233 $21.6974 $20.1479 $20.0755
450578 ............................................................................. 0.9374 0.8053 $17.3010 $20.0454 $20.2695 $19.1233
450580 ............................................................................. 1.1083 0.8053 $18.5225 $20.4293 $21.1574 $20.0321
450584 ............................................................................. 1.0438 0.8053 $16.9021 $19.0373 $21.0808 $18.9453
450586 ............................................................................. 0.9752 0.8053 $14.9061 $14.6574 $16.1003 $15.2149
450587 ............................................................................. 1.1638 0.8053 $19.0648 $19.9712 $20.4512 $19.8609
450591 ............................................................................. 1.2345 0.9996 $19.6229 $22.4991 $23.9992 $22.0639
450596 h ........................................................................... 1.1192 1.0299 $24.3714 $24.7477 $25.3317 $24.8345
450597 ............................................................................. 0.9804 0.8130 $19.9596 $22.9337 $23.1711 $22.1268
450603 ............................................................................. *** * $20.6138 * * $20.6138
450604 ............................................................................. 1.2585 0.8053 $19.5288 $20.5273 $20.9514 $20.3776
450605 ............................................................................. 1.1730 0.8549 $22.0210 $23.8820 $22.2205 $22.7037
450609 ............................................................................. 1.0151 * $16.6870 $18.3856 * $17.5807
450610 ............................................................................. 1.6074 0.9996 $24.7706 $22.5451 $26.8710 $24.6655
450614 ............................................................................. *** * $18.5895 * * $18.5895
450615 ............................................................................. 0.9562 0.8053 $17.2717 $18.2166 $20.3028 $18.6840
450617 ............................................................................. 1.4119 0.9996 $22.7514 $25.2211 $26.5026 $24.9284
450620 ............................................................................. 0.9963 0.8053 $17.1333 $18.1819 $17.7138 $17.6710
450623 ............................................................................. 1.0807 0.9938 $25.1400 $28.3354 $28.3552 $27.2112
450626 ............................................................................. 0.9173 * $17.7454 $21.4445 $26.8375 $21.3925
450630 ............................................................................. 1.5413 0.9996 $24.8096 $27.8856 $29.6796 $27.5230
450631 ............................................................................. *** * $22.8637 $24.5409 * $23.7681
450634 ............................................................................. 1.6132 1.0222 $24.8258 $27.0412 $28.1705 $26.8022
450638 ............................................................................. 1.5906 0.9996 $26.3653 $29.5385 $29.6184 $28.6129
450639 ............................................................................. 1.5166 0.9938 $24.2919 $27.3593 $29.2669 $27.0735
450641 ............................................................................. 0.9774 0.8053 $17.4072 $17.0805 $17.5845 $17.3565
450643 ............................................................................. 1.3324 0.8093 $20.2000 $20.9674 $21.1205 $20.7972
450644 ............................................................................. 1.4557 0.9996 $24.4574 $27.2047 $29.0186 $27.0517
450646 ............................................................................. 1.3717 0.9007 $21.8500 $22.6541 $23.8908 $22.8626
450647 ............................................................................. 1.8252 1.0222 $26.8276 $28.8881 $30.7334 $28.8704
450648 ............................................................................. 0.9121 * $17.3678 $18.2826 * $17.7872
450649 ............................................................................. 0.9495 * $17.5761 $18.1118 * $17.8381
450651 ............................................................................. 1.6339 1.0222 $26.9215 $28.9829 $32.4822 $29.5833
450653 ............................................................................. 1.1250 0.9307 $22.7236 $21.8654 $23.2603 $22.6099
450654 ............................................................................. 0.9105 0.8053 $16.3057 $19.6054 $19.9992 $18.6631
450656 ............................................................................. 1.4088 0.9030 $20.7824 $22.7284 $23.8280 $22.4984
450658 ............................................................................. 0.9058 0.8053 $19.6855 $19.9597 $20.5398 $20.0788
450659 ............................................................................. 1.4571 0.9996 $26.0224 $28.8671 $30.1727 $28.5108
450661 ............................................................................. 1.1789 0.9883 $20.0716 $21.5537 $23.2989 $21.6941
450662 ............................................................................. 1.5509 0.9835 $26.3794 $24.5815 $28.0913 $26.3697
450665 ............................................................................. 0.8701 * $15.8571 $17.2566 $18.6054 $17.2495
450668 ............................................................................. 1.5078 0.9007 $24.0081 $26.4508 $26.2375 $25.5681
450669 ............................................................................. 1.2177 1.0222 $25.0200 $25.6411 $27.4507 $26.1045
450670 ............................................................................. 1.3444 0.9996 $19.9621 $22.0495 $25.1575 $22.3620
450672 ............................................................................. 1.7311 0.9938 $25.3106 $26.7785 $27.6359 $26.6135
450673 ............................................................................. 1.0701 0.8319 $16.3319 $19.4030 * $17.7858
450674 ............................................................................. 0.9544 * $24.8137 $26.8081 * $25.8948
450675 ............................................................................. 1.4447 0.9938 $24.8661 $26.1555 $28.7765 $26.7882
450677 ............................................................................. 1.3508 0.9938 $22.9529 $24.0218 $27.3728 $24.7773
450678 ............................................................................. 1.4249 1.0222 $28.1917 $30.1134 $30.1500 $29.5324
450683 ............................................................................. 1.1505 1.0222 $24.5013 $24.0080 $24.6609 $24.3870
450684 ............................................................................. 1.2328 0.9996 $23.8945 $26.2906 $27.6789 $25.9648
450686 ............................................................................. 1.6362 0.8781 $17.9181 $21.0565 $23.2367 $20.7924
450688 ............................................................................. 1.2067 1.0222 $21.7922 $23.7796 $27.9057 $24.4771
450690 ............................................................................. 1.5005 0.9182 $33.1576 $28.7529 $28.2531 $29.5860
450694 ............................................................................. 1.0995 0.9996 $21.4784 $22.3081 $23.5790 $22.4747
450697 ............................................................................. 1.3398 0.8978 $20.8951 $21.2662 $23.7155 $22.0489
450698 ............................................................................. 0.8879 0.8053 $18.1764 $18.5436 $18.6494 $18.4560
450700 ............................................................................. 0.9342 * $17.3458 $18.6373 * $18.0024
450702 ............................................................................. 1.5147 0.8732 $22.2953 $24.8628 $25.6147 $24.3137
450709 ............................................................................. 1.2721 0.9996 $23.4246 $25.0932 $25.4855 $24.7135
450711 ............................................................................. 1.6188 0.8936 $22.1489 $24.8277 $28.0104 $25.1428
450712 ............................................................................. *** * $18.4547 * * $18.4547
450713 ............................................................................. 1.5285 0.9439 $24.4002 $26.7190 $27.2801 $26.1943
450715 ............................................................................. 1.2751 1.0222 * $16.1897 $28.0365 $20.5948
450716 ............................................................................. 1.2400 0.9996 $24.8614 $28.8043 $30.8440 $28.2641

Case-mix FY 2006
450718 ............................................................................. 1.2057 0.9439 $24.9162 $27.6672 $27.3408 $26.7229

450723 ............................................................................. 1.4250 1.0222 $24.1618 $27.0055 $28.0812 $26.5571
450724 ............................................................................. *** * $21.9630 * * $21.9630
450727 ............................................................................. *** * $16.0843 * * $16.0843
450730 ............................................................................. 1.3060 1.0222 $27.8476 $30.7567 $29.9430 $29.5510
450733 ............................................................................. *** * $23.8143 $25.5624 $26.4976 $25.4115
450742 ............................................................................. 1.2106 1.0222 $25.1295 $26.3414 $26.1190 $25.8920
450743 ............................................................................. 1.4856 1.0222 $23.7424 $24.7397 $27.3213 $25.3404
450746 ............................................................................. 0.9624 0.8053 $11.1672 $16.9209 $12.4748 $13.1222
450747 ............................................................................. 1.2120 0.9938 $21.5883 $24.2674 $22.2870 $22.7471
450749 ............................................................................. 1.0156 0.8053 $17.8696 $18.4095 $17.8227 $18.0184
450751 ............................................................................. 1.2544 0.8285 $23.3154 $22.9070 $19.3265 $21.7472
450754 ............................................................................. 0.9201 0.8053 $19.2827 $21.3043 $20.8968 $20.5167
450755 ............................................................................. 0.9728 0.8781 $19.2768 $19.5168 $18.0092 $18.8178
450758 ............................................................................. 1.2417 1.0222 $22.8713 $24.0226 $25.6548 $24.1232
450760 ............................................................................. 1.1481 0.9007 $23.2959 $25.7453 $24.6349 $24.3909
450761 ............................................................................. 0.8514 0.8053 $15.5151 $16.2605 $15.7483 $15.8642
450763 ............................................................................. 1.1347 0.8289 $19.8939 $21.4171 $22.4905 $21.2790
450766 ............................................................................. 1.8764 1.0222 $27.2499 $28.8576 $30.0441 $28.7197
450770 ............................................................................. 1.1592 0.9439 $19.9412 $20.1763 $20.3656 $20.1550
450771 ............................................................................. 1.6473 1.0222 $25.0490 $26.0618 $31.3924 $27.9152
450774 ............................................................................. 1.7574 0.9996 $21.7906 $24.8562 $24.9683 $23.8170
450775 ............................................................................. 1.2079 0.9996 $23.6621 $25.3924 $24.4006 $24.5023
450776 ............................................................................. 0.9805 * $14.6695 * * $14.6695
450779 ............................................................................. 1.2281 0.9938 $23.8882 $22.5857 $26.9908 $24.4772
450780 ............................................................................. 1.8676 0.8978 $21.9046 $22.8688 $23.9516 $22.9443
450788 ............................................................................. 1.5572 0.8549 $21.4467 $24.2643 $25.4172 $23.7014
450795 ............................................................................. 1.1356 0.9996 $19.1371 $28.1448 $23.7510 $23.4235
450796 ............................................................................. 2.1987 0.9156 $22.4973 $24.7564 $27.9734 $25.1133
450797 ............................................................................. *** * $18.6839 $23.8708 $20.5379 $20.9547
450801 ............................................................................. 1.4958 0.8285 $19.7790 $22.2426 $23.0373 $21.7315
450803 ............................................................................. 1.2419 0.9996 $23.8343 $26.3054 $30.6093 $27.0662
450804 ............................................................................. 1.8238 0.9996 $22.8275 $26.0003 $26.0980 $25.0247
450808 ............................................................................. 1.5928 0.9439 $18.6555 $22.8247 $23.8067 $21.6597
450809 ............................................................................. 1.5794 0.9439 $23.8758 $24.7763 $26.3659 $25.0664
450811 ............................................................................. 1.8227 0.8936 $22.7583 $23.1022 $25.8491 $24.4306
450813 ............................................................................. 1.1010 0.8248 $21.7208 $22.1326 $25.5949 $23.1456
450817 ............................................................................. *** * $28.4441 * * $28.4441
450820 ............................................................................. 1.2204 0.9996 $26.9121 $27.9187 $30.5288 $28.8719
450822 ............................................................................. 1.1446 1.0222 $26.7821 $29.7067 $31.1431 $29.3455
450824 ............................................................................. 2.4144 0.9439 $24.5885 * $26.7803 $25.7897
450825 ............................................................................. 1.4991 0.8936 $18.8510 $18.7069 $20.2959 $19.3490
450827 ............................................................................. 1.4354 0.8319 $29.5838 $21.1788 $20.9704 $23.0851
450828 ............................................................................. 1.1790 0.8053 $20.9509 $21.4128 $22.3667 $21.5956
450829 ............................................................................. *** * $14.4463 $18.2860 $19.5014 $17.2726
450830 ............................................................................. 0.9415 0.9584 $24.7834 $26.9917 $28.1617 $26.6450
450831 ............................................................................. 1.6975 0.9996 * $20.0581 $22.7885 $21.7038
450832 ............................................................................. 1.1361 0.9996 $24.8572 $26.4725 $26.6628 $26.1075
450833 ............................................................................. 1.1880 1.0222 $18.3196 $26.1256 $26.0044 $23.5951
450834 ............................................................................. 1.3968 0.8902 $21.7217 $22.7691 $21.2204 $21.8968
450835 ............................................................................. *** * $24.8374 * * $24.8374
450837 ............................................................................. *** * $24.2964 * * $24.2964
450838 ............................................................................. 1.1224 0.8053 * $15.0454 $15.8026 $15.4717
450839 ............................................................................. 0.9384 0.8758 * $21.1905 $22.9711 $22.0566
450840 ............................................................................. 1.0125 1.0222 * $29.5215 $31.1914 $30.4233
450841 ............................................................................. 1.6639 0.9835 * $17.6635 $18.9468 $18.3289
450842 ............................................................................. *** * * $23.0945 * $23.0945
450844 ............................................................................. 1.2802 0.9996 * $34.4235 $28.7296 $30.4450
450845 ............................................................................. 1.8830 0.9007 * $26.5040 $27.7461 $27.1743
450846 ............................................................................. *** * * $24.0791 * $24.0791
450847 ............................................................................. 1.1998 0.9996 * $26.8892 $27.6854 $27.3036
450848 ............................................................................. 1.1978 0.9996 * $26.5609 $27.8100 $27.1855
450850 ............................................................................. 1.5011 0.9513 * * $22.1334 $22.1334
450851 ............................................................................. 2.4409 1.0222 * * $30.1213 $30.1213
450852 ............................................................................. *** * * * $30.0191 $30.0191
450853 ............................................................................. 2.0332 1.0222 * * * *
450855 ............................................................................. 1.5141 0.9835 * * * *

Case-mix FY 2006
450856 ............................................................................. 2.1787 0.8978 * * * *

450858 ............................................................................. 2.0535 0.9938 * * * *
450860 ............................................................................. 2.3115 0.9996 * * * *
450861 ............................................................................. 1.7724 0.8732 * * * *
450862 ............................................................................. 1.1272 0.9996 * * * *
450864 ............................................................................. 2.1054 0.9182 * * * *
450865 ............................................................................. 1.0980 0.9439 * * * *
450866 ............................................................................. 1.4767 0.8549 * * * *
450867 ............................................................................. 1.2710 0.9439 * * * *
450868 ............................................................................. 1.9100 0.9883 * * * *
450869 ............................................................................. 1.4134 0.8936 * * * *
450870 ............................................................................. 1.5311 0.9996 * * * *
450871 ............................................................................. 1.8928 0.9439 * * * *
450872 ............................................................................. 1.2891 0.9938 * * * *
450873 ............................................................................. 3.2128 0.8978 * * * *
450874 ............................................................................. 1.6081 1.0222 * * * *
450875 ............................................................................. 1.5726 0.9156 * * * *
450876 ............................................................................. 2.3412 0.8781 * * * *
450877 ............................................................................. 1.4156 0.9007 * * * *
450878 ............................................................................. 2.7131 0.8978 * * * *
450879 ............................................................................. 1.6032 0.8093 * * * *
450880 ............................................................................. 1.5062 0.9938 * * * *
450881 ............................................................................. 1.3511 0.8549 * * * *
450882 ............................................................................. 1.4154 0.9182 * * * *
450883 ............................................................................. 2.0287 1.0222 * * * *
450884 ............................................................................. 1.0601 0.8732 * * * *
450885 ............................................................................. 1.3287 1.0222 * * * *
460001 ............................................................................. 1.8912 0.9484 $24.8844 $25.6932 $27.0757 $25.8934
460003 ............................................................................. 1.5251 0.9424 $26.5141 $24.3527 $26.1372 $25.6304
460004 ............................................................................. 1.6710 0.9424 $24.3409 $25.2191 $26.4498 $25.3907
460005 ............................................................................. 1.4452 0.9424 $25.0063 $22.6809 $23.5633 $23.6783
460006 ............................................................................. 1.2988 0.9424 $23.4200 $24.4350 $25.4787 $24.4752
460007 ............................................................................. 1.3349 0.9407 $23.3603 $24.2875 $25.6686 $24.4644
460008 ............................................................................. 1.3638 0.9424 $24.8233 $24.4453 $26.5672 $25.2587
460009 ............................................................................. 1.9243 0.9424 $24.5865 $25.0984 $26.2833 $25.3688
460010 ............................................................................. 2.1081 0.9424 $25.1240 $26.2331 $27.4648 $26.2912
460011 ............................................................................. 1.2796 0.9484 $21.2634 $22.3601 $23.4023 $22.3027
460013 ............................................................................. 1.3598 0.9484 $23.1467 $23.4765 $25.2448 $23.9897
460014 ............................................................................. 1.0871 0.9424 $22.6125 $23.9400 $24.1412 $23.6345
460015 ............................................................................. 1.3061 0.9174 $23.1068 $24.0939 $25.6576 $24.3035
460016 ............................................................................. *** * $18.7453 * * $18.7453
460017 ............................................................................. 1.3428 0.8518 $20.7789 $21.7082 $23.0388 $21.8220
460018 h ........................................................................... 0.8785 1.2082 $16.7143 $18.8942 $20.3755 $18.6334
460019 ............................................................................. 1.1075 0.8126 $18.1995 $20.3625 $19.9900 $19.5496
460020 ............................................................................. 1.0596 0.8126 $15.2162 $19.4960 $19.5669 $17.9384
460021 ............................................................................. 1.6969 1.1237 $23.8565 $24.9725 $26.3420 $25.1139
460023 ............................................................................. 1.1724 0.9484 $25.0874 $25.0376 $25.3094 $25.1556
460025 ............................................................................. 0.9642 * $22.3098 $18.7978 * $20.4201
460026 ............................................................................. 0.9859 0.8126 $21.9316 $22.7589 $24.1547 $22.9505
460029 ............................................................................. 1.0962 * $24.4379 * * $24.4379
460030 ............................................................................. 1.1340 0.8126 $21.2546 $22.6129 $23.4679 $22.4925
460032 ............................................................................. 0.9822 * $21.2715 $22.8987 * $22.1308
460033 ............................................................................. 0.9225 0.8126 $21.7216 $22.7816 $22.0248 $22.1909
460035 ............................................................................. 0.9306 0.8126 $16.9657 $16.9019 $17.5723 $17.1694
460036 ............................................................................. 1.2605 0.9484 $23.9910 $25.2647 $27.2865 $25.5949
460037 ............................................................................. 0.8792 0.8126 $20.0323 $19.8478 $21.1035 $20.3240
460039 ............................................................................. 1.0049 0.9039 $26.3795 $27.5912 $28.5656 $27.5288
460041 ............................................................................. 1.3290 0.9424 $23.5132 $24.0431 $25.2744 $24.2809
460042 ............................................................................. 1.3456 0.9424 $22.0844 $23.5819 $22.9949 $22.8865
460043 ............................................................................. 0.9252 0.9484 $26.0277 $26.6870 $28.2089 $27.0296
460044 ............................................................................. 1.2503 0.9424 $24.7138 $25.7342 $26.6795 $25.7463
460047 ............................................................................. 1.6480 0.9424 $24.9214 $25.1721 $25.7920 $25.3219
460049 ............................................................................. 1.9646 0.9424 $21.9357 $23.0683 $24.5164 $23.1856
460051 ............................................................................. 1.1714 0.9424 $22.7540 $23.4970 $25.5881 $24.0241
460052 ............................................................................. 1.4469 0.9484 $23.1717 $24.0797 $25.3163 $24.2177
460053 ............................................................................. *** * $23.2274 * * $23.2274
460054 ............................................................................. 1.7584 0.9174 * $23.5227 $25.8668 $24.6922

Case-mix FY 2006
470001 ............................................................................. 1.2107 1.1319 $23.5882 $24.5499 $27.7329 $25.2768

470003 ............................................................................. 1.8911 1.1274 $24.1739 $24.6660 $26.4919 $25.1321
470005 ............................................................................. 1.3365 1.0189 $24.9625 $25.7288 $29.8255 $26.8311
470006 ............................................................................. 1.1911 1.0189 $21.6036 $26.0884 $26.9651 $24.9417
470008 ............................................................................. 1.1620 * $20.7659 $21.8951 * $21.3386
470010 ............................................................................. 1.1547 * $23.2072 $22.9777 $26.1273 $24.1019
470011 ............................................................................. 1.2118 1.0982 $24.6034 $25.9246 $28.3911 $26.3395
470012 ............................................................................. 1.2312 1.0189 $20.5072 $22.9159 $24.3425 $22.6924
470018 ............................................................................. 1.1718 1.0476 $21.2904 $25.9300 $28.3419 $25.0848
470023 ............................................................................. 1.2182 * $24.1395 $26.7486 * $25.4614
470024 ............................................................................. 1.1526 1.0189 $22.4659 $23.7745 $25.2427 $23.8783
490001 ............................................................................. 1.0933 0.8697 $22.3622 $21.7111 $21.9953 $22.0191
490002 ............................................................................. 1.0694 0.8025 $17.5098 $18.5220 $19.5613 $18.6066
490003 ............................................................................. *** * $20.9783 $23.8112 $27.3456 $23.8351
490004 ............................................................................. 1.2856 0.9771 $22.7154 $24.4580 $25.4597 $24.2345
490005 ............................................................................. 1.6321 1.0802 $25.2213 $27.6425 $28.5744 $27.1963
490006 ............................................................................. 1.1903 * $13.4277 $16.7679 * $15.2211
490007 ............................................................................. 2.2537 0.8832 $22.2526 $24.9533 $26.2481 $24.5292
490009 ............................................................................. 1.9369 1.0184 $25.2181 $27.5905 $29.0740 $27.2278
490011 ............................................................................. 1.4455 0.8832 $20.0136 $22.4410 $24.5687 $22.4266
490012 ............................................................................. 1.0101 0.8025 $15.8346 $18.3697 $19.2275 $17.8014
490013 ............................................................................. 1.2579 0.8697 $19.5094 $21.4838 $22.4772 $21.1592
490015 ............................................................................. *** * $21.2557 $22.5641 * $21.9516
490017 ............................................................................. 1.4111 0.8832 $20.7691 $22.9632 $24.6845 $22.9273
490018 ............................................................................. 1.2599 0.9771 $22.0810 $23.2215 $24.5196 $23.2792
490019 h ........................................................................... 1.1526 1.2168 $23.3077 $24.4524 $25.9761 $24.6213
490020 ............................................................................. 1.2675 0.9309 $21.2094 $23.6611 $24.8001 $23.2943
490021 ............................................................................. 1.4510 0.8697 $22.2537 $23.5930 $24.6440 $23.5199
490022 ............................................................................. 1.4942 1.0928 $24.4682 $25.0277 $28.0749 $25.8811
490023 ............................................................................. 1.2305 1.0928 $24.9734 $28.8354 $29.7774 $27.9947
490024 ............................................................................. 1.6861 0.8506 $21.2619 $21.7268 $23.0982 $22.0522
490027 ............................................................................. 1.1502 0.8025 $20.3644 $19.8345 $18.9409 $19.7128
490031 ............................................................................. 1.1149 * $18.4826 $22.4300 $22.0579 $20.9706
490032 ............................................................................. 1.8941 0.9309 $23.6489 $22.8942 $25.1381 $23.9005
490033 ............................................................................. 1.0545 1.0928 $24.4370 $27.6355 $30.0909 $27.5418
490037 ............................................................................. 1.1617 0.8025 $17.5104 $19.0583 $21.3035 $19.2834
490038 ............................................................................. 1.1629 0.8047 $18.1405 $19.6427 $22.3976 $20.0632
490040 ............................................................................. 1.5260 1.0928 $27.0513 $30.1820 $32.8738 $30.0780
490041 ............................................................................. 1.4210 0.8832 $19.9314 $22.2955 $24.5738 $22.3542
490042 ............................................................................. 1.2653 0.8025 $19.5127 $20.5845 $21.8749 $20.7701
490043 ............................................................................. 1.1834 1.0928 $25.4354 $28.2969 $30.8871 $28.4640
490044 ............................................................................. 1.3934 0.8832 $20.8739 $22.1324 $20.8351 $21.2628
490045 ............................................................................. 1.3093 1.0928 $24.7131 $27.2132 $28.8279 $27.0743
490046 ............................................................................. 1.5630 0.8832 $22.0040 $24.6391 $25.6328 $24.1719
490047 ............................................................................. 1.0180 0.8989 $19.8220 $21.9156 $22.5424 $21.3597
490048 ............................................................................. 1.4326 0.8442 $22.3138 $24.1639 $25.0097 $23.8716
490050 ............................................................................. 1.5381 1.0928 $26.1521 $29.4660 $30.5037 $28.7334
490052 ............................................................................. 1.6805 0.8832 $19.2480 $21.4035 $22.8889 $21.2086
490053 ............................................................................. 1.3101 0.8087 $18.6541 $20.9367 $21.8432 $20.4783
490057 ............................................................................. 1.5890 0.8832 $22.1612 $25.1898 $26.1128 $24.5153
490059 ............................................................................. 1.5707 0.9309 $23.3895 $26.1518 $28.7276 $26.1974
490060 ............................................................................. 1.0326 0.8025 $20.6028 $21.0828 $22.4200 $21.3908
490063 ............................................................................. 1.8508 1.0928 $31.0162 $29.4216 $30.3632 $30.2230
490066 ............................................................................. 1.3227 0.8832 $22.1034 $23.3835 $24.7146 $23.4575
490067 ............................................................................. 1.1949 0.9309 $20.4058 $21.8730 $22.9188 $21.7183
490069 ............................................................................. 1.5281 0.9309 $20.6957 $24.4542 $26.8791 $24.1400
490071 ............................................................................. 1.2916 0.9309 $25.4678 $27.0374 $28.4381 $27.0687
490073 ............................................................................. 1.6246 1.0928 $27.6711 $25.2859 $31.7743 $27.8898
490075 ............................................................................. 1.4433 0.8506 $22.3230 $22.8303 $23.8191 $23.0000
490077 ............................................................................. 1.3282 1.0184 $22.2643 $24.8309 $26.0800 $24.4773
490079 ............................................................................. 1.2836 0.8951 $19.2196 $19.8100 $23.4728 $20.7435
490084 ............................................................................. 1.1993 0.8192 $19.8598 $22.7945 $24.5965 $22.3566
490088 ............................................................................. 1.0701 0.8697 $19.7549 $21.4818 $22.4186 $21.1984
490089 ............................................................................. 1.0571 0.8442 $21.1522 $21.2123 $22.6461 $21.7546
490090 ............................................................................. 1.1232 0.8025 $20.3015 $21.3410 $22.2907 $21.2854
490092 ............................................................................. 1.1162 0.9309 $23.8364 $21.6466 $23.8656 $23.0587
490093 ............................................................................. 1.4419 0.8832 $20.7388 $23.6779 $25.0751 $23.2941

Case-mix FY 2006
490094 ............................................................................. 1.0191 0.9309 $21.9886 $26.0755 $26.5726 $25.0296

490097 ............................................................................. 1.0192 0.8025 $18.1022 $23.5366 $23.8005 $21.5573
490098 ............................................................................. 1.2373 0.8025 $19.7116 $20.9805 $21.7231 $20.8214
490101 ............................................................................. 1.2797 1.0928 $28.5200 $30.1800 $30.4285 $29.7644
490104 ............................................................................. 0.8032 0.9309 $28.0286 $33.1215 $17.3295 $24.4559
490105 ............................................................................. 0.7403 0.8087 $40.6821 $38.2813 $24.7923 $34.3492
490106 ............................................................................. 0.9467 0.9771 $31.6541 $30.1492 $23.0199 $28.3157
490107 ............................................................................. 1.2712 1.0928 $26.5312 $28.7296 $29.7000 $28.3786
490108 ............................................................................. 0.9960 0.8697 $28.7277 $27.9090 $22.4345 $26.3471
490109 ............................................................................. 0.9901 0.9309 $28.0978 $28.0548 $21.9878 $25.9914
490110 ............................................................................. 1.3190 0.8107 $23.6080 $21.3126 $22.5974 $22.4319
490111 ............................................................................. 1.2958 0.8025 $19.4041 $20.6373 $22.0199 $20.6805
490112 ............................................................................. 1.6780 0.9309 $23.6028 $25.8312 $26.6453 $25.4222
490113 ............................................................................. 1.2749 1.0928 $28.0893 $29.1786 $29.5698 $28.9669
490114 ............................................................................. 0.9738 0.8025 $19.9725 $20.0555 $20.9116 $20.3167
490115 ............................................................................. 1.1853 0.8025 $19.9151 $20.3615 $21.4666 $20.5969
490116 ............................................................................. 1.1376 0.8025 $19.7007 $21.3083 $22.9017 $21.2429
490117 ............................................................................. 1.2083 0.8025 $15.6078 $17.4111 $18.0277 $17.0302
490118 ............................................................................. 1.7166 0.9309 $25.2230 $26.8810 $27.4050 $26.6600
490119 ............................................................................. 1.3223 0.8832 $21.3883 $23.7813 $25.2549 $23.5234
490120 ............................................................................. 1.3949 0.8832 $22.2389 $23.1535 $24.4434 $23.3020
490122 ............................................................................. 1.4407 1.0928 $27.3509 $28.7020 $31.0449 $29.0227
490123 ............................................................................. 1.1014 0.8025 $20.9506 $22.9511 $23.9233 $22.6075
490124 ............................................................................. *** * $21.3713 $29.7939 * $25.7258
490126 ............................................................................. 1.2494 0.8025 $20.4660 $23.1423 $22.2859 $21.9403
490127 ............................................................................. 1.1159 0.8025 $17.8070 $19.4005 $20.4289 $19.2585
490130 ............................................................................. 1.3278 0.8832 $18.6038 $22.0769 $22.8512 $21.1640
490132 ............................................................................. *** * $19.5849 * * $19.5849
490133 ............................................................................. *** * * * $26.5683 $26.5683
490134 ............................................................................. 1.0280 0.8025 * * * *
490135 ............................................................................. 0.7108 0.8442 * * * *
500001 ............................................................................. 1.6005 1.1562 $26.6420 $26.7502 $29.3707 $27.5939
500002 ............................................................................. 1.4190 1.0480 $24.0374 $25.0665 $25.3347 $24.8482
500003 ............................................................................. 1.2854 1.1562 $27.3435 $28.4174 $29.6341 $28.5098
500005 ............................................................................. 1.8323 1.1562 $28.9512 $31.4415 $32.0972 $30.7955
500007 ............................................................................. 1.2993 1.0688 $23.5774 $26.1318 $28.0476 $25.9648
500008 ............................................................................. 1.9468 1.1562 $28.9380 $31.0128 $31.8837 $30.6288
500011 ............................................................................. 1.3733 1.1562 $27.6762 $28.3391 $30.6508 $28.9502
500012 ............................................................................. 1.6030 1.0480 $26.2263 $29.2045 $30.6856 $28.7227
500014 ............................................................................. 1.6603 1.1562 $27.4248 $30.1061 $33.7536 $30.6058
500015 ............................................................................. 1.4325 1.1562 $27.3397 $30.1596 $32.0592 $29.8941
500016 ............................................................................. 1.6712 1.1562 $27.7863 $29.3634 $31.4221 $29.6282
500019 ............................................................................. 1.2772 1.0693 $25.7691 $26.9702 $28.6669 $27.1697
500021 ............................................................................. 1.3194 1.0793 $26.4648 $28.5926 $30.1690 $28.5893
500023 ............................................................................. 1.1440 * $23.9513 $27.3823 * $25.6872
500024 ............................................................................. 1.7104 1.0982 $27.2967 $29.3946 $30.7917 $29.1683
500025 ............................................................................. 1.7397 1.1562 $29.0400 $31.7335 $34.7252 $31.7861
500026 ............................................................................. 1.4646 1.1562 $28.7532 $31.4152 $33.2937 $31.1325
500027 ............................................................................. 1.5653 1.1562 $30.6901 $29.5939 $34.2175 $31.5063
500030 ............................................................................. 1.5850 1.1693 $29.0487 $30.5926 $32.7446 $30.8324
500031 ............................................................................. 1.2010 1.0959 $26.0740 $28.5398 $31.2186 $28.5887
500033 ............................................................................. 1.3030 1.0480 $25.4345 $26.6704 $29.4627 $27.2338
500036 ............................................................................. 1.3831 1.0480 $25.4753 $26.0223 $27.0072 $26.1929
500037 ............................................................................. 1.0377 1.0480 $23.5414 $24.6548 $26.9969 $25.0377
500039 ............................................................................. 1.4538 1.1562 $26.1409 $27.9651 $29.8809 $28.0919
500041 ............................................................................. 1.3106 1.1235 $24.9004 $26.9101 $26.7829 $26.2464
500044 ............................................................................. 1.9846 1.0887 $27.0880 $26.9323 $30.3164 $28.1645
500049 ............................................................................. 1.3037 1.0480 $26.6407 $25.6104 $27.1819 $26.4960
500050 ............................................................................. 1.4538 1.1235 $25.0907 $26.8971 $29.9791 $27.4347
500051 ............................................................................. 1.7670 1.1562 $26.9538 $29.0100 $31.9406 $29.4441
500052 ............................................................................. 1.3564 1.1562 * * * *
500053 ............................................................................. 1.2591 1.0608 $26.0112 $26.8074 $28.4130 $27.1467
500054 ............................................................................. 2.0344 1.0887 $27.1965 $28.8062 $30.8067 $28.9786
500055 ............................................................................. *** * $25.3095 * * $25.3095
500057 ............................................................................. 1.3870 * $21.0357 $21.4393 * $21.2461
500058 ............................................................................. 1.6695 1.0608 $27.3411 $28.4247 $30.4699 $28.8635
500060 ............................................................................. 1.3027 1.1562 $31.7480 $33.5169 $34.1523 $33.1768

Case-mix FY 2006
500064 ............................................................................. 1.7633 1.1562 $29.2539 $31.1459 $31.5371 $30.6791

500065 ............................................................................. 1.2534 * $26.5880 $26.0960 * $26.3295
500071 ............................................................................. 1.1937 * $23.2071 * * $23.2071
500072 ............................................................................. 1.1555 1.1562 $27.5706 $29.3087 $33.4863 $30.1715
500074 ............................................................................. *** * $21.9019 * * $21.9019
500077 ............................................................................. 1.4845 1.0887 $26.5692 $27.8819 $29.4199 $28.0167
500079 ............................................................................. 1.3547 1.0793 $27.1775 $28.4934 $29.6623 $28.4444
500084 ............................................................................. 1.3241 1.1562 $26.5864 $27.6306 $29.3484 $27.9397
500086 ............................................................................. 1.2860 * $25.9705 * * $25.9705
500088 ............................................................................. 1.3895 1.1562 $30.1689 $31.2757 $33.4302 $31.6945
500092 ............................................................................. 0.9229 * $20.8601 $23.2466 * $22.0417
500104 ............................................................................. 1.0850 * $26.8007 $27.0034 * $26.9067
500108 ............................................................................. 1.6584 1.0793 $27.4156 $28.7206 $29.4244 $28.5667
500110 ............................................................................. 1.1842 * $24.8448 $25.4785 * $25.1652
500118 ............................................................................. 1.1235 * $26.1971 $28.1074 * $27.1693
500119 ............................................................................. 1.3675 1.0887 $25.1576 $27.2335 $30.9999 $27.7928
500122 ............................................................................. 1.2120 1.0480 $26.9006 $27.4405 $30.1396 $28.2069
500124 ............................................................................. 1.4141 1.1562 $24.8357 $28.6598 $31.5438 $28.2647
500129 ............................................................................. 1.5421 1.0793 $27.8351 $30.0223 $30.7536 $29.5772
500134 ............................................................................. 0.5051 1.1562 $21.3921 $24.2990 $26.8608 $24.3808
500138 ............................................................................. 1.0850 * * * * *
500139 ............................................................................. 1.5453 1.0982 $27.7281 $29.2357 $31.6591 $29.5383
500141 ............................................................................. 1.2808 1.1562 $28.2968 $30.7478 $30.5456 $29.9289
500143 ............................................................................. 0.4899 1.0982 $19.0982 $20.7093 $22.1419 $20.7552
500147 ............................................................................. 0.8386 1.0480 * $16.3669 $24.5807 $16.9814
500148 ............................................................................. 1.1214 1.0480 * $18.2168 $22.2161 $20.0814
510001 ............................................................................. 1.9255 0.8832 $21.4247 $22.9351 $23.4477 $22.6536
510002 ............................................................................. 1.1692 0.8442 $20.9822 $22.4751 $25.9597 $23.1031
510006 ............................................................................. 1.2555 0.8832 $21.0214 $22.2947 $23.5727 $22.3142
510007 ............................................................................. 1.5691 0.9473 $23.4411 $24.3499 $25.2835 $24.3672
510008 ............................................................................. 1.1973 0.9518 $22.7595 $24.5293 $24.6959 $24.0287
510012 ............................................................................. 0.9588 0.7734 $16.7710 $18.5816 $18.2845 $17.8391
510013 ............................................................................. 1.1829 0.7734 $19.7937 $19.9710 $20.8782 $20.2065
510015 ............................................................................. 0.9570 * $17.9040 * * $17.9040
510018 ............................................................................. 1.0130 0.8293 $19.9490 $21.8475 $20.5556 $20.7431
510022 ............................................................................. 1.8454 0.8446 $22.7534 $24.1481 $24.2125 $23.7112
510023 ............................................................................. 1.2765 0.7813 $17.9267 $19.4321 $20.4908 $19.2664
510024 ............................................................................. 1.7302 0.8832 $21.3662 $23.3115 $24.0444 $22.9061
510026 ............................................................................. 1.0194 0.7734 $16.5389 $18.0855 $16.6192 $17.0257
510028 ............................................................................. 1.0034 * $4.6544 $23.0518 $21.7134 $23.1596
510029 ............................................................................. 1.2652 0.8446 $19.8202 $21.7527 $22.4556 $21.3887
510030 ............................................................................. 1.1840 0.8324 $19.8220 $22.3658 $21.5583 $21.2766
510031 ............................................................................. 1.3935 0.8446 $20.5743 $21.6294 $21.7637 $21.3498
510033 ............................................................................. 1.3919 0.8295 $19.6921 $21.0707 $23.0305 $21.2329
510038 ............................................................................. 1.0348 0.7734 $16.1016 $16.8744 $17.2832 $16.7659
510039 ............................................................................. 1.2761 0.7846 $17.6173 $19.1280 $19.5468 $18.7692
510043 ............................................................................. 0.9124 * $15.5857 $16.0586 * $15.8328
510046 ............................................................................. 1.3006 0.8293 $19.2802 $21.2792 $21.2540 $20.5978
510047 ............................................................................. 1.1387 0.8832 $22.1953 $23.2093 $24.0954 $23.1668
510048 ............................................................................. 1.1193 0.7734 $16.3761 $17.6785 $17.5096 $17.1529
510050 ............................................................................. 1.5322 0.7846 $18.9990 $20.1943 $19.9766 $19.7250
510053 ............................................................................. 1.1441 0.7734 $18.1054 $20.7538 $20.8609 $19.9625
510055 ............................................................................. 1.4649 0.9473 $27.7422 $29.3962 $30.7868 $29.3287
510058 ............................................................................. 1.2960 0.8295 $20.1104 $21.9352 $22.6976 $21.6021
510059 ............................................................................. 0.6597 0.8446 $18.1543 $18.8712 $21.9550 $19.5138
510061 ............................................................................. 0.9980 * $14.8848 $15.3355 * $15.1074
510062 ............................................................................. 1.1657 0.7734 $21.3405 $21.1568 $23.3216 $21.9387
510067 ............................................................................. 1.1851 0.7734 $18.0113 $22.1582 $21.2099 $20.4433
510068 ............................................................................. 1.1255 1.0928 $19.9056 $20.0007 $23.1011 $21.0310
510070 ............................................................................. 1.1911 0.8293 $20.0974 $21.1895 $23.2382 $21.5724
510071 ............................................................................. 1.2969 0.8293 $19.4029 $21.5439 $23.1685 $21.4107
510072 ............................................................................. 1.0729 0.7734 $18.4566 $19.7990 $20.1997 $19.5568
510077 ............................................................................. 1.1634 0.9110 $20.9153 $22.8104 $23.6585 $22.4770
510082 ............................................................................. 1.1080 0.7734 $17.2891 $16.4742 $19.1878 $17.5963
510085 ............................................................................. 1.2085 0.8446 $20.6364 $22.6563 $23.7173 $22.3503
510086 ............................................................................. 1.0952 0.7734 $16.3051 $17.8234 $17.5933 $17.2267
510088 ............................................................................. 0.9948 * $16.4373 $18.3401 * $17.3534

Case-mix FY 2006
510089 ............................................................................. *** * * * $27.7062 $27.7062

520002 ............................................................................. 1.2818 0.9954 $22.0838 $23.7316 $24.9950 $23.6544
520003 ............................................................................. 1.1894 * $20.4234 $21.8662 * $21.1608
520004 ............................................................................. 1.3553 0.9548 $22.8530 $24.4711 $25.4639 $24.2888
520008 ............................................................................. 1.6058 1.0150 $26.0931 $27.8127 $29.8354 $27.9737
520009 ............................................................................. 1.6967 0.9507 $21.5169 $23.4265 $26.1503 $23.6455
520010 ............................................................................. 1.1229 * $26.3965 $28.5569 * $27.4794
520011 ............................................................................. 1.2646 0.9507 $22.7880 $23.7785 $25.2747 $23.9992
520013 ............................................................................. 1.3824 0.9507 $23.1173 $24.4766 $26.6225 $24.8211
520014 ............................................................................. 1.0852 * $20.4281 $22.1064 * $21.2683
520015 ............................................................................. 1.1605 * $22.8094 $23.0403 * $22.9239
520017 ............................................................................. 1.1534 0.9507 $21.7542 $23.4044 $24.6676 $23.3009
520019 ............................................................................. 1.2740 0.9507 $22.6895 $24.9871 $26.7433 $24.8231
520021 ............................................................................. 1.3888 1.0646 $24.1284 $25.4872 $26.6935 $25.4468
520024 ............................................................................. 1.0767 * $17.5368 $18.5072 * $18.0423
520026 ............................................................................. 1.1060 * $25.0504 $26.1056 * $25.6168
520027 ............................................................................. 1.2807 1.0150 $22.2089 $26.2516 $27.6771 $25.6136
520028 ............................................................................. 1.2640 1.0429 $24.3592 $25.7778 $25.4164 $25.1844
520030 ............................................................................. 1.7815 0.9954 $23.9474 $25.3807 $27.0185 $25.5053
520032 ............................................................................. 1.1395 * $22.7220 $25.3059 * $24.0314
520033 ............................................................................. 1.3048 0.9507 $22.2650 $23.9791 $25.0854 $23.8247
520034 ............................................................................. 1.1321 0.9507 $22.6160 $23.6563 $23.9850 $23.4634
520035 ............................................................................. 1.2930 0.9584 $20.8563 $23.2625 $24.7767 $23.0160
520037 ............................................................................. 1.7966 0.9954 $25.0587 $28.6984 $29.7234 $27.8508
520038 ............................................................................. 1.2111 1.0150 $23.1036 $24.6650 $26.6470 $24.8476
520040 ............................................................................. 1.3871 1.0150 $21.5671 $23.8501 $27.2325 $24.2221
520041 ............................................................................. 1.1135 1.0654 $22.6216 $22.8236 $22.7596 $22.7396
520042 ............................................................................. 1.0925 * $21.9935 $24.0788 * $23.0540
520044 ............................................................................. 1.3353 0.9584 $22.7627 $24.9387 $26.0191 $24.5777
520045 ............................................................................. 1.5315 0.9507 $24.1624 $24.5844 $26.0030 $24.9427
520047 ............................................................................. 0.9448 * $22.5686 $25.5346 * $24.0011
520048 ............................................................................. 1.6734 0.9507 $20.5069 $23.1653 $25.1724 $22.8848
520049 ............................................................................. 2.1816 0.9507 $22.7424 $24.1083 $25.9256 $24.2130
520051 ............................................................................. 1.6481 1.0150 $27.6695 $28.8249 $28.4880 $28.3551
520057 ............................................................................. 1.1630 0.9625 $21.2729 $23.3205 $25.3745 $23.3399
520058 ............................................................................. *** * $23.2907 * * $23.2907
520059 ............................................................................. 1.2689 1.0434 $24.1863 $26.5596 $28.0906 $26.3220
520060 ............................................................................. 1.3044 0.9507 $21.1271 $22.0132 $23.8817 $22.3382
520062 ............................................................................. 1.2988 1.0150 $23.7166 $24.9988 $28.2215 $25.7059
520063 ............................................................................. 1.1399 1.0150 $23.3037 $25.3674 $27.4101 $25.4095
520064 ............................................................................. 1.5081 1.0150 $24.3043 $27.1120 $28.6101 $26.6968
520066 ............................................................................. 1.5467 1.0429 $23.9212 $25.8812 $27.1657 $25.6782
520068 ............................................................................. 0.8965 0.9507 $21.4413 $23.4746 $24.8184 $23.2981
520069 ............................................................................. *** * $32.6484 * * $32.6484
520070 ............................................................................. 1.7413 0.9507 $22.0590 $23.9908 $24.8935 $23.6970
520071 ............................................................................. 1.2243 0.9988 $23.4832 $26.3154 $27.6202 $25.7950
520075 ............................................................................. 1.5645 0.9507 $23.7322 $26.0600 $27.1699 $25.6758
520076 ............................................................................. 1.1878 1.0429 $22.2993 $24.0879 $26.1698 $24.2625
520078 ............................................................................. 1.5329 1.0150 $23.4414 $25.7662 $27.5989 $25.6772
520083 ............................................................................. 1.7400 1.0654 $25.7108 $27.0012 $28.8407 $27.2481
520084 ............................................................................. 1.0630 * $24.7909 $25.5777 * $25.1765
520087 ............................................................................. 1.6720 0.9548 $22.8974 $24.5280 $27.3374 $24.8782
520088 ............................................................................. 1.3449 0.9988 $23.8938 $26.0882 $26.9936 $25.7252
520089 ............................................................................. 1.5576 1.0654 $24.4435 $26.6013 $30.0448 $27.0527
520091 ............................................................................. 1.2792 0.9507 $22.8914 $24.8269 $24.6320 $24.0764
520092 ............................................................................. 1.0343 * $21.8662 $23.4043 * $22.6433
520094 ............................................................................. *** * $22.3925 $25.3166 $25.7567 $24.5483
520095 ............................................................................. 1.1997 1.0429 $25.1402 $28.6376 $26.7863 $26.8360
520096 ............................................................................. 1.3385 0.9988 $21.1759 $22.9929 $24.5758 $22.9775
520097 ............................................................................. 1.4029 0.9507 $23.6512 $25.1135 $26.3321 $25.1104
520098 ............................................................................. 2.0235 1.0654 $25.8184 $28.0730 $30.6150 $28.2679
520100 ............................................................................. 1.2871 0.9551 $21.7072 $24.5914 $26.2161 $24.1896
520102 ............................................................................. 1.0893 0.9988 $23.7739 $25.6146 $26.8234 $25.4621
520103 ............................................................................. 1.6079 1.0150 $23.5984 $25.5361 $27.9147 $25.8275
520107 ............................................................................. 1.2288 0.9507 $25.7379 $27.7413 $28.3431 $27.2253
520109 ............................................................................. 1.0449 0.9507 $20.6357 $22.4048 $23.3271 $22.1487
520111 ............................................................................. *** * $26.9666 $26.3095 * $26.6016

Case-mix FY 2006
520112 ............................................................................. 1.1268 * $19.1409 $20.4034 * $19.7623

520113 ............................................................................. 1.2767 0.9507 $24.0822 $26.7926 $27.4135 $26.1479
520114 ............................................................................. 1.1723 * $21.9847 $22.0536 * $22.0194
520116 ............................................................................. 1.2125 0.9988 $23.9066 $26.3057 $26.9902 $25.8557
520117 ............................................................................. 1.0299 * $21.9915 $22.0023 * $21.9973
520123 ............................................................................. 1.0697 * $21.2360 $22.2430 * $21.7461
520130 ............................................................................. *** * $20.0277 * * $20.0277
520132 ............................................................................. 1.1196 0.9584 $19.5140 $21.6025 $23.1941 $21.3823
520134 ............................................................................. *** * $20.8502 * * $20.8502
520135 ............................................................................. 0.9154 * $18.8254 $18.5618 * $18.6918
520136 ............................................................................. 1.6288 1.0150 $23.2573 $25.5145 $27.7703 $25.5032
520138 ............................................................................. 1.8595 1.0150 $25.1434 $26.9047 $28.4394 $26.8513
520139 ............................................................................. 1.2667 1.0150 $23.7727 $25.4424 $26.5110 $25.3279
520140 ............................................................................. 1.6795 1.0150 $23.9176 $26.1616 $28.4433 $26.1128
520145 ............................................................................. *** * $25.0770 * * $25.0770
520148 ............................................................................. 1.2321 * $22.4299 $26.2258 * $24.3567
520151 ............................................................................. 1.0412 * $20.1995 $22.9592 * $21.5728
520152 ............................................................................. 1.0642 0.9507 $22.5440 $23.2493 $24.9392 $23.6620
520154 ............................................................................. 1.1649 * $23.2635 $23.7160 * $23.4910
520156 ............................................................................. 1.0583 * $23.7157 $24.9258 * $24.3330
520160 ............................................................................. 1.8346 0.9507 $22.9475 $24.3528 $25.7588 $24.4208
520161 ............................................................................. 0.9291 * $22.1857 $24.0673 * $23.1340
520170 ............................................................................. 1.3020 1.0150 $25.5470 $25.6124 $27.2221 $26.1781
520173 ............................................................................. 1.0993 1.0226 $24.4723 $26.2224 $28.0995 $26.3133
520177 ............................................................................. 1.6514 1.0150 $27.5560 $28.4663 $30.7317 $29.0456
520178 ............................................................................. 0.9717 0.9507 $22.3193 $23.0419 $20.2666 $21.8785
520189 ............................................................................. 1.1196 1.0646 $23.1658 $26.3172 $28.4720 $26.3169
520192 ............................................................................. *** * $22.5641 * * $22.5641
520193 ............................................................................. 1.6120 0.9507 * * $26.0885 $26.0885
520194 ............................................................................. 1.6325 1.0150 * * $24.9408 $24.9408
520195 ............................................................................. 0.3856 1.0150 * * $36.6973 $36.6973
520196 ............................................................................. 1.5394 0.9507 * * $35.1043 $35.1043
520197 ............................................................................. 2.9023 1.0150 * * * *
520198 ............................................................................. 1.2053 0.9507 * * * *
520199 ............................................................................. 2.5005 1.0150 * * * *
530002 ............................................................................. 1.1639 0.9249 $23.8852 $25.2983 $26.8356 $25.4030
530004 ............................................................................. *** * $19.7857 * * $19.7857
530006 ............................................................................. 1.1388 0.9249 $21.3429 $22.8344 $24.9318 $23.0266
530007 ............................................................................. 1.2503 0.9249 $22.3309 $19.3476 $20.4391 $20.6774
530008 2 ........................................................................... 1.2306 0.9249 $21.8714 $23.8271 $23.8589 $23.1777
530009 ............................................................................. 0.9743 0.9249 $22.0450 $24.2426 $26.8316 $24.1997
530010 2 ........................................................................... 1.2580 0.9249 $21.4890 $23.9255 $25.8482 $23.7290
530011 ............................................................................. 1.0395 0.9249 $22.5720 $24.1396 $24.8245 $23.8464
530012 ............................................................................. 1.7093 0.9249 $22.4716 $24.3454 $25.2526 $24.0014
530014 ............................................................................. 1.6048 0.9249 $21.7314 $23.6907 $24.5947 $23.3995
530015 ............................................................................. 1.2734 0.9887 $25.3915 $26.3107 $27.6876 $26.4934
530016 ............................................................................. 1.3338 * $21.0666 $21.6575 * $21.3685
530017 ............................................................................. 0.9854 0.9249 $19.5630 $23.5415 $25.3362 $22.8987
530023 ............................................................................. 1.1516 * $22.5535 $24.1493 $21.3813 $22.6451
530025 ............................................................................. 1.2853 1.0136 $25.4693 $27.7988 $28.6938 $27.3568
530026 ............................................................................. *** * $21.0732 * * $21.0732
530029 ............................................................................. *** * $19.9691 * * $19.9691
530031 ............................................................................. 0.9626 * $16.8825 $16.3472 * $16.6017
530032 ............................................................................. 1.0395 0.9249 $19.4449 $22.6584 $25.7728 $22.4852
1 Based on salaries adjusted for occupational mix, according to the calculation in section III.F. of the preamble to this final rule.
2 These hospitals are assigned a wage index value under a special exceptions policy (FY 2005 IPPS final rule, 69 FR 49105).
3 The transfer-adjusted case-mix index is based on the billed DRG on the FY 2004 MedPAR.
h These hospitals are assigned a wage index value according to section III.B.3.d of the preamble to this final rule.
* Denotes wage data not available for the provider for that year.
** Based on the sum of the salaries and hours computed for Federal FYs 2004, 2005, and 2006.
*** Denotes MedPAR data not available for the provider for FY 2004.
TABLE 3A.—FY 2006 AND 3-YEAR AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA
[*Based on the salaries and hours computed for Federal fiscal years 2004, 2005, and 2006]
FY 2006 av- 3-Year aver-

CBSA code Urban Area erage hourly age hourly
wage wage
10180 ....... Abilene, TX ............................................................................................................................................... 22.1701 20.4985

10380 ....... Aguadilla-Isabela-San Sebastián, PR ....................................................................................................... 13.2502 11.5908
10420 ....... Akron, OH ................................................................................................................................................. 25.1189 23.9584
10500 ....... Albany, GA ................................................................................................................................................ 24.1796 26.6197
10580 ....... Albany-Schenectady-Troy, NY .................................................................................................................. 24.1014 22.6789
10740 ....... Albuquerque, NM ...................................................................................................................................... 27.1248 25.7999
10780 ....... Alexandria, LA ........................................................................................................................................... 22.5148 21.3129
10900 ....... Allentown-Bethlehem-Easton, PA-NJ ....................................................................................................... 27.5389 25.5762
11020 ....... Altoona, PA ............................................................................................................................................... 25.0167 22.9759
11100 ....... Amarillo, TX .............................................................................................................................................. 25.6410 24.0270
11180 ....... Ames, IA ................................................................................................................................................... 26.7068 25.0247
11260 ....... Anchorage, AK .......................................................................................................................................... 33.3083 31.9786
11300 ....... Anderson, IN ............................................................................................................................................. 24.1549 23.0714
11340 ....... Anderson, SC ............................................................................................................................................ 25.1692 23.0401
11460 ....... Ann Arbor, MI ............................................................................................................................................ 30.4505 29.1802
11500 ....... Anniston-Oxford, AL .................................................................................................................................. 21.5588 20.7900
11540 ....... Appleton, WI ............................................................................................................................................. 25.9098 24.1044
11700 ....... Asheville, NC ............................................................................................................................................ 26.0511 24.5466
12020 ....... Athens-Clarke County, GA ....................................................................................................................... 27.5156 26.2160
12060 ....... Atlanta-Sandy Springs-Marietta, GA ......................................................................................................... 27.3919 26.2708
12100 ....... Atlantic City, NJ ........................................................................................................................................ 32.4848 29.4864
12220 ....... Auburn-Opelika, AL ................................................................................................................................... 22.6976 21.8061
12260 ....... Augusta-Richmond County, GA-SC ......................................................................................................... 27.3055 25.0262
12420 ....... Austin-Round Rock, TX ............................................................................................................................ 26.4319 25.2266
12540 ....... Bakersfield, CA ......................................................................................................................................... 29.3597 26.7401
12580 ....... Baltimore-Towson, MD ............................................................................................................................. 27.6740 26.1267
12620 ....... Bangor, ME ............................................................................................................................................... 27.9343 26.2399
12700 ....... Barnstable Town, MA ............................................................................................................................... 35.2615 33.3166
12940 ....... Baton Rouge, LA ...................................................................................................................................... 24.0727 22.2182
12980 ....... Battle Creek, MI ........................................................................................................................................ 26.5750 24.8236
13020 ....... Bay City, MI .............................................................................................................................................. 26.1760 25.1852
13140 ....... Beaumont-Port Arthur, TX ........................................................................................................................ 23.5603 22.3855
13380 ....... Bellingham, WA ........................................................................................................................................ 32.7446 30.8324
13460 ....... Bend, OR .................................................................................................................................................. 30.1666 28.0136
13644 ....... Bethesda- Gaithersburg-Frederick, MD .................................................................................................... 32.0899 29.4426
13740 ....... Billings, MT ............................................................................................................................................... 24.7710 23.5742
13780 ....... Binghamton, NY ........................................................................................................................................ 24.0264 22.4051
13820 ....... Birmingham-Hoover, AL ............................................................................................................................ 25.0894 23.9488
13900 ....... Bismarck, ND ............................................................................................................................................ 21.2118 20.2286
13980 ....... Blacksburg-Christiansburg-Radford, VA ................................................................................................... 22.3143 21.3890
14020 ....... Bloomington, IN ........................................................................................................................................ 23.7061 22.5941
14060 ....... Bloomington-Normal, IL ............................................................................................................................ 25.4101 23.7897
14260 ....... Boise City-Nampa, ID ............................................................................................................................... 25.3133 24.3052
14484 ....... Boston-Quincy, MA ................................................................................................................................... 32.3479 30.7412
14500 ....... Boulder, CO .............................................................................................................................................. 27.2574 26.2715
14540 ....... Bowling Green, KY ................................................................................................................................... 23.0011 21.8437
14740 ....... Bremerton-Silverdale, WA ........................................................................................................................ 29.8809 28.0919
14860 ....... Bridgeport-Stamford-Norwalk, CT ............................................................................................................. 35.2864 33.7913
15180 ....... Brownsville-Harlingen, TX ......................................................................................................................... 27.5422 26.6603
15260 ....... Brunswick, GA .......................................................................................................................................... 26.1311 28.6493
15380 ....... Buffalo-Niagara Falls, NY ......................................................................................................................... 26.6130 24.9557
15500 ....... Burlington, NC ........................................................................................................................................... 24.9033 23.6142
15540 ....... Burlington-South Burlington, VT ............................................................................................................... 26.3427 24.9877
15764 ....... Cambridge-Newton-Framingham, MA ...................................................................................................... 31.2691 29.3376
15804 ....... Camden, NJ .............................................................................................................................................. 29.4132 28.1192
15940 ....... Canton-Massillon, OH ............................................................................................................................... 25.0564 23.6833
15980 ....... Cape Coral-Fort Myers, FL ....................................................................................................................... 26.1090 25.0248
16180 ....... Carson City, NV ........................................................................................................................................ 28.6158 27.0192
16220 ....... Casper, WY ............................................................................................................................................... 25.2526 24.0014
16300 ....... Cedar Rapids, IA ...................................................................................................................................... 24.6804 23.4375
16580 ....... Champaign-Urbana, IL .............................................................................................................................. 26.8325 25.4853
16620 ....... Charleston, WV ......................................................................................................................................... 23.6532 22.9870
16700 ....... Charleston-North Charleston, SC ............................................................................................................. 25.8747 24.5912
16740 ....... Charlotte-Gastonia-Concord, NC-SC ........................................................................................................ 27.1833 25.6469
16820 ....... Charlottesville, VA ..................................................................................................................................... 28.5185 26.7670
16860 ....... Chattanooga, TN-GA ................................................................................................................................ 25.4537 24.0895
16940 ....... Cheyenne, WY .......................................................................................................................................... 24.5947 23.3995
16974 ....... Chicago-Naperville-Joliet, IL ..................................................................................................................... 30.2086 28.6207
17020 ....... Chico, CA .................................................................................................................................................. 29.4447 27.4655
TABLE 3A.—FY 2006 AND 3-YEAR AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued

wage wage
17140 ....... Cincinnati-Middletown, OH-KY-IN ............................................................................................................. 26.8708 25.0243

17300 ....... Clarksville, TN-KY ..................................................................................................................................... 23.1419 21.5444
17420 ....... Cleveland, TN ........................................................................................................................................... 22.8430 21.2185
17460 ....... Cleveland-Elyria-Mentor, OH .................................................................................................................... 25.7836 25.0847
17660 ....... Coeur d’Alene, ID ..................................................................................................................................... 26.9749 25.1364
17780 ....... College Station-Bryan, TX ........................................................................................................................ 24.9298 23.8756
17820 ....... Colorado Springs, CO ............................................................................................................................... 26.4562 25.5473
17860 ....... Columbia, MO ........................................................................................................................................... 23.3470 22.3003
17900 ....... Columbia, SC ............................................................................................................................................ 25.3899 24.0229
17980 ....... Columbus, GA-AL ..................................................................................................................................... 23.9764 22.7919
18020 ....... Columbus, IN ............................................................................................................................................ 26.8458 25.0573
18140 ....... Columbus, OH .......................................................................................................................................... 27.6046 25.7378
18580 ....... Corpus Christi, TX .................................................................................................................................... 23.9399 22.6210
18700 ....... Corvallis, OR ............................................................................................................................................. 29.9648 28.7806
19060 ....... Cumberland, MD-WV ................................................................................................................................ 26.0448 22.8828
19124 ....... Dallas-Plano-Irving, TX ............................................................................................................................. 28.6253 26.6921
19140 ....... Dalton, GA ................................................................................................................................................ 25.3917 24.9002
19180 ....... Danville, IL ................................................................................................................................................ 25.3127 22.9099
19260 ....... Danville, VA .............................................................................................................................................. 23.8191 23.0000
19340 ....... Davenport-Moline-Rock Island, IA-IL ........................................................................................................ 24.3881 23.2416
19380 ....... Dayton, OH ............................................................................................................................................... 25.3708 24.5739
19460 ....... Decatur, AL ............................................................................................................................................... 23.7138 22.9734
19500 ....... Decatur, IL ................................................................................................................................................ 22.5852 21.4281
19660 ....... Deltona-Daytona Beach-Ormond Beach, FL ............................................................................................ 26.0389 23.9763
19740 ....... Denver-Aurora, CO ................................................................................................................................... 29.9610 28.5121
19780 ....... Des Moines, IA ......................................................................................................................................... 27.0740 24.6825
19804 ....... Detroit-Livonia-Dearborn, MI ..................................................................................................................... 29.2241 27.2889
20020 ....... Dothan, AL ................................................................................................................................................ 21.7218 20.2740
20100 ....... Dover, DE ................................................................................................................................................. 27.4921 25.9420
20220 ....... Dubuque, IA .............................................................................................................................................. 25.2183 23.4077
20260 ....... Duluth, MN-WI .......................................................................................................................................... 28.5692 26.9746
20500 ....... Durham, NC .............................................................................................................................................. 28.5649 27.3142
20740 ....... Eau Claire, WI ........................................................................................................................................... 25.7563 24.1573
20764 ....... Edison, NJ ................................................................................................................................................. 31.5082 29.5433
20940 ....... El Centro, CA ............................................................................................................................................ 25.1083 23.7136
21060 ....... Elizabethtown, KY ..................................................................................................................................... 24.6642 22.6125
21140 ....... Elkhart-Goshen, IN ................................................................................................................................... 26.9005 25.1975
21300 ....... Elmira, NY ................................................................................................................................................. 23.1540 22.0419
21340 ....... El Paso, TX ............................................................................................................................................... 25.2243 24.0882
21500 ....... Erie, PA ..................................................................................................................................................... 24.4677 22.8915
21604 ....... Essex County, MA .................................................................................................................................... 29.4964 27.9829
21660 ....... Eugene-Springfield, OR ............................................................................................................................ 30.2425 29.1289
21780 ....... Evansville, IN-KY ...................................................................................................................................... 24.4379 22.4161
21820 ....... Fairbanks, AK ........................................................................................................................................... 31.8995 29.8198
21940 ....... Fajardo, PR ............................................................................................................................................... 11.6386 10.6772
22020 ....... Fargo, ND-MN ........................................................................................................................................... 23.7360 23.9742
22140 ....... Farmington, NM ........................................................................................................................................ 23.8264 22.4376
22180 ....... Fayetteville, NC ......................................................................................................................................... 26.3708 24.3719
22220 ....... Fayetteville-Springdale-Rogers, AR-MO ................................................................................................... 24.3098 22.6799
22380 ....... Flagstaff, AZ .............................................................................................................................................. 33.8333 30.2808
22420 ....... Flint, MI ..................................................................................................................................................... 29.8067 28.6898
22500 ....... Florence, SC ............................................................................................................................................. 25.1218 23.2632
22520 ....... Florence-Muscle Shoals, AL ..................................................................................................................... 23.2344 21.0532
22540 ....... Fond du Lac, WI ....................................................................................................................................... 26.9936 25.7252
22660 ....... Fort Collins-Loveland, CO ........................................................................................................................ 28.2568 26.7964
22744 ....... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ........................................................................... 29.1773 27.0873
22900 ....... Fort Smith, AR-OK .................................................................................................................................... 23.0943 21.9290
23020 ....... Fort Walton Beach-Crestview-Destin, FL ................................................................................................. 24.8333 23.4332
23060 ....... Fort Wayne, IN .......................................................................................................................................... 27.4082 25.7154
23104 ....... Fort Worth-Arlington, TX ........................................................................................................................... 26.5774 24.9346
23420 ....... Fresno, CA ................................................................................................................................................ 29.6408 27.6994
23460 ....... Gadsden, AL ............................................................................................................................................. 22.3074 21.3197
23540 ....... Gainesville, FL .......................................................................................................................................... 26.2530 25.0755
23580 ....... Gainesville, GA ......................................................................................................................................... 24.8893 24.3617
23844 ....... Gary, IN ..................................................................................................................................................... 26.2968 24.6962
24020 ....... Glens Falls, NY ......................................................................................................................................... 24.0232 22.4577
24140 ....... Goldsboro, NC .......................................................................................................................................... 24.5666 23.0280
24220 ....... Grand Forks, ND-MN ................................................................................................................................ 22.1960 22.4966
24300 ....... Grand Junction, CO .................................................................................................................................. 26.8293 25.6655

wage wage
24340 ....... Grand Rapids-Wyoming, MI ..................................................................................................................... 26.2918 24.8538

24500 ....... Great Falls, MT ......................................................................................................................................... 25.2873 23.4084
24540 ....... Greeley, CO .............................................................................................................................................. 26.8470 25.0779
24580 ....... Green Bay, WI .......................................................................................................................................... 26.5187 25.1688
24660 ....... Greensboro-High Point, NC ...................................................................................................................... 25.5495 24.2161
24780 ....... Greenville, NC ........................................................................................................................................... 26.3325 24.3631
24860 ....... Greenville, SC ........................................................................................................................................... 28.0058 25.6717
25020 ....... Guayama, PR ........................................................................................................................................... 08.9125 09.5939
25060 ....... Gulfport-Biloxi, MS .................................................................................................................................... 24.9592 23.9056
25180 ....... Hagerstown-Martinsburg, MD-WV ............................................................................................................ 26.6548 25.0347
25260 ....... Hanford-Corcoran, CA .............................................................................................................................. 28.1814 25.1270
25420 ....... Harrisburg-Carlisle, PA ............................................................................................................................. 26.0656 24.4948
25500 ....... Harrisonburg, VA ...................................................................................................................................... 25.4597 24.2345
25540 ....... Hartford-West Hartford-East Hartford, CT ................................................................................................ 31.0129 29.5961
25620 ....... Hattiesburg, MS ........................................................................................................................................ 21.3089 19.6542
25860 ....... Hickory-Lenoir-Morganton, NC ................................................................................................................. 25.0061 24.2967
25980 ....... 1 Hinesville-Fort Stewart, GA .................................................................................................................... .................... ....................
26100 ....... Holland-Grand Haven, MI ......................................................................................................................... 25.4579 24.5609
26180 ....... Honolulu, HI .............................................................................................................................................. 31.3996 29.2678
26300 ....... Hot Springs, AR ........................................................................................................................................ 25.2584 24.0637
26380 ....... Houma-Bayou Cane-Thibodaux, LA ......................................................................................................... 22.1079 20.5356
26420 ....... Houston- Sugar Land-Baytown, TX .......................................................................................................... 27.9917 26.1333
26580 ....... Huntington-Ashland, WV-KY-OH .............................................................................................................. 26.5266 25.1442
26620 ....... Huntsville, AL ............................................................................................................................................ 25.5407 23.9283
26820 ....... Idaho Falls, ID ........................................................................................................................................... 26.3236 24.2135
26900 ....... Indianapolis, IN ......................................................................................................................................... 27.7571 26.3923
26980 ....... Iowa City, IA .............................................................................................................................................. 27.2791 25.4755
27060 ....... Ithaca, NY ................................................................................................................................................. 27.5699 25.6624
27100 ....... Jackson, MI ............................................................................................................................................... 26.0171 24.0809
27140 ....... Jackson, MS ............................................................................................................................................. 23.2553 21.9059
27180 ....... Jackson, TN .............................................................................................................................................. 25.0772 23.6035
27260 ....... Jacksonville, FL ........................................................................................................................................ 26.0254 24.9544
27340 ....... Jacksonville, NC ....................................................................................................................................... 23.0236 22.0702
27500 ....... Janesville, WI ............................................................................................................................................ 26.7462 25.0136
27620 ....... Jefferson City, MO .................................................................................................................................... 23.4699 22.4350
27740 ....... Johnson City, TN ...................................................................................................................................... 22.2633 21.2152
27780 ....... Johnstown, PA .......................................................................................................................................... 23.3540 22.1239
27860 ....... Jonesboro, AR .......................................................................................................................................... 22.2913 21.0721
27900 ....... Joplin, MO ................................................................................................................................................. 24.0416 22.8597
28020 ....... Kalamazoo-Portage, MI ............................................................................................................................ 29.1036 28.0936
28100 ....... Kankakee-Bradley, IL ................................................................................................................................ 30.0693 28.0168
28140 ....... Kansas City, MO-KS ................................................................................................................................. 26.4999 25.3015
28420 ....... Kennewick-Richland-Pasco, WA .............................................................................................................. 29.7070 27.8472
28660 ....... Killeen-Temple-Fort Hood, TX .................................................................................................................. 23.9626 23.6807
28700 ....... Kingsport-Bristol-Bristol, TN-VA ................................................................................................................ 22.5380 21.6666
28740 ....... Kingston, NY ............................................................................................................................................. 25.9268 24.2968
28940 ....... Knoxville, TN ............................................................................................................................................. 23.6812 22.7352
29020 ....... Kokomo, IN ............................................................................................................................................... 26.7312 24.3627
29100 ....... La Crosse, WI-MN .................................................................................................................................... 26.7369 24.6616
29140 ....... Lafayette, IN .............................................................................................................................................. 24.4215 23.5470
29180 ....... Lafayette, LA ............................................................................................................................................. 23.5797 22.0745
29340 ....... Lake Charles, LA ...................................................................................................................................... 21.9512 20.7364
29404 ....... Lake County-Kenosha County, IL-WI ....................................................................................................... 29.2180 27.4051
29460 ....... Lakeland, FL ............................................................................................................................................. 24.9925 23.4702
29540 ....... Lancaster, PA ........................................................................................................................................... 27.1801 25.5025
29620 ....... Lansing-East Lansing, MI ......................................................................................................................... 27.4106 25.6482
29700 ....... Laredo, TX ................................................................................................................................................ 22.6637 21.9619
29740 ....... Las Cruces, NM ........................................................................................................................................ 23.6548 22.8284
29820 ....... Las Vegas-Paradise, NV .......................................................................................................................... 31.9355 30.3760
29940 ....... Lawrence, KS ............................................................................................................................................ 23.8863 22.7099
30020 ....... Lawton, OK ............................................................................................................................................... 22.1442 21.4717
30140 ....... Lebanon, PA ............................................................................................................................................. 24.2087 23.0471
30300 ....... Lewiston, ID-WA ....................................................................................................................................... 27.6345 24.9793
30340 ....... Lewiston-Auburn, ME ................................................................................................................................ 26.1064 24.8965
30460 ....... Lexington-Fayette, KY .............................................................................................................................. 25.3464 23.8890
30620 ....... Lima, OH ................................................................................................................................................... 25.7797 24.7454
30700 ....... Lincoln, NE ................................................................................................................................................ 28.5262 26.8068
30780 ....... Little Rock-North Little Rock, AR .............................................................................................................. 24.5286 23.3089
30860 ....... Logan, UT-ID ............................................................................................................................................ 25.6905 24.2109

wage wage
30980 ....... Longview, TX ............................................................................................................................................ 24.4521 23.4643

31020 ....... Longview, WA ........................................................................................................................................... 26.7829 26.2464
31084 ....... Los Angeles-Long Beach-Glendale, CA ................................................................................................... 33.0239 31.0836
31140 ....... Louisville, KY-IN ........................................................................................................................................ 25.9154 24.2971
31180 ....... Lubbock, TX .............................................................................................................................................. 24.5905 22.6838
31340 ....... Lynchburg, VA .......................................................................................................................................... 24.3559 23.5846
31420 ....... Macon, GA ................................................................................................................................................ 26.5343 25.0025
31460 ....... Madera, CA ............................................................................................................................................... 24.4061 22.5247
31540 ....... Madison, WI .............................................................................................................................................. 29.8344 27.4212
31700 ....... Manchester-Nashua, NH .......................................................................................................................... 28.9688 27.6888
31900 ....... Mansfield, OH ........................................................................................................................................... 27.7289 25.0968
32420 ....... Mayagüez, PR .......................................................................................................................................... 11.2545 11.3971
32580 ....... McAllen-Edinburg-Mission, TX .................................................................................................................. 25.0238 22.9932
32780 ....... Medford, OR ............................................................................................................................................. 28.6299 27.7062
32820 ....... Memphis, TN-MS-AR ................................................................................................................................ 26.3296 24.2774
32900 ....... Merced, CA ............................................................................................................................................... 31.1184 27.6673
33124 ....... Miami-Miami Beach-Kendall, FL ............................................................................................................... 27.2956 25.9760
33140 ....... Michigan City-La Porte, IN ........................................................................................................................ 26.3221 24.7313
33260 ....... Midland, TX ............................................................................................................................................... 26.6395 25.3824
33340 ....... Milwaukee-Waukesha-West Allis, WI ....................................................................................................... 28.4248 26.6213
33460 ....... Minneapolis-St. Paul-Bloomington, MN-WI .............................................................................................. 30.9505 29.1179
33540 ....... Missoula, MT ............................................................................................................................................. 26.4227 24.2896
33660 ....... Mobile, AL ................................................................................................................................................. 22.1176 20.9653
33700 ....... Modesto, CA ............................................................................................................................................. 33.3566 31.0924
33740 ....... Monroe, LA ............................................................................................................................................... 22.5035 20.9918
33780 ....... Monroe, MI ................................................................................................................................................ 26.4882 25.0486
33860 ....... Montgomery, AL ........................................................................................................................................ 24.1674 21.7986
34060 ....... Morgantown, WV ...................................................................................................................................... 23.6097 22.7263
34100 ....... Morristown, TN .......................................................................................................................................... 22.3067 20.9421
34580 ....... Mount Vernon-Anacortes, WA .................................................................................................................. 29.2146 27.8316
34620 ....... Muncie, IN ................................................................................................................................................. 25.0449 23.0977
34740 ....... Muskegon-Norton Shores, MI ................................................................................................................... 27.0713 25.4822
34820 ....... Myrtle Beach-Conway-North Myrtle Beach, SC ....................................................................................... 25.0051 23.7988
34900 ....... Napa, CA .................................................................................................................................................. 35.3683 32.9923
34940 ....... Naples-Marco Island, FL ........................................................................................................................... 28.3230 26.9127
34980 ....... Nashville-Davidson--Murfreesboro, TN ..................................................................................................... 27.2496 26.0281
35004 ....... Nassau-Suffolk, NY ................................................................................................................................... 35.6748 34.1135
35084 ....... Newark-Union, NJ-PA ............................................................................................................................... 33.2663 30.9022
35300 ....... New Haven-Milford, CT ............................................................................................................................ 33.3518 31.3675
35380 ....... New Orleans-Metairie-Kenner, LA ............................................................................................................ 25.1827 23.9688
35644 ....... New York-White Plains-Wayne, NY-NJ .................................................................................................... 36.9486 35.2809
35660 ....... Niles-Benton Harbor, MI ........................................................................................................................... 24.8541 23.3997
35980 ....... Norwich-New London, CT ......................................................................................................................... 31.8526 30.4467
36084 ....... Oakland-Fremont-Hayward, CA ................................................................................................................ 42.9160 40.0373
36100 ....... Ocala, FL .................................................................................................................................................. 25.0519 24.4578
36140 ....... Ocean City, NJ .......................................................................................................................................... 30.8612 28.5543
36220 ....... Odessa, TX ............................................................................................................................................... 27.6769 25.1761
36260 ....... Ogden-Clearfield, UT ................................................................................................................................ 25.2772 24.5654
36420 ....... Oklahoma City, OK ................................................................................................................................... 25.2975 23.8010
36500 ....... Olympia, WA ............................................................................................................................................. 30.5859 28.9079
36540 ....... Omaha-Council Bluffs, NE-IA ................................................................................................................... 26.7314 25.5148
36740 ....... Orlando-Kissimmee, FL ............................................................................................................................ 26.4642 25.3744
36780 ....... Oshkosh-Neenah, WI ................................................................................................................................ 25.6249 23.9585
36980 ....... Owensboro, KY ......................................................................................................................................... 24.6348 22.4970
37100 ....... Oxnard-Thousand Oaks-Ventura, CA ....................................................................................................... 32.5213 29.7621
37340 ....... Palm Bay-Melbourne-Titusville, FL ........................................................................................................... 27.5289 25.7640
37460 ....... Panama City-Lynn Haven, FL .................................................................................................................. 22.4111 21.3800
37620 ....... Parkersburg-Marietta-Vienna, WV-OH ..................................................................................................... 23.2293 21.6543
37700 ....... Pascagoula, MS ........................................................................................................................................ 22.8397 21.4591
37860 ....... Pensacola-Ferry Pass-Brent, FL .............................................................................................................. 22.6287 22.0289
37900 ....... Peoria, IL ................................................................................................................................................... 24.7705 23.2523
37964 ....... Philadelphia, PA ........................................................................................................................................ 30.8816 28.8533
38060 ....... Phoenix-Mesa-Scottsdale, AZ .................................................................................................................. 28.3642 26.6290
38220 ....... Pine Bluff, AR ........................................................................................................................................... 24.3824 22.1870
38300 ....... Pittsburgh, PA ........................................................................................................................................... 24.7324 23.2424
38340 ....... Pittsfield, MA ............................................................................................................................................. 28.4877 27.1701
38540 ....... Pocatello, ID .............................................................................................................................................. 26.1526 24.5528
38660 ....... Ponce, PR ................................................................................................................................................. 13.8322 12.8492
38860 ....... Portland-South Portland-Biddeford, ME ................................................................................................... 29.0440 26.7442

wage wage
38900 ....... Portland-Vancouver-Beaverton, OR-WA .................................................................................................. 31.4628 29.7783

38940 ....... Port St. Lucie-Fort Pierce, FL ................................................................................................................... 28.3669 26.5761
39100 ....... Poughkeepsie-Newburgh-Middletown, NY ............................................................................................... 30.5020 29.4326
39140 ....... Prescott, AZ .............................................................................................................................................. 27.6508 26.3318
39300 ....... Providence-New Bedford-Fall River, RI-MA ............................................................................................. 30.6740 28.8463
39340 ....... Provo-Orem, UT ........................................................................................................................................ 26.5574 25.4669
39380 ....... Pueblo, CO ............................................................................................................................................... 24.1431 23.0046
39460 ....... Punta Gorda, FL ....................................................................................................................................... 25.9442 24.8140
39540 ....... Racine, WI ................................................................................................................................................ 25.2201 23.6789
39580 ....... Raleigh-Cary, NC ...................................................................................................................................... 27.0728 25.4570
39660 ....... Rapid City, SD .......................................................................................................................................... 25.1848 23.5321
39740 ....... Reading, PA .............................................................................................................................................. 27.1301 24.7239
39820 ....... Redding, CA .............................................................................................................................................. 34.1503 31.2183
39900 ....... Reno-Sparks, NV ...................................................................................................................................... 30.7272 28.3079
40060 ....... Richmond, VA ........................................................................................................................................... 26.0695 24.6756
40140 ....... Riverside-San Bernardino-Ontario, CA ..................................................................................................... 30.8793 29.3344
40220 ....... Roanoke, VA ............................................................................................................................................. 23.4915 22.4289
40340 ....... Rochester, MN .......................................................................................................................................... 31.1302 30.1737
40380 ....... Rochester, NY ........................................................................................................................................... 25.5478 24.5634
40420 ....... Rockford, IL ............................................................................................................................................... 27.9047 25.7272
40484 ....... Rockingham County-Strafford County, NH ............................................................................................... 29.0055 27.0997
40580 ....... Rocky Mount, NC ...................................................................................................................................... 24.9648 23.7216
40660 ....... Rome, GA ................................................................................................................................................. 26.3370 23.8100
40900 ....... Sacramento--Arden-Arcade--Roseville, CA .............................................................................................. 36.2611 32.0875
40980 ....... Saginaw-Saginaw Township North, MI ..................................................................................................... 25.5958 25.5607
41060 ....... St. Cloud, MN ........................................................................................................................................... 28.0585 26.2839
41100 ....... St. George, UT .......................................................................................................................................... 26.3420 25.1139
41140 ....... St. Joseph, MO-KS ................................................................................................................................... 26.7587 25.8174
41180 ....... St. Louis, MO-IL ........................................................................................................................................ 25.0846 23.8052
41420 ....... Salem, OR ................................................................................................................................................ 29.2207 27.6647
41500 ....... Salinas, CA ............................................................................................................................................... 39.5570 37.1828
41540 ....... Salisbury, MD ............................................................................................................................................ 25.3485 24.0517
41620 ....... Salt Lake City, UT ..................................................................................................................................... 26.3906 25.4257
41660 ....... San Angelo, TX ......................................................................................................................................... 23.1837 21.9567
41700 ....... San Antonio, TX ........................................................................................................................................ 25.1428 23.6261
41740 ....... San Diego-Carlsbad-San Marcos, CA ...................................................................................................... 31.9401 29.7863
41780 ....... Sandusky, OH ........................................................................................................................................... 25.2762 23.6583
41884 ....... San Francisco-San Mateo-Redwood City, CA ......................................................................................... 41.9335 38.9830
41900 ....... San Germán-Cabo Rojo, PR .................................................................................................................... 12.9971 13.4135
41940 ....... San Jose-Sunnyvale-Santa Clara, CA ..................................................................................................... 42.2523 39.0890
41980 ....... San Juan-Caguas-Guaynabo, PR ............................................................................................................ 12.9393 12.3162
42020 ....... San Luis Obispo-Paso Robles, CA .......................................................................................................... 31.7731 29.7965
42044 ....... Santa Ana-Anaheim-Irvine, CA ................................................................................................................. 32.3373 30.4076
42060 ....... Santa Barbara-Santa Maria, CA ............................................................................................................... 32.7103 28.9597
42100 ....... Santa Cruz-Watsonville, CA ..................................................................................................................... 42.4095 37.7929
42140 ....... Santa Fe, NM ............................................................................................................................................ 30.5158 28.6521
42220 ....... Santa Rosa-Petaluma, CA ........................................................................................................................ 37.7122 34.6300
42260 ....... Sarasota-Bradenton-Venice, FL ............................................................................................................... 26.9389 25.6422
42340 ....... Savannah, GA ........................................................................................................................................... 26.5021 24.9741
42540 ....... Scranton--Wilkes-Barre, PA ...................................................................................................................... 23.8629 22.4039
42644 ....... Seattle-Bellevue-Everett, WA ................................................................................................................... 32.3767 30.4445
43100 ....... Sheboygan, WI ......................................................................................................................................... 24.9924 23.3301
43300 ....... Sherman-Denison, TX .............................................................................................................................. 26.6281 25.3544
43340 ....... Shreveport-Bossier City, LA ..................................................................................................................... 24.5258 23.6868
43580 ....... Sioux City, IA-NE-SD ................................................................................................................................ 26.2251 24.1116
43620 ....... Sioux Falls, SD ......................................................................................................................................... 26.9029 24.9570
43780 ....... South Bend-Mishawaka, IN-MI ................................................................................................................. 27.3743 25.4781
43900 ....... Spartanburg, SC ....................................................................................................................................... 25.6900 24.5737
44060 ....... Spokane, WA ............................................................................................................................................ 30.4868 28.5450
44100 ....... Springfield, IL ............................................................................................................................................ 24.6057 23.2284
44140 ....... Springfield, MA .......................................................................................................................................... 28.7008 27.2255
44180 ....... Springfield, MO ......................................................................................................................................... 23.0819 22.2164
44220 ....... Springfield, OH .......................................................................................................................................... 23.4939 22.7752
44300 ....... State College, PA ..................................................................................................................................... 23.4099 22.4626
44700 ....... Stockton, CA ............................................................................................................................................. 31.7251 28.5148
44940 ....... Sumter, SC ............................................................................................................................................... 23.4355 22.1331
45060 ....... Syracuse, NY ............................................................................................................................................ 26.8515 25.0736
45104 ....... Tacoma, WA ............................................................................................................................................. 30.0701 28.9533
45220 ....... Tallahassee, FL ........................................................................................................................................ 24.3724 22.7559

wage wage
45300 ....... Tampa-St. Petersburg-Clearwater, FL ...................................................................................................... 25.9983 24.1939

45460 ....... Terre Haute, IN ......................................................................................................................................... 23.2574 22.0638
45500 ....... Texarkana, TX-Texarkana, AR ................................................................................................................. 23.2000 21.8927
45780 ....... Toledo, OH ................................................................................................................................................ 26.7822 25.0440
45820 ....... Topeka, KS ............................................................................................................................................... 24.9561 23.6665
45940 ....... Trenton-Ewing, NJ .................................................................................................................................... 30.3180 27.8778
46060 ....... Tucson, AZ ................................................................................................................................................ 25.2779 23.7062
46140 ....... Tulsa, OK .................................................................................................................................................. 23.9970 23.2073
46220 ....... Tuscaloosa, AL ......................................................................................................................................... 24.2170 22.0794
46340 ....... Tyler, TX ................................................................................................................................................... 25.7125 24.7325
46540 ....... Utica-Rome, NY ........................................................................................................................................ 23.4607 22.0280
46660 ....... Valdosta, GA ............................................................................................................................................. 24.8233 22.3922
46700 ....... Vallejo-Fairfield, CA .................................................................................................................................. 41.7968 38.4584
46940 ....... Vero Beach, FL ......................................................................................................................................... 26.4579 25.3120
47020 ....... Victoria, TX ............................................................................................................................................... 22.7937 21.7204
47220 ....... Vineland-Millville-Bridgeton, NJ ................................................................................................................ 27.5232 27.0476
47260 ....... Virginia Beach-Norfolk-Newport News, VA-NC ........................................................................................ 24.7332 23.2422
47300 ....... Visalia-Porterville, CA ............................................................................................................................... 28.4356 26.3659
47380 ....... Waco, TX .................................................................................................................................................. 23.8678 22.0171
47580 ....... Warner Robins, GA ................................................................................................................................... 24.2312 22.6117
47644 ....... Warren-Farmington Hills-Troy, MI ............................................................................................................ 27.6345 26.2898
47894 ....... Washington-Arlington-Alexandria, DC-VA-MD-WV .................................................................................. 30.6032 28.8853
47940 ....... Waterloo-Cedar Falls, IA .......................................................................................................................... 23.9572 22.5445
48140 ....... Wausau, WI .............................................................................................................................................. 27.0185 25.5053
48260 ....... Weirton-Steubenville, WV-OH .................................................................................................................. 21.8793 21.4989
48300 ....... Wenatchee, WA ........................................................................................................................................ 28.1544 26.5892
48424 ....... West Palm Beach-Boca Raton-Boynton Beach, FL ................................................................................. 28.1452 26.6150
48540 ....... Wheeling, WV-OH ..................................................................................................................................... 20.0483 19.3905
48620 ....... Wichita, KS ............................................................................................................................................... 25.6747 24.4913
48660 ....... Wichita Falls, TX ....................................................................................................................................... 23.2954 21.9177
48700 ....... Williamsport, PA ........................................................................................................................................ 23.3959 21.9847
48864 ....... Wilmington, DE-MD-NJ ............................................................................................................................. 29.4490 28.5184
48900 ....... Wilmington, NC ......................................................................................................................................... 26.7996 24.9839
49020 ....... Winchester, VA-WV .................................................................................................................................. 28.5744 27.1963
49180 ....... Winston-Salem, NC .................................................................................................................................. 25.0655 24.1158
49340 ....... Worcester, MA .......................................................................................................................................... 30.8984 29.3325
49420 ....... Yakima, WA .............................................................................................................................................. 28.4267 27.0566
49500 ....... Yauco, PR ................................................................................................................................................. 12.3449 12.0750
49620 ....... York-Hanover, PA ..................................................................................................................................... 26.1806 24.2981
49660 ....... Youngstown-Warren-Boardman, OH-PA .................................................................................................. 24.0832 23.4825
49700 ....... Yuba City, CA ........................................................................................................................................... 30.6351 27.8070
49740 ....... Yuma, AZ .................................................................................................................................................. 25.7050 23.8047
1 This area has no average hourly wage because there are no short-term, acute care hospitals in the area.
TABLE 3B.—FY 2006 AND 3-YEAR* AVERAGE HOURLY WAGE FOR RURAL AREAS BY CBSA
[Based on the sum of the salaries and hours computed for federal fiscal years 2004, 2005, and 2006]

CBSA code Nonurban area erage hourly age hourly
wage wage
01 ............. Alabama .................................................................................................................................................... 20.8999 19.9031

02 ............. Alaska ....................................................................................................................................................... 33.5065 31.3627
03 ............. Arizona ...................................................................................................................................................... 24.5771 23.5781
04 ............. Arkansas ................................................................................................................................................... 20.9832 19.6639
05 ............. California ................................................................................................................................................... 30.9228 27.8406
06 ............. Colorado .................................................................................................................................................... 26.2370 24.4898
07 ............. Connecticut ............................................................................................................................................... 32.8379 31.4900
08 ............. Delaware ................................................................................................................................................... 26.8262 25.1791
10 ............. Florida ....................................................................................................................................................... 24.0373 22.7337
11 ............. Georgia ..................................................................................................................................................... 21.5043 20.4917
12 ............. Hawaii ....................................................................................................................................................... 29.6476 27.4203
13 ............. Idaho ......................................................................................................................................................... 22.5556 21.6648
14 ............. Illinois ........................................................................................................................................................ 23.1784 21.7802
15 ............. Indiana ...................................................................................................................................................... 24.1547 22.8438
16 ............. Iowa ........................................................................................................................................................... 23.8311 22.1480
17 ............. Kansas ...................................................................................................................................................... 22.5158 21.1668
18 ............. Kentucky ................................................................................................................................................... 21.7864 20.5845
TABLE 3B.—FY 2006 AND 3-YEAR* AVERAGE HOURLY WAGE FOR RURAL AREAS BY CBSA—Continued
[Based on the sum of the salaries and hours computed for federal fiscal years 2004, 2005, and 2006]

CBSA code Nonurban area erage hourly age hourly
wage wage
19 ............. Louisiana ................................................................................................................................................... 20.8290 19.5825

20 ............. Maine ........................................................................................................................................................ 24.7292 23.4474
21 ............. Maryland ................................................................................................................................................... 26.2028 24.3521
22 ............. Massachusetts 1 ........................................................................................................................................ .................... ....................
23 ............. Michigan .................................................................................................................................................... 24.9169 23.3830
24 ............. Minnesota .................................................................................................................................................. 25.5734 24.3287
25 ............. Mississippi ................................................................................................................................................. 21.5293 20.3356
26 ............. Missouri ..................................................................................................................................................... 22.1677 20.6486
27 ............. Montana .................................................................................................................................................... 24.5083 22.9955
28 ............. Nebraska ................................................................................................................................................... 24.2446 23.2964
29 ............. Nevada ...................................................................................................................................................... 25.3983 24.4345
30 ............. New Hampshire ........................................................................................................................................ 30.2715 26.9284
31 ............. New Jersey 1 ............................................................................................................................................. .................... ....................
32 ............. New Mexico .............................................................................................................................................. 24.1961 22.4946
33 ............. New York .................................................................................................................................................. 22.8722 21.6322
34 ............. North Carolina ........................................................................................................................................... 23.9254 22.5449
35 ............. North Dakota ............................................................................................................................................. 20.3602 20.0194
36 ............. Ohio ........................................................................................................................................................... 24.7151 23.1099
37 ............. Oklahoma .................................................................................................................................................. 21.2973 20.1405
38 ............. Oregon ...................................................................................................................................................... 27.4930 25.9289
39 ............. Pennsylvania ............................................................................................................................................. 23.2122 21.9228
40 ............. Puerto Rico 1 ............................................................................................................................................. .................... ....................
41 ............. Rhode Island 1 ........................................................................................................................................... .................... ....................
42 ............. South Carolina .......................................................................................................................................... 24.2524 22.7760
43 ............. South Dakota ............................................................................................................................................ 23.9456 21.9995
44 ............. Tennessee ................................................................................................................................................ 22.1887 20.8141
45 ............. Texas ........................................................................................................................................................ 22.4960 20.9804
46 ............. Utah ........................................................................................................................................................... 22.7561 21.7591
47 ............. Vermont ..................................................................................................................................................... 27.4761 24.9413
49 ............. Virginia ...................................................................................................................................................... 22.4742 21.2303
50 ............. Washington ............................................................................................................................................... 29.4354 27.3014
51 ............. West Virginia ............................................................................................................................................. 21.6576 20.5854
52 ............. Wisconsin .................................................................................................................................................. 26.6228 24.7285
53 ............. Wyoming ................................................................................................................................................... 25.9018 24.1183
1 All counties in the State or Territory are classified as urban, with the exception of Massachusetts. Massachusetts has area(s) designated as
rural. However, no short-term, acute care hospitals are located in the area(s) for FY 2006.
TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA
Wage
CBSA code Urban area (constituent counties) GAF
index
10180 ....... 2 Abilene, TX ..................................................................................................................................................... 0.8053 0.8622

Callahan County, TX.
Jones County, TX.
Taylor County, TX.
10380 ....... Aguadilla-Isabela-San Sebastián, PR ............................................................................................................... 0.4732 0.5991
Aguada Municipio, PR.
Aguadilla Municipio, PR.
Añasco Municipio, PR.
Isabela Municipio, PR.
Lares Municipio, PR.
Moca Municipio, PR.
Rinc0́n Municipio, PR.
San Sebastián Municipio, PR.
10420 ....... Akron, OH ......................................................................................................................................................... 0.8970 0.9283
Portage County, OH.
Summit County, OH.
10500 ....... Albany, GA ........................................................................................................................................................ 0.8634 0.9043
Baker County, GA.
Dougherty County, GA.
Lee County, GA.
Terrell County, GA.
Worth County, GA.
10580 ....... Albany-Schenectady-Troy, NY .......................................................................................................................... 0.8607 0.9024
Albany County, NY.
Rensselaer County, NY.
Saratoga County, NY.
TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA—
Continued
Wage
index
Schenectady County, NY.

Schoharie County, NY.
10740 ....... Albuquerque, NM .............................................................................................................................................. 0.9686 0.9784
Bernalillo County, NM.
Sandoval County, NM.
Torrance County, NM.
Valencia County, NM.
10780 ....... Alexandria, LA ................................................................................................................................................... 0.8040 0.8612
Grant Parish, LA.
Rapides Parish, LA.
10900 ....... Allentown-Bethlehem-Easton, PA-NJ (PA Hospitals) ....................................................................................... 0.9834 0.9886
Warren County, NJ.
Carbon County, PA.
Lehigh County, PA.
Northampton County, PA.
10900 ....... 2 Allentown-Bethlehem-Easton, PA-NJ (NJ Hospitals) ..................................................................................... 1.1227 1.0825
Warren County, NJ.
Carbon County, PA.
Lehigh County, PA.
Northampton County, PA.
11020 ....... Altoona, PA ....................................................................................................................................................... 0.8933 0.9256
Blair County, PA.
11100 ....... Amarillo, TX ...................................................................................................................................................... 0.9156 0.9414
Armstrong County, TX.
Carson County, TX.
Potter County, TX.
Randall County, TX.
11180 ....... Ames, IA ........................................................................................................................................................... 0.9537 0.9681
Story County, IA.
11260 ....... 2 Anchorage, AK ................................................................................................................................................ 1.1965 1.1307
Anchorage Municipality, AK.
Matanuska-Susitna Borough, AK.
11300 ....... Anderson, IN ..................................................................................................................................................... 0.8626 0.9037
Madison County, IN.
11340 ....... Anderson, SC .................................................................................................................................................... 0.8988 0.9295
Anderson County, SC.
11460 ....... Ann Arbor, MI .................................................................................................................................................... 1.0874 1.0591
Washtenaw County, MI.
11500 ....... Anniston-Oxford, AL .......................................................................................................................................... 0.7717 0.8374
Calhoun County, AL.
11540 ....... 2 Appleton, WI ................................................................................................................................................... 0.9507 0.9660
Calumet County, WI.
Outagamie County, WI.
11700 ....... Asheville, NC .................................................................................................................................................... 0.9303 0.9517
Buncombe County, NC.
Haywood County, NC.
Henderson County, NC.
Madison County, NC.
12020 ....... Athens-Clarke County, GA ................................................................................................................................ 0.9826 0.9881
Clarke County, GA.
Madison County, GA.
Oconee County, GA.
Oglethorpe County, GA.
12060 ....... 1 Atlanta-Sandy Springs-Marietta, GA ............................................................................................................... 0.9782 0.9850
Barrow County, GA.
Bartow County, GA.
Butts County, GA.
Carroll County, GA.
Cherokee County, GA.
Clayton County, GA.
Cobb County, GA.
Coweta County, GA.
Dawson County, GA.
DeKalb County, GA.
Douglas County, GA.
Fayette County, GA.
Forsyth County, GA.
Fulton County, GA.
Gwinnett County, GA.
Haralson County, GA.
Continued
Wage
index
Heard County, GA.

Henry County, GA.
Jasper County, GA.
Lamar County, GA.
Meriwether County, GA.
Newton County, GA.
Paulding County, GA.
Pickens County, GA.
Pike County, GA.
Rockdale County, GA.
Spalding County, GA.
Walton County, GA.
12100 ....... Atlantic City, NJ ................................................................................................................................................ 1.1600 1.1070
Atlantic County, NJ.
12220 ....... Auburn-Opelika, AL ........................................................................................................................................... 0.8105 0.8660
Lee County, AL.
12260 ....... Augusta-Richmond County, GA-SC .................................................................................................................. 0.9751 0.9829
Burke County, GA.
Columbia County, GA.
McDuffie County, GA.
Richmond County, GA.
Aiken County, SC.
Edgefield County, SC.
12420 ....... 1 Austin-Round Rock, TX .................................................................................................................................. 0.9439 0.9612
Bastrop County, TX.
Caldwell County, TX.
Hays County, TX.
Travis County, TX.
Williamson County, TX.
12540 ....... 2 Bakersfield, CA ............................................................................................................................................... 1.1042 1.0702
Kern County, CA.
12580 ....... 1 Baltimore-Towson, MD ................................................................................................................................... 0.9882 0.9919
Anne Arundel County, MD.
Baltimore County, MD.
Carroll County, MD.
Harford County, MD.
Howard County, MD.
Queen Anne’s County, MD.
Baltimore City, MD.
12620 ....... Bangor, ME ....................................................................................................................................................... 0.9975 0.9983
Penobscot County, ME.
12700 ....... Barnstable Town, MA ........................................................................................................................................ 1.2592 1.1710
Barnstable County, MA.
12940 ....... Baton Rouge, LA .............................................................................................................................................. 0.8596 0.9016
Ascension Parish, LA.
East Baton Rouge Parish, LA.
East Feliciana Parish, LA.
Iberville Parish, LA.
Livingston Parish, LA.
Pointe Coupee Parish, LA.
St. Helena Parish, LA.
West Baton Rouge Parish, LA.
West Feliciana Parish, LA.
12980 ....... Battle Creek, MI ................................................................................................................................................ 0.9490 0.9648
Calhoun County, MI.
13020 ....... Bay City, MI ...................................................................................................................................................... 0.9525 0.9672
Bay County, MI.
13140 ....... Beaumont-Port Arthur, TX ................................................................................................................................ 0.8413 0.8884
Hardin County, TX.
Jefferson County, TX.
Orange County, TX.
13380 ....... Bellingham, WA ................................................................................................................................................ 1.1693 1.1131
Whatcom County, WA.
13460 ....... Bend, OR .......................................................................................................................................................... 1.0772 1.0522
Deschutes County, OR.
13644 ....... 1 Bethesda-Gaithersburg-Frederick, MD ........................................................................................................... 1.1459 1.0978
Frederick County, MD.
Montgomery County, MD.
13740 ....... Billings, MT ....................................................................................................................................................... 0.8846 0.9195
Carbon County, MT.
Continued
Wage
index
Yellowstone County, MT.

13780 ....... Binghamton, NY ................................................................................................................................................ 0.8580 0.9004
Broome County, NY.
Tioga County, NY.
13820 ....... 1 Birmingham-Hoover, AL .................................................................................................................................. 0.8959 0.9275
Bibb County, AL.
Blount County, AL.
Chilton County, AL.
Jefferson County, AL.
St. Clair County, AL.
Shelby County, AL.
Walker County, AL.
13900 ....... Bismarck, ND .................................................................................................................................................... 0.7575 0.8268
Burleigh County, ND.
Morton County, ND.
13980 ....... 2 Blacksburg-Christiansburg-Radford, VA ......................................................................................................... 0.8025 0.8601
Giles County, VA.
Montgomery County, VA.
Pulaski County, VA.
Radford City, VA.
14020 ....... 2 Bloomington, IN .............................................................................................................................................. 0.8626 0.9037
Greene County, IN.
Monroe County, IN.
Owen County, IN.
14060 ....... Bloomington-Normal, IL .................................................................................................................................... 0.9074 0.9356
McLean County, IL.
14260 ....... Boise City-Nampa, ID ....................................................................................................................................... 0.9039 0.9331
Ada County, ID.
Boise County, ID.
Canyon County, ID.
Gem County, ID.
Owyhee County, ID.
14484 ....... 1 Boston-Quincy, MA ......................................................................................................................................... 1.1551 1.1038
Norfolk County, MA.
Plymouth County, MA.
Suffolk County, MA.
14500 ....... Boulder, CO ...................................................................................................................................................... 0.9733 0.9816
Boulder County, CO.
14540 ....... Bowling Green, KY ........................................................................................................................................... 0.8214 0.8740
Edmonson County, KY.
Warren County, KY.
14740 ....... Bremerton-Silverdale, WA ................................................................................................................................. 1.0670 1.0454
Kitsap County, WA.
14860 ....... Bridgeport-Stamford-Norwalk, CT ..................................................................................................................... 1.2601 1.1715
Fairfield County, CT.
15180 ....... Brownsville-Harlingen, TX ................................................................................................................................. 0.9835 0.9887
Cameron County, TX.
15260 ....... Brunswick, GA .................................................................................................................................................. 0.9331 0.9537
Brantley County, GA.
Glynn County, GA.
McIntosh County, GA.
15380 ....... 1 Buffalo-Niagara Falls, NY ............................................................................................................................... 0.9503 0.9657
Erie County, NY.
Niagara County, NY.
15500 ....... Burlington, NC ................................................................................................................................................... 0.8893 0.9228
Alamance County, NC.
15540 ....... 2 Burlington-South Burlington, VT ..................................................................................................................... 1.0189 1.0129
Chittenden County, VT.
Franklin County, VT.
Grand Isle County, VT.
15764 ....... 1 Cambridge-Newton-Framingham, MA ............................................................................................................ 1.1166 1.0785
Middlesex County, MA.
15804 ....... 1, 2 Camden, NJ ................................................................................................................................................. 1.1227 1.0825
Burlington County, NJ.
Camden County, NJ.
Gloucester County, NJ.
15940 ....... Canton-Massillon, OH ....................................................................................................................................... 0.8948 0.9267
Carroll County, OH.
Stark County, OH.
15980 ....... Cape Coral-Fort Myers, FL ............................................................................................................................... 0.9323 0.9531
Continued
Wage
index
Lee County, FL.

16180 ....... Carson City, NV ................................................................................................................................................ 1.0219 1.0149
Carson City, NV.
16220 ....... 2 Casper, WY ..................................................................................................................................................... 0.9249 0.9479
Natrona County, WY.
16300 ....... Cedar Rapids, IA .............................................................................................................................................. 0.8813 0.9171
Benton County, IA.
Jones County, IA.
Linn County, IA.
16580 ....... Champaign-Urbana, IL ...................................................................................................................................... 0.9582 0.9712
Champaign County, IL.
Ford County, IL.
Piatt County, IL.
16620 ....... Charleston, WV ................................................................................................................................................. 0.8446 0.8908
Boone County, WV.
Clay County, WV.
Kanawha County, WV.
Lincoln County, WV.
Putnam County, WV.
16700 ....... Charleston-North Charleston, SC ..................................................................................................................... 0.9240 0.9473
Berkeley County, SC.
Charleston County, SC.
Dorchester County, SC.
16740 ....... 1 Charlotte-Gastonia-Concord, NC-SC .............................................................................................................. 0.9707 0.9798
Anson County, NC.
Cabarrus County, NC.
Gaston County, NC.
Mecklenburg County, NC.
Union County, NC.
York County, SC.
16820 ....... Charlottesville, VA ............................................................................................................................................. 1.0184 1.0126
Albemarle County, VA.
Fluvanna County, VA.
Greene County, VA.
Nelson County, VA.
Charlottesville City, VA.
16860 ....... Chattanooga, TN-GA ........................................................................................................................................ 0.9089 0.9367
Catoosa County, GA.
Dade County, GA.
Walker County, GA.
Hamilton County, TN.
Marion County, TN.
Sequatchie County, TN.
16940 ....... 2 Cheyenne, WY ................................................................................................................................................ 0.9249 0.9479
Laramie County, WY.
16974 ....... 1 Chicago-Naperville-Joliet, IL ........................................................................................................................... 1.0787 1.0532
Cook County, IL.
DeKalb County, IL.
DuPage County, IL.
Grundy County, IL.
Kane County, IL.
Kendall County, IL.
McHenry County, IL.
Will County, IL.
17020 ....... 2 Chico, CA ........................................................................................................................................................ 1.1042 1.0702
Butte County, CA.
17140 ....... 1 Cincinnati-Middletown, OH-KY-IN ................................................................................................................... 0.9595 0.9721
Dearborn County, IN.
Franklin County, IN.
Ohio County, IN.
Boone County, KY.
Bracken County, KY.
Campbell County, KY.
Gallatin County, KY.
Grant County, KY.
Kenton County, KY.
Pendleton County, KY.
Brown County, OH.
Butler County, OH.
Clermont County, OH.
Continued
Wage
index
Hamilton County, OH.

Warren County, OH.
17300 ....... Clarksville, TN-KY ............................................................................................................................................. 0.8264 0.8776
Christian County, KY.
Trigg County, KY.
Montgomery County, TN.
Stewart County, TN.
17420 ....... Cleveland, TN ................................................................................................................................................... 0.8157 0.8698
Bradley County, TN.
Polk County, TN.
17460 ....... 1 Cleveland-Elyria-Mentor, OH .......................................................................................................................... 0.9207 0.9450
Cuyahoga County, OH.
Geauga County, OH.
Lake County, OH.
Lorain County, OH.
Medina County, OH.
17660 ....... Coeur d’Alene, ID ............................................................................................................................................. 0.9633 0.9747
Kootenai County, ID.
17780 ....... College Station-Bryan, TX ................................................................................................................................ 0.8902 0.9234
Brazos County, TX.
Burleson County, TX.
Robertson County, TX.
17820 ....... Colorado Springs, CO ....................................................................................................................................... 0.9447 0.9618
El Paso County, CO.
Teller County, CO.
17860 ....... Columbia, MO ................................................................................................................................................... 0.8357 0.8843
Boone County, MO.
Howard County, MO.
17900 ....... Columbia, SC .................................................................................................................................................... 0.9067 0.9351
Calhoun County, SC.
Fairfield County, SC.
Kershaw County, SC.
Lexington County, SC.
Richland County, SC.
Saluda County, SC.
17980 ....... Columbus, GA-AL ............................................................................................................................................. 0.8562 0.8991
Russell County, AL.
Chattahoochee County, GA.
Harris County, GA.
Marion County, GA.
Muscogee County, GA.
18020 ....... Columbus, IN .................................................................................................................................................... 0.9586 0.9715
Bartholomew County, IN.
18140 ....... 1 Columbus, OH ................................................................................................................................................ 0.9857 0.9902
Delaware County, OH.
Fairfield County, OH.
Franklin County, OH.
Licking County, OH.
Madison County, OH.
Morrow County, OH.
Pickaway County, OH.
Union County, OH.
18580 ....... Corpus Christi, TX ............................................................................................................................................. 0.8549 0.8982
Aransas County, TX.
Nueces County, TX.
San Patricio County, TX.
18700 ....... Corvallis, OR ..................................................................................................................................................... 1.0700 1.0474
Benton County, OR.
19060 ....... 2 Cumberland, MD-WV (MD Hospitals) ............................................................................................................. 0.9357 0.9555
Allegany County, MD.
Mineral County, WV.
19060 ....... Cumberland, MD-WV (WV Hospitals) ............................................................................................................... 0.9300 0.9515
Allegany County, MD.
Mineral County, WV.
19124 ....... 1 Dallas-Plano-Irving, TX ................................................................................................................................... 1.0222 1.0151
Collin County, TX.
Dallas County, TX.
Delta County, TX.
Denton County, TX.
Ellis County, TX.
Continued
Wage
index
Hunt County, TX.

Kaufman County, TX.
Rockwall County, TX.
19140 ....... Dalton, GA ........................................................................................................................................................ 0.9067 0.9351
Murray County, GA.
Whitfield County, GA.
19180 ....... Danville, IL ........................................................................................................................................................ 0.9039 0.9331
Vermilion County, IL.
19260 ....... Danville, VA ...................................................................................................................................................... 0.8506 0.8951
Pittsylvania County, VA.
Danville City, VA.
19340 ....... Davenport-Moline-Rock Island, IA-IL ................................................................................................................ 0.8709 0.9097
Henry County, IL.
Mercer County, IL.
Rock Island County, IL.
Scott County, IA.
19380 ....... Dayton, OH ....................................................................................................................................................... 0.9060 0.9346
Greene County, OH.
Miami County, OH.
Montgomery County, OH.
Preble County, OH.
19460 ....... Decatur, AL ....................................................................................................................................................... 0.8509 0.8953
Lawrence County, AL.
Morgan County, AL.
19500 ....... 2 Decatur, IL ...................................................................................................................................................... 0.8279 0.8787
Macon County, IL.
19660 ....... Deltona-Daytona Beach-Ormond Beach, FL .................................................................................................... 0.9298 0.9514
Volusia County, FL.
19740 ....... 1 Denver-Aurora, CO ......................................................................................................................................... 1.0699 1.0474
Adams County, CO.
Arapahoe County, CO.
Broomfield County, CO.
Clear Creek County, CO.
Denver County, CO.
Douglas County, CO.
Elbert County, CO.
Gilpin County, CO.
Jefferson County, CO.
Park County, CO.
19780 ....... Des Moines, IA ................................................................................................................................................. 0.9668 0.9771
Dallas County, IA.
Guthrie County, IA.
Madison County, IA.
Polk County, IA.
Warren County, IA.
19804 ....... 1 Detroit-Livonia-Dearborn, MI ........................................................................................................................... 1.0436 1.0297
Wayne County, MI.
20020 ....... Dothan, AL ........................................................................................................................................................ 0.7757 0.8404
Geneva County, AL.
Henry County, AL.
Houston County, AL.
20100 ....... Dover, DE ......................................................................................................................................................... 0.9817 0.9874
Kent County, DE.
20220 ....... Dubuque, IA ...................................................................................................................................................... 0.9005 0.9307
Dubuque County, IA.
20260 ....... Duluth, MN-WI .................................................................................................................................................. 1.0226 1.0154
Carlton County, MN.
St. Louis County, MN.
Douglas County, WI.
20500 ....... Durham, NC ...................................................................................................................................................... 1.0200 1.0137
Chatham County, NC.
Durham County, NC.
Orange County, NC.
Person County, NC.
20740 ....... 2 Eau Claire, WI ................................................................................................................................................. 0.9507 0.9660
Chippewa County, WI.
Eau Claire County, WI.
20764 ....... 1 Edison, NJ ....................................................................................................................................................... 1.1290 1.0866
Middlesex County, NJ.
Monmouth County, NJ.
Continued
Wage
index
Ocean County, NJ.

Somerset County, NJ.
20940 ....... 2 El Centro, CA .................................................................................................................................................. 1.1042 1.0702
Imperial County, CA.
21060 ....... Elizabethtown, KY ............................................................................................................................................. 0.8807 0.9167
Hardin County, KY.
Larue County, KY.
21140 ....... Elkhart-Goshen, IN ........................................................................................................................................... 0.9606 0.9728
Elkhart County, IN.
21300 ....... Elmira, NY ......................................................................................................................................................... 0.8268 0.8779
Chemung County, NY.
21340 ....... El Paso, TX ....................................................................................................................................................... 0.9007 0.9309
El Paso County, TX.
21500 ....... Erie, PA ............................................................................................................................................................. 0.8737 0.9117
Erie County, PA.
21604 ....... 2 Essex County, MA .......................................................................................................................................... 1.0715 1.0484
Essex County, MA.
21660 ....... Eugene-Springfield, OR .................................................................................................................................... 1.0799 1.0540
Lane County, OR.
21780 ....... Evansville, IN-KY .............................................................................................................................................. 0.8727 0.9110
Gibson County, IN.
Posey County, IN.
Vanderburgh County, IN.
Warrick County, IN.
Henderson County, KY.
Webster County, KY.
21820 ....... 2 Fairbanks, AK ................................................................................................................................................. 1.1965 1.1307
Fairbanks North Star Borough, AK.
21940 ....... Fajardo, PR ....................................................................................................................................................... 0.4156 0.5481
Ceiba Municipio, PR.
Fajardo Municipio, PR.
Luquillo Municipio, PR.
22020 ....... Fargo, ND-MN (ND Hospitals) .......................................................................................................................... 0.8769 0.9140
Clay County, MN.
Cass County, ND.
22020 ....... 2 Fargo, ND-MN (MN Hospitals) ....................................................................................................................... 0.9132 0.9397
Clay County, MN.
Cass County, ND.
22140 ....... 2 Farmington, NM .............................................................................................................................................. 0.8640 0.9047
San Juan County, NM.
22180 ....... Fayetteville, NC ................................................................................................................................................. 0.9417 0.9597
Cumberland County, NC.
Hoke County, NC.
22220 ....... Fayetteville-Springdale-Rogers, AR-MO ........................................................................................................... 0.8707 0.9095
Benton County, AR.
Madison County, AR.
Washington County, AR.
McDonald County, MO.
22380 ....... Flagstaff, AZ ...................................................................................................................................................... 1.2082 1.1383
Coconino County, AZ.
22420 ....... Flint, MI ............................................................................................................................................................. 1.0644 1.0437
Genesee County, MI.
22500 ....... Florence, SC ..................................................................................................................................................... 0.8971 0.9283
Darlington County, SC.
Florence County, SC.
22520 ....... Florence-Muscle Shoals, AL ............................................................................................................................. 0.8297 0.8800
Colbert County, AL.
Lauderdale County, AL.
22540 ....... Fond du Lac, WI ............................................................................................................................................... 0.9639 0.9751
Fond du Lac County, WI.
22660 ....... Fort Collins-Loveland, CO ................................................................................................................................. 1.0136 1.0093
Larimer County, CO.
22744 ....... 1 Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ................................................................................. 1.0497 1.0338
Broward County, FL.
22900 ....... Fort Smith, AR-OK ............................................................................................................................................ 0.8247 0.8764
Crawford County, AR.
Franklin County, AR.
Sebastian County, AR.
Le Flore County, OK.
Sequoyah County, OK.
Continued
Wage
index
23020 ....... Fort Walton Beach-Crestview-Destin, FL ......................................................................................................... 0.8868 0.9210

Okaloosa County, FL.
23060 ....... Fort Wayne, IN .................................................................................................................................................. 0.9787 0.9854
Allen County, IN.
Wells County, IN.
Whitley County, IN.
23104 ....... 1 Fort Worth-Arlington, TX ................................................................................................................................. 0.9491 0.9649
Johnson County, TX.
Parker County, TX.
Tarrant County, TX.
Wise County, TX.
23420 ....... 2 Fresno, CA ...................................................................................................................................................... 1.1042 1.0702
Fresno County, CA.
23460 ....... Gadsden, AL ..................................................................................................................................................... 0.7966 0.8558
Etowah County, AL.
23540 ....... Gainesville, FL .................................................................................................................................................. 0.9375 0.9568
Alachua County, FL.
Gilchrist County, FL.
23580 ....... Gainesville, GA ................................................................................................................................................. 0.8888 0.9224
Hall County, GA.
23844 ....... Gary, IN ............................................................................................................................................................. 0.9390 0.9578
Jasper County, IN.
Lake County, IN.
Newton County, IN.
Porter County, IN.
24020 ....... Glens Falls, NY ................................................................................................................................................. 0.8579 0.9004
Warren County, NY.
Washington County, NY.
24140 ....... Goldsboro, NC .................................................................................................................................................. 0.8773 0.9143
Wayne County, NC.
24220 ....... Grand Forks, ND-MN (ND Hospitals) ............................................................................................................... 0.7926 0.8528
Polk County, MN.
Grand Forks County, ND.
24220 ....... 2 Grand Forks, ND-MN (MN Hospitals) ............................................................................................................. 0.9132 0.9397
Polk County, MN.
Grand Forks County, ND.
24300 ....... Grand Junction, CO .......................................................................................................................................... 0.9581 0.9711
Mesa County, CO.
24340 ....... Grand Rapids-Wyoming, MI .............................................................................................................................. 0.9389 0.9577
Barry County, MI.
Ionia County, MI.
Kent County, MI.
Newaygo County, MI.
24500 ....... Great Falls, MT ................................................................................................................................................. 0.9065 0.9350
Cascade County, MT.
24540 ....... Greeley, CO ...................................................................................................................................................... 0.9587 0.9715
Weld County, CO.
24580 ....... 2 Green Bay, WI ................................................................................................................................................ 0.9507 0.9660
Brown County, WI.
Kewaunee County, WI.
Oconto County, WI.
24660 ....... Greensboro-High Point, NC .............................................................................................................................. 0.9124 0.9391
Guilford County, NC.
Randolph County, NC.
Rockingham County, NC.
24780 ....... Greenville, NC ................................................................................................................................................... 0.9404 0.9588
Greene County, NC.
Pitt County, NC.
24860 ....... Greenville, SC ................................................................................................................................................... 1.0001 1.0001
Greenville County, SC.
Laurens County, SC.
Pickens County, SC.
25020 ....... Guayama, PR ................................................................................................................................................... 0.3183 0.4566
Arroyo Municipio, PR.
Guayama Municipio, PR.
Patillas Municipio, PR.
25060 ....... Gulfport-Biloxi, MS ............................................................................................................................................ 0.8913 0.9242
Hancock County, MS.
Harrison County, MS.
Stone County, MS.
Continued
Wage
index
25180 ....... Hagerstown-Martinsburg, MD-WV .................................................................................................................... 0.9518 0.9667

Washington County, MD.
Berkeley County, WV.
Morgan County, WV.
25260 ....... 2 Hanford-Corcoran, CA .................................................................................................................................... 1.1042 1.0702
Kings County, CA.
25420 ....... Harrisburg-Carlisle, PA ..................................................................................................................................... 0.9308 0.9521
Cumberland County, PA.
Dauphin County, PA.
Perry County, PA.
25500 ....... Harrisonburg, VA .............................................................................................................................................. 0.9092 0.9369
Rockingham County, VA.
Harrisonburg City, VA.
25540 ....... 1, 2 Hartford-West Hartford-East Hartford, CT ................................................................................................... 1.1726 1.1152
Hartford County, CT.
Litchfield County, CT.
Middlesex County, CT.
Tolland County, CT.
25620 ....... 2 Hattiesburg, MS .............................................................................................................................................. 0.7688 0.8352
Forrest County, MS.
Lamar County, MS.
Perry County, MS.
25860 ....... Hickory-Lenoir-Morganton, NC ......................................................................................................................... 0.8930 0.9254
Alexander County, NC.
Burke County, NC.
Caldwell County, NC.
Catawba County, NC.
25980 ....... Hinesville-Fort Stewart, GA ............................................................................................................................... 0.7679 0.8346
Liberty County, GA.
Long County, GA.
26100 ....... Holland-Grand Haven, MI ................................................................................................................................. 0.9124 0.9391
Ottawa County, MI.
26180 ....... Honolulu, HI ...................................................................................................................................................... 1.1213 1.0816
Honolulu County, HI.
26300 ....... Hot Springs, AR ................................................................................................................................................ 0.9020 0.9318
Garland County, AR.
26380 ....... Houma-Bayou Cane-Thibodaux, LA ................................................................................................................. 0.7895 0.8506
Lafourche Parish, LA.
Terrebonne Parish, LA.
26420 ....... 1 Houston-Sugar Land-Baytown, TX ................................................................................................................. 0.9996 0.9997
Austin County, TX.
Brazoria County, TX.
Chambers County, TX.
Fort Bend County, TX.
Galveston County, TX.
Harris County, TX.
Liberty County, TX.
Montgomery County, TX.
San Jacinto County, TX.
Waller County, TX.
26580 ....... Huntington-Ashland, WV-KY-OH ...................................................................................................................... 0.9473 0.9636
Boyd County, KY.
Greenup County, KY.
Lawrence County, OH.
Cabell County, WV.
Wayne County, WV.
26620 ....... Huntsville, AL .................................................................................................................................................... 0.9120 0.9389
Limestone County, AL.
Madison County, AL.
26820 ....... Idaho Falls, ID ................................................................................................................................................... 0.8689 0.9083
Bonneville County, ID.
Jefferson County, ID.
26900 ....... 1 Indianapolis, IN ............................................................................................................................................... 0.9912 0.9940
Boone County, IN.
Brown County, IN.
Hamilton County, IN.
Hancock County, IN.
Hendricks County, IN.
Johnson County, IN.
Marion County, IN.
Continued
Wage
index
Morgan County, IN.

Putnam County, IN.
Shelby County, IN.
26980 ....... Iowa City, IA ...................................................................................................................................................... 0.9741 0.9822
Johnson County, IA.
Washington County, IA.
27060 ....... Ithaca, NY ......................................................................................................................................................... 0.9845 0.9894
Tompkins County, NY.
27100 ....... Jackson, MI ....................................................................................................................................................... 0.9291 0.9509
Jackson County, MI.
27140 ....... Jackson, MS ..................................................................................................................................................... 0.8304 0.8805
Copiah County, MS.
Hinds County, MS.
Madison County, MS.
Rankin County, MS.
Simpson County, MS.
27180 ....... Jackson, TN ...................................................................................................................................................... 0.8955 0.9272
Chester County, TN.
Madison County, TN.
27260 ....... 1 Jacksonville, FL .............................................................................................................................................. 0.9294 0.9511
Baker County, FL.
Clay County, FL.
Duval County, FL.
Nassau County, FL.
St. Johns County, FL.
27340 ....... 2 Jacksonville, NC ............................................................................................................................................. 0.8544 0.8978
Onslow County, NC.
27500 ....... Janesville, WI .................................................................................................................................................... 0.9551 0.9690
Rock County, WI.
27620 ....... Jefferson City, MO ............................................................................................................................................ 0.8381 0.8861
Callaway County, MO.
Cole County, MO.
Moniteau County, MO.
Osage County, MO.
27740 ....... 2 Johnson City, TN ............................................................................................................................................ 0.8003 0.8585
Carter County, TN.
Unicoi County, TN.
Washington County, TN.
27780 ....... Johnstown, PA .................................................................................................................................................. 0.8340 0.8831
Cambria County, PA.
27860 ....... Jonesboro, AR .................................................................................................................................................. 0.7960 0.8554
Craighead County, AR.
Poinsett County, AR.
27900 ....... Joplin, MO ......................................................................................................................................................... 0.8585 0.9008
Jasper County, MO.
Newton County, MO.
28020 ....... Kalamazoo-Portage, MI .................................................................................................................................... 1.0393 1.0267
Kalamazoo County, MI.
Van Buren County, MI.
28100 ....... Kankakee-Bradley, IL ........................................................................................................................................ 1.0738 1.0500
Kankakee County, IL.
28140 ....... 1 Kansas City, MO-KS ....................................................................................................................................... 0.9463 0.9629
Franklin County, KS.
Johnson County, KS.
Leavenworth County, KS.
Linn County, KS.
Miami County, KS.
Wyandotte County, KS.
Bates County, MO.
Caldwell County, MO.
Cass County, MO.
Clay County, MO.
Clinton County, MO.
Jackson County, MO.
Lafayette County, MO.
Platte County, MO.
Ray County, MO.
28420 ....... Kennewick-Richland-Pasco, WA ....................................................................................................................... 1.0608 1.0412
Benton County, WA.
Franklin County, WA.
Continued
Wage
index
28660 ....... Killeen-Temple-Fort Hood, TX .......................................................................................................................... 0.8557 0.8988

Bell County, TX.
Coryell County, TX.
Lampasas County, TX.
28700 ....... Kingsport-Bristol-Bristol, TN-VA ........................................................................................................................ 0.8087 0.8647
Hawkins County, TN.
Sullivan County, TN.
Bristol City, VA.
Scott County, VA.
Washington County, VA.
28740 ....... Kingston, NY ..................................................................................................................................................... 0.9258 0.9486
Ulster County, NY.
28940 ....... Knoxville, TN ..................................................................................................................................................... 0.8456 0.8915
Anderson County, TN.
Blount County, TN.
Knox County, TN.
Loudon County, TN.
Union County, TN.
29020 ....... Kokomo, IN ....................................................................................................................................................... 0.9546 0.9687
Howard County, IN.
Tipton County, IN.
29100 ....... La Crosse, WI-MN ............................................................................................................................................ 0.9548 0.9688
Houston County, MN.
La Crosse County, WI.
29140 ....... Lafayette, IN ...................................................................................................................................................... 0.8721 0.9105
Benton County, IN.
Carroll County, IN.
Tippecanoe County, IN.
29180 ....... Lafayette, LA ..................................................................................................................................................... 0.8420 0.8889
Lafayette Parish, LA.
St. Martin Parish, LA.
29340 ....... Lake Charles, LA .............................................................................................................................................. 0.7839 0.8464
Calcasieu Parish, LA.
Cameron Parish, LA.
29404 ....... Lake County-Kenosha County, IL-WI ............................................................................................................... 1.0434 1.0295
Lake County, IL.
Kenosha County, WI.
29460 ....... Lakeland, FL ..................................................................................................................................................... 0.8925 0.9251
Polk County, FL.
29540 ....... Lancaster, PA ................................................................................................................................................... 0.9706 0.9798
Lancaster County, PA.
29620 ....... Lansing-East Lansing, MI ................................................................................................................................. 0.9788 0.9854
Clinton County, MI.
Eaton County, MI.
Ingham County, MI.
29700 ....... Laredo, TX ........................................................................................................................................................ 0.8093 0.8651
Webb County, TX.
29740 ....... 2 Las Cruces, NM .............................................................................................................................................. 0.8640 0.9047
Dona Ana County, NM.
29820 ....... 1 Las Vegas-Paradise, NV ................................................................................................................................ 1.1404 1.0941
Clark County, NV.
29940 ....... Lawrence, KS .................................................................................................................................................... 0.8530 0.8968
Douglas County, KS.
30020 ....... Lawton, OK ....................................................................................................................................................... 0.7908 0.8515
Comanche County, OK.
30140 ....... Lebanon, PA ..................................................................................................................................................... 0.8645 0.9051
Lebanon County, PA.
30300 ....... Lewiston, ID-WA (ID Hospitals) ........................................................................................................................ 0.9868 0.9909
Nez Perce County, ID.
Asotin County, WA.
30300 ....... 2 Lewiston, ID-WA (WA Hospitals) .................................................................................................................... 1.0480 1.0326
Nez Perce County, ID.
Asotin County, WA.
30340 ....... Lewiston-Auburn, ME ........................................................................................................................................ 0.9322 0.9531
Androscoggin County, ME.
30460 ....... Lexington-Fayette, KY ...................................................................................................................................... 0.9051 0.9340
Bourbon County, KY.
Clark County, KY.
Fayette County, KY.
Jessamine County, KY.
Continued
Wage
index
Scott County, KY.

Woodford County, KY.
30620 ....... Lima, OH ........................................................................................................................................................... 0.9271 0.9495
Allen County, OH.
30700 ....... Lincoln, NE ........................................................................................................................................................ 1.0187 1.0128
Lancaster County, NE.
Seward County, NE.
30780 ....... Little Rock-North Little Rock, AR ...................................................................................................................... 0.8759 0.9133
Faulkner County, AR.
Grant County, AR.
Lonoke County, AR.
Perry County, AR.
Pulaski County, AR.
Saline County, AR.
30860 ....... Logan, UT-ID .................................................................................................................................................... 0.9174 0.9427
Franklin County, ID.
Cache County, UT.
30980 ....... Longview, TX .................................................................................................................................................... 0.8732 0.9113
Gregg County, TX.
Rusk County, TX.
Upshur County, TX.
31020 ....... 2 Longview, WA ................................................................................................................................................. 1.0480 1.0326
Cowlitz County, WA.
31084 ....... 1 Los Angeles-Long Beach-Glendale, CA ......................................................................................................... 1.1793 1.1196
Los Angeles County, CA.
31140 ....... 1 Louisville, KY-IN .............................................................................................................................................. 0.9254 0.9483
Clark County, IN.
Floyd County, IN.
Harrison County, IN.
Washington County, IN.
Bullitt County, KY.
Henry County, KY.
Jefferson County, KY.
Meade County, KY.
Nelson County, KY.
Oldham County, KY.
Shelby County, KY.
Spencer County, KY.
Trimble County, KY.
31180 ....... Lubbock, TX ...................................................................................................................................................... 0.8781 0.9148
Crosby County, TX.
Lubbock County, TX.
31340 ....... Lynchburg, VA .................................................................................................................................................. 0.8697 0.9088
Amherst County, VA.
Appomattox County, VA.
Bedford County, VA.
Campbell County, VA.
Bedford City, VA.
Lynchburg City, VA.
31420 ....... Macon, GA ........................................................................................................................................................ 0.9475 0.9637
Bibb County, GA.
Crawford County, GA.
Jones County, GA.
Monroe County, GA.
Twiggs County, GA.
31460 ....... 2 Madera, CA ..................................................................................................................................................... 1.1042 1.0702
Madera County, CA.
31540 ....... Madison, WI ...................................................................................................................................................... 1.0654 1.0443
Columbia County, WI.
Dane County, WI.
Iowa County, WI.
31700 ....... 2 Manchester-Nashua, NH ................................................................................................................................ 1.1561 1.1044
Hillsborough County, NH.
Merrimack County, NH.
31900 ....... Mansfield, OH ................................................................................................................................................... 0.9902 0.9933
Richland County, OH.
32420 ....... Mayagüez, PR .................................................................................................................................................. 0.4019 0.5357
Hormigueros Municipio, PR.
Mayagüez Municipio, PR.
32580 ....... McAllen-Edinburg-Mission, TX .......................................................................................................................... 0.8936 0.9259
Continued
Wage
index
Hidalgo County, TX.

32780 ....... 2 Medford, OR ................................................................................................................................................... 1.0301 1.0205
Jackson County, OR.
32820 ....... 1 Memphis, TN-MS-AR ...................................................................................................................................... 0.9402 0.9587
Crittenden County, AR.
DeSoto County, MS.
Marshall County, MS.
Tate County, MS.
Tunica County, MS.
Fayette County, TN.
Shelby County, TN.
Tipton County, TN.
32900 ....... Merced, CA ....................................................................................................................................................... 1.1112 1.0749
Merced County, CA.
33124 ....... 1 Miami-Miami Beach-Kendall, FL ..................................................................................................................... 0.9747 0.9826
Miami-Dade County, FL.
33140 ....... Michigan City-La Porte, IN ................................................................................................................................ 0.9400 0.9585
LaPorte County, IN.
33260 ....... Midland, TX ....................................................................................................................................................... 0.9513 0.9664
Midland County, TX.
33340 ....... 1 Milwaukee-Waukesha-West Allis, WI ............................................................................................................. 1.0150 1.0102
Milwaukee County, WI.
Ozaukee County, WI.
Washington County, WI.
Waukesha County, WI.
33460 ....... 1 Minneapolis-St. Paul-Bloomington, MN-WI .................................................................................................... 1.1052 1.0709
Anoka County, MN.
Carver County, MN.
Chisago County, MN.
Dakota County, MN.
Hennepin County, MN.
Isanti County, MN.
Ramsey County, MN.
Scott County, MN.
Sherburne County, MN.
Washington County, MN.
Wright County, MN.
Pierce County, WI.
St. Croix County, WI.
33540 ....... Missoula, MT ..................................................................................................................................................... 0.9526 0.9673
Missoula County, MT.
33660 ....... Mobile, AL ......................................................................................................................................................... 0.7898 0.8508
Mobile County, AL.
33700 ....... Modesto, CA ..................................................................................................................................................... 1.1960 1.1304
Stanislaus County, CA.
33740 ....... Monroe, LA ....................................................................................................................................................... 0.8036 0.8609
Ouachita Parish, LA.
Union Parish, LA.
33780 ....... Monroe, MI ........................................................................................................................................................ 0.9459 0.9626
Monroe County, MI.
33860 ....... Montgomery, AL ................................................................................................................................................ 0.8630 0.9040
Autauga County, AL.
Elmore County, AL.
Lowndes County, AL.
Montgomery County, AL.
34060 ....... Morgantown, WV .............................................................................................................................................. 0.8431 0.8897
Monongalia County, WV.
Preston County, WV.
34100 ....... 2 Morristown, TN ................................................................................................................................................ 0.8003 0.8585
Grainger County, TN.
Hamblen County, TN.
Jefferson County, TN.
34580 ....... 2 Mount Vernon-Anacortes, WA ........................................................................................................................ 1.0480 1.0326
Skagit County, WA.
34620 ....... Muncie, IN ......................................................................................................................................................... 0.8943 0.9264
Delaware County, IN.
34740 ....... Muskegon-Norton Shores, MI ........................................................................................................................... 0.9667 0.9771
Muskegon County, MI.
34820 ....... Myrtle Beach-Conway-North Myrtle Beach, SC ............................................................................................... 0.8929 0.9254
Horry County, SC.
Continued
Wage
index
34900 ....... Napa, CA .......................................................................................................................................................... 1.2630 1.1734

Napa County, CA.
34940 ....... Naples-Marco Island, FL ................................................................................................................................... 1.0114 1.0078
Collier County, FL.
34980 ....... 1 Nashville-Davidson--Murfreesboro, TN ........................................................................................................... 0.9731 0.9815
Cannon County, TN.
Cheatham County, TN.
Davidson County, TN.
Dickson County, TN.
Hickman County, TN.
Macon County, TN.
Robertson County, TN.
Rutherford County, TN.
Smith County, TN.
Sumner County, TN.
Trousdale County, TN.
Williamson County, TN.
Wilson County, TN.
35004 ....... 1 Nassau-Suffolk, NY ......................................................................................................................................... 1.2739 1.1803
Nassau County, NY.
Suffolk County, NY.
35084 ....... 1 Newark-Union, NJ-PA ..................................................................................................................................... 1.1879 1.1251
Essex County, NJ.
Hunterdon County, NJ.
Morris County, NJ.
Sussex County, NJ.
Union County, NJ.
Pike County, PA.
35300 ....... New Haven-Milford, CT ..................................................................................................................................... 1.1910 1.1272
New Haven County, CT.
35380 ....... 1 New Orleans-Metairie-Kenner, LA .................................................................................................................. 0.8993 0.9299
Jefferson Parish, LA.
Orleans Parish, LA.
Plaquemines Parish, LA.
St. Bernard Parish, LA.
St. Charles Parish, LA.
St. John the Baptist Parish, LA.
St. Tammany Parish, LA.
35644 ....... 1 New York-White Plains-Wayne, NY-NJ .......................................................................................................... 1.3194 1.2090
Bergen County, NJ.
Hudson County, NJ.
Passaic County, NJ.
Bronx County, NY.
Kings County, NY.
New York County, NY.
Putnam County, NY.
Queens County, NY.
Richmond County, NY.
Rockland County, NY.
Westchester County, NY.
35660 ....... 2 Niles-Benton Harbor, MI ................................................................................................................................. 0.8966 0.9280
Berrien County, MI.
35980 ....... 2 Norwich-New London, CT ............................................................................................................................... 1.1726 1.1152
New London County, CT.
36084 ....... 1 Oakland-Fremont-Hayward, CA ...................................................................................................................... 1.5463 1.3478
Alameda County, CA.
Contra Costa County, CA.
36100 ....... Ocala, FL .......................................................................................................................................................... 0.8946 0.9266
Marion County, FL.
36140 ....... 2 Ocean City, NJ ................................................................................................................................................ 1.1227 1.0825
Cape May County, NJ.
36220 ....... Odessa, TX ....................................................................................................................................................... 0.9883 0.9920
Ector County, TX.
36260 ....... Ogden-Clearfield, UT ........................................................................................................................................ 0.9039 0.9331
Davis County, UT.
Morgan County, UT.
Weber County, UT.
36420 ....... 1 Oklahoma City, OK ......................................................................................................................................... 0.9034 0.9328
Canadian County, OK.
Cleveland County, OK.
Continued
Wage
index
Grady County, OK.

Lincoln County, OK.
Logan County, OK.
McClain County, OK.
Oklahoma County, OK.
36500 ....... Olympia, WA ..................................................................................................................................................... 1.0959 1.0647
Thurston County, WA.
36540 ....... Omaha-Council Bluffs, NE-IA ........................................................................................................................... 0.9546 0.9687
Harrison County, IA.
Mills County, IA.
Pottawattamie County, IA.
Cass County, NE.
Douglas County, NE.
Sarpy County, NE.
Saunders County, NE.
Washington County, NE.
36740 ....... 1 Orlando-Kissimmee, FL .................................................................................................................................. 0.9450 0.9620
Lake County, FL.
Orange County, FL.
Osceola County, FL.
Seminole County, FL.
36780 ....... 2 Oshkosh-Neenah, WI ...................................................................................................................................... 0.9507 0.9660
Winnebago County, WI.
36980 ....... Owensboro, KY ................................................................................................................................................. 0.8797 0.9160
Daviess County, KY.
Hancock County, KY.
McLean County, KY.
37100 ....... Oxnard-Thousand Oaks-Ventura, CA ............................................................................................................... 1.1613 1.1078
Ventura County, CA.
37340 ....... Palm Bay-Melbourne-Titusville, FL ................................................................................................................... 0.9830 0.9883
Brevard County, FL.
37460 ....... 2 Panama City-Lynn Haven, FL ........................................................................................................................ 0.8584 0.9007
Bay County, FL.
37620 ....... Parkersburg-Marietta-Vienna, WV-OH (WV Hospitals) .................................................................................... 0.8295 0.8798
Washington County, OH.
Pleasants County, WV.
Wirt County, WV.
Wood County, WV.
37620 ....... 2 Parkersburg-Marietta-Vienna, WV-OH (OH Hospitals) .................................................................................. 0.8826 0.9180
Washington County, OH.
Pleasants County, WV.
Wirt County, WV.
Wood County, WV.
37700 ....... Pascagoula, MS ................................................................................................................................................ 0.8156 0.8697
George County, MS.
Jackson County, MS.
37860 ....... 2 Pensacola-Ferry Pass-Brent, FL .................................................................................................................... 0.8584 0.9007
Escambia County, FL.
Santa Rosa County, FL.
37900 ....... Peoria, IL ........................................................................................................................................................... 0.8845 0.9194
Marshall County, IL.
Peoria County, IL.
Stark County, IL.
Tazewell County, IL.
Woodford County, IL.
37964 ....... 1 Philadelphia, PA .............................................................................................................................................. 1.1028 1.0693
Bucks County, PA.
Chester County, PA.
Delaware County, PA.
Montgomery County, PA.
Philadelphia County, PA.
38060 ....... 1 Phoenix-Mesa-Scottsdale, AZ ........................................................................................................................ 1.0129 1.0088
Maricopa County, AZ.
Pinal County, AZ.
38220 ....... Pine Bluff, AR ................................................................................................................................................... 0.8707 0.9095
Cleveland County, AR.
Jefferson County, AR.
Lincoln County, AR.
38300 ....... 1 Pittsburgh, PA ................................................................................................................................................. 0.8832 0.9185
Allegheny County, PA.
Continued
Wage
index
Armstrong County, PA.

Beaver County, PA.
Butler County, PA.
Fayette County, PA.
Washington County, PA.
Westmoreland County, PA.
38340 ....... 2 Pittsfield, MA ................................................................................................................................................... 1.0715 1.0484
Berkshire County, MA.
38540 ....... Pocatello, ID ...................................................................................................................................................... 0.9394 0.9581
Bannock County, ID.
Power County, ID.
38660 ....... Ponce, PR ......................................................................................................................................................... 0.4939 0.6169
Juana Dı́az Municipio, PR.
Ponce Municipio, PR.
Villalba Municipio, PR.
38860 ....... Portland-South Portland-Biddeford, ME ............................................................................................................ 1.0371 1.0253
Cumberland County, ME.
Sagadahoc County, ME.
York County, ME.
38900 ....... 1 Portland-Vancouver-Beaverton, OR-WA ........................................................................................................ 1.1235 1.0830
Clackamas County, OR.
Columbia County, OR.
Multnomah County, OR.
Washington County, OR.
Yamhill County, OR.
Clark County, WA.
Skamania County, WA.
38940 ....... Port St. Lucie-Fort Pierce, FL ........................................................................................................................... 1.0151 1.0103
Martin County, FL.
St. Lucie County, FL.
39100 ....... Poughkeepsie-Newburgh-Middletown, NY ....................................................................................................... 1.0892 1.0603
Dutchess County, NY.
Orange County, NY.
39140 ....... Prescott, AZ ...................................................................................................................................................... 0.9422 0.9600
Yavapai County, AZ.
39300 ....... 1 Providence-New Bedford-Fall River, RI-MA ................................................................................................... 1.0954 1.0644
Bristol County, MA.
Bristol County, RI.
Kent County, RI.
Newport County, RI.
Providence County, RI.
Washington County, RI.
39340 ....... Provo-Orem, UT ................................................................................................................................................ 0.9484 0.9644
Juab County, UT.
Utah County, UT.
39380 ....... 2 Pueblo, CO ..................................................................................................................................................... 0.9369 0.9563
Pueblo County, CO.
39460 ....... Punta Gorda, FL ............................................................................................................................................... 0.9265 0.9491
Charlotte County, FL.
39540 ....... 2 Racine, WI ...................................................................................................................................................... 0.9507 0.9660
Racine County, WI.
39580 ....... Raleigh-Cary, NC .............................................................................................................................................. 0.9668 0.9771
Franklin County, NC.
Johnston County, NC.
Wake County, NC.
39660 ....... Rapid City, SD .................................................................................................................................................. 0.8993 0.9299
Meade County, SD.
Pennington County, SD.
39740 ....... Reading, PA ...................................................................................................................................................... 0.9688 0.9785
Berks County, PA.
39820 ....... Redding, CA ...................................................................................................................................................... 1.2195 1.1456
Shasta County, CA.
39900 ....... Reno-Sparks, NV .............................................................................................................................................. 1.0973 1.0657
Storey County, NV.
Washoe County, NV.
40060 ....... 1 Richmond, VA ................................................................................................................................................. 0.9309 0.9521
Amelia County, VA.
Caroline County, VA.
Charles City County, VA.
Chesterfield County, VA.
Continued
Wage
index
Cumberland County, VA.

Dinwiddie County, VA.
Goochland County, VA.
Hanover County, VA.
Henrico County, VA.
King and Queen County, VA.
King William County, VA.
Louisa County, VA.
New Kent County, VA.
Powhatan County, VA.
Prince George County, VA.
Sussex County, VA.
Colonial Heights City, VA.
Hopewell City, VA.
Petersburg City, VA.
Richmond City, VA.
40140 ....... 1, 2 Riverside-San Bernardino-Ontario, CA ........................................................................................................ 1.1042 1.0702
Riverside County, CA.
San Bernardino County, CA.
40220 ....... Roanoke, VA ..................................................................................................................................................... 0.8442 0.8905
Botetourt County, VA.
Craig County, VA.
Franklin County, VA.
Roanoke County, VA.
Roanoke City, VA.
Salem City, VA.
40340 ....... Rochester, MN .................................................................................................................................................. 1.1116 1.0751
Dodge County, MN.
Olmsted County, MN.
Wabasha County, MN.
40380 ....... 1 Rochester, NY ................................................................................................................................................. 0.9123 0.9391
Livingston County, NY.
Monroe County, NY.
Ontario County, NY.
Orleans County, NY.
Wayne County, NY.
40420 ....... Rockford, IL ....................................................................................................................................................... 0.9965 0.9976
Boone County, IL.
Winnebago County, IL.
40484 ....... 2 Rockingham County-Strafford County, NH ..................................................................................................... 1.1561 1.1044
Rockingham County, NH.
Strafford County, NH.
40580 ....... Rocky Mount, NC .............................................................................................................................................. 0.8915 0.9244
Edgecombe County, NC.
Nash County, NC.
40660 ....... Rome, GA ......................................................................................................................................................... 0.9405 0.9589
Floyd County, GA.
40900 ....... 1 Sacramento--Arden-Arcade--Roseville, CA .................................................................................................... 1.2949 1.1936
El Dorado County, CA.
Placer County, CA.
Sacramento County, CA.
Yolo County, CA.
40980 ....... Saginaw-Saginaw Township North, MI ............................................................................................................. 0.9140 0.9403
Saginaw County, MI.
41060 ....... St. Cloud, MN ................................................................................................................................................... 1.0020 1.0014
Benton County, MN.
Stearns County, MN.
41100 ....... St. George, UT .................................................................................................................................................. 0.9407 0.9590
Washington County, UT.
41140 ....... St. Joseph, MO-KS ........................................................................................................................................... 0.9555 0.9693
Doniphan County, KS.
Andrew County, MO.
Buchanan County, MO.
DeKalb County, MO.
41180 ....... St. Louis, MO-IL ................................................................................................................................................ 0.8958 0.9274
Bond County, IL.
Calhoun County, IL.
Clinton County, IL.
Jersey County, IL.
Macoupin County, IL.
Continued
Wage
index
Madison County, IL.

Monroe County, IL.
St. Clair County, IL.
Crawford County, MO.
Franklin County, MO.
Jefferson County, MO.
Lincoln County, MO.
St. Charles County, MO.
St. Louis County, MO.
Warren County, MO.
Washington County, MO.
St. Louis City, MO.
41420 ....... Salem, OR ........................................................................................................................................................ 1.0435 1.0296
Marion County, OR.
Polk County, OR.
41500 ....... Salinas, CA ....................................................................................................................................................... 1.4126 1.2669
Monterey County, CA.
41540 ....... 2 Salisbury, MD .................................................................................................................................................. 0.9357 0.9555
Somerset County, MD.
Wicomico County, MD.
41620 ....... Salt Lake City, UT ............................................................................................................................................. 0.9424 0.9602
Salt Lake County, UT.
Summit County, UT.
Tooele County, UT.
41660 ....... San Angelo, TX ................................................................................................................................................. 0.8279 0.8787
Irion County, TX.
Tom Green County, TX.
41700 ....... 1 San Antonio, TX .............................................................................................................................................. 0.8978 0.9288
Atascosa County, TX.
Bandera County, TX.
Bexar County, TX.
Comal County, TX.
Guadalupe County, TX.
Kendall County, TX.
Medina County, TX.
Wilson County, TX.
41740 ....... 1 San Diego-Carlsbad-San Marcos, CA ............................................................................................................ 1.1406 1.0943
San Diego County, CA.
41780 ....... Sandusky, OH ................................................................................................................................................... 0.9026 0.9322
Erie County, OH.
41884 ....... 1 San Francisco-San Mateo-Redwood City, CA ............................................................................................... 1.4974 1.3185
Marin County, CA.
San Francisco County, CA.
San Mateo County, CA.
41900 ....... San Germán-Cabo Rojo, PR ............................................................................................................................ 0.4641 0.5911
Cabo Rojo Municipio, PR.
Lajas Municipio, PR.
Sabana Grande Municipio, PR.
San Germán Municipio, PR.
41940 ....... 1 San Jose-Sunnyvale-Santa Clara, CA ........................................................................................................... 1.5088 1.3253
San Benito County, CA.
Santa Clara County, CA.
41980 ....... 1 San Juan-Caguas-Guaynabo, PR .................................................................................................................. 0.4621 0.5894
Aguas Buenas Municipio, PR.
Aibonito Municipio, PR.
Arecibo Municipio, PR.
Barceloneta Municipio, PR.
Barranquitas Municipio, PR.
Bayamón Municipio, PR.
Caguas Municipio, PR.
Camuy Municipio, PR.
Canóvanas Municipio, PR.
Carolina Municipio, PR.
Cataño Municipio, PR.
Cayey Municipio, PR.
Ciales Municipio, PR.
Cidra Municipio, PR.
Comerı́o Municipio, PR.
Corozal Municipio, PR.
Dorado Municipio, PR.
Continued
Wage
index
Florida Municipio, PR.

Guaynabo Municipio, PR.
Gurabo Municipio, PR.
Hatillo Municipio, PR.
Humacao Municipio, PR.
Juncos Municipio, PR.
Las Piedras Municipio, PR.
Loı́za Municipio, PR.
Manatı́ Municipio, PR.
Maunabo Municipio, PR.
Morovis Municipio, PR.
Naguabo Municipio, PR.
Naranjito Municipio, PR.
Orocovis Municipio, PR.
Quebradillas Municipio, PR.
Rı́o Grande Municipio, PR.
San Juan Municipio, PR.
San Lorenzo Municipio, PR.
Toa Alta Municipio, PR.
Toa Baja Municipio, PR.
Trujillo Alto Municipio, PR.
Vega Alta Municipio, PR.
Vega Baja Municipio, PR.
Yabucoa Municipio, PR.
42020 ....... San Luis Obispo-Paso Robles, CA ................................................................................................................... 1.1346 1.0903
San Luis Obispo County, CA.
42044 ....... 1 Santa Ana-Anaheim-Irvine, CA ....................................................................................................................... 1.1547 1.1035
Orange County, CA.
42060 ....... Santa Barbara-Santa Maria, CA ....................................................................................................................... 1.1681 1.1123
Santa Barbara County, CA.
42100 ....... Santa Cruz-Watsonville, CA ............................................................................................................................. 1.5144 1.3287
Santa Cruz County, CA.
42140 ....... Santa Fe, NM .................................................................................................................................................... 1.0897 1.0606
Santa Fe County, NM.
42220 ....... Santa Rosa-Petaluma, CA ................................................................................................................................ 1.3467 1.2261
Sonoma County, CA.
42260 ....... Sarasota-Bradenton-Venice, FL ........................................................................................................................ 0.9634 0.9748
Manatee County, FL.
Sarasota County, FL.
42340 ....... Savannah, GA ................................................................................................................................................... 0.9464 0.9630
Bryan County, GA.
Chatham County, GA.
Effingham County, GA.
42540 ....... Scranton--Wilkes-Barre, PA .............................................................................................................................. 0.8521 0.8962
Lackawanna County, PA.
Luzerne County, PA.
Wyoming County, PA.
42644 ....... 1 Seattle-Bellevue-Everett, WA ......................................................................................................................... 1.1562 1.1045
King County, WA.
Snohomish County, WA.
43100 ....... 2 Sheboygan, WI ............................................................................................................................................... 0.9507 0.9660
Sheboygan County, WI.
43300 ....... Sherman-Denison, TX ....................................................................................................................................... 0.9509 0.9661
Grayson County, TX.
43340 ....... Shreveport-Bossier City, LA .............................................................................................................................. 0.8758 0.9132
Bossier Parish, LA.
Caddo Parish, LA.
De Soto Parish, LA.
43580 ....... Sioux City, IA-NE-SD ........................................................................................................................................ 0.9365 0.9561
Woodbury County, IA.
Dakota County, NE.
Dixon County, NE.
Union County, SD.
43620 ....... Sioux Falls, SD ................................................................................................................................................. 0.9607 0.9729
Lincoln County, SD.
McCook County, SD.
Minnehaha County, SD.
Turner County, SD.
43780 ....... South Bend-Mishawaka, IN-MI ......................................................................................................................... 0.9775 0.9845
St. Joseph County, IN.
Continued
Wage
index
Cass County, MI.

43900 ....... Spartanburg, SC ............................................................................................................................................... 0.9174 0.9427
Spartanburg County, SC.
44060 ....... Spokane, WA .................................................................................................................................................... 1.0887 1.0599
Spokane County, WA.
44100 ....... Springfield, IL .................................................................................................................................................... 0.8787 0.9153
Menard County, IL.
Sangamon County, IL.
44140 ....... 2 Springfield, MA ................................................................................................................................................ 1.0715 1.0484
Franklin County, MA.
Hampden County, MA.
Hampshire County, MA.
44180 ....... Springfield, MO ................................................................................................................................................. 0.8242 0.8760
Christian County, MO.
Dallas County, MO.
Greene County, MO.
Polk County, MO.
Webster County, MO.
44220 ....... 2 Springfield, OH ................................................................................................................................................ 0.8826 0.9180
Clark County, OH.
44300 ....... State College, PA ............................................................................................................................................. 0.8360 0.8846
Centre County, PA.
44700 ....... Stockton, CA ..................................................................................................................................................... 1.1329 1.0892
San Joaquin County, CA.
44940 ....... 2 Sumter, SC ..................................................................................................................................................... 0.8660 0.9062
Sumter County, SC.
45060 ....... Syracuse, NY .................................................................................................................................................... 0.9589 0.9717
Madison County, NY.
Onondaga County, NY.
Oswego County, NY.
45104 ....... Tacoma, WA ..................................................................................................................................................... 1.0738 1.0500
Pierce County, WA.
45220 ....... Tallahassee, FL ................................................................................................................................................ 0.8703 0.9093
Gadsden County, FL.
Jefferson County, FL.
Leon County, FL.
Wakulla County, FL.
45300 ....... 1 Tampa-St. Petersburg-Clearwater, FL ............................................................................................................ 0.9328 0.9535
Hernando County, FL.
Hillsborough County, FL.
Pasco County, FL.
Pinellas County, FL.
45460 ....... 2 Terre Haute, IN ............................................................................................................................................... 0.8626 0.9037
Clay County, IN.
Sullivan County, IN.
Vermillion County, IN.
Vigo County, IN.
45500 ....... Texarkana, TX-Texarkana, AR ......................................................................................................................... 0.8285 0.8791
Miller County, AR.
Bowie County, TX.
45780 ....... Toledo, OH ........................................................................................................................................................ 0.9564 0.9699
Fulton County, OH.
Lucas County, OH.
Ottawa County, OH.
Wood County, OH.
45820 ....... Topeka, KS ....................................................................................................................................................... 0.8912 0.9242
Jackson County, KS.
Jefferson County, KS.
Osage County, KS.
Shawnee County, KS.
Wabaunsee County, KS.
45940 ....... 2 Trenton-Ewing, NJ .......................................................................................................................................... 1.1227 1.0825
Mercer County, NJ.
46060 ....... Tucson, AZ ........................................................................................................................................................ 0.9027 0.9323
Pima County, AZ.
46140 ....... Tulsa, OK .......................................................................................................................................................... 0.8569 0.8996
Creek County, OK.
Okmulgee County, OK.
Osage County, OK.
Pawnee County, OK.
Continued
Wage
index
Rogers County, OK.

Tulsa County, OK.
Wagoner County, OK.
46220 ....... Tuscaloosa, AL ................................................................................................................................................. 0.8648 0.9053
Greene County, AL.
Hale County, AL.
Tuscaloosa County, AL.
46340 ....... Tyler, TX ........................................................................................................................................................... 0.9182 0.9432
Smith County, TX.
46540 ....... Utica-Rome, NY ................................................................................................................................................ 0.8378 0.8859
Herkimer County, NY.
Oneida County, NY.
46660 ....... Valdosta, GA ..................................................................................................................................................... 0.8864 0.9207
Brooks County, GA.
Echols County, GA.
Lanier County, GA.
Lowndes County, GA.
46700 ....... Vallejo-Fairfield, CA .......................................................................................................................................... 1.4925 1.3155
Solano County, CA.
46940 ....... Vero Beach, FL ................................................................................................................................................. 0.9448 0.9619
Indian River County, FL.
47020 ....... Victoria, TX ....................................................................................................................................................... 0.8140 0.8686
Calhoun County, TX.
Goliad County, TX.
Victoria County, TX.
47220 ....... 2 Vineland-Millville-Bridgeton, NJ ...................................................................................................................... 1.1227 1.0825
Cumberland County, NJ.
47260 ....... 1 Virginia Beach-Norfolk-Newport News, VA-NC .............................................................................................. 0.8832 0.9185
Currituck County, NC.
Gloucester County, VA.
Isle of Wight County, VA.
James City County, VA.
Mathews County, VA.
Surry County, VA.
York County, VA.
Chesapeake City, VA.
Hampton City, VA.
Newport News City, VA.
Norfolk City, VA.
Poquoson City, VA.
Portsmouth City, VA.
Suffolk City, VA.
Virginia Beach City, VA.
Williamsburg City, VA.
47300 ....... 2 Visalia-Porterville, CA ..................................................................................................................................... 1.1042 1.0702
Tulare County, CA.
47380 ....... Waco, TX .......................................................................................................................................................... 0.8523 0.8963
McLennan County, TX.
47580 ....... Warner Robins, GA ........................................................................................................................................... 0.8653 0.9057
Houston County, GA.
47644 ....... 1 Warren-Farmington Hills-Troy, MI .................................................................................................................. 0.9868 0.9909
Lapeer County, MI.
Livingston County, MI.
Macomb County, MI.
Oakland County, MI.
St. Clair County, MI.
47894 ....... 1 Washington-Arlington-Alexandria, DC-VA-MD-WV ........................................................................................ 1.0928 1.0627
District of Columbia, DC.
Calvert County, MD.
Charles County, MD.
Prince George’s County, MD.
Arlington County, VA.
Clarke County, VA.
Fairfax County, VA.
Fauquier County, VA.
Loudoun County, VA.
Prince William County, VA.
Spotsylvania County, VA.
Stafford County, VA.
Warren County, VA.
Continued
Wage
index
Alexandria City, VA.

Fairfax City, VA.
Falls Church City, VA.
Fredericksburg City, VA.
Manassas City, VA.
Manassas Park City, VA.
Jefferson County, WV.
47940 ....... Waterloo-Cedar Falls, IA ................................................................................................................................... 0.8555 0.8986
Black Hawk County, IA.
Bremer County, IA.
Grundy County, IA.
48140 ....... Wausau, WI ...................................................................................................................................................... 0.9954 0.9968
Marathon County, WI.
48260 ....... Weirton-Steubenville, WV-OH (WV Hospitals) ................................................................................................. 0.7813 0.8445
Jefferson County, OH.
Brooke County, WV.
Hancock County, WV.
48260 ....... 2 Weirton-Steubenville, WV-OH (OH Hospitals) ............................................................................................... 0.8826 0.9180
Jefferson County, OH.
Brooke County, WV.
Hancock County, WV.
48300 ....... 2 Wenatchee, WA .............................................................................................................................................. 1.0480 1.0326
Chelan County, WA.
Douglas County, WA.
48424 ....... 1 West Palm Beach-Boca Raton-Boynton Beach, FL ....................................................................................... 1.0051 1.0035
Palm Beach County, FL.
48540 ....... 2 Wheeling, WV-OH (WV Hospitals) ................................................................................................................. 0.7734 0.8386
Belmont County, OH.
Marshall County, WV.
Ohio County, WV.
48540 ....... 2 Wheeling, WV-OH (OH Hospitals) .................................................................................................................. 0.8826 0.9180
Belmont County, OH.
Marshall County, WV.
Ohio County, WV.
48620 ....... Wichita, KS ....................................................................................................................................................... 0.9168 0.9422
Butler County, KS.
Harvey County, KS.
Sedgwick County, KS.
Sumner County, KS.
48660 ....... Wichita Falls, TX ............................................................................................................................................... 0.8319 0.8816
Archer County, TX.
Clay County, TX.
Wichita County, TX.
48700 ....... Williamsport, PA ................................................................................................................................................ 0.8355 0.8842
Lycoming County, PA.
48864 ....... Wilmington, DE-MD-NJ (DE, MD Hospitals) ..................................................................................................... 1.0516 1.0351
New Castle County, DE.
Cecil County, MD.
Salem County, NJ.
48864 ....... 2 Wilmington, DE-MD-NJ (NJ Hospitals) ........................................................................................................... 1.1227 1.0825
New Castle County, DE.
Cecil County, MD.
Salem County, NJ.
48900 ....... Wilmington, NC ................................................................................................................................................. 0.9570 0.9704
Brunswick County, NC.
New Hanover County, NC.
Pender County, NC.
49020 ....... Winchester, VA-WV .......................................................................................................................................... 1.0204 1.0139
Frederick County, VA.
Winchester City, VA.
Hampshire County, WV.
49180 ....... Winston-Salem, NC ........................................................................................................................................... 0.8951 0.9269
Davie County, NC.
Forsyth County, NC.
Stokes County, NC.
Yadkin County, NC.
49340 ....... Worcester, MA .................................................................................................................................................. 1.1034 1.0697
Worcester County, MA.
49420 ....... 2 Yakima, WA .................................................................................................................................................... 1.0480 1.0326
Yakima County, WA.
Continued
Wage
index
49500 ....... Yauco, PR ......................................................................................................................................................... 0.4408 0.5707

Guánica Municipio, PR.
Guayanilla Municipio, PR.
Peñuelas Municipio, PR.
Yauco Municipio, PR.
49620 ....... York-Hanover, PA ............................................................................................................................................. 0.9349 0.9549
York County, PA.
49660 ....... 2 Youngstown-Warren-Boardman, OH-PA (OH Hospitals) ............................................................................... 0.8826 0.9180
Mahoning County, OH.
Trumbull County, OH.
Mercer County, PA.
49660 ....... Youngstown-Warren-Boardman, OH-PA (PA Hospitals) .................................................................................. 0.8600 0.9019
Mahoning County, OH.
Trumbull County, OH.
Mercer County, PA.
49700 ....... 2 Yuba City, CA ................................................................................................................................................. 1.1042 1.0702
Sutter County, CA.
Yuba County, CA.
49740 ....... Yuma, AZ .......................................................................................................................................................... 0.9179 0.9430
Yuma County, AZ.
1 Large urban area.
2 Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2006.
TABLE 4B.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT (GAF) FOR RURAL AREAS BY CBSA
Wage
CBSA code Nonurban area GAF
index
1 ............... Alabama ............................................................................................................................................................ 0.7463 0.8184

2 ............... Alaska ............................................................................................................................................................... 1.1965 1.1307
3 ............... Arizona .............................................................................................................................................................. 0.9007 0.9309
4 ............... Arkansas ........................................................................................................................................................... 0.7493 0.8207
5 ............... California ........................................................................................................................................................... 1.1042 1.0702
6 ............... Colorado ............................................................................................................................................................ 0.9369 0.9563
7 ............... Connecticut ....................................................................................................................................................... 1.1726 1.1152
8 ............... Delaware ........................................................................................................................................................... 0.9579 0.9710
0 ............... Florida ............................................................................................................................................................... 0.8584 0.9007
1 ............... Georgia ............................................................................................................................................................. 0.7679 0.8346
2 ............... Hawaii ............................................................................................................................................................... 1.0587 1.0398
3 ............... Idaho ................................................................................................................................................................. 0.8689 0.9083
4 ............... Illinois ................................................................................................................................................................ 0.8279 0.8787
5 ............... Indiana .............................................................................................................................................................. 0.8626 0.9037
6 ............... Iowa ................................................................................................................................................................... 0.8553 0.8985
7 ............... Kansas .............................................................................................................................................................. 0.8076 0.8639
8 ............... Kentucky ........................................................................................................................................................... 0.7780 0.8421
9 ............... Louisiana ........................................................................................................................................................... 0.7438 0.8165
20 ............. Maine ................................................................................................................................................................ 0.8831 0.9184
21 ............. Maryland ........................................................................................................................................................... 0.9357 0.9555
22 ............. Massachusetts 1 ................................................................................................................................................ 1.0715 1.0484
23 ............. Michigan ............................................................................................................................................................ 0.8966 0.9280
24 ............. Minnesota .......................................................................................................................................................... 0.9132 0.9397
25 ............. Mississippi ......................................................................................................................................................... 0.7688 0.8352
26 ............. Missouri ............................................................................................................................................................. 0.7919 0.8523
27 ............. Montana ............................................................................................................................................................ 0.8752 0.9128
28 ............. Nebraska ........................................................................................................................................................... 0.8658 0.9060
29 ............. Nevada .............................................................................................................................................................. 0.9070 0.9353
30 ............. New Hampshire ................................................................................................................................................ 1.1561 1.1044
31 ............. New Jersey1 ..................................................................................................................................................... 1.1227 1.0825
32 ............. New Mexico ...................................................................................................................................................... 0.8640 0.9047
33 ............. New York .......................................................................................................................................................... 0.8217 0.8742
34 ............. North Carolina ................................................................................................................................................... 0.8544 0.8978
35 ............. North Dakota ..................................................................................................................................................... 0.7271 0.8039
36 ............. Ohio ................................................................................................................................................................... 0.8826 0.9180
37 ............. Oklahoma .......................................................................................................................................................... 0.7607 0.8292
38 ............. Oregon .............................................................................................................................................................. 1.0301 1.0205
39 ............. Pennsylvania ..................................................................................................................................................... 0.8289 0.8794
40 ............. Puerto Rico 1 ..................................................................................................................................................... ................ ................
41 ............. Rhode Island 1 ................................................................................................................................................... 1.0954 1.0644
42 ............. South Carolina .................................................................................................................................................. 0.8660 0.9062
TABLE 4B.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT (GAF) FOR RURAL AREAS BY CBSA—Continued
Wage
CBSA code Nonurban area GAF
index
43 ............. South Dakota .................................................................................................................................................... 0.8551 0.8983

44 ............. Tennessee ........................................................................................................................................................ 0.8003 0.8585
45 ............. Texas ................................................................................................................................................................ 0.8053 0.8622
46 ............. Utah ................................................................................................................................................................... 0.8126 0.8675
47 ............. Vermont ............................................................................................................................................................. 1.0189 1.0129
49 ............. Virginia .............................................................................................................................................................. 0.8025 0.8601
50 ............. Washington ....................................................................................................................................................... 1.0480 1.0326
51 ............. West Virginia ..................................................................................................................................................... 0.7734 0.8386
52 ............. Wisconsin .......................................................................................................................................................... 0.9507 0.9660
53 ............. Wyoming ........................................................................................................................................................... 0.9249 0.9479
1 All counties in the State or Territory are classified as urban, with the exception of Massachusetts. Massachusetts has area(s) designated as
rural. However, no short-term, acute care hospitals are located in the area(s) for FY 2006.
Massachusetts, New Jersey, and Rhode Island rural floors are imputed as discussed in the FY 2005 final rule, 69 FR 49109.
TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE
RECLASSIFIED BY CBSA
Wage
CBSA code Area GAF
index
10180 ....... Abilene, TX ....................................................................................................................................................... 0.8053 0.8622

10420 ....... Akron, OH ......................................................................................................................................................... 0.8970 0.9283
10580 ....... Albany-Schenectady-Troy, NY .......................................................................................................................... 0.8607 0.9024
10740 ....... Albuquerque, NM .............................................................................................................................................. 0.9548 0.9688
10780 ....... Alexandria, LA ................................................................................................................................................... 0.8040 0.8612
10900 ....... Allentown-Bethlehem-Easton, PA-NJ ............................................................................................................... 0.9834 0.9886
11020 ....... Altoona, PA ....................................................................................................................................................... 0.8933 0.9256
11100 ....... Amarillo, TX ...................................................................................................................................................... 0.9156 0.9414
11180 ....... Ames, IA ........................................................................................................................................................... 0.9272 0.9496
11460 ....... Ann Arbor, MI .................................................................................................................................................... 1.0570 1.0387
11500 ....... Anniston-Oxford, AL .......................................................................................................................................... 0.7717 0.8374
11700 ....... Asheville, NC .................................................................................................................................................... 0.9303 0.9517
12020 ....... Athens-Clarke County, GA ................................................................................................................................ 0.9694 0.9789
12060 ....... Atlanta-Sandy Springs-Marietta, GA ................................................................................................................. 0.9782 0.9850
12420 ....... Austin-Round Rock, TX .................................................................................................................................... 0.9439 0.9612
12620 ....... Bangor, ME ....................................................................................................................................................... 0.9975 0.9983
12700 ....... Barnstable Town, MA ........................................................................................................................................ 1.2303 1.1525
12940 ....... Baton Rouge, LA .............................................................................................................................................. 0.8461 0.8919
13020 ....... Bay City, MI ...................................................................................................................................................... 0.9525 0.9672
13780 ....... Binghamton, NY ................................................................................................................................................ 0.8462 0.8919
13820 ....... Birmingham-Hoover, AL .................................................................................................................................... 0.8959 0.9275
14260 ....... Boise City-Nampa, ID ....................................................................................................................................... 0.9039 0.9331
14484 ....... Boston-Quincy, MA ........................................................................................................................................... 1.1274 1.0856
14540 ....... Bowling Green, KY ........................................................................................................................................... 0.8214 0.8740
15380 ....... Buffalo-Niagara Falls, NY ................................................................................................................................. 0.9503 0.9657
15540 ....... Burlington-South Burlington, VT ....................................................................................................................... 0.9278 0.9500
15764 ....... Cambridge-Newton-Framingham, MA (NH Hospitals) ...................................................................................... 1.1561 1.1044
15764 ....... Cambridge-Newton-Framingham, MA (VT Hospitals) ...................................................................................... 1.0982 1.0662
16180 ....... Carson City, NV ................................................................................................................................................ 0.9776 0.9846
16220 ....... Casper, WY ....................................................................................................................................................... 0.9249 0.9479
16580 ....... Champaign-Urbana, IL ...................................................................................................................................... 0.9262 0.9489
16620 ....... Charleston, WV (WV Hospitals) ........................................................................................................................ 0.8293 0.8797
16620 ....... Charleston, WV (OH Hospitals) ........................................................................................................................ 0.8826 0.9180
16700 ....... Charleston-North Charleston, SC ..................................................................................................................... 0.9240 0.9473
16740 ....... Charlotte-Gastonia-Concord, NC-SC ................................................................................................................ 0.9577 0.9708
16820 ....... Charlottesville, VA ............................................................................................................................................. 0.9771 0.9843
16860 ....... Chattanooga, TN-GA ........................................................................................................................................ 0.9089 0.9367
16974 ....... Chicago-Naperville-Joliet, IL ............................................................................................................................. 1.0646 1.0438
17140 ....... Cincinnati-Middletown, OH-KY-IN ..................................................................................................................... 0.9595 0.9721
17300 ....... Clarksville, TN-KY ............................................................................................................................................. 0.8084 0.8645
17460 ....... Cleveland-Elyria-Mentor, OH ............................................................................................................................ 0.9207 0.9450
17780 ....... College Station-Bryan, TX ................................................................................................................................ 0.8902 0.9234
17860 ....... Columbia, MO ................................................................................................................................................... 0.8357 0.8843
17900 ....... Columbia, SC .................................................................................................................................................... 0.9067 0.9351
17980 ....... Columbus, GA-AL ............................................................................................................................................. 0.8394 0.8870
18140 ....... Columbus, OH .................................................................................................................................................. 0.9857 0.9902
18700 ....... Corvallis, OR ..................................................................................................................................................... 1.0301 1.0205
19124 ....... Dallas-Plano-Irving, TX ..................................................................................................................................... 0.9938 0.9958
19380 ....... Dayton, OH ....................................................................................................................................................... 0.9060 0.9346
19460 ....... Decatur, AL ....................................................................................................................................................... 0.8509 0.8953
RECLASSIFIED BY CBSA—Continued
Wage
CBSA code Area GAF
index
19740 ....... Denver-Aurora, CO ........................................................................................................................................... 1.0507 1.0344

19780 ....... Des Moines, IA ................................................................................................................................................. 0.9430 0.9606
19804 ....... Detroit-Livonia-Dearborn, MI ............................................................................................................................. 1.0436 1.0297
20260 ....... Duluth, MN-WI .................................................................................................................................................. 1.0226 1.0154
20500 ....... Durham, NC ...................................................................................................................................................... 0.9944 0.9962
20764 ....... Edison, NJ ......................................................................................................................................................... 1.1290 1.0866
21060 ....... Elizabethtown, KY ............................................................................................................................................. 0.8278 0.8786
21500 ....... Erie, PA ............................................................................................................................................................. 0.8415 0.8885
21660 ....... Eugene-Springfield, OR .................................................................................................................................... 1.0419 1.0285
21780 ....... Evansville, IN-KY .............................................................................................................................................. 0.8499 0.8946
22020 ....... Fargo, ND-MN (ND, SD Hospitals) ................................................................................................................... 0.8769 0.9140
22020 ....... Fargo, ND-MN (MN Hospitals) .......................................................................................................................... 0.9132 0.9397
22180 ....... Fayetteville, NC ................................................................................................................................................. 0.9183 0.9433
22220 ....... Fayetteville-Springdale-Rogers, AR-MO ........................................................................................................... 0.8707 0.9095
22380 ....... Flagstaff, AZ ...................................................................................................................................................... 1.1382 1.0927
22420 ....... Flint, MI ............................................................................................................................................................. 1.0461 1.0313
22540 ....... Fond du Lac, WI ............................................................................................................................................... 0.9507 0.9660
22660 ....... Fort Collins-Loveland, CO ................................................................................................................................. 1.0136 1.0093
22744 ....... Ft Lauderdale-Pompano Beach-Deerfield Beach, FL ....................................................................................... 1.0497 1.0338
22900 ....... Fort Smith, AR-OK ............................................................................................................................................ 0.7998 0.8581
23020 ....... Fort Walton Beach-Crestview-Destin, FL ......................................................................................................... 0.8584 0.9007
23060 ....... Fort Wayne, IN .................................................................................................................................................. 0.9787 0.9854
23104 ....... Fort Worth-Arlington, TX ................................................................................................................................... 0.9491 0.9649
23540 ....... Gainesville, FL .................................................................................................................................................. 0.9375 0.9568
23844 ....... Gary, IN ............................................................................................................................................................. 0.9390 0.9578
24340 ....... Grand Rapids-Wyoming, MI .............................................................................................................................. 0.9389 0.9577
24500 ....... Great Falls, MT ................................................................................................................................................. 0.9065 0.9350
24540 ....... Greeley, CO ...................................................................................................................................................... 0.9587 0.9715
24580 ....... Green Bay, WI (WI Hospitals) .......................................................................................................................... 0.9507 0.9660
24580 ....... Green Bay, WI (MI Hospitals) ........................................................................................................................... 0.9470 0.9634
24780 ....... Greenville, NC ................................................................................................................................................... 0.9404 0.9588
24860 ....... Greenville, SC ................................................................................................................................................... 0.9702 0.9795
25060 ....... Gulfport-Biloxi, MS ............................................................................................................................................ 0.8603 0.9021
25420 ....... Harrisburg-Carlisle, PA ..................................................................................................................................... 0.9139 0.9402
25500 ....... Harrisonburg, VA .............................................................................................................................................. 0.8989 0.9296
25540 ....... Hartford-West Hartford-East Hartford, CT (CT Hospitals) ................................................................................ 1.1726 1.1152
25540 ....... Hartford-West Hartford-East Hartford, CT (MA Hospitals) ............................................................................... 1.1075 1.0724
25860 ....... Hickory-Lenoir-Morganton, NC ......................................................................................................................... 0.8930 0.9254
26100 ....... Holland-Grand Haven, MI ................................................................................................................................. 0.9124 0.9391
26180 ....... Honolulu, HI ...................................................................................................................................................... 1.1213 1.0816
26300 ....... Hot Springs, AR ................................................................................................................................................ 0.8842 0.9192
26420 ....... Houston-Sugar Land-Baytown, TX ................................................................................................................... 0.9996 0.9997
26580 ....... Huntington-Ashland, WV-KY-OH ...................................................................................................................... 0.9110 0.9382
26620 ....... Huntsville, AL .................................................................................................................................................... 0.9120 0.9389
26900 ....... Indianapolis, IN ................................................................................................................................................. 0.9766 0.9839
26980 ....... Iowa City, IA ...................................................................................................................................................... 0.9556 0.9694
27060 ....... Ithaca, NY ......................................................................................................................................................... 0.9195 0.9441
27140 ....... Jackson, MS ..................................................................................................................................................... 0.8174 0.8710
27180 ....... Jackson, TN ...................................................................................................................................................... 0.8790 0.9155
27260 ....... Jacksonville, FL ................................................................................................................................................ 0.9294 0.9511
27860 ....... Jonesboro, AR .................................................................................................................................................. 0.7784 0.8424
27900 ....... Joplin, MO ......................................................................................................................................................... 0.8450 0.8911
28020 ....... Kalamazoo-Portage, MI .................................................................................................................................... 1.0393 1.0267
28100 ....... Kankakee-Bradley, IL ........................................................................................................................................ 1.0738 1.0500
28140 ....... Kansas City, MO-KS ......................................................................................................................................... 0.9463 0.9629
28420 ....... Kennewick-Richland-Pasco, WA ....................................................................................................................... 1.0480 1.0326
28700 ....... Kingsport-Bristol-Bristol, TN-VA ........................................................................................................................ 0.8087 0.8647
28740 ....... Kingston, NY ..................................................................................................................................................... 0.8900 0.9233
28940 ....... Knoxville, TN ..................................................................................................................................................... 0.8456 0.8915
29180 ....... Lafayette, LA ..................................................................................................................................................... 0.8420 0.8889
29404 ....... Lake County-Kenosha County, IL-WI ............................................................................................................... 1.0434 1.0295
29460 ....... Lakeland, FL ..................................................................................................................................................... 0.8925 0.9251
29620 ....... Lansing-East Lansing, MI ................................................................................................................................. 0.9788 0.9854
29740 ....... Las Cruces, NM ................................................................................................................................................ 0.8640 0.9047
29820 ....... Las Vegas-Paradise, NV ................................................................................................................................... 1.1237 1.0831
30020 ....... Lawton, OK ....................................................................................................................................................... 0.7666 0.8336
30460 ....... Lexington-Fayette, KY ...................................................................................................................................... 0.8732 0.9113
30620 ....... Lima, OH ........................................................................................................................................................... 0.9271 0.9495
30700 ....... Lincoln, NE ........................................................................................................................................................ 0.9656 0.9763
30780 ....... Little Rock-North Little Rock, AR ...................................................................................................................... 0.8558 0.8989
Wage
CBSA code Area GAF
index
30980 ....... Longview, TX .................................................................................................................................................... 0.8612 0.9027

31084 ....... Los Angeles-Long Beach-Santa Ana, CA ........................................................................................................ 1.1687 1.1127
31140 ....... Louisville, KY-IN ................................................................................................................................................ 0.9254 0.9483
31180 ....... Lubbock, TX ...................................................................................................................................................... 0.8781 0.9148
31340 ....... Lynchburg, VA .................................................................................................................................................. 0.8697 0.9088
31420 ....... Macon, GA ........................................................................................................................................................ 0.9078 0.9359
31540 ....... Madison, WI ...................................................................................................................................................... 1.0429 1.0292
31700 ....... Manchester-Nashua, NH ................................................................................................................................... 1.1561 1.1044
32780 ....... Medford, OR ..................................................................................................................................................... 1.0301 1.0205
32820 ....... Memphis, TN-MS-AR ........................................................................................................................................ 0.9148 0.9408
33124 ....... Miami-Miami Beach-Kendall, FL ....................................................................................................................... 0.9747 0.9826
33260 ....... Midland, TX ....................................................................................................................................................... 0.9307 0.9520
33340 ....... Milwaukee-Waukesha-West Allis, WI ............................................................................................................... 0.9988 0.9992
33460 ....... Minneapolis-St. Paul-Bloomington, MN-WI ....................................................................................................... 1.0900 1.0608
33540 ....... Missoula, MT ..................................................................................................................................................... 0.9526 0.9673
33660 ....... Mobile, AL ......................................................................................................................................................... 0.7898 0.8508
33700 ....... Modesto, CA ..................................................................................................................................................... 1.1960 1.1304
33860 ....... Montgomery, AL ................................................................................................................................................ 0.8300 0.8802
34060 ....... Morgantown, WV .............................................................................................................................................. 0.8324 0.8819
34740 ....... Muskegon-Norton Shores, MI ........................................................................................................................... 0.9667 0.9771
34980 ....... Nashville-Davidson--Murfreesboro, TN ............................................................................................................. 0.9450 0.9620
35084 ....... Newark-Union, NJ-PA ....................................................................................................................................... 1.1879 1.1251
35380 ....... New Orleans-Metairie-Kenner, LA .................................................................................................................... 0.8993 0.9299
35644 ....... New York-White Plains-Wayne, NY-NJ ............................................................................................................ 1.3194 1.2090
36084 ....... Oakland-Fremont-Hayward, CA ........................................................................................................................ 1.5463 1.3478
36100 ....... Ocala, FL .......................................................................................................................................................... 0.8946 0.9266
36140 ....... Ocean City, NJ .................................................................................................................................................. 1.0279 1.0190
36220 ....... Odessa, TX ....................................................................................................................................................... 0.9584 0.9713
36260 ....... Ogden-Clearfield, UT ........................................................................................................................................ 0.9039 0.9331
36420 ....... Oklahoma City, OK ........................................................................................................................................... 0.9034 0.9328
36500 ....... Olympia, WA ..................................................................................................................................................... 1.0959 1.0647
36540 ....... Omaha-Council Bluffs, NE-IA ........................................................................................................................... 0.9546 0.9687
36740 ....... Orlando-Kissimmee, FL .................................................................................................................................... 0.9450 0.9620
37860 ....... Pensacola-Ferry Pass-Brent, FL ....................................................................................................................... 0.8081 0.8642
37900 ....... Peoria, IL ........................................................................................................................................................... 0.8743 0.9121
37964 ....... Philadelphia, PA ................................................................................................................................................ 1.1028 1.0693
38220 ....... Pine Bluff, AR ................................................................................................................................................... 0.8091 0.8650
38300 ....... Pittsburgh, PA ................................................................................................................................................... 0.8832 0.9185
38340 ....... Pittsfield, MA ..................................................................................................................................................... 1.0189 1.0129
38540 ....... Pocatello, ID ...................................................................................................................................................... 0.9394 0.9581
38860 ....... Portland-South Portland-Biddeford, ME ............................................................................................................ 0.9874 0.9914
38900 ....... Portland-Vancouver-Beaverton, OR-WA .......................................................................................................... 1.1235 1.0830
38940 ....... Port St. Lucie-Fort Pierce, FL ........................................................................................................................... 1.0151 1.0103
39100 ....... Poughkeepsie-Newburgh-Middletown, NY ....................................................................................................... 1.0677 1.0459
39340 ....... Provo-Orem, UT ................................................................................................................................................ 0.9484 0.9644
39580 ....... Raleigh-Cary, NC .............................................................................................................................................. 0.9411 0.9593
39740 ....... Reading, PA ...................................................................................................................................................... 0.9491 0.9649
39820 ....... Redding, CA ...................................................................................................................................................... 1.1897 1.1263
39900 ....... Reno-Sparks, NV (NV Hospitals) ...................................................................................................................... 1.0794 1.0537
39900 ....... Reno-Sparks, NV (CA Hospitals) ...................................................................................................................... 1.1042 1.0702
40060 ....... Richmond, VA ................................................................................................................................................... 0.9309 0.9521
40220 ....... Roanoke, VA ..................................................................................................................................................... 0.8442 0.8905
40340 ....... Rochester, MN .................................................................................................................................................. 1.1116 1.0751
40380 ....... Rochester, NY ................................................................................................................................................... 0.9123 0.9391
40420 ....... Rockford, IL ....................................................................................................................................................... 0.9664 0.9769
40484 ....... Rockingham County, NH .................................................................................................................................. 1.0492 1.0334
40660 ....... Rome, GA ......................................................................................................................................................... 0.9405 0.9589
40900 ....... Sacramento--Arden-Arcade--Roseville, CA ...................................................................................................... 1.2949 1.1936
40980 ....... Saginaw-Saginaw Township North, MI ............................................................................................................. 0.8966 0.9280
41060 ....... St. Cloud, MN ................................................................................................................................................... 0.9775 0.9845
41100 ....... St. George, UT .................................................................................................................................................. 0.9407 0.9590
41180 ....... St. Louis, MO-IL ................................................................................................................................................ 0.8958 0.9274
41620 ....... Salt Lake City, UT ............................................................................................................................................. 0.9424 0.9602
41700 ....... San Antonio, TX ................................................................................................................................................ 0.8978 0.9288
41884 ....... San Francisco-San Mateo-Redwood City, CA ................................................................................................. 1.4740 1.3043
41980 ....... San Juan-Caguas-Guaynabo, PR .................................................................................................................... 0.4621 0.5894
42044 ....... Santa Ana-Anaheim-Irvine, CA ......................................................................................................................... 1.1296 1.0870
42140 ....... Santa Fe, NM .................................................................................................................................................... 1.0152 1.0104
42220 ....... Santa Rosa-Petaluma, CA ................................................................................................................................ 1.3467 1.2261
42260 ....... Sarasota-Bradenton-Venice, FL ........................................................................................................................ 0.9634 0.9748
Wage
CBSA code Area GAF
index
42340 ....... Savannah, GA ................................................................................................................................................... 0.9300 0.9515

42644 ....... Seattle-Bellevue-Everett, WA ............................................................................................................................ 1.1562 1.1045
43300 ....... Sherman-Denison, TX ....................................................................................................................................... 0.8962 0.9277
43340 ....... Shreveport-Bossier City, LA .............................................................................................................................. 0.8758 0.9132
43620 ....... Sioux Falls, SD ................................................................................................................................................. 0.9607 0.9729
43780 ....... South Bend-Mishawaka, IN-MI ......................................................................................................................... 0.9775 0.9845
43900 ....... Spartanburg, SC ............................................................................................................................................... 0.9174 0.9427
44060 ....... Spokane, WA .................................................................................................................................................... 1.0711 1.0482
44180 ....... Springfield, MO ................................................................................................................................................. 0.8242 0.8760
44300 ....... State College, PA ............................................................................................................................................. 0.8289 0.8794
44940 ....... Sumter, SC ....................................................................................................................................................... 0.8660 0.9062
45060 ....... Syracuse, NY .................................................................................................................................................... 0.9318 0.9528
45300 ....... Tampa-St. Petersburg-Clearwater, FL .............................................................................................................. 0.9328 0.9535
45500 ....... Texarkana, TX-Texarkana, AR ......................................................................................................................... 0.8285 0.8791
45820 ....... Topeka, KS ....................................................................................................................................................... 0.8776 0.9145
46140 ....... Tulsa, OK .......................................................................................................................................................... 0.8569 0.8996
46220 ....... Tuscaloosa, AL ................................................................................................................................................. 0.8648 0.9053
46340 ....... Tyler, TX ........................................................................................................................................................... 0.9030 0.9325
46660 ....... Valdosta, GA ..................................................................................................................................................... 0.8701 0.9091
46700 ....... Vallejo-Fairfield, CA .......................................................................................................................................... 1.3972 1.2574
47260 ....... Virginia Beach-Norfolk-Newport News, VA ....................................................................................................... 0.8832 0.9185
47380 ....... Waco, TX .......................................................................................................................................................... 0.8523 0.8963
47894 ....... Washington-Arlington-Alexandria DC-VA ......................................................................................................... 1.0802 1.0543
48140 ....... Wausau, WI ...................................................................................................................................................... 0.9954 0.9968
48620 ....... Wichita, KS ....................................................................................................................................................... 0.8977 0.9288
48700 ....... Williamsport, PA ................................................................................................................................................ 0.8289 0.8794
48864 ....... Wilmington, DE-MD-NJ (DE Hospitals) ............................................................................................................ 1.0325 1.0221
48864 ....... Wilmington, DE-MD-NJ (NJ Hospitals) ............................................................................................................. 1.1227 1.0825
48900 ....... Wilmington, NC ................................................................................................................................................. 0.9384 0.9574
49020 ....... Winchester, VA-WV .......................................................................................................................................... 1.0204 1.0139
49180 ....... Winston-Salem, NC ........................................................................................................................................... 0.8951 0.9269
49660 ....... Youngstown-Warren-Boardman, OH-PA (OH Hospitals) ................................................................................. 0.8826 0.9180
49660 ....... Youngstown-Warren-Boardman, OH-PA (PA Hospitals) .................................................................................. 0.8600 0.9019
04 ............. Arkansas ........................................................................................................................................................... 0.7493 0.8207
05 ............. California ........................................................................................................................................................... 1.1042 1.0702
07 ............. Connecticut ....................................................................................................................................................... 1.1726 1.1152
10 ............. Florida (FL Hospitals) ........................................................................................................................................ 0.8584 0.9007
10 ............. Florida (GA Hosp.) ............................................................................................................................................ 0.8385 0.8864
14 ............. Illinois ................................................................................................................................................................ 0.8279 0.8787
15 ............. Indiana .............................................................................................................................................................. 0.8626 0.9037
16 ............. Iowa ................................................................................................................................................................... 0.8553 0.8985
17 ............. Kansas .............................................................................................................................................................. 0.8076 0.8639
19 ............. Louisiana ........................................................................................................................................................... 0.7438 0.8165
23 ............. Michigan ............................................................................................................................................................ 0.8966 0.9280
26 ............. Missouri ............................................................................................................................................................. 0.7919 0.8523
30 ............. New Hampshire (VT Hospitals) ........................................................................................................................ 1.1319 1.0885
33 ............. New York .......................................................................................................................................................... 0.8217 0.8742
37 ............. Oklahoma .......................................................................................................................................................... 0.7607 0.8292
38 ............. Oregon .............................................................................................................................................................. 1.0301 1.0205
39 ............. Pennsylvania ..................................................................................................................................................... 0.8289 0.8794
44 ............. Tennessee ........................................................................................................................................................ 0.8003 0.8585
45 ............. Texas ................................................................................................................................................................ 0.8053 0.8622
50 ............. Washington (WA Hospitals) .............................................................................................................................. 1.0480 1.0326
50 ............. Washington (ID Hospitals) ................................................................................................................................ 1.0095 1.0065
53 ............. Wyoming ........................................................................................................................................................... 0.9249 0.9479
TABLE 4F.—PUERTO RICO WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) BY CBSA
Wage GAF—re-
CBSA index—re-
Area Wage index GAF classified
code classified hospitals
hospitals
10380 ....... Aguadilla-Isabela-San Sebastián, PR ....................................................... 1.0347 1.0236 .................... ....................

21940 ....... Fajardo, PR ................................................................................................ 0.9089 0.9367 .................... ....................
25020 ....... Guayama, PR ............................................................................................ 0.6960 0.7802 .................... ....................
32420 ....... Mayagüez, PR ........................................................................................... 0.8789 0.9154 .................... ....................
38660 ....... Ponce, PR .................................................................................................. 1.0802 1.0543 .................... ....................
41900 ....... San Germán-Cabo Rojo, PR ..................................................................... 1.0150 1.0102 .................... ....................
TABLE 4F.—PUERTO RICO WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) BY CBSA—Continued
Wage GAF—re-
CBSA index—re-
Area Wage index GAF classified
code classified hospitals
hospitals
41980 ....... San Juan-Caguas-Guaynabo, PR ............................................................. 1.0104 1.0071 1.0104 1.0071

49500 ....... Yauco, PR .................................................................................................. 0.9640 0.9752 .................... ....................
TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006

[The following list represents all hospitals that are eligible to have their wage index increased by the out-migration adjustment listed in this table.
Hospitals cannot receive the out-migration adjustment if they are reclassified under section 1886(d)(10) of the Act, reclassified under section
508 of Pub. L. 108–173, or redesignated under section 1886(d)(8) of the Act. Hospitals were given 45 days from the date of publication of
the FY 2006 IPPS proposed rule to review their individual situations to determine whether to submit a request to withdraw their reclassifica-
tion/redesignation and receive the out-migration adjustment instead. Hospitals that have already been reclassified under section 1886(d)(10)
of the Act, reclassified under section 508 of Pub. L. 108–173, or redesignated under section 1886(d)(8) of the Act and did not withdraw their
reclassification/redesignation for FY 2006 are designated with an asterisk]
Out-migra-
Asterisk
Provider No. tion adjust- Qualifying county name
note ment
010005 .............................................................................. .................... 0.0259 Marshall

010008 .............................................................................. * 0.0212 Crenshaw
010009 .............................................................................. .................... 0.0092 Morgan
010010 .............................................................................. .................... 0.0259 Marshall
010012 .............................................................................. * 0.0205 De Kalb
010022 .............................................................................. * 0.0714 Cherokee
010025 .............................................................................. * 0.0235 Chambers
010029 .............................................................................. * 0.0107 Lee
010035 .............................................................................. * 0.0375 Cullman
010038 .............................................................................. .................... 0.0062 Calhoun
010045 .............................................................................. * 0.0160 Fayette
010047 .............................................................................. .................... 0.0155 Butler
010054 .............................................................................. .................... 0.0092 Morgan
010061 .............................................................................. .................... 0.0506 Jackson
010072 .............................................................................. * 0.0310 Talladega
010078 .............................................................................. .................... 0.0062 Calhoun
010083 .............................................................................. * 0.0121 Baldwin
010085 .............................................................................. .................... 0.0092 Morgan
010100 .............................................................................. * 0.0121 Baldwin
010101 .............................................................................. * 0.0310 Talladega
010109 .............................................................................. .................... 0.0451 Pickens
010115 .............................................................................. .................... 0.0093 Franklin
010129 .............................................................................. .................... 0.0121 Baldwin
010143 .............................................................................. * 0.0375 Cullman
010146 .............................................................................. .................... 0.0062 Calhoun
010150 .............................................................................. * 0.0155 Butler
010158 .............................................................................. * 0.0093 Franklin
010164 .............................................................................. * 0.0310 Talladega
040014 .............................................................................. * 0.0159 White
040019 .............................................................................. * 0.0697 St. Francis
040047 .............................................................................. * 0.0090 Randolph
040069 .............................................................................. * 0.0140 Mississippi
040071 .............................................................................. .................... 0.0026 Jefferson
040076 .............................................................................. * 0.1075 Hot Spring
040100 .............................................................................. * 0.0159 White
050008 .............................................................................. .................... 0.0026 San Francisco
050009 .............................................................................. * 0.0478 Napa
050013 .............................................................................. * 0.0478 Napa
050014 .............................................................................. * 0.0131 Amador
050016 .............................................................................. .................... 0.0103 San Luis Obispo
050042 .............................................................................. * 0.0219 Tehama
050046 .............................................................................. .................... 0.0156 Ventura
050047 .............................................................................. .................... 0.0026 San Francisco
050055 .............................................................................. .................... 0.0026 San Francisco
050065 .............................................................................. * 0.0029 Orange
050069 .............................................................................. * 0.0029 Orange
050073 .............................................................................. * 0.0269 Solano
050076 .............................................................................. * 0.0026 San Francisco
050082 .............................................................................. .................... 0.0156 Ventura
050084 .............................................................................. .................... 0.0555 San Joaquin
050089 .............................................................................. * 0.0152 San Bernardino
050090 .............................................................................. * 0.0308 Sonoma
050099 .............................................................................. * 0.0152 San Bernardino
TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued

Out-migra-
Asterisk
note ment
050101 .............................................................................. .................... 0.0269 Solano

050117 .............................................................................. .................... 0.0463 Merced
050118 .............................................................................. * 0.0555 San Joaquin
050122 .............................................................................. .................... 0.0555 San Joaquin
050129 .............................................................................. * 0.0152 San Bernardino
050133 .............................................................................. .................... 0.0170 Yuba
050136 .............................................................................. * 0.0308 Sonoma
050140 .............................................................................. * 0.0152 San Bernardino
050150 .............................................................................. * 0.0316 Nevada
050152 .............................................................................. .................... 0.0026 San Francisco
050159 .............................................................................. .................... 0.0156 Ventura
050167 .............................................................................. .................... 0.0555 San Joaquin
050168 .............................................................................. * 0.0029 Orange
050173 .............................................................................. * 0.0029 Orange
050174 .............................................................................. * 0.0308 Sonoma
050177 .............................................................................. .................... 0.0156 Ventura
050193 .............................................................................. * 0.0029 Orange
050224 .............................................................................. * 0.0029 Orange
050226 .............................................................................. * 0.0029 Orange
050228 .............................................................................. * 0.0026 San Francisco
050230 .............................................................................. * 0.0029 Orange
050232 .............................................................................. .................... 0.0103 San Luis Obispo
050236 .............................................................................. .................... 0.0156 Ventura
050245 .............................................................................. * 0.0152 San Bernardino
050272 .............................................................................. * 0.0152 San Bernardino
050279 .............................................................................. * 0.0152 San Bernardino
050291 .............................................................................. * 0.0308 Sonoma
050298 .............................................................................. * 0.0152 San Bernardino
050300 .............................................................................. * 0.0152 San Bernardino
050313 .............................................................................. .................... 0.0555 San Joaquin
050325 .............................................................................. .................... 0.0176 Tuolumne
050327 .............................................................................. * 0.0152 San Bernardino
050331 .............................................................................. * 0.0308 Sonoma
050335 .............................................................................. .................... 0.0176 Tuolumne
050336 .............................................................................. .................... 0.0555 San Joaquin
050348 .............................................................................. * 0.0029 Orange
050367 .............................................................................. .................... 0.0269 Solano
050385 .............................................................................. * 0.0308 Sonoma
050394 .............................................................................. .................... 0.0156 Ventura
050407 .............................................................................. .................... 0.0026 San Francisco
050426 .............................................................................. * 0.0029 Orange
050444 .............................................................................. .................... 0.0463 Merced
050454 .............................................................................. .................... 0.0026 San Francisco
050457 .............................................................................. .................... 0.0026 San Francisco
050469 .............................................................................. * 0.0152 San Bernardino
050476 .............................................................................. .................... 0.0257 Lake
050494 .............................................................................. * 0.0316 Nevada
050506 .............................................................................. .................... 0.0103 San Luis Obispo
050517 .............................................................................. * 0.0152 San Bernardino
050526 .............................................................................. * 0.0029 Orange
050528 .............................................................................. * 0.0463 Merced
050535 .............................................................................. * 0.0029 Orange
050539 .............................................................................. .................... 0.0257 Lake
050543 .............................................................................. * 0.0029 Orange
050547 .............................................................................. * 0.0308 Sonoma
050548 .............................................................................. * 0.0029 Orange
050549 .............................................................................. * 0.0156 Ventura
050550 .............................................................................. * 0.0029 Orange
050551 .............................................................................. * 0.0029 Orange
050567 .............................................................................. * 0.0029 Orange
050568 .............................................................................. .................... 0.0062 Madera
050570 .............................................................................. * 0.0029 Orange
050580 .............................................................................. * 0.0029 Orange
050584 .............................................................................. * 0.0152 San Bernardino

Out-migra-
Asterisk
note ment
050585 .............................................................................. * 0.0029 Orange

050586 .............................................................................. * 0.0152 San Bernardino
050589 .............................................................................. * 0.0029 Orange
050592 .............................................................................. * 0.0029 Orange
050594 .............................................................................. * 0.0029 Orange
050603 .............................................................................. * 0.0029 Orange
050609 .............................................................................. * 0.0029 Orange
050616 .............................................................................. .................... 0.0156 Ventura
050618 .............................................................................. * 0.0152 San Bernardino
050633 .............................................................................. .................... 0.0103 San Luis Obispo
050667 .............................................................................. * 0.0478 Napa
050668 .............................................................................. * 0.0026 San Francisco
050678 .............................................................................. * 0.0029 Orange
050680 .............................................................................. .................... 0.0269 Solano
050690 .............................................................................. * 0.0308 Sonoma
050693 .............................................................................. * 0.0029 Orange
050695 .............................................................................. .................... 0.0555 San Joaquin
050720 .............................................................................. * 0.0029 Orange
050728 .............................................................................. * 0.0308 Sonoma
050731 .............................................................................. .................... 0.0152 San Bernardino
060001 .............................................................................. * 0.0294 Weld
060003 .............................................................................. * 0.0203 Boulder
060027 .............................................................................. * 0.0203 Boulder
060103 .............................................................................. * 0.0203 Boulder
070003 .............................................................................. * 0.0009 Windham
070006 .............................................................................. * 0.0047 Fairfield
070010 .............................................................................. * 0.0047 Fairfield
070018 .............................................................................. * 0.0047 Fairfield
070020 .............................................................................. .................... 0.0073 Middlesex
070021 .............................................................................. * 0.0009 Windham
070028 .............................................................................. * 0.0047 Fairfield
070033 .............................................................................. * 0.0047 Fairfield
070034 .............................................................................. * 0.0047 Fairfield
080001 .............................................................................. .................... 0.0063 New Castle
080003 .............................................................................. .................... 0.0063 New Castle
100014 .............................................................................. .................... 0.0118 Volusia
100017 .............................................................................. .................... 0.0118 Volusia
100045 .............................................................................. * 0.0118 Volusia
100047 .............................................................................. .................... 0.0021 Charlotte
100062 .............................................................................. .................... 0.0060 Marion
100068 .............................................................................. .................... 0.0118 Volusia
100072 .............................................................................. .................... 0.0118 Volusia
100077 .............................................................................. .................... 0.0021 Charlotte
100102 .............................................................................. .................... 0.0125 Columbia
100118 .............................................................................. * 0.0398 Flagler
100156 .............................................................................. .................... 0.0125 Columbia
100175 .............................................................................. .................... 0.0231 De Soto
100212 .............................................................................. .................... 0.0060 Marion
100232 .............................................................................. .................... 0.0347 Putnam
100236 .............................................................................. .................... 0.0021 Charlotte
100252 .............................................................................. * 0.0233 Okeechobee
100290 .............................................................................. .................... 0.0582 Sumter
110023 .............................................................................. * 0.0500 Gordon
110027 .............................................................................. .................... 0.0387 Franklin
110029 .............................................................................. * 0.0063 Hall
110041 .............................................................................. * 0.0777 Habersham
110069 .............................................................................. * 0.0474 Houston
110124 .............................................................................. .................... 0.0428 Wayne
110136 .............................................................................. .................... 0.0261 Baldwin
110150 .............................................................................. * 0.0261 Baldwin
110153 .............................................................................. * 0.0474 Houston
110187 .............................................................................. * 0.1172 Lumpkin
110189 .............................................................................. * 0.0031 Fannin
110190 .............................................................................. .................... 0.0182 Macon

Out-migra-
Asterisk
note ment
110205 .............................................................................. * 0.0779 Gilmer

130003 .............................................................................. * 0.0095 Nez Perce
130024 .............................................................................. .................... 0.0275 Bonner
130049 .............................................................................. * 0.0349 Kootenai
130066 .............................................................................. .................... 0.0349 Kootenai
140012 .............................................................................. * 0.0220 Lee
140026 .............................................................................. .................... 0.0346 La Salle
140033 .............................................................................. .................... 0.0147 Lake
140043 .............................................................................. * 0.0046 Whiteside
140058 .............................................................................. * 0.0081 Morgan
140084 .............................................................................. .................... 0.0147 Lake
140100 .............................................................................. .................... 0.0147 Lake
140110 .............................................................................. * 0.0346 La Salle
140130 .............................................................................. .................... 0.0147 Lake
140155 .............................................................................. .................... 0.0027 Kankakee
140160 .............................................................................. * 0.0286 Stephenson
140161 .............................................................................. * 0.0138 Livingston
140186 .............................................................................. .................... 0.0027 Kankakee
140202 .............................................................................. .................... 0.0147 Lake
140205 .............................................................................. .................... 0.0163 Boone
140234 .............................................................................. * 0.0346 La Salle
140291 .............................................................................. * 0.0147 Lake
540022 .............................................................................. .................... 0.0249 Montgomery
540030 .............................................................................. * 0.0201 Henry
540035 .............................................................................. .................... 0.0083 Porter
540045 .............................................................................. .................... 0.0416 De Kalb
540060 .............................................................................. .................... 0.0051 Vermillion
540062 .............................................................................. .................... 0.0153 Decatur
540065 .............................................................................. * 0.0139 Jackson
540076 .............................................................................. * 0.0189 Marshall
540088 .............................................................................. * 0.0196 Madison
540091 .............................................................................. .................... 0.0573 Huntington
540102 .............................................................................. * 0.0160 Starke
540113 .............................................................................. * 0.0196 Madison
540122 .............................................................................. .................... 0.0199 Ripley
640013 .............................................................................. .................... 0.0218 Muscatine
640026 .............................................................................. * 0.0496 Boone
640030 .............................................................................. .................... 0.0040 Story
640032 .............................................................................. .................... 0.0272 Jasper
640080 .............................................................................. * 0.0049 Clinton
740137 .............................................................................. * 0.0336 Douglas
840012 .............................................................................. * 0.0083 Hardin
840066 .............................................................................. * 0.0567 Logan
840127 .............................................................................. * 0.0352 Franklin
840128 .............................................................................. .................... 0.0282 Lawrence
190001 .............................................................................. * 0.0645 Washington
190003 .............................................................................. * 0.0107 Iberia
190010 .............................................................................. .................... 0.0401 Tangipahoa
190015 .............................................................................. * 0.0401 Tangipahoa
190017 .............................................................................. .................... 0.0235 St. Landry
190054 .............................................................................. .................... 0.0107 Iberia
190078 .............................................................................. .................... 0.0235 St. Landry
190088 .............................................................................. .................... 0.0705 Webster
190099 .............................................................................. * 0.0390 Avoyelles
190106 .............................................................................. * 0.0238 Allen
190133 .............................................................................. .................... 0.0238 Allen
190144 .............................................................................. .................... 0.0705 Webster
190184 .............................................................................. .................... 0.0161 Caldwell
190190 .............................................................................. .................... 0.0161 Caldwell
190191 .............................................................................. * 0.0235 St. Landry
190246 .............................................................................. .................... 0.0161 Caldwell
200002 .............................................................................. * 0.0129 Lincoln
200013 .............................................................................. .................... 0.0186 Waldo
200024 .............................................................................. * 0.0071 Androscoggin

Out-migra-
Asterisk
note ment
200032 .............................................................................. .................... 0.0466 Oxford

200034 .............................................................................. * 0.0071 Androscoggin
200050 .............................................................................. * 0.0140 Hancock
210001 .............................................................................. .................... 0.0129 Washington
210004 .............................................................................. .................... 0.0040 Montgomery
210016 .............................................................................. .................... 0.0040 Montgomery
210018 .............................................................................. .................... 0.0040 Montgomery
210022 .............................................................................. .................... 0.0040 Montgomery
210023 .............................................................................. .................... 0.0209 Anne Arundel
210043 .............................................................................. .................... 0.0209 Anne Arundel
210048 .............................................................................. .................... 0.0287 Howard
210057 .............................................................................. .................... 0.0040 Montgomery
220001 .............................................................................. * 0.0056 Worcester
220002 .............................................................................. .................... 0.0249 Middlesex
220003 .............................................................................. * 0.0056 Worcester
220006 .............................................................................. .................... 0.0306 Essex
220010 .............................................................................. * 0.0306 Essex
220011 .............................................................................. .................... 0.0249 Middlesex
220019 .............................................................................. * 0.0056 Worcester
220025 .............................................................................. * 0.0056 Worcester
220028 .............................................................................. * 0.0056 Worcester
220029 .............................................................................. * 0.0306 Essex
220033 .............................................................................. * 0.0306 Essex
220035 .............................................................................. * 0.0306 Essex
220049 .............................................................................. .................... 0.0249 Middlesex
220058 .............................................................................. * 0.0056 Worcester
220062 .............................................................................. * 0.0056 Worcester
220063 .............................................................................. .................... 0.0249 Middlesex
220070 .............................................................................. .................... 0.0249 Middlesex
220080 .............................................................................. * 0.0306 Essex
220082 .............................................................................. .................... 0.0249 Middlesex
220084 .............................................................................. .................... 0.0249 Middlesex
220089 .............................................................................. .................... 0.0249 Middlesex
220090 .............................................................................. * 0.0056 Worcester
220095 .............................................................................. * 0.0056 Worcester
220098 .............................................................................. .................... 0.0249 Middlesex
220101 .............................................................................. .................... 0.0249 Middlesex
220105 .............................................................................. .................... 0.0249 Middlesex
220163 .............................................................................. * 0.0056 Worcester
220171 .............................................................................. .................... 0.0249 Middlesex
220174 .............................................................................. * 0.0306 Essex
230003 .............................................................................. * 0.0035 Ottawa
230013 .............................................................................. * 0.0091 Oakland
230015 .............................................................................. .................... 0.0359 St. Joseph
230019 .............................................................................. * 0.0091 Oakland
230021 .............................................................................. .................... 0.0136 Berrien
230022 .............................................................................. * 0.0113 Branch
230029 .............................................................................. * 0.0091 Oakland
230037 .............................................................................. * 0.0178 Hillsdale
230041 .............................................................................. .................... 0.0099 Bay
230042 .............................................................................. * 0.0685 Allegan
230047 .............................................................................. * 0.0082 Macomb
230069 .............................................................................. * 0.0487 Livingston
230071 .............................................................................. * 0.0091 Oakland
230072 .............................................................................. * 0.0035 Ottawa
230075 .............................................................................. .................... 0.0145 Calhoun
230078 .............................................................................. * 0.0136 Berrien
230092 .............................................................................. .................... 0.0389 Jackson
230093 .............................................................................. * 0.0079 Mecosta
230096 .............................................................................. * 0.0359 St. Joseph
230099 .............................................................................. * 0.0339 Monroe
230106 .............................................................................. * 0.0030 Newaygo
230121 .............................................................................. * 0.0691 Shiawassee
230130 .............................................................................. * 0.0091 Oakland

Out-migra-
Asterisk
note ment
230151 .............................................................................. * 0.0091 Oakland

230174 .............................................................................. * 0.0035 Ottawa
230184 .............................................................................. .................... 0.0389 Jackson
230195 .............................................................................. * 0.0082 Macomb
230204 .............................................................................. * 0.0082 Macomb
230207 .............................................................................. * 0.0091 Oakland
230217 .............................................................................. * 0.0145 Calhoun
230222 .............................................................................. .................... 0.0228 Midland
230223 .............................................................................. * 0.0091 Oakland
230227 .............................................................................. * 0.0082 Macomb
230254 .............................................................................. * 0.0091 Oakland
230257 .............................................................................. * 0.0082 Macomb
230264 .............................................................................. * 0.0082 Macomb
230269 .............................................................................. * 0.0091 Oakland
230277 .............................................................................. * 0.0091 Oakland
230279 .............................................................................. * 0.0487 Livingston
240013 .............................................................................. * 0.0226 Morrison
240018 .............................................................................. * 0.1196 Goodhue
240021 .............................................................................. .................... 0.0920 Le Sueur
240044 .............................................................................. .................... 0.0868 Winona
240064 .............................................................................. * 0.0138 Itasca
240069 .............................................................................. * 0.0419 Steele
240071 .............................................................................. * 0.0454 Rice
240152 .............................................................................. * 0.0735 Kanabec
240154 .............................................................................. .................... 0.0138 Itasca
240187 .............................................................................. * 0.0506 Mc Leod
240211 .............................................................................. * 0.0705 Pine
250040 .............................................................................. * 0.0294 Jackson
250045 .............................................................................. .................... 0.0042 Hancock
260011 .............................................................................. .................... 0.0007 Cole
260025 .............................................................................. * 0.0078 Marion
260047 .............................................................................. * 0.0007 Cole
260074 .............................................................................. * 0.0158 Randolph
260097 .............................................................................. .................... 0.0425 Johnson
260127 .............................................................................. .................... 0.0158 Pike
280054 .............................................................................. .................... 0.0137 Gage
280077 .............................................................................. * 0.0089 Dodge
280123 .............................................................................. .................... 0.0137 Gage
290019 .............................................................................. * 0.0026 Carson City
290049 .............................................................................. .................... 0.0026 Carson City
300011 .............................................................................. * 0.0069 Hillsborough
300012 .............................................................................. * 0.0069 Hillsborough
300017 .............................................................................. .................... 0.0361 Rockingham
300020 .............................................................................. * 0.0069 Hillsborough
300023 .............................................................................. .................... 0.0361 Rockingham
300029 .............................................................................. .................... 0.0361 Rockingham
300034 .............................................................................. * 0.0069 Hillsborough
310002 .............................................................................. * 0.0351 Essex
310009 .............................................................................. * 0.0351 Essex
310010 .............................................................................. .................... 0.0092 Mercer
310011 .............................................................................. .................... 0.0115 Cape May
310013 .............................................................................. * 0.0351 Essex
310018 .............................................................................. * 0.0351 Essex
310021 .............................................................................. * 0.0092 Mercer
310038 .............................................................................. * 0.0350 Middlesex
310039 .............................................................................. .................... 0.0350 Middlesex
310044 .............................................................................. .................... 0.0092 Mercer
310054 .............................................................................. * 0.0351 Essex
310070 .............................................................................. * 0.0350 Middlesex
310076 .............................................................................. * 0.0351 Essex
310078 .............................................................................. * 0.0351 Essex
310083 .............................................................................. * 0.0351 Essex
310092 .............................................................................. .................... 0.0092 Mercer
310093 .............................................................................. * 0.0351 Essex

Out-migra-
Asterisk
note ment
310096 .............................................................................. * 0.0351 Essex

310108 .............................................................................. .................... 0.0350 Middlesex
310110 .............................................................................. .................... 0.0092 Mercer
310119 .............................................................................. * 0.0351 Essex
310123 .............................................................................. .................... 0.0351 Essex
310124 .............................................................................. .................... 0.0350 Middlesex
320003 .............................................................................. .................... 0.0629 San Miguel
320011 .............................................................................. .................... 0.0442 Rio Arriba
320018 .............................................................................. .................... 0.0063 Dona Ana
320085 .............................................................................. .................... 0.0063 Dona Ana
330004 .............................................................................. * 0.0959 Ulster
330008 .............................................................................. * 0.0470 Wyoming
330027 .............................................................................. * 0.0137 Nassau
330094 .............................................................................. * 0.0778 Columbia
330106 .............................................................................. * 0.0137 Nassau
330126 .............................................................................. * 0.0560 Orange
330135 .............................................................................. * 0.0560 Orange
330167 .............................................................................. .................... 0.0137 Nassau
330181 .............................................................................. * 0.0137 Nassau
330182 .............................................................................. * 0.0137 Nassau
330191 .............................................................................. * 0.0026 Warren
330198 .............................................................................. .................... 0.0137 Nassau
330205 .............................................................................. * 0.0560 Orange
330209 .............................................................................. * 0.0560 Orange
330224 .............................................................................. .................... 0.0959 Ulster
330225 .............................................................................. .................... 0.0137 Nassau
330235 .............................................................................. * 0.0270 Cayuga
330259 .............................................................................. .................... 0.0137 Nassau
330264 .............................................................................. * 0.0560 Orange
330276 .............................................................................. .................... 0.0063 Fulton
330331 .............................................................................. .................... 0.0137 Nassau
330332 .............................................................................. .................... 0.0137 Nassau
330372 .............................................................................. .................... 0.0137 Nassau
330386 .............................................................................. * 0.1139 Sullivan
340015 .............................................................................. .................... 0.0267 Rowan
340020 .............................................................................. .................... 0.0207 Lee
340021 .............................................................................. * 0.0216 Cleveland
340037 .............................................................................. .................... 0.0216 Cleveland
340039 .............................................................................. * 0.0144 Iredell
340069 .............................................................................. * 0.0053 Wake
340070 .............................................................................. .................... 0.0448 Alamance
340073 .............................................................................. * 0.0053 Wake
340085 .............................................................................. .................... 0.0377 Davidson
340096 .............................................................................. .................... 0.0377 Davidson
340104 .............................................................................. .................... 0.0216 Cleveland
340114 .............................................................................. * 0.0053 Wake
340126 .............................................................................. * 0.0161 Wilson
340127 .............................................................................. * 0.0961 Granville
340129 .............................................................................. * 0.0144 Iredell
340133 .............................................................................. .................... 0.0308 Martin
340138 .............................................................................. * 0.0053 Wake
340144 .............................................................................. * 0.0144 Iredell
340145 .............................................................................. * 0.0563 Lincoln
340173 .............................................................................. * 0.0053 Wake
360013 .............................................................................. * 0.0166 Shelby
360025 .............................................................................. * 0.0087 Erie
360036 .............................................................................. * 0.0263 Wayne
360065 .............................................................................. * 0.0141 Huron
360070 .............................................................................. .................... 0.0028 Stark
360078 .............................................................................. * 0.0159 Portage
360084 .............................................................................. .................... 0.0028 Stark
360086 .............................................................................. * 0.0168 Clark
360095 .............................................................................. * 0.0087 Hancock
360100 .............................................................................. .................... 0.0028 Stark

Out-migra-
Asterisk
note ment
360107 .............................................................................. * 0.0213 Sandusky

360131 .............................................................................. .................... 0.0028 Stark
360151 .............................................................................. .................... 0.0028 Stark
360156 .............................................................................. .................... 0.0213 Sandusky
360175 .............................................................................. * 0.0159 Clinton
360187 .............................................................................. * 0.0168 Clark
360197 .............................................................................. * 0.0092 Logan
360267 .............................................................................. .................... 0.0028 Stark
370004 .............................................................................. * 0.0193 Ottawa
370014 .............................................................................. * 0.0831 Bryan
370015 .............................................................................. * 0.0463 Mayes
370023 .............................................................................. .................... 0.0084 Stephens
370065 .............................................................................. .................... 0.0121 Craig
370113 .............................................................................. * 0.0205 Delaware
370149 .............................................................................. .................... 0.0356 Pottawatomie
370179 .............................................................................. * 0.0314 Okfuskee
380002 .............................................................................. .................... 0.0130 Josephine
380008 .............................................................................. * 0.0201 Linn
380022 .............................................................................. .................... 0.0201 Linn
380029 .............................................................................. .................... 0.0075 Marion
380051 .............................................................................. .................... 0.0075 Marion
380056 .............................................................................. .................... 0.0075 Marion
390011 .............................................................................. .................... 0.0012 Cambria
390044 .............................................................................. .................... 0.0200 Berks
390046 .............................................................................. .................... 0.0098 York
390056 .............................................................................. .................... 0.0042 Huntingdon
390065 .............................................................................. * 0.0501 Adams
390066 .............................................................................. * 0.0259 Lebanon
390096 .............................................................................. .................... 0.0200 Berks
390101 .............................................................................. .................... 0.0098 York
390110 .............................................................................. * 0.0012 Cambria
390130 .............................................................................. .................... 0.0012 Cambria
390138 .............................................................................. * 0.0325 Franklin
390146 .............................................................................. .................... 0.0053 Warren
390150 .............................................................................. * 0.0206 Greene
390151 .............................................................................. * 0.0325 Franklin
390162 .............................................................................. .................... 0.0200 Northampton
390201 .............................................................................. .................... 0.1127 Monroe
390233 .............................................................................. .................... 0.0098 York
420007 .............................................................................. .................... 0.0001 Spartanburg
420020 .............................................................................. * 0.0035 Georgetown
420027 .............................................................................. .................... 0.0210 Anderson
420030 .............................................................................. * 0.0103 Colleton
420039 .............................................................................. * 0.0153 Union
420043 .............................................................................. .................... 0.0177 Cherokee
420068 .............................................................................. * 0.0097 Orangeburg
420070 .............................................................................. * 0.0101 Sumter
420083 .............................................................................. .................... 0.0001 Spartanburg
420093 .............................................................................. .................... 0.0001 Spartanburg
420098 .............................................................................. .................... 0.0035 Georgetown
440008 .............................................................................. * 0.0663 Henderson
440024 .............................................................................. .................... 0.0387 Bradley
440030 .............................................................................. .................... 0.0056 Hamblen
440035 .............................................................................. * 0.0441 Montgomery
440047 .............................................................................. .................... 0.0499 Gibson
440056 .............................................................................. .................... 0.0321 Jefferson
440060 .............................................................................. * 0.0499 Gibson
440063 .............................................................................. .................... 0.0011 Washington
440067 .............................................................................. * 0.0056 Hamblen
440073 .............................................................................. * 0.0513 Maury
440105 .............................................................................. .................... 0.0011 Washington
440114 .............................................................................. .................... 0.0523 Lauderdale
440115 .............................................................................. .................... 0.0499 Gibson
440148 .............................................................................. * 0.0568 De Kalb

Out-migra-
Asterisk
note ment
440153 .............................................................................. .................... 0.0007 Cocke

440174 .............................................................................. .................... 0.0372 Haywood
440181 .............................................................................. .................... 0.0407 Hardeman
440184 .............................................................................. .................... 0.0011 Washington
440185 .............................................................................. * 0.0387 Bradley
450032 .............................................................................. * 0.0416 Harrison
450039 .............................................................................. * 0.0097 Tarrant
450050 .............................................................................. .................... 0.0750 Ward
450059 .............................................................................. * 0.0073 Comal
450064 .............................................................................. * 0.0097 Tarrant
450087 .............................................................................. * 0.0097 Tarrant
450099 .............................................................................. * 0.0180 Gray
450121 .............................................................................. * 0.0097 Tarrant
450135 .............................................................................. * 0.0097 Tarrant
450137 .............................................................................. * 0.0097 Tarrant
450144 .............................................................................. * 0.0573 Andrews
450163 .............................................................................. .................... 0.0134 Kleberg
450187 .............................................................................. * 0.0264 Washington
450194 .............................................................................. * 0.0328 Cherokee
450214 .............................................................................. * 0.0368 Wharton
450224 .............................................................................. * 0.0411 Wood
450347 .............................................................................. * 0.0427 Walker
450362 .............................................................................. .................... 0.0486 Burnet
450370 .............................................................................. .................... 0.0258 Colorado
450389 .............................................................................. * 0.0881 Henderson
450395 .............................................................................. .................... 0.0484 Polk
450419 .............................................................................. * 0.0097 Tarrant
450438 .............................................................................. * 0.0258 Colorado
450447 .............................................................................. * 0.0358 Navarro
450451 .............................................................................. * 0.0551 Somervell
450465 .............................................................................. .................... 0.0435 Matagorda
450547 .............................................................................. * 0.0411 Wood
450563 .............................................................................. * 0.0097 Tarrant
450565 .............................................................................. .................... 0.0486 Palo Pinto
450596 .............................................................................. .................... 0.0808 Hood
450597 .............................................................................. .................... 0.0077 De Witt
450623 .............................................................................. * 0.0492 Fannin
450626 .............................................................................. .................... 0.0294 Jackson
450639 .............................................................................. * 0.0097 Tarrant
450672 .............................................................................. * 0.0097 Tarrant
450675 .............................................................................. * 0.0097 Tarrant
450677 .............................................................................. * 0.0097 Tarrant
450694 .............................................................................. * 0.0368 Wharton
450747 .............................................................................. * 0.0195 Anderson
450755 .............................................................................. * 0.0484 Hockley
450763 .............................................................................. .................... 0.0236 Hutchinson
450779 .............................................................................. * 0.0097 Tarrant
450813 .............................................................................. .................... 0.0195 Anderson
450858 .............................................................................. * 0.0097 Tarrant
450872 .............................................................................. * 0.0097 Tarrant
450880 .............................................................................. * 0.0097 Tarrant
460017 .............................................................................. .................... 0.0392 Box Elder
460036 .............................................................................. * 0.0700 Wasatch
460039 .............................................................................. * 0.0392 Box Elder
470018 .............................................................................. .................... 0.0287 Windsor
490019 .............................................................................. .................... 0.1240 Culpeper
490038 .............................................................................. .................... 0.0022 Smyth
490047 .............................................................................. * 0.0198 Page
490084 .............................................................................. .................... 0.0167 Essex
490105 .............................................................................. * 0.0022 Smyth
490110 .............................................................................. .................... 0.0082 Montgomery
500003 .............................................................................. * 0.0208 Skagit
500007 .............................................................................. .................... 0.0208 Skagit
500019 .............................................................................. .................... 0.0213 Lewis

Out-migra-
Asterisk
note ment
500021 .............................................................................. .................... 0.0055 Pierce

500024 .............................................................................. .................... 0.0023 Thurston
500039 .............................................................................. * 0.0174 Kitsap
500041 .............................................................................. * 0.0118 Cowlitz
500079 .............................................................................. .................... 0.0055 Pierce
500108 .............................................................................. .................... 0.0055 Pierce
500122 .............................................................................. * 0.0459 Island
500129 .............................................................................. .................... 0.0055 Pierce
500139 .............................................................................. .................... 0.0023 Thurston
500143 .............................................................................. .................... 0.0023 Thurston
510018 .............................................................................. * 0.0209 Jackson
510028 .............................................................................. * 0.0141 Fayette
510039 .............................................................................. .................... 0.0112 Ohio
510047 .............................................................................. * 0.0275 Marion
510050 .............................................................................. .................... 0.0112 Ohio
510077 .............................................................................. * 0.0021 Mingo
520028 .............................................................................. * 0.0157 Green
520035 .............................................................................. .................... 0.0077 Sheboygan
520044 .............................................................................. .................... 0.0077 Sheboygan
520057 .............................................................................. .................... 0.0118 Sauk
520059 .............................................................................. * 0.0200 Racine
520071 .............................................................................. * 0.0239 Jefferson
520095 .............................................................................. * 0.0118 Sauk
520096 .............................................................................. * 0.0200 Racine
520102 .............................................................................. * 0.0298 Walworth
520116 .............................................................................. * 0.0239 Jefferson
520132 .............................................................................. .................... 0.0077 Sheboygan
TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC
MEAN LENGTH OF STAY (LOS)
FY 2006
FY 2006 postacute Geo- Arithmetic
postacute care spe- Relative metric
DRG MDC TYPE DRG title mean
care trans- cial pay weights mean LOS
fer DRG transfer LOS
DRG
1 ............... Yes .......... No ............ 01 SURG ...... CRANIOTOMY AGE >17 W CC .............. 3.4347 7.6 10.1
2 ............... Yes .......... No ............ 01 SURG ...... CRANIOTOMY AGE >17 W/O CC .......... 1.9587 3.5 4.6
3 ............... No ............ No ............ 01 SURG * .... CRANIOTOMY AGE 0-17 ....................... 1.9860 12.7 12.7
4 ............... No ............ No ............ 01 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0
5 ............... No ............ No ............ 01 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0
6 ............... No ............ No ............ 01 SURG ...... CARPAL TUNNEL RELEASE ................. 0.7878 2.2 3.0
7 ............... Yes .......... Yes .......... 01 SURG ...... PERIPH & CRANIAL NERVE & OTHER 2.6978 6.7 9.7
NERV SYST PROC W CC.
8 ............... Yes .......... Yes .......... 01 SURG ...... PERIPH & CRANIAL NERVE & OTHER 1.5635 2.0 3.0
NERV SYST PROC W/O CC.
9 ............... No ............ No ............ 01 MED ......... SPINAL DISORDERS & INJURIES ........ 1.4045 4.5 6.4
10 ............. Yes .......... No ............ 01 MED ......... NERVOUS SYSTEM NEOPLASMS W 1.2222 4.6 6.2
CC.
11 ............. Yes .......... No ............ 01 MED ......... NERVOUS SYSTEM NEOPLASMS W/O 0.8736 2.9 3.8
CC.
12 ............. Yes .......... No ............ 01 MED ......... DEGENERATIVE NERVOUS SYSTEM 0.8998 4.3 5.5
DISORDERS.
13 ............. Yes .......... No ............ 01 MED ......... MULTIPLE SCLEROSIS & CERE- 0.8575 4.0 5.0
BELLAR ATAXIA.
14 ............. Yes .......... No ............ 01 MED ......... INTRACRANIAL HEMORRHAGE OR 1.2456 4.5 5.8
CEREBRAL INFARCTION.
15 ............. Yes .......... No ............ 01 MED ......... NONSPECIFIC CVA & PRECEREBRAL 0.9421 3.7 4.6
OCCLUSION W/O INFARCT.
16 ............. Yes .......... No ............ 01 MED ......... NONSPECIFIC CEREBROVASCULAR 1.3351 5.0 6.5
DISORDERS W CC.
MEAN LENGTH OF STAY (LOS)—Continued
FY 2006
DRG
17 ............. Yes .......... No ............ 01 MED ......... NONSPECIFIC CEREBROVASCULAR 0.7229 2.5 3.2
DISORDERS W/O CC.
18 ............. Yes .......... No ............ 01 MED ......... CRANIAL & PERIPHERAL NERVE DIS- 0.9903 4.1 5.3
ORDERS W CC.
19 ............. Yes .......... No ............ 01 MED ......... CRANIAL & PERIPHERAL NERVE DIS- 0.7077 2.7 3.5
ORDERS W/O CC.
20 ............. Yes .......... No ............ 01 MED ......... NERVOUS SYSTEM INFECTION EX- 2.7865 8.0 10.4
CEPT VIRAL MENINGITIS.
21 ............. No ............ No ............ 01 MED ......... VIRAL MENINGITIS ................................ 1.4451 4.9 6.3
22 ............. No ............ No ............ 01 MED ......... HYPERTENSIVE ENCEPHALOPATHY .. 1.1304 4.0 5.2
23 ............. No ............ No ............ 01 MED ......... NONTRAUMATIC STUPOR & COMA .... 0.7712 3.0 3.9
24 ............. Yes .......... No ............ 01 MED ......... SEIZURE & HEADACHE AGE >17 W 0.9970 3.6 4.8
CC.
25 ............. Yes .......... No ............ 01 MED ......... SEIZURE & HEADACHE AGE >17 W/O 0.6180 2.5 3.1
CC.
26 ............. No ............ No ............ 01 MED ......... SEIZURE & HEADACHE AGE 0-17 ....... 1.8191 3.4 6.3
27 ............. No ............ No ............ 01 MED ......... TRAUMATIC STUPOR & COMA, COMA 1.3531 3.2 5.2
>1 HR.
28 ............. Yes .......... No ............ 01 MED ......... TRAUMATIC STUPOR & COMA, COMA 1.3353 4.4 5.9
<1 HR AGE >17 W CC.
29 ............. Yes .......... No ............ 01 MED ......... TRAUMATIC STUPOR & COMA, COMA 0.7212 2.6 3.4
<1 HR AGE >17 W/O CC.
30 ............. No ............ No ............ 01 MED * ...... TRAUMATIC STUPOR & COMA, COMA 0.3359 2.0 2.0
<1 HR AGE 0-17.
31 ............. No ............ No ............ 01 MED ......... CONCUSSION AGE >17 W CC .............. 0.9567 3.0 4.0
32 ............. No ............ No ............ 01 MED ......... CONCUSSION AGE >17 W/O CC .......... 0.6194 1.9 2.4
33 ............. No ............ No ............ 01 MED * ...... CONCUSSION AGE 0-17 ....................... 0.2109 1.6 1.6
34 ............. Yes .......... No ............ 01 MED ......... OTHER DISORDERS OF NERVOUS 1.0062 3.7 4.8
SYSTEM W CC.
35 ............. Yes .......... No ............ 01 MED ......... OTHER DISORDERS OF NERVOUS 0.6241 2.4 3.0
SYSTEM W/O CC.
36 ............. No ............ No ............ 02 SURG ...... RETINAL PROCEDURES ....................... 0.7288 1.3 1.6
37 ............. No ............ No ............ 02 SURG ...... ORBITAL PROCEDURES ....................... 1.1858 2.7 4.2
38 ............. No ............ No ............ 02 SURG ...... PRIMARY IRIS PROCEDURES .............. 0.6975 2.5 3.5
39 ............. No ............ No ............ 02 SURG ...... LENS PROCEDURES WITH OR WITH- 0.7108 1.7 2.4
OUT VITRECTOMY.
40 ............. No ............ No ............ 02 SURG ...... EXTRAOCULAR PROCEDURES EX- 0.9627 3.0 4.1
CEPT ORBIT AGE >17.
41 ............. No ............ No ............ 02 SURG * .... EXTRAOCULAR PROCEDURES EX- 0.3419 1.6 1.6
CEPT ORBIT AGE 0-17.
42 ............. No ............ No ............ 02 SURG ...... INTRAOCULAR PROCEDURES EX- 0.7852 2.0 2.8
CEPT RETINA, IRIS & LENS.
43 ............. No ............ No ............ 02 MED ......... HYPHEMA ............................................... 0.6141 2.4 3.1
44 ............. No ............ No ............ 02 MED ......... ACUTE MAJOR EYE INFECTIONS ........ 0.6874 3.9 4.8
45 ............. No ............ No ............ 02 MED ......... NEUROLOGICAL EYE DISORDERS ..... 0.7474 2.5 3.1
46 ............. No ............ No ............ 02 MED ......... OTHER DISORDERS OF THE EYE 0.7524 3.2 4.2
AGE >17 W CC.
47 ............. No ............ No ............ 02 MED ......... OTHER DISORDERS OF THE EYE 0.5203 2.3 2.9
AGE >17 W/O CC.
48 ............. No ............ No ............ 02 MED * ...... OTHER DISORDERS OF THE EYE 0.3012 2.9 2.9
AGE 0-17.
49 ............. No ............ No ............ 03 SURG ...... MAJOR HEAD & NECK PROCEDURES 1.6361 3.1 4.4
50 ............. No ............ No ............ 03 SURG ...... SIALOADENECTOMY ............................. 0.8690 1.5 1.8
51 ............. No ............ No ............ 03 SURG ...... SALIVARY GLAND PROCEDURES EX- 0.8809 1.9 2.8
CEPT SIALOADENECTOMY.
52 ............. No ............ No ............ 03 SURG ...... CLEFT LIP & PALATE REPAIR .............. 0.8348 1.5 1.9
53 ............. No ............ No ............ 03 SURG ...... SINUS & MASTOID PROCEDURES 1.3269 2.4 3.9
AGE >17.
54 ............. No ............ No ............ 03 SURG * .... SINUS & MASTOID PROCEDURES 0.4882 3.2 3.2
AGE 0-17.
55 ............. No ............ No ............ 03 SURG ...... MISCELLANEOUS EAR, NOSE, 0.9597 2.0 3.1
MOUTH & THROAT PROCEDURES.
56 ............. No ............ No ............ 03 SURG ...... RHINOPLASTY ........................................ 0.8711 1.8 2.6
57 ............. No ............ No ............ 03 SURG ...... T&A PROC, EXCEPT TONSILLECTOMY 1.0428 2.3 3.6
&/OR ADENOIDECTOMY ONLY, AGE
>17.
FY 2006
DRG
58 ............. No ............ No ............ 03 SURG * .... T&A PROC, EXCEPT TONSILLECTOMY 0.2772 1.5 1.5
&/OR ADENOIDECTOMY ONLY, AGE
0-17.
59 ............. No ............ No ............ 03 SURG ...... TONSILLECTOMY &/OR 0.8082 1.8 2.6
ADENOIDECTOMY ONLY, AGE >17.
60 ............. No ............ No ............ 03 SURG * .... TONSILLECTOMY &/OR 0.2110 1.5 1.5
ADENOIDECTOMY ONLY, AGE 0-17.
61 ............. No ............ No ............ 03 SURG ...... MYRINGOTOMY W TUBE INSERTION 1.2867 3.3 5.4
AGE >17.
62 ............. No ............ No ............ 03 SURG * .... MYRINGOTOMY W TUBE INSERTION 0.2989 1.3 1.3
AGE 0-17.
63 ............. No ............ No ............ 03 SURG ...... OTHER EAR, NOSE, MOUTH & 1.3983 3.0 4.5
THROAT O.R. PROCEDURES.
64 ............. No ............ No ............ 03 MED ......... EAR, NOSE, MOUTH & THROAT MA- 1.1663 4.1 6.1
LIGNANCY.
65 ............. No ............ No ............ 03 MED ......... DYSEQUILIBRIUM .................................. 0.5991 2.3 2.8
66 ............. No ............ No ............ 03 MED ......... EPISTAXIS .............................................. 0.5958 2.4 3.1
67 ............. No ............ No ............ 03 MED ......... EPIGLOTTITIS ......................................... 0.7725 2.9 3.7
68 ............. No ............ No ............ 03 MED ......... OTITIS MEDIA & URI AGE >17 W CC 0.6611 3.2 4.0
69 ............. No ............ No ............ 03 MED ......... OTITIS MEDIA & URI AGE >17 W/O 0.4850 2.5 3.0
CC.
70 ............. No ............ No ............ 03 MED ......... OTITIS MEDIA & URI AGE 0-17 ............. 0.4210 2.1 2.3
71 ............. No ............ No ............ 03 MED ......... LARYNGOTRACHEITIS .......................... 0.7524 3.2 4.0
72 ............. No ............ No ............ 03 MED ......... NASAL TRAUMA & DEFORMITY ........... 0.7449 2.6 3.4
73 ............. Yes .......... No ............ 03 MED ......... OTHER EAR, NOSE, MOUTH & 0.8527 3.3 4.4
THROAT DIAGNOSES AGE >17.
74 ............. No ............ No ............ 03 MED * ...... OTHER EAR, NOSE, MOUTH & 0.3398 2.1 2.1
THROAT DIAGNOSES AGE 0-17.
75 ............. Yes .......... No ............ 04 SURG ...... MAJOR CHEST PROCEDURES ............ 3.0732 7.6 9.9
76 ............. Yes .......... No ............ 04 SURG ...... OTHER RESP SYSTEM O.R. PROCE- 2.8830 8.4 11.1
DURES W CC.
77 ............. Yes .......... No ............ 04 SURG ...... OTHER RESP SYSTEM O.R. PROCE- 1.1857 3.3 4.7
DURES W/O CC.
78 ............. Yes .......... No ............ 04 MED ......... PULMONARY EMBOLISM ...................... 1.2427 5.4 6.4
79 ............. Yes .......... No ............ 04 MED ......... RESPIRATORY INFECTIONS & IN- 1.6238 6.7 8.5
FLAMMATIONS AGE >17 W CC.
80 ............. Yes .......... No ............ 04 MED ......... RESPIRATORY INFECTIONS & IN- 0.8947 4.4 5.5
FLAMMATIONS AGE >17 W/O CC.
81 ............. No ............ No ............ 04 MED * ...... RESPIRATORY INFECTIONS & IN- 1.5383 6.1 6.1
FLAMMATIONS AGE 0-17.
82 ............. Yes .......... No ............ 04 MED ......... RESPIRATORY NEOPLASMS ................ 1.3936 5.1 6.8
83 ............. Yes .......... No ............ 04 MED ......... MAJOR CHEST TRAUMA W CC ............ 0.9828 4.2 5.3
84 ............. Yes .......... No ............ 04 MED ......... MAJOR CHEST TRAUMA W/O CC ........ 0.5799 2.6 3.2
85 ............. Yes .......... No ............ 04 MED ......... PLEURAL EFFUSION W CC .................. 1.2405 4.8 6.3
86 ............. Yes .......... No ............ 04 MED ......... PLEURAL EFFUSION W/O CC .............. 0.6974 2.8 3.6
87 ............. No ............ No ............ 04 MED ......... PULMONARY EDEMA & RES- 1.3654 4.9 6.4
PIRATORY FAILURE.
88 ............. No ............ No ............ 04 MED ......... CHRONIC OBSTRUCTIVE PUL- 0.8778 4.0 4.9
MONARY DISEASE.
89 ............. Yes .......... No ............ 04 MED ......... SIMPLE PNEUMONIA & PLEURISY 1.0320 4.7 5.7
AGE >17 W CC.
90 ............. Yes .......... No ............ 04 MED ......... SIMPLE PNEUMONIA & PLEURISY 0.6104 3.2 3.8
AGE >17 W/O CC.
91 ............. No ............ No ............ 04 MED ......... SIMPLE PNEUMONIA & PLEURISY 0.8124 3.4 4.4
AGE 0-17.
92 ............. Yes .......... No ............ 04 MED ......... INTERSTITIAL LUNG DISEASE W CC .. 1.1853 4.8 6.1
93 ............. Yes .......... No ............ 04 MED ......... INTERSTITIAL LUNG DISEASE W/O CC 0.7150 3.1 3.9
94 ............. No ............ No ............ 04 MED ......... PNEUMOTHORAX W CC ....................... 1.1354 4.6 6.2
95 ............. No ............ No ............ 04 MED ......... PNEUMOTHORAX W/O CC ................... 0.6035 2.9 3.6
96 ............. No ............ No ............ 04 MED ......... BRONCHITIS & ASTHMA AGE >17 W 0.7303 3.6 4.4
CC.
97 ............. No ............ No ............ 04 MED ......... BRONCHITIS & ASTHMA AGE >17 W/O 0.5364 2.8 3.4
CC.
98 ............. No ............ No ............ 04 MED * ...... BRONCHITIS & ASTHMA AGE 0-17 ...... 0.5560 3.7 3.7
99 ............. No ............ No ............ 04 MED ......... RESPIRATORY SIGNS & SYMPTOMS 0.7094 2.4 3.1
W CC.
FY 2006
DRG
100 ........... No ............ No ............ 04 MED ......... RESPIRATORY SIGNS & SYMPTOMS 0.5382 1.7 2.1
W/O CC.
101 ........... Yes .......... No ............ 04 MED ......... OTHER RESPIRATORY SYSTEM DIAG- 0.8733 3.3 4.3
NOSES W CC.
102 ........... Yes .......... No ............ 04 MED ......... OTHER RESPIRATORY SYSTEM DIAG- 0.5402 2.0 2.5
NOSES W/O CC.
103 ........... No ............ No ............ PRE SURG ...... HEART TRANSPLANT OR IMPLANT OF 18.5617 23.7 37.7
HEART ASSIST SYSTEM.
104 ........... Yes .......... No ............ 05 SURG ...... CARDIAC VALVE & OTH MAJOR 8.2201 12.7 14.9
CARDIOTHORACIC PROC W CARD
CATH.
105 ........... Yes .......... No ............ 05 SURG ...... CARDIAC VALVE & OTH MAJOR 6.0192 8.4 10.2
CARDIOTHORACIC PROC W/O
CARD CATH.
106 ........... No ............ No ............ 05 SURG ...... CORONARY BYPASS W PTCA ............. 7.0346 9.5 11.2
107 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 13.5 13.5
108 ........... Yes .......... No ............ 05 SURG ...... OTHER CARDIOTHORACIC PROCE- 5.8789 8.6 11.0
DURES.
110 ........... No ............ No ............ 05 SURG ...... MAJOR CARDIOVASCULAR PROCE- 3.8417 5.7 8.4
DURES W CC.
111 ........... No ............ No ............ 05 SURG ...... MAJOR CARDIOVASCULAR PROCE- 2.4840 2.6 3.4
DURES W/O CC.
113 ........... Yes .......... No ............ 05 SURG ...... AMPUTATION FOR CIRC SYSTEM DIS- 3.1682 10.8 13.7
ORDERS EXCEPT UPPER LIMB &
TOE.
114 ........... Yes .......... No ............ 05 SURG ...... UPPER LIMB & TOE AMPUTATION 1.7354 6.7 8.9
FOR CIRC SYSTEM DISORDERS.
117 ........... No ............ No ............ 05 SURG ...... CARDIAC PACEMAKER REVISION EX- 1.3223 2.6 4.2
CEPT DEVICE REPLACEMENT.
118 ........... No ............ No ............ 05 SURG ...... CARDIAC PACEMAKER DEVICE RE- 1.6380 2.1 3.0
PLACEMENT.
119 ........... No ............ No ............ 05 SURG ...... VEIN LIGATION & STRIPPING .............. 1.3456 3.3 5.5
120 ........... Yes .......... No ............ 05 SURG ...... OTHER CIRCULATORY SYSTEM O.R. 2.3853 5.9 9.2
PROCEDURES.
121 ........... Yes .......... No ............ 05 MED ......... CIRCULATORY DISORDERS W AMI & 1.6136 5.3 6.6
MAJOR COMP, DISCHARGED ALIVE.
122 ........... No ............ No ............ 05 MED ......... CIRCULATORY DISORDERS W AMI W/ 0.9847 2.8 3.5
O MAJOR COMP, DISCHARGED
ALIVE.
123 ........... No ............ No ............ 05 MED ......... CIRCULATORY DISORDERS W AMI, 1.5407 2.9 4.8
EXPIRED.
124 ........... No ............ No ............ 05 MED ......... CIRCULATORY DISORDERS EXCEPT 1.4425 3.3 4.4
AMI, W CARD CATH & COMPLEX
DIAG.
125 ........... No ............ No ............ 05 MED ......... CIRCULATORY DISORDERS EXCEPT 1.0948 2.1 2.7
AMI, W CARD CATH W/O COMPLEX
DIAG.
126 ........... Yes .......... No ............ 05 MED ......... ACUTE & SUBACUTE ENDOCARDITIS 2.7440 9.4 12.0
127 ........... Yes .......... No ............ 05 MED ......... HEART FAILURE & SHOCK ................... 1.0345 4.1 5.2
128 ........... No ............ No ............ 05 MED ......... DEEP VEIN THROMBOPHLEBITIS ........ 0.6949 4.4 5.2
129 ........... No ............ No ............ 05 MED ......... CARDIAC ARREST, UNEXPLAINED ...... 1.0404 1.7 2.6
130 ........... Yes .......... No ............ 05 MED ......... PERIPHERAL VASCULAR DISORDERS 0.9425 4.4 5.5
W CC.
131 ........... Yes .......... No ............ 05 MED ......... PERIPHERAL VASCULAR DISORDERS 0.5566 3.2 3.9
W/O CC.
132 ........... No ............ No ............ 05 MED ......... ATHEROSCLEROSIS W CC .................. 0.6273 2.2 2.8
133 ........... No ............ No ............ 05 MED ......... ATHEROSCLEROSIS W/O CC ............... 0.5337 1.8 2.2
134 ........... No ............ No ............ 05 MED ......... HYPERTENSION ..................................... 0.6068 2.4 3.1
135 ........... No ............ No ............ 05 MED ......... CARDIAC CONGENITAL & VALVULAR 0.8917 3.2 4.3
DISORDERS AGE >17 W CC.
136 ........... No ............ No ............ 05 MED ......... CARDIAC CONGENITAL & VALVULAR 0.6214 2.2 2.8
DISORDERS AGE >17 W/O CC.
FY 2006
DRG
137 ........... No ............ No ............ 05 MED * ...... CARDIAC CONGENITAL & VALVULAR 0.8288 3.3 3.3
DISORDERS AGE 0-17.
138 ........... No ............ No ............ 05 MED ......... CARDIAC ARRHYTHMIA & CONDUC- 0.8287 3.0 3.9
TION DISORDERS W CC.
139 ........... No ............ No ............ 05 MED ......... CARDIAC ARRHYTHMIA & CONDUC- 0.5227 2.0 2.4
TION DISORDERS W/O CC.
140 ........... No ............ No ............ 05 MED ......... ANGINA PECTORIS ................................ 0.5116 2.0 2.4
141 ........... No ............ No ............ 05 MED ......... SYNCOPE & COLLAPSE W CC ............. 0.7521 2.7 3.5
142 ........... No ............ No ............ 05 MED ......... SYNCOPE & COLLAPSE W/O CC ......... 0.5852 2.0 2.5
143 ........... No ............ No ............ 05 MED ......... CHEST PAIN ........................................... 0.5659 1.7 2.1
144 ........... Yes .......... No ............ 05 MED ......... OTHER CIRCULATORY SYSTEM DIAG- 1.2761 4.1 5.8
NOSES W CC.
145 ........... Yes .......... No ............ 05 MED ......... OTHER CIRCULATORY SYSTEM DIAG- 0.5835 2.1 2.6
NOSES W/O CC.
146 ........... Yes .......... No ............ 06 SURG ...... RECTAL RESECTION W CC .................. 2.6621 8.6 10.0
147 ........... Yes .......... No ............ 06 SURG ...... RECTAL RESECTION W/O CC .............. 1.4781 5.2 5.8
148 ........... Yes .......... No ............ 06 SURG ...... MAJOR SMALL & LARGE BOWEL 3.4479 10.0 12.3
PROCEDURES W CC.
149 ........... Yes .......... No ............ 06 SURG ...... MAJOR SMALL & LARGE BOWEL 1.4324 5.4 6.0
PROCEDURES W/O CC.
150 ........... Yes .......... No ............ 06 SURG ...... PERITONEAL ADHESIOLYSIS W CC .... 2.8061 8.9 11.0
151 ........... Yes .......... No ............ 06 SURG ...... PERITONEAL ADHESIOLYSIS W/O CC 1.2641 4.0 5.1
152 ........... No ............ No ............ 06 SURG ...... MINOR SMALL & LARGE BOWEL PRO- 1.8783 6.7 8.0
CEDURES W CC.
153 ........... No ............ No ............ 06 SURG ...... MINOR SMALL & LARGE BOWEL PRO- 1.0821 4.5 5.0
CEDURES W/O CC.
154 ........... Yes .......... No ............ 06 SURG ...... STOMACH, ESOPHAGEAL & DUODE- 4.0399 9.9 13.3
NAL PROCEDURES AGE >17 W CC.
155 ........... Yes .......... No ............ 06 SURG ...... STOMACH, ESOPHAGEAL & DUODE- 1.2889 3.1 4.1
NAL PROCEDURES AGE >17 W/O
CC.
156 ........... No ............ No ............ 06 SURG * .... STOMACH, ESOPHAGEAL & DUODE- 0.8535 6.0 6.0
NAL PROCEDURES AGE 0-17.
157 ........... Yes .......... No ............ 06 SURG ...... ANAL & STOMAL PROCEDURES W CC 1.3356 4.1 5.8
158 ........... Yes .......... No ............ 06 SURG ...... ANAL & STOMAL PROCEDURES W/O 0.6657 2.1 2.6
CC.
159 ........... No ............ No ............ 06 SURG ...... HERNIA PROCEDURES EXCEPT IN- 1.4081 3.8 5.1
GUINAL & FEMORAL AGE >17 W CC.
160 ........... No ............ No ............ 06 SURG ...... HERNIA PROCEDURES EXCEPT IN- 0.8431 2.2 2.7
GUINAL & FEMORAL AGE >17 W/O
CC.
161 ........... No ............ No ............ 06 SURG ...... INGUINAL & FEMORAL HERNIA PRO- 1.1931 3.1 4.4
CEDURES AGE >17 W CC.
162 ........... No ............ No ............ 06 SURG ...... INGUINAL & FEMORAL HERNIA PRO- 0.6785 1.7 2.1
CEDURES AGE >17 W/O CC.
163 ........... No ............ No ............ 06 SURG ...... HERNIA PROCEDURES AGE 0-17 ........ 0.6723 2.2 2.9
164 ........... No ............ No ............ 06 SURG ...... APPENDECTOMY W COMPLICATED 2.2476 6.6 8.0
PRINCIPAL DIAG W CC.
165 ........... No ............ No ............ 06 SURG ...... APPENDECTOMY W COMPLICATED 1.1868 3.6 4.2
PRINCIPAL DIAG W/O CC.
166 ........... No ............ No ............ 06 SURG ...... APPENDECTOMY W/O COMPLICATED 1.4521 3.3 4.5
PRINCIPAL DIAG W CC.
167 ........... No ............ No ............ 06 SURG ...... APPENDECTOMY W/O COMPLICATED 0.8929 1.9 2.2
PRINCIPAL DIAG W/O CC.
168 ........... No ............ No ............ 03 SURG ...... MOUTH PROCEDURES W CC .............. 1.2662 3.3 4.9
169 ........... No ............ No ............ 03 SURG ...... MOUTH PROCEDURES W/O CC ........... 0.7297 1.8 2.3
170 ........... Yes .......... No ............ 06 SURG ...... OTHER DIGESTIVE SYSTEM O.R. 2.9612 7.8 11.0
PROCEDURES W CC.
171 ........... Yes .......... No ............ 06 SURG ...... OTHER DIGESTIVE SYSTEM O.R. 1.1905 3.1 4.1
PROCEDURES W/O CC.
172 ........... Yes .......... No ............ 06 MED ......... DIGESTIVE MALIGNANCY W CC .......... 1.4125 5.1 7.0
173 ........... Yes .......... No ............ 06 MED ......... DIGESTIVE MALIGNANCY W/O CC ...... 0.7443 2.7 3.6
174 ........... No ............ No ............ 06 MED ......... G.I. HEMORRHAGE W CC ..................... 1.0060 3.8 4.7
175 ........... No ............ No ............ 06 MED ......... G.I. HEMORRHAGE W/O CC ................. 0.5646 2.4 2.9
176 ........... Yes .......... No ............ 06 MED ......... COMPLICATED PEPTIC ULCER ........... 1.1246 4.1 5.2
FY 2006
DRG
177 ........... No ............ No ............ 06 MED ......... UNCOMPLICATED PEPTIC ULCER W 0.9166 3.6 4.4
CC.
178 ........... No ............ No ............ 06 MED ......... UNCOMPLICATED PEPTIC ULCER W/ 0.7013 2.6 3.1
O CC.
179 ........... No ............ No ............ 06 MED ......... INFLAMMATORY BOWEL DISEASE ...... 1.0911 4.5 5.9
180 ........... Yes .......... No ............ 06 MED ......... G.I. OBSTRUCTION W CC ..................... 0.9784 4.2 5.4
181 ........... Yes .......... No ............ 06 MED ......... G.I. OBSTRUCTION W/O CC ................. 0.5614 2.8 3.3
182 ........... No ............ aNo .......... 06 MED ......... ESOPHAGITIS, GASTROENT & MISC 0.8413 3.4 4.4
DIGEST DISORDERS AGE >17 W CC.
183 ........... No ............ No ............ 06 MED ......... ESOPHAGITIS, GASTROENT & MISC 0.5848 2.3 2.9
DIGEST DISORDERS AGE >17 W/O
CC.
184 ........... No ............ No ............ 06 MED ......... ESOPHAGITIS, GASTROENT & MISC 0.5663 2.5 3.3
DIGEST DISORDERS AGE 0-17.
185 ........... No ............ No ............ 03 MED ......... DENTAL & ORAL DIS EXCEPT EX- 0.8702 3.2 4.5
TRACTIONS & RESTORATIONS,
AGE >17.
186 ........... No ............ No ............ 03 MED * ...... DENTAL & ORAL DIS EXCEPT EX- 0.3253 2.9 2.9
TRACTIONS & RESTORATIONS,
AGE 0-17.
187 ........... No ............ No ............ 03 MED ......... DENTAL EXTRACTIONS & RESTORA- 0.8363 3.1 4.2
TIONS.
188 ........... Yes .......... No ............ 06 MED ......... OTHER DIGESTIVE SYSTEM DIAG- 1.1290 4.2 5.6
NOSES AGE >17 W CC.
189 ........... Yes .......... No ............ 06 MED ......... OTHER DIGESTIVE SYSTEM DIAG- 0.6064 2.4 3.1
NOSES AGE >17 W/O CC.
190 ........... No ............ No ............ 06 MED ......... OTHER DIGESTIVE SYSTEM DIAG- 0.6179 3.1 4.4
NOSES AGE 0-17.
191 ........... Yes .......... No ............ 07 SURG ...... PANCREAS, LIVER & SHUNT PROCE- 3.9680 9.0 12.9
DURES W CC.
192 ........... Yes .......... No ............ 07 SURG ...... PANCREAS, LIVER & SHUNT PROCE- 1.6793 4.3 5.7
DURES W/O CC.
193 ........... No ............ No ............ 07 SURG ...... BILIARY TRACT PROC EXCEPT ONLY 3.2818 9.9 12.1
CHOLECYST W OR W/O C.D.E. W
CC.
194 ........... No ............ No ............ 07 SURG ...... BILIARY TRACT PROC EXCEPT ONLY 1.5748 5.6 6.7
CHOLECYST W OR W/O C.D.E. W/O
CC.
195 ........... No ............ No ............ 07 SURG ...... CHOLECYSTECTOMY W C.D.E. W CC 3.0530 8.8 10.6
196 ........... No ............ No ............ 07 SURG ...... CHOLECYSTECTOMY W C.D.E. W/O 1.6031 4.9 5.7
CC.
197 ........... Yes .......... No ............ 07 SURG ...... CHOLECYSTECTOMY EXCEPT BY 2.5425 7.5 9.2
LAPAROSCOPE W/O C.D.E. W CC.
198 ........... Yes .......... No ............ 07 SURG ...... CHOLECYSTECTOMY EXCEPT BY 1.1604 3.7 4.3
LAPAROSCOPE W/O C.D.E. W/O CC.
199 ........... No ............ No ............ 07 SURG ...... HEPATOBILIARY DIAGNOSTIC PRO- 2.4073 6.8 9.5
CEDURE FOR MALIGNANCY.
200 ........... No ............ No ............ 07 SURG ...... HEPATOBILIARY DIAGNOSTIC PRO- 2.7868 6.5 9.8
CEDURE FOR NON-MALIGNANCY.
201 ........... No ............ No ............ 07 SURG ...... OTHER HEPATOBILIARY OR PAN- 3.7339 9.9 13.7
CREAS O.R. PROCEDURES.
202 ........... No ............ No ............ 07 MED ......... CIRRHOSIS & ALCOHOLIC HEPATITIS 1.3318 4.7 6.2
203 ........... No ............ No ............ 07 MED ......... MALIGNANCY OF HEPATOBILIARY 1.3552 4.9 6.5
SYSTEM OR PANCREAS.
204 ........... No ............ No ............ 07 MED ......... DISORDERS OF PANCREAS EXCEPT 1.1249 4.2 5.6
MALIGNANCY.
205 ........... Yes .......... No ............ 07 MED ......... DISORDERS OF LIVER EXCEPT 1.2059 4.4 6.0
MALIG,CIRR,ALC HEPA W CC.
206 ........... Yes .......... No ............ 07 MED ......... DISORDERS OF LIVER EXCEPT 0.7292 3.0 3.9
MALIG,CIRR,ALC HEPA W/O CC.
207 ........... No ............ No ............ 07 MED ......... DISORDERS OF THE BILIARY TRACT 1.1746 4.1 5.3
W CC.
208 ........... No ............ No ............ 07 MED ......... DISORDERS OF THE BILIARY TRACT 0.6895 2.3 2.9
W/O CC.
FY 2006
DRG
210 ........... Yes .......... Yes .......... 08 SURG ...... HIP & FEMUR PROCEDURES EXCEPT 1.9059 6.1 6.9
MAJOR JOINT AGE >17 W CC.
211 ........... Yes .......... Yes .......... 08 SURG ...... HIP & FEMUR PROCEDURES EXCEPT 1.2690 4.4 4.7
MAJOR JOINT AGE >17 W/O CC.
212 ........... No ............ No ............ 08 SURG ...... HIP & FEMUR PROCEDURES EXCEPT 1.2877 2.4 2.9
MAJOR JOINT AGE 0-17.
213 ........... Yes .......... No ............ 08 SURG ...... AMPUTATION FOR MUSCULO- 2.0428 7.2 9.7
SKELETAL SYSTEM & CONN TIS-
SUE DISORDERS.
216 ........... Yes .......... No ............ 08 SURG ...... BIOPSIES OF MUSCULOSKELETAL 1.9131 3.3 5.8
SYSTEM & CONNECTIVE TISSUE.
217 ........... Yes .......... No ............ 08 SURG ...... WND DEBRID & SKN GRFT EXCEPT 3.0596 9.3 13.2
HAND,FOR MUSCSKELET & CONN
TISS DIS.
218 ........... Yes .......... No ............ 08 SURG ...... LOWER EXTREM & HUMER PROC EX- 1.6648 4.4 5.6
CEPT HIP,FOOT,FEMUR AGE >17 W
CC.
219 ........... Yes .......... No ............ 08 SURG ...... LOWER EXTREM & HUMER PROC EX- 1.0443 2.6 3.1
CEPT HIP,FOOT,FEMUR AGE >17
W/O CC.
220 ........... No ............ No ............ 08 SURG * .... LOWER EXTREM & HUMER PROC EX- 0.5913 5.3 5.3
CEPT HIP,FOOT,FEMUR AGE 0-17.
223 ........... No ............ No ............ 08 SURG ...... MAJOR SHOULDER/ELBOW PROC, 1.1164 2.3 3.2
OR OTHER UPPER EXTREMITY
PROC W CC.
224 ........... No ............ No ............ 08 SURG ...... SHOULDER,ELBOW OR FOREARM 0.8185 1.6 1.9
PROC,EXC MAJOR JOINT PROC, W/
O CC.
225 ........... Yes .......... No ............ 08 SURG ...... FOOT PROCEDURES ............................ 1.2251 3.7 5.2
226 ........... Yes .......... No ............ 08 SURG ...... SOFT TISSUE PROCEDURES W CC .... 1.5884 4.5 6.5
227 ........... Yes .......... No ............ 08 SURG ...... SOFT TISSUE PROCEDURES W/O CC 0.8311 2.1 2.6
228 ........... No ............ No ............ 08 SURG ...... MAJOR THUMB OR JOINT PROC,OR 1.1459 2.8 4.1
OTH HAND OR WRIST PROC W CC.
229 ........... No ............ No ............ 08 SURG ...... HAND OR WRIST PROC, EXCEPT 0.6976 1.9 2.5
MAJOR JOINT PROC, W/O CC.
230 ........... No ............ No ............ 08 SURG ...... LOCAL EXCISION & REMOVAL OF INT 1.3174 3.7 5.6
FIX DEVICES OF HIP & FEMUR.
232 ........... No ............ No ............ 08 SURG ...... ARTHROSCOPY ..................................... 0.9702 1.8 2.8
233 ........... Yes .......... Yes .......... 08 SURG ...... OTHER MUSCULOSKELET SYS & 1.9184 4.6 6.8
CONN TISS O.R. PROC W CC.
234 ........... Yes .......... Yes .......... 08 SURG ...... OTHER MUSCULOSKELET SYS & 1.2219 2.0 2.8
CONN TISS O.R. PROC W/O CC.
235 ........... Yes .......... No ............ 08 MED ......... FRACTURES OF FEMUR ....................... 0.7768 3.8 4.8
236 ........... Yes .......... No ............ 08 MED ......... FRACTURES OF HIP & PELVIS ............ 0.7407 3.8 4.6
237 ........... No ............ No ............ 08 MED ......... SPRAINS, STRAINS, & DISLOCATIONS 0.6090 3.0 3.7
OF HIP, PELVIS & THIGH.
238 ........... Yes .......... No ............ 08 MED ......... OSTEOMYELITIS .................................... 1.4401 6.7 8.7
239 ........... Yes .......... No ............ 08 MED ......... PATHOLOGICAL FRACTURES & MUS- 1.0767 5.0 6.2
CULOSKELETAL & CONN TISS MA-
LIGNANCY.
240 ........... Yes .......... No ............ 08 MED ......... CONNECTIVE TISSUE DISORDERS W 1.4051 5.0 6.7
CC.
241 ........... Yes .......... No ............ 08 MED ......... CONNECTIVE TISSUE DISORDERS W/ 0.6629 3.0 3.7
O CC.
242 ........... No ............ No ............ 08 MED ......... SEPTIC ARTHRITIS ................................ 1.1504 5.1 6.7
243 ........... No ............ No ............ 08 MED ......... MEDICAL BACK PROBLEMS ................. 0.7658 3.6 4.5
244 ........... Yes .......... No ............ 08 MED ......... BONE DISEASES & SPECIFIC 0.7200 3.6 4.5
ARTHROPATHIES W CC.
245 ........... Yes .......... No ............ 08 MED ......... BONE DISEASES & SPECIFIC 0.4583 2.5 3.1
ARTHROPATHIES W/O CC.
246 ........... No ............ No ............ 08 MED ......... NON-SPECIFIC ARTHROPATHIES ........ 0.5932 2.8 3.6
FY 2006
DRG
247 ........... No ............ No ............ 08 MED ......... SIGNS & SYMPTOMS OF MUSCULO- 0.5795 2.6 3.3
SKELETAL SYSTEM & CONN TIS-
SUE.
248 ........... No ............ No ............ 08 MED ......... TENDONITIS, MYOSITIS & BURSITIS ... 0.8554 3.8 4.8
249 ........... No ............ No ............ 08 MED ......... AFTERCARE, MUSCULOSKELETAL 0.7095 2.7 3.9
SYSTEM & CONNECTIVE TISSUE.
250 ........... Yes .......... No ............ 08 MED ......... FX, SPRN, STRN & DISL OF FORE- 0.6974 3.2 3.9
ARM, HAND, FOOT AGE >17 W CC.
251 ........... Yes .......... No ............ 08 MED ......... FX, SPRN, STRN & DISL OF FORE- 0.4749 2.3 2.8
ARM, HAND, FOOT AGE >17 W/O
CC.
252 ........... No ............ No ............ 08 MED * ...... FX, SPRN, STRN & DISL OF FORE- 0.2567 1.8 1.8
ARM, HAND, FOOT AGE 0-17.
253 ........... Yes .......... No ............ 08 MED ......... FX, SPRN, STRN & DISL OF 0.7747 3.8 4.6
UPARM,LOWLEG EX FOOT AGE >17
W CC.
254 ........... Yes .......... No ............ 08 MED ......... FX, SPRN, STRN & DISL OF 0.4588 2.6 3.1
UPARM,LOWLEG EX FOOT AGE >17
W/O CC.
255 ........... No ............ No ............ 08 MED * ...... FX, SPRN, STRN & DISL OF 0.2990 2.9 2.9
UPARM,LOWLEG EX FOOT AGE 0-
17.
256 ........... Yes .......... No ............ 08 MED ......... OTHER MUSCULOSKELETAL SYSTEM 0.8509 3.9 5.1
& CONNECTIVE TISSUE DIAG-
NOSES.
257 ........... No ............ No ............ 09 SURG ...... TOTAL MASTECTOMY FOR MALIG- 0.8967 2.0 2.6
NANCY W CC.
258 ........... No ............ No ............ 09 SURG ...... TOTAL MASTECTOMY FOR MALIG- 0.7138 1.5 1.7
NANCY W/O CC.
259 ........... No ............ No ............ 09 SURG ...... SUBTOTAL MASTECTOMY FOR MA- 0.9671 1.8 2.8
LIGNANCY W CC.
260 ........... No ............ No ............ 09 SURG ...... SUBTOTAL MASTECTOMY FOR MA- 0.7032 1.2 1.4
LIGNANCY W/O CC.
261 ........... No ............ No ............ 09 SURG ...... BREAST PROC FOR NON-MALIG- 0.9732 1.6 2.2
NANCY EXCEPT BIOPSY & LOCAL
EXCISION.
262 ........... No ............ No ............ 09 SURG ...... BREAST BIOPSY & LOCAL EXCISION 0.9766 3.3 4.8
FOR NON-MALIGNANCY.
263 ........... Yes .......... No ............ 09 SURG ...... SKIN GRAFT &/OR DEBRID FOR SKN 2.1130 8.6 11.4
ULCER OR CELLULITIS W CC.
264 ........... Yes .......... No ............ 09 SURG ...... SKIN GRAFT &/OR DEBRID FOR SKN 1.0635 5.0 6.5
ULCER OR CELLULITIS W/O CC.
265 ........... Yes .......... No ............ 09 SURG ...... SKIN GRAFT &/OR DEBRID EXCEPT 1.6593 4.4 6.8
FOR SKIN ULCER OR CELLULITIS W
CC.
266 ........... Yes .......... No ............ 09 SURG ...... SKIN GRAFT &/OR DEBRID EXCEPT 0.8637 2.3 3.2
FOR SKIN ULCER OR CELLULITIS
W/O CC.
267 ........... No ............ No ............ 09 SURG ...... PERIANAL & PILONIDAL PROCE- 0.8962 2.8 4.2
DURES.
268 ........... No ............ No ............ 09 SURG ...... SKIN, SUBCUTANEOUS TISSUE & 1.1326 2.4 3.5
BREAST PLASTIC PROCEDURES.
269 ........... Yes .......... No ............ 09 SURG ...... OTHER SKIN, SUBCUT TISS & 1.8352 6.2 8.6
BREAST PROC W CC.
270 ........... Yes .......... No ............ 09 SURG ...... OTHER SKIN, SUBCUT TISS & 0.8313 2.7 3.9
BREAST PROC W/O CC.
271 ........... Yes .......... No ............ 09 MED ......... SKIN ULCERS ......................................... 1.0195 5.6 7.1
272 ........... Yes .......... No ............ 09 MED ......... MAJOR SKIN DISORDERS W CC ......... 0.9860 4.5 5.9
273 ........... Yes .......... No ............ 09 MED ......... MAJOR SKIN DISORDERS W/O CC ...... 0.5539 2.9 3.7
274 ........... No ............ No ............ 09 MED ......... MALIGNANT BREAST DISORDERS W 1.1294 4.7 6.3
CC.
275 ........... No ............ No ............ 09 MED ......... MALIGNANT BREAST DISORDERS W/ 0.5340 2.4 3.3
O CC.
276 ........... No ............ No ............ 09 MED ......... NON-MALIGNANT BREAST DIS- 0.6892 3.5 4.5
ORDERS.
277 ........... Yes .......... No ............ 09 MED ......... CELLULITIS AGE >17 W CC .................. 0.8676 4.6 5.6
FY 2006
DRG
278 ........... Yes .......... No ............ 09 MED ......... CELLULITIS AGE >17 W/O CC .............. 0.5391 3.4 4.1
279 ........... No ............ No ............ 09 MED * ...... CELLULITIS AGE 0-17 ............................ 0.7822 4.2 4.2
280 ........... Yes .......... No ............ 09 MED ......... TRAUMA TO THE SKIN, SUBCUT TISS 0.7313 3.2 4.1
& BREAST AGE >17 W CC.
281 ........... Yes .......... No ............ 09 MED ......... TRAUMA TO THE SKIN, SUBCUT TISS 0.4913 2.3 2.9
& BREAST AGE >17 W/O CC.
282 ........... No ............ No ............ 09 MED * ...... TRAUMA TO THE SKIN, SUBCUT TISS 0.2600 2.2 2.2
& BREAST AGE 0-17.
283 ........... Yes .......... No ............ 09 MED ......... MINOR SKIN DISORDERS W CC .......... 0.7423 3.5 4.6
284 ........... Yes .......... No ............ 09 MED ......... MINOR SKIN DISORDERS W/O CC ...... 0.4563 2.4 3.0
285 ........... Yes .......... No ............ 10 SURG ...... AMPUTAT OF LOWER LIMB FOR EN- 2.1831 8.2 10.5
DOCRINE,NUTRIT,& METABOL DIS-
ORDERS.
286 ........... No ............ No ............ 10 SURG ...... ADRENAL & PITUITARY PROCE- 1.9390 4.0 5.5
DURES.
287 ........... Yes .......... No ............ 10 SURG ...... SKIN GRAFTS & WOUND DEBRID FOR 1.9470 7.8 10.4
ENDOC, NUTRIT & METAB DIS-
ORDERS.
288 ........... No ............ No ............ 10 SURG ...... O.R. PROCEDURES FOR OBESITY ...... 2.0384 3.2 4.1
289 ........... No ............ No ............ 10 SURG ...... PARATHYROID PROCEDURES ............. 0.9315 1.7 2.6
290 ........... No ............ No ............ 10 SURG ...... THYROID PROCEDURES ...................... 0.8891 1.6 2.1
291 ........... No ............ No ............ 10 SURG ...... THYROGLOSSAL PROCEDURES ......... 1.0877 1.6 2.8
292 ........... Yes .......... No ............ 10 SURG ...... OTHER ENDOCRINE, NUTRIT & 2.6395 7.3 10.3
METAB O.R. PROC W CC.
293 ........... Yes .......... No ............ 10 SURG ...... OTHER ENDOCRINE, NUTRIT & 1.3472 3.2 4.5
METAB O.R. PROC W/O CC.
294 ........... Yes .......... No ............ 10 MED ......... DIABETES AGE >35 ............................... 0.7652 3.3 4.3
295 ........... No ............ No ............ 10 MED ......... DIABETES AGE 0-35 .............................. 0.7267 2.8 3.7
296 ........... Yes .......... No ............ 10 MED ......... NUTRITIONAL & MISC METABOLIC 0.8187 3.7 4.8
DISORDERS AGE >17 W CC.
297 ........... Yes .......... No ............ 10 MED ......... NUTRITIONAL & MISC METABOLIC 0.4879 2.5 3.1
DISORDERS AGE >17 W/O CC.
298 ........... No ............ No ............ 10 MED ......... NUTRITIONAL & MISC METABOLIC 0.5486 2.5 3.9
DISORDERS AGE 0-17.
299 ........... No ............ No ............ 10 MED ......... INBORN ERRORS OF METABOLISM .... 1.0329 3.7 5.2
300 ........... Yes .......... No ............ 10 MED ......... ENDOCRINE DISORDERS W CC .......... 1.0922 4.6 6.0
301 ........... Yes .......... No ............ 10 MED ......... ENDOCRINE DISORDERS W/O CC ...... 0.6118 2.7 3.4
302 ........... No ............ No ............ 11 SURG ...... KIDNEY TRANSPLANT ........................... 3.1679 7.0 8.2
303 ........... No ............ No ............ 11 SURG ...... KIDNEY,URETER & MAJOR BLADDER 2.2183 5.8 7.4
PROCEDURES FOR NEOPLASM.
304 ........... Yes .......... No ............ 11 SURG ...... KIDNEY,URETER & MAJOR BLADDER 2.3761 6.1 8.6
PROC FOR NON-NEOPL W CC.
305 ........... Yes .......... No ............ 11 SURG ...... KIDNEY,URETER & MAJOR BLADDER 1.1595 2.6 3.2
PROC FOR NON-NEOPL W/O CC.
306 ........... No ............ No ............ 11 SURG ...... PROSTATECTOMY W CC ...................... 1.2700 3.6 5.5
307 ........... No ............ No ............ 11 SURG ...... PROSTATECTOMY W/O CC .................. 0.6202 1.7 2.1
308 ........... No ............ No ............ 11 SURG ...... MINOR BLADDER PROCEDURES W 1.6349 3.9 6.1
CC.
309 ........... No ............ No ............ 11 SURG ...... MINOR BLADDER PROCEDURES W/O 0.9085 1.6 2.0
CC.
310 ........... No ............ No ............ 11 SURG ...... TRANSURETHRAL PROCEDURES W 1.1898 3.0 4.5
CC.
311 ........... No ............ No ............ 11 SURG ...... TRANSURETHRAL PROCEDURES W/O 0.6432 1.5 1.9
CC.
312 ........... No ............ No ............ 11 SURG ...... URETHRAL PROCEDURES, AGE >17 1.1159 3.2 4.8
W CC.
313 ........... No ............ No ............ 11 SURG ...... URETHRAL PROCEDURES, AGE >17 0.6783 1.7 2.2
W/O CC.
314 ........... No ............ No ............ 11 SURG * .... URETHRAL PROCEDURES, AGE 0-17 0.5012 2.3 2.3
315 ........... No ............ No ............ 11 SURG ...... OTHER KIDNEY & URINARY TRACT 2.0823 3.6 6.8
O.R. PROCEDURES.
316 ........... Yes .......... No ............ 11 MED ......... RENAL FAILURE ..................................... 1.2692 4.9 6.4
317 ........... No ............ No ............ 11 MED ......... ADMIT FOR RENAL DIALYSIS .............. 0.7942 2.4 3.5
318 ........... No ............ No ............ 11 MED ......... KIDNEY & URINARY TRACT NEO- 1.1539 4.2 5.8
PLASMS W CC.
FY 2006
DRG
319 ........... No ............ No ............ 11 MED ......... KIDNEY & URINARY TRACT NEO- 0.6385 2.1 2.8
PLASMS W/O CC.
320 ........... Yes .......... No ............ 11 MED ......... KIDNEY & URINARY TRACT INFEC- 0.8658 4.2 5.2
TIONS AGE >17 W CC.
321 ........... Yes .......... No ............ 11 MED ......... KIDNEY & URINARY TRACT INFEC- 0.5652 3.0 3.6
TIONS AGE >17 W/O CC.
322 ........... No ............ No ............ 11 MED ......... KIDNEY & URINARY TRACT INFEC- 0.5498 2.9 3.4
TIONS AGE 0-17.
323 ........... No ............ No ............ 11 MED ......... URINARY STONES W CC, &/OR ESW 0.8214 2.3 3.1
LITHOTRIPSY.
324 ........... No ............ No ............ 11 MED ......... URINARY STONES W/O CC .................. 0.5050 1.6 1.9
325 ........... No ............ No ............ 11 MED ......... KIDNEY & URINARY TRACT SIGNS & 0.6436 2.9 3.7
SYMPTOMS AGE >17 W CC.
326 ........... No ............ No ............ 11 MED ......... KIDNEY & URINARY TRACT SIGNS & 0.4391 2.1 2.6
SYMPTOMS AGE >17 W/O CC.
327 ........... No ............ No ............ 11 MED * ...... KIDNEY & URINARY TRACT SIGNS & 0.3748 3.1 3.1
SYMPTOMS AGE 0-17.
328 ........... No ............ No ............ 11 MED ......... URETHRAL STRICTURE AGE >17 W 0.7079 2.6 3.5
CC.
329 ........... No ............ No ............ 11 MED ......... URETHRAL STRICTURE AGE >17 W/O 0.4701 1.5 1.8
CC.
330 ........... No ............ No ............ 11 MED * ...... URETHRAL STRICTURE AGE 0-17 ....... 0.3227 1.6 1.6
331 ........... Yes .......... No ............ 11 MED ......... OTHER KIDNEY & URINARY TRACT 1.0619 4.1 5.5
DIAGNOSES AGE >17 W CC.
332 ........... Yes .......... No ............ 11 MED ......... OTHER KIDNEY & URINARY TRACT 0.6160 2.4 3.1
DIAGNOSES AGE >17 W/O CC.
333 ........... No ............ No ............ 11 MED ......... OTHER KIDNEY & URINARY TRACT 0.9669 3.5 5.3
DIAGNOSES AGE 0-17.
334 ........... No ............ No ............ 12 SURG ...... MAJOR MALE PELVIC PROCEDURES 1.4368 3.5 4.3
W CC.
335 ........... No ............ No ............ 12 SURG ...... MAJOR MALE PELVIC PROCEDURES 1.1004 2.4 2.7
W/O CC.
336 ........... No ............ No ............ 12 SURG ...... TRANSURETHRAL PROSTATECTOMY 0.8425 2.5 3.3
W CC.
337 ........... No ............ No ............ 12 SURG ...... TRANSURETHRAL PROSTATECTOMY 0.5747 1.7 1.9
W/O CC.
338 ........... No ............ No ............ 12 SURG ...... TESTES PROCEDURES, FOR MALIG- 1.3772 3.9 6.2
NANCY.
339 ........... No ............ No ............ 12 SURG ...... TESTES PROCEDURES, NON-MALIG- 1.1866 3.2 5.1
NANCY AGE >17.
340 ........... No ............ No ............ 12 SURG * .... TESTES PROCEDURES, NON-MALIG- 0.2868 2.4 2.4
NANCY AGE 0-17.
341 ........... No ............ No ............ 12 SURG ...... PENIS PROCEDURES ............................ 1.2622 1.9 3.2
342 ........... No ............ No ............ 12 SURG ...... CIRCUMCISION AGE >17 ...................... 0.8737 2.5 3.4
343 ........... No ............ No ............ 12 SURG * .... CIRCUMCISION AGE 0-17 ..................... 0.1559 1.7 1.7
344 ........... No ............ No ............ 12 SURG ...... OTHER MALE REPRODUCTIVE SYS- 1.2475 1.7 2.7
TEM O.R. PROCEDURES FOR MA-
LIGNANCY.
345 ........... No ............ No ............ 12 SURG ...... OTHER MALE REPRODUCTIVE SYS- 1.1472 3.1 4.8
TEM O.R. PROC EXCEPT FOR MA-
LIGNANCY.
346 ........... No ............ No ............ 12 MED ......... MALIGNANCY, MALE REPRODUCTIVE 1.0441 4.2 5.7
SYSTEM, W CC.
347 ........... No ............ No ............ 12 MED ......... MALIGNANCY, MALE REPRODUCTIVE 0.6104 2.2 3.1
SYSTEM, W/O CC.
348 ........... No ............ No ............ 12 MED ......... BENIGN PROSTATIC HYPERTROPHY 0.7188 3.2 4.1
W CC.
349 ........... No ............ No ............ 12 MED ......... BENIGN PROSTATIC HYPERTROPHY 0.4210 1.9 2.4
W/O CC.
350 ........... No ............ No ............ 12 MED ......... INFLAMMATION OF THE MALE RE- 0.7289 3.5 4.5
PRODUCTIVE SYSTEM.
351 ........... No ............ No ............ 12 MED * ...... STERILIZATION, MALE .......................... 0.2392 1.3 1.3
352 ........... No ............ No ............ 12 MED ......... OTHER MALE REPRODUCTIVE SYS- 0.7360 2.9 4.0
TEM DIAGNOSES.
FY 2006
DRG
353 ........... No ............ No ............ 13 SURG ...... PELVIC EVISCERATION, RADICAL 1.8504 4.7 6.3
HYSTERECTOMY & RADICAL
VULVECTOMY.
354 ........... No ............ No ............ 13 SURG ...... UTERINE,ADNEXA PROC FOR NON- 1.5135 4.6 5.7
OVARIAN/ADNEXAL MALIG W CC.
355 ........... No ............ No ............ 13 SURG ...... UTERINE,ADNEXA PROC FOR NON- 0.8824 2.8 3.1
OVARIAN/ADNEXAL MALIG W/O CC.
356 ........... No ............ No ............ 13 SURG ...... FEMALE REPRODUCTIVE SYSTEM 0.7428 1.7 1.9
RECONSTRUCTIVE PROCEDURES.
357 ........... No ............ No ............ 13 SURG ...... UTERINE & ADNEXA PROC FOR 2.2237 6.5 8.1
OVARIAN OR ADNEXAL MALIG-
NANCY.
358 ........... No ............ No ............ 13 SURG ...... UTERINE & ADNEXA PROC FOR NON- 1.1448 3.2 4.0
MALIGNANCY W CC.
359 ........... No ............ No ............ 13 SURG ...... UTERINE & ADNEXA PROC FOR NON- 0.7948 2.2 2.4
MALIGNANCY W/O CC.
360 ........... No ............ No ............ 13 SURG ...... VAGINA, CERVIX & VULVA PROCE- 0.8582 2.0 2.6
DURES.
361 ........... No ............ No ............ 13 SURG ...... LAPAROSCOPY & INCISIONAL TUBAL 1.0847 2.2 3.0
INTERRUPTION.
362 ........... No ............ No ............ 13 SURG * .... ENDOSCOPIC TUBAL INTERRUPTION 0.3057 1.4 1.4
363 ........... No ............ No ............ 13 SURG ...... D&C, CONIZATION & RADIO-IMPLANT, 0.9728 2.7 3.8
FOR MALIGNANCY.
364 ........... No ............ No ............ 13 SURG ...... D&C, CONIZATION EXCEPT FOR MA- 0.8709 3.0 4.2
LIGNANCY.
365 ........... No ............ No ............ 13 SURG ...... OTHER FEMALE REPRODUCTIVE 2.0408 5.3 7.7
SYSTEM O.R. PROCEDURES.
366 ........... No ............ No ............ 13 MED ......... MALIGNANCY, FEMALE REPRODUC- 1.2348 4.8 6.6
TIVE SYSTEM W CC.
367 ........... No ............ No ............ 13 MED ......... MALIGNANCY, FEMALE REPRODUC- 0.5728 2.3 3.0
TIVE SYSTEM W/O CC.
368 ........... No ............ No ............ 13 MED ......... INFECTIONS, FEMALE REPRODUC- 1.1684 5.2 6.7
TIVE SYSTEM.
369 ........... No ............ No ............ 13 MED ......... MENSTRUAL & OTHER FEMALE RE- 0.6310 2.4 3.3
PRODUCTIVE SYSTEM DISORDERS.
370 ........... No ............ No ............ 14 SURG ...... CESAREAN SECTION W CC ................. 0.8974 4.1 5.2
371 ........... No ............ No ............ 14 SURG ...... CESAREAN SECTION W/O CC ............. 0.6066 3.1 3.4
372 ........... No ............ No ............ 14 MED ......... VAGINAL DELIVERY W COMPLI- 0.5027 2.5 3.2
CATING DIAGNOSES.
373 ........... No ............ No ............ 14 MED ......... VAGINAL DELIVERY W/O COMPLI- 0.3556 2.0 2.2
CATING DIAGNOSES.
374 ........... No ............ No ............ 14 SURG ...... VAGINAL DELIVERY W STERILIZA- 0.6712 2.5 2.8
TION &/OR D&C.
375 ........... No ............ No ............ 14 SURG * .... VAGINAL DELIVERY W O.R. PROC EX- 0.5837 4.4 4.4
CEPT STERIL &/OR D&C.
376 ........... No ............ No ............ 14 MED ......... POSTPARTUM & POST ABORTION DI- 0.5242 2.6 3.4
AGNOSES W/O O.R. PROCEDURE.
377 ........... No ............ No ............ 14 SURG ...... POSTPARTUM & POST ABORTION DI- 1.6996 2.9 4.5
AGNOSES W O.R. PROCEDURE.
378 ........... No ............ No ............ 14 MED ......... ECTOPIC PREGNANCY ......................... 0.7472 1.9 2.3
379 ........... No ............ No ............ 14 MED ......... THREATENED ABORTION ..................... 0.3578 2.0 2.8
380 ........... No ............ No ............ 14 MED ......... ABORTION W/O D&C ............................. 0.3925 1.6 2.1
381 ........... No ............ No ............ 14 SURG ...... ABORTION W D&C, ASPIRATION 0.6034 1.6 2.2
CURETTAGE OR HYSTEROTOMY.
382 ........... No ............ No ............ 14 MED ......... FALSE LABOR ........................................ 0.2070 1.3 1.4
383 ........... No ............ No ............ 14 MED ......... OTHER ANTEPARTUM DIAGNOSES W 0.5053 2.6 3.7
MEDICAL COMPLICATIONS.
384 ........... No ............ No ............ 14 MED ......... OTHER ANTEPARTUM DIAGNOSES W/ 0.3225 1.8 2.6
O MEDICAL COMPLICATIONS.
385 ........... No ............ No ............ 15 MED * ...... NEONATES, DIED OR TRANSFERRED 1.3930 1.8 1.8
TO ANOTHER ACUTE CARE FACIL-
ITY.
386 ........... No ............ No ............ 15 MED * ...... EXTREME IMMATURITY OR RES- 4.5935 17.9 17.9
PIRATORY DISTRESS SYNDROME,
NEONATE.
387 ........... No ............ No ............ 15 MED * ...... PREMATURITY W MAJOR PROBLEMS 3.1372 13.3 13.3
FY 2006
DRG
388 ........... No ............ No ............ 15 MED * ...... PREMATURITY W/O MAJOR PROB- 1.8929 8.6 8.6
LEMS.
389 ........... No ............ No ............ 15 MED * ...... FULL TERM NEONATE W MAJOR 3.2226 4.7 4.7
PROBLEMS.
390 ........... No ............ No ............ 15 MED * ...... NEONATE W OTHER SIGNIFICANT 1.1406 3.4 3.4
PROBLEMS.
391 ........... No ............ No ............ 15 MED * ...... NORMAL NEWBORN .............................. 0.1544 3.1 3.1
392 ........... No ............ No ............ 16 SURG ...... SPLENECTOMY AGE >17 ...................... 3.0459 6.5 9.2
393 ........... No ............ No ............ 16 SURG * .... SPLENECTOMY AGE 0-17 ..................... 1.3645 9.1 9.1
394 ........... No ............ No ............ 16 SURG ...... OTHER O.R. PROCEDURES OF THE 1.9109 4.5 7.4
BLOOD AND BLOOD FORMING OR-
GANS.
395 ........... Yes .......... No ............ 16 MED ......... RED BLOOD CELL DISORDERS AGE 0.8328 3.2 4.3
>17.
396 ........... No ............ No ............ 16 MED * ...... RED BLOOD CELL DISORDERS AGE 0.8323 2.6 4.3
0-17.
397 ........... No ............ No ............ 16 MED ......... COAGULATION DISORDERS ................ 1.2986 3.7 5.1
398 ........... No ............ No ............ 16 MED ......... RETICULOENDOTHELIAL & IMMUNITY 1.2082 4.4 5.7
DISORDERS W CC.
399 ........... No ............ No ............ 16 MED ......... RETICULOENDOTHELIAL & IMMUNITY 0.6674 2.7 3.3
DISORDERS W/O CC.
401 ........... Yes .......... No ............ 17 SURG ...... LYMPHOMA & NON-ACUTE LEUKEMIA 2.9678 8.0 11.3
W OTHER O.R. PROC W CC.
402 ........... Yes .......... No ............ 17 SURG ...... LYMPHOMA & NON-ACUTE LEUKEMIA 1.1810 2.8 4.1
W OTHER O.R. PROC W/O CC.
403 ........... Yes .......... No ............ 17 MED ......... LYMPHOMA & NON-ACUTE LEUKEMIA 1.8432 5.8 8.1
W CC.
404 ........... Yes .......... No ............ 17 MED ......... LYMPHOMA & NON-ACUTE LEUKEMIA 0.9265 3.0 4.2
W/O CC.
405 ........... No ............ No ............ 17 MED * ...... ACUTE LEUKEMIA W/O MAJOR O.R. 1.9346 4.9 4.9
PROCEDURE AGE 0-17.
406 ........... No ............ No ............ 17 SURG ...... MYELOPROLIF DISORD OR POORLY 2.7897 7.0 9.9
DIFF NEOPL W MAJ O.R.PROC W
CC.
DIFF NEOPL W MAJ O.R.PROC W/O
CC.
DIFF NEOPL W OTHER O.R.PROC.
409 ........... No ............ No ............ 17 MED ......... RADIOTHERAPY ..................................... 1.2074 4.3 5.8
410 ........... No ............ No ............ 17 MED ......... CHEMOTHERAPY W/O ACUTE LEU- 1.1069 3.0 3.8
KEMIA AS SECONDARY DIAGNOSIS.
411 ........... No ............ No ............ 17 MED ......... HISTORY OF MALIGNANCY W/O EN- 0.3635 2.5 3.3
DOSCOPY.
412 ........... No ............ No ............ 17 MED ......... HISTORY OF MALIGNANCY W EN- 0.8451 1.8 2.8
DOSCOPY.
413 ........... No ............ No ............ 17 MED ......... OTHER MYELOPROLIF DIS OR POOR- 1.3048 5.0 6.8
LY DIFF NEOPL DIAG W CC.
414 ........... No ............ No ............ 17 MED ......... OTHER MYELOPROLIF DIS OR POOR- 0.7788 3.0 4.0
LY DIFF NEOPL DIAG W/O CC.
415 ........... Yes .......... No ............ 18 SURG ...... O.R. PROCEDURE FOR INFECTIOUS 3.9890 11.0 14.8
& PARASITIC DISEASES.
416 ........... Yes .......... No ............ 18 MED ......... SEPTICEMIA AGE >17 ........................... 1.6774 5.6 7.5
417 ........... No ............ No ............ 18 MED ......... SEPTICEMIA AGE 0-17 .......................... 1.1689 3.2 4.1
418 ........... Yes .......... No ............ 18 MED ......... POSTOPERATIVE & POST-TRAU- 1.0716 4.8 6.2
MATIC INFECTIONS.
419 ........... No ............ No ............ 18 MED ......... FEVER OF UNKNOWN ORIGIN AGE 0.8453 3.4 4.4
>17 W CC.
420 ........... No ............ No ............ 18 MED ......... FEVER OF UNKNOWN ORIGIN AGE 0.6077 2.7 3.4
>17 W/O CC.
421 ........... No ............ No ............ 18 MED ......... VIRAL ILLNESS AGE >17 ....................... 0.7664 3.1 4.1
422 ........... No ............ No ............ 18 MED ......... VIRAL ILLNESS & FEVER OF UN- 0.6171 2.6 3.7
KNOWN ORIGIN AGE 0-17.
423 ........... Yes .......... No ............ 18 MED ......... OTHER INFECTIOUS & PARASITIC 1.9196 6.0 8.4
DISEASES DIAGNOSES.
FY 2006
DRG
424 ........... No ............ No ............ 19 SURG ...... O.R. PROCEDURE W PRINCIPAL DI- 2.2773 7.3 12.4
AGNOSES OF MENTAL ILLNESS.
425 ........... No ............ No ............ 19 MED ......... ACUTE ADJUSTMENT REACTION & 0.6191 2.6 3.5
PSYCHOSOCIAL DYSFUNCTION.
426 ........... No ............ No ............ 19 MED ......... DEPRESSIVE NEUROSES ..................... 0.4656 3.0 4.1
427 ........... No ............ No ............ 19 MED ......... NEUROSES EXCEPT DEPRESSIVE ..... 0.5135 3.2 4.7
428 ........... No ............ No ............ 19 MED ......... DISORDERS OF PERSONALITY & IM- 0.6981 4.6 7.3
PULSE CONTROL.
429 ........... Yes .......... No ............ 19 MED ......... ORGANIC DISTURBANCES & MENTAL 0.7919 4.3 5.6
RETARDATION.
430 ........... Yes .......... No ............ 19 MED ......... PSYCHOSES ........................................... 0.6483 5.8 7.9
431 ........... No ............ No ............ 19 MED ......... CHILDHOOD MENTAL DISORDERS ..... 0.5178 4.0 5.9
432 ........... No ............ No ............ 19 MED ......... OTHER MENTAL DISORDER DIAG- 0.6282 2.9 4.3
NOSES.
433 ........... No ............ No ............ 20 MED ......... ALCOHOL/DRUG ABUSE OR DEPEND- 0.2776 2.2 3.0
ENCE, LEFT AMA.
434 ........... No ............ No ............ 20 MED ......... NO LONGER VALID ................................ 0.0000 0.0 0.0
438 ........... No ............ No ............ 20 .................. NO LONGER VALID ................................ 0.0000 0.0 0.0
439 ........... No ............ No ............ 21 SURG ...... SKIN GRAFTS FOR INJURIES ............... 1.9398 5.4 8.9
440 ........... Yes .......... No ............ 21 SURG ...... WOUND DEBRIDEMENTS FOR INJU- 1.9457 5.9 9.2
RIES.
441 ........... No ............ No ............ 21 SURG ...... HAND PROCEDURES FOR INJURIES .. 0.9382 2.3 3.4
442 ........... Yes .......... No ............ 21 SURG ...... OTHER O.R. PROCEDURES FOR IN- 2.5660 6.0 8.9
JURIES W CC.
443 ........... Yes .......... No ............ 21 SURG ...... OTHER O.R. PROCEDURES FOR IN- 0.9943 2.6 3.4
JURIES W/O CC.
444 ........... Yes .......... No ............ 21 MED ......... TRAUMATIC INJURY AGE >17 W CC ... 0.7556 3.2 4.1
445 ........... Yes .......... No ............ 21 MED ......... TRAUMATIC INJURY AGE >17 W/O CC 0.5033 2.2 2.8
446 ........... No ............ No ............ 21 MED * ...... TRAUMATIC INJURY AGE 0-17 ............. 0.2999 2.4 2.4
447 ........... No ............ No ............ 21 MED ......... ALLERGIC REACTIONS AGE >17 ......... 0.5569 1.9 2.6
448 ........... No ............ No ............ 21 MED * ...... ALLERGIC REACTIONS AGE 0-17 ........ 0.0987 2.9 2.9
449 ........... No ............ No ............ 21 MED ......... POISONING & TOXIC EFFECTS OF 0.8529 2.6 3.7
DRUGS AGE >17 W CC.
450 ........... No ............ No ............ 21 MED ......... POISONING & TOXIC EFFECTS OF 0.4282 1.6 2.0
DRUGS AGE >17 W/O CC.
451 ........... No ............ No ............ 21 MED * ...... POISONING & TOXIC EFFECTS OF 0.2663 2.1 2.1
DRUGS AGE 0-17.
452 ........... No ............ No ............ 21 MED ......... COMPLICATIONS OF TREATMENT W 1.0462 3.5 4.9
CC.
453 ........... No ............ No ............ 21 MED ......... COMPLICATIONS OF TREATMENT W/ 0.5285 2.2 2.8
O CC.
454 ........... No ............ No ............ 21 MED ......... OTHER INJURY, POISONING & TOXIC 0.8141 2.9 4.1
EFFECT DIAG W CC.
455 ........... No ............ No ............ 21 MED ......... OTHER INJURY, POISONING & TOXIC 0.4725 1.7 2.2
EFFECT DIAG W/O CC.
456 ........... No ............ No ............ 22 .................. NO LONGER VALID ................................ 0.0000 0.0 0.0
461 ........... No ............ No ............ 23 SURG ...... O.R. PROC W DIAGNOSES OF OTHER 1.3974 3.0 5.1
CONTACT W HEALTH SERVICES.
462 ........... Yes .......... No ............ 23 MED ......... REHABILITATION ................................... 0.8700 8.9 10.8
463 ........... Yes .......... No ............ 23 MED ......... SIGNS & SYMPTOMS W CC ................. 0.6960 3.1 3.9
464 ........... Yes .......... No ............ 23 MED ......... SIGNS & SYMPTOMS W/O CC .............. 0.5055 2.4 2.9
465 ........... No ............ No ............ 23 MED ......... AFTERCARE W HISTORY OF MALIG- 0.6224 2.4 3.8
NANCY AS SECONDARY DIAG-
NOSIS.
466 ........... No ............ No ............ 23 MED ......... AFTERCARE W/O HISTORY OF MA- 0.7806 2.8 5.3
LIGNANCY AS SECONDARY DIAG-
NOSIS.
467 ........... No ............ No ............ 23 MED ......... OTHER FACTORS INFLUENCING 0.4803 2.0 2.7
HEALTH STATUS.
FY 2006
DRG
468 ........... Yes .......... No ............ ................ .................. EXTENSIVE O.R. PROCEDURE UNRE- 4.0031 9.7 13.2
LATED TO PRINCIPAL DIAGNOSIS.
469 ........... No ............ No ............ ................ ** .............. PRINCIPAL DIAGNOSIS INVALID AS 0.0000 0.0 0.0
DISCHARGE DIAGNOSIS.
470 ........... No ............ No ............ ................ ** .............. UNGROUPABLE ..................................... 0.0000 0.0 0.0
471 ........... Yes .......... Yes .......... 08 SURG ...... BILATERAL OR MULTIPLE MAJOR 3.1391 4.5 5.1
JOINT PROCS OF LOWER EXTREM-
ITY.
473 ........... No ............ No ............ 17 MED ......... ACUTE LEUKEMIA W/O MAJOR O.R. 3.4231 7.4 12.7
PROCEDURE AGE >17.
475 ........... Yes .......... No ............ 04 MED ......... RESPIRATORY SYSTEM DIAGNOSIS 3.6091 8.1 11.3
WITH VENTILATOR SUPPORT.
476 ........... No ............ No ............ ................ SURG ...... PROSTATIC O.R. PROCEDURE UNRE- 2.1822 7.4 10.5
LATED TO PRINCIPAL DIAGNOSIS.
477 ........... Yes .......... No ............ ................ SURG ...... NON-EXTENSIVE O.R. PROCEDURE 2.0607 5.8 8.7
UNRELATED TO PRINCIPAL DIAG-
NOSIS.
479 ........... No ............ No ............ 05 SURG ...... OTHER VASCULAR PROCEDURES W/ 1.4434 2.1 2.8
O CC.
480 ........... No ............ No ............ PRE SURG ...... LIVER TRANSPLANT AND/OR INTES- 8.9693 13.7 18.0
TINAL TRANSPLANT.
481 ........... No ............ No ............ PRE SURG ...... BONE MARROW TRANSPLANT ............ 6.2321 18.2 21.7
482 ........... Yes .......... No ............ PRE SURG ...... TRACHEOSTOMY FOR FACE,MOUTH 3.3387 9.6 12.1
& NECK DIAGNOSES.
483 ........... No ............ No ............ PRE SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0
484 ........... No ............ No ............ 24 SURG ...... CRANIOTOMY FOR MULTIPLE SIG- 5.1438 9.3 12.8
NIFICANT TRAUMA.
485 ........... Yes .......... No ............ 24 SURG ...... LIMB REATTACHMENT, HIP AND 3.4952 8.4 10.2
FEMUR PROC FOR MULTIPLE SIG-
NIFICANT TRA.
486 ........... No ............ No ............ 24 SURG ...... OTHER O.R. PROCEDURES FOR MUL- 4.7323 8.5 12.5
TIPLE SIGNIFICANT TRAUMA.
487 ........... Yes .......... No ............ 24 MED ......... OTHER MULTIPLE SIGNIFICANT 1.9459 5.3 7.3
TRAUMA.
488 ........... No ............ No ............ 25 SURG ...... HIV W EXTENSIVE O.R. PROCEDURE 4.4353 11.8 16.4
489 ........... No ............ No ............ 25 MED ......... HIV W MAJOR RELATED CONDITION .. 1.8058 5.9 8.4
490 ........... No ............ No ............ 25 MED ......... HIV W OR W/O OTHER RELATED 1.0639 3.8 5.4
CONDITION.
491 ........... No ............ No ............ 08 SURG ...... MAJOR JOINT & LIMB REATTACH- 1.6780 2.6 3.1
MENT PROCEDURES OF UPPER
EXTREMITY.
492 ........... No ............ No ............ 17 MED ......... CHEMOTHERAPY W ACUTE LEU- 3.5926 8.8 13.7
KEMIA OR W USE OF HI DOSE
CHEMOAGENT.
493 ........... No ............ No ............ 07 SURG ...... LAPAROSCOPIC CHOLECYS- 1.8333 4.5 6.1
TECTOMY W/O C.D.E. W CC.
494 ........... No ............ No ............ 07 SURG ...... LAPAROSCOPIC CHOLECYS- 1.0285 2.1 2.7
TECTOMY W/O C.D.E. W/O CC.
495 ........... No ............ No ............ PRE SURG ...... LUNG TRANSPLANT .............................. 8.5736 14.0 17.3
496 ........... No ............ No ............ 08 SURG ...... COMBINED ANTERIOR/POSTERIOR 6.0932 6.4 8.8
SPINAL FUSION.
497 ........... Yes .......... Yes .......... 08 SURG ...... SPINAL FUSION EXCEPT CERVICAL 3.6224 5.0 5.9
W CC.
498 ........... Yes .......... Yes .......... 08 SURG ...... SPINAL FUSION EXCEPT CERVICAL 2.7791 3.4 3.8
W/O CC.
499 ........... No ............ No ............ 08 SURG ...... BACK & NECK PROCEDURES EXCEPT 1.3831 3.1 4.3
SPINAL FUSION W CC.
500 ........... No ............ No ............ 08 SURG ...... BACK & NECK PROCEDURES EXCEPT 0.9046 1.8 2.2
SPINAL FUSION W/O CC.
501 ........... Yes .......... No ............ 08 SURG ...... KNEE PROCEDURES W PDX OF IN- 2.6462 8.5 10.4
FECTION W CC.
502 ........... Yes .......... No ............ 08 SURG ...... KNEE PROCEDURES W PDX OF IN- 1.4462 4.9 5.9
FECTION W/O CC.
FY 2006
DRG
503 ........... No ............ No ............ 08 SURG ...... KNEE PROCEDURES W/O PDX OF IN- 1.2038 2.9 3.8
FECTION.
504 ........... No ............ No ............ 22 SURG ...... EXTEN. BURNS OR FULL THICKNESS 11.8018 21.7 27.3
BURN W/MV 96+HRS W/SKIN GFT.
505 ........... No ............ No ............ 22 MED ......... EXTEN. BURNS OR FULL THICKNESS 2.2953 2.4 4.6
BURN W/MV 96+HRS W/O SKIN GFT.
506 ........... No ............ No ............ 22 SURG ...... FULL THICKNESS BURN W SKIN 4.0939 11.2 15.9
GRAFT OR INHAL INJ W CC OR SIG
TRAUMA.
507 ........... No ............ No ............ 22 SURG ...... FULL THICKNESS BURN W SKIN 1.7369 5.8 8.5
GRFT OR INHAL INJ W/O CC OR
SIG TRAUMA.
508 ........... No ............ No ............ 22 MED ......... FULL THICKNESS BURN W/O SKIN 1.2767 5.1 7.4
GRFT OR INHAL INJ W CC OR SIG
TRAUMA.
509 ........... No ............ No ............ 22 MED ......... FULL THICKNESS BURN W/O SKIN 0.8217 3.6 5.2
GRFT OR INH INJ W/O CC OR SIG
TRAUMA.
510 ........... No ............ No ............ 22 MED ......... NON-EXTENSIVE BURNS W CC OR 1.1817 4.4 6.4
SIGNIFICANT TRAUMA.
511 ........... No ............ No ............ 22 MED ......... NON-EXTENSIVE BURNS W/O CC OR 0.7424 2.6 4.1
SIGNIFICANT TRAUMA.
512 ........... No ............ No ............ PRE SURG ...... SIMULTANEOUS PANCREAS/KIDNEY 5.3660 10.7 12.8
TRANSPLANT.
513 ........... No ............ No ............ PRE SURG ...... PANCREAS TRANSPLANT .................... 5.9669 8.9 9.9
515 ........... No ............ No ............ 05 SURG ...... CARDIAC DEFIBRILLATOR IMPLANT 5.5205 2.6 4.3
W/O CARDIAC CATH.
518 ........... No ............ No ............ 05 SURG ...... PERC CARDIO PROC W/O CORO- 1.6544 1.8 2.5
NARY ARTERY STENT OR AMI.
519 ........... No ............ No ............ 08 SURG ...... CERVICAL SPINAL FUSION W CC ....... 2.4695 3.0 4.8
520 ........... No ............ No ............ 08 SURG ...... CERVICAL SPINAL FUSION W/O CC .... 1.6788 1.6 2.0
521 ........... Yes .......... No ............ 20 MED ......... ALCOHOL/DRUG ABUSE OR DEPEND- 0.6939 4.2 5.6
ENCE W CC.
522 ........... Yes .......... No ............ 20 MED ......... ALC/DRUG ABUSE OR DEPEND W RE- 0.4794 7.7 9.6
HABILITATION THERAPY W/O CC.
523 ........... No ............ No ............ 20 MED ......... ALC/DRUG ABUSE OR DEPEND W/O 0.3793 3.2 3.9
REHABILITATION THERAPY W/O CC.
524 ........... No ............ No ............ 01 MED ......... TRANSIENT ISCHEMIA .......................... 0.7288 2.6 3.2
525 ........... No ............ No ............ 05 SURG ...... OTHER HEART ASSIST SYSTEM IM- 11.4282 7.2 13.6
PLANT.
527 ........... No ............ aNo .......... 05 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0
528 ........... No ............ No ............ 01 SURG ...... INTRACRANIAL VASCULAR PROC W 7.0505 13.8 17.2
PDX HEMORRHAGE.
529 ........... Yes .......... No ............ 01 SURG ...... VENTRICULAR SHUNT PROCEDURES 2.3160 5.3 8.3
W CC.
530 ........... Yes .......... No ............ 01 SURG ...... VENTRICULAR SHUNT PROCEDURES 1.2041 2.4 3.1
W/O CC.
531 ........... Yes .......... No ............ 01 SURG ...... SPINAL PROCEDURES W CC ............... 3.1279 6.5 9.6
532 ........... Yes .......... No ............ 01 SURG ...... SPINAL PROCEDURES W/O CC ........... 1.4195 2.8 3.7
533 ........... No ............ No ............ 01 SURG ...... EXTRACRANIAL PROCEDURES W CC 1.5767 2.4 3.8
534 ........... No ............ No ............ 01 SURG ...... EXTRACRANIAL PROCEDURES W/O 1.0201 1.5 1.8
CC.
535 ........... No ............ No ............ 05 SURG ...... CARDIAC DEFIB IMPLANT W CARDIAC 7.9738 7.9 10.3
CATH W AMI/HF/SHOCK.
536 ........... No ............ No ............ 05 SURG ...... CARDIAC DEFIB IMPLANT W CARDIAC 6.9144 5.9 7.6
CATH W/O AMI/HF/SHOCK.
537 ........... Yes .......... No ............ 08 SURG ...... LOCAL EXCIS & REMOV OF INT FIX 1.8360 4.8 6.9
DEV EXCEPT HIP & FEMUR W CC.
538 ........... Yes .......... No ............ 08 SURG ...... LOCAL EXCIS & REMOV OF INT FIX 0.9833 2.1 2.8
DEV EXCEPT HIP & FEMUR W/O CC.
539 ........... No ............ No ............ 17 SURG ...... LYMPHOMA & LEUKEMIA W MAJOR 3.2782 7.0 10.8
OR PROCEDURE W CC.
FY 2006
DRG
540 ........... No ............ No ............ 17 SURG ...... LYMPHOMA & LEUKEMIA W MAJOR 1.1940 2.6 3.6
OR PROCEDURE W/O CC.
541 ........... Yes .......... No ............ PRE SURG ...... ECMO OR TRACH W MV 96+HRS OR 19.8038 38.1 45.7
PDX EXC FACE, MOUTH & NECK W
MAJ O.R..
542 ........... Yes .......... No ............ PRE SURG ...... TRACH W MV 96+HRS OR PDX EXC 12.8719 29.1 35.1
FACE, MOUTH & NECK W/O MAJ
O.R..
543 ........... Yes .......... No ............ 01 SURG ...... CRANIOTOMY W/IMPLANT OF CHEMO 4.4184 8.5 12.3
AGENT OR ACUTE COMPLX CNS
PDX.
544 ........... Yes .......... Yes .......... 08 SURG ...... MAJOR JOINT REPLACEMENT OR RE- 1.9643 4.1 4.5
ATTACHMENT OF LOWER EXTREM-
ITY.
545 ........... Yes .......... Yes .......... 08 SURG ...... REVISION OF HIP OR KNEE RE- 2.4827 4.5 5.2
PLACEMENT.
546 ........... No ............ No ............ 08 SURG ...... SPINAL FUSION EXC CERV WITH 5.0739 7.1 8.8
CURVATURE OF THE SPINE OR
MALIG.
547 ........... Yes .......... No ............ 05 SURG ...... CORONARY BYPASS W CARDIAC 6.1948 10.8 12.3
CATH W MAJOR CV DX.
548 ........... Yes .......... No ............ 05 SURG ...... CORONARY BYPASS W CARDIAC 4.7198 8.2 9.0
CATH W/O MAJOR CV DX.
549 ........... Yes .......... Yes .......... 05 SURG ...... CORONARY BYPASS W/O CARDIAC 5.0980 8.7 10.3
CATH W MAJOR CV DX.
550 ........... Yes .......... Yes .......... 05 SURG ...... CORONARY BYPASS W/O CARDIAC 3.6151 6.2 6.9
CATH W/O MAJOR CV DX.
551 ........... No ............ No ............ 05 SURG ...... PERMANENT CARDIAC PACEMAKER 3.1007 4.4 6.4
IMPL W MAJ CV DX OR AICD LEAD
OR GNRTR.
552 ........... No ............ No ............ 05 SURG ...... OTHER PERMANENT CARDIAC PACE- 2.0996 2.5 3.5
MAKER IMPLANT W/O MAJOR CV
DX.
553 ........... Yes .......... No ............ 05 SURG ...... OTHER VASCULAR PROCEDURES W 3.0957 6.6 9.7
CC W MAJOR CV DX.
554 ........... Yes .......... No ............ 05 SURG ...... OTHER VASCULAR PROCEDURES W 2.0721 4.0 5.9
CC W/O MAJOR CV DX.
555 ........... No ............ No ............ 05 SURG ...... PERCUTANEOUS CARDIOVASCULAR 2.4315 3.4 4.7
PROC W MAJOR CV DX.
556 ........... No ............ No ............ 05 SURG ...... PERCUTANEOUS CARDIOVASC PROC 1.9132 1.6 2.1
W NON-DRUG-ELUTING STENT W/O
MAJ CV DX.
PROC W DRUG-ELUTING STENT W
MAJOR CV DX.
PROC W DRUG-ELUTING STENT W/
O MAJ CV DX.
559 ........... No ............ No ............ 01 MED ......... ACUTE ISCHEMIC STROKE WITH USE 2.2473 5.8 7.2
OF THROMBOLYTIC AGENT.
* Medicare data have been supplemented by data from 19 States for low volume DRGs.
** DRGs 469 and 470 contain vases which could not be assigned to valid DRGs.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is presented for informational purposes only.
Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients.
TABLE 6A.—NEW DIAGNOSIS CODES

Diagnosis Description CC MDC DRG
code
259.5 ........ Androgen insensitivity syndrome ................................................................................................... N 10 300, 301

276.50 ...... Volume depletion, unspecified ....................................................................................................... Y 10 296, 297, 298,
15 387 1, 389 1,
25 2 490
TABLE 6A.—NEW DIAGNOSIS CODES—Continued

code
276.51 ...... Dehydration .................................................................................................................................... Y 10 296, 297, 298,

15 387 1, 389 1,
25 2 490
276.52 ...... Hypovolemia .................................................................................................................................. Y 10 296, 297, 298,
15 387 1, 389 1,
25 2 490
278.02 ...... Overweight ..................................................................................................................................... N 10 296, 297, 298
287.30 ...... Primary thrombocytopenia, unspecified ........................................................................................ Y 16 397
287.31 ...... Immune thrombocytopenic purpura ............................................................................................... Y 16 397
287.32 ...... Evans’ syndrome ........................................................................................................................... Y 16 397
287.33 ...... Congenital and hereditary thrombocytopenic purpura .................................................................. Y 16 397
287.39 ...... Other primary thrombocytopenia ................................................................................................... Y 16 397
291.82 ...... Alcohol induced sleep disorders .................................................................................................... N 20 521, 522, 523
292.85 ...... Drug induced sleep disorders ........................................................................................................ N 20 521, 522, 523
327.00 ...... Organic insomnia, unspecified ...................................................................................................... N 19 432
327.01 ...... Insomnia due to medical condition classified elsewhere .............................................................. N 19 432
327.02 ...... Insomnia due to mental disorder ................................................................................................... N 19 432
327.09 ...... Other organic insomnia ................................................................................................................. N 19 432
327.10 ...... Organic hypersomnia, unspecified ................................................................................................ N 19 432
327.11 ...... Idiopathic hypersomnia with long sleep time ................................................................................ N 19 432
327.12 ...... Idiopathic hypersomnia without long sleep time ........................................................................... N 19 432
327.13 ...... Recurrent hypersomnia ................................................................................................................. N 19 432
327.14 ...... Hypersomnia due to medical condition classified elsewhere ........................................................ N 19 432
327.15 ...... Hypersomnia due to mental disorder ............................................................................................ N 19 432
327.19 ...... Other organic hypersomnia ........................................................................................................... N 19 432
327.20 ...... Organic sleep apnea, unspecified ................................................................................................. N PRE 482
3 73, 74
327.21 ...... Primary central sleep apnea .......................................................................................................... N PRE 482
1 34, 35
327.22 ...... High altitude periodic breathing ..................................................................................................... N PRE 482
4 99, 100
327.23 ...... Obstructive sleep apnea (adult) (pediatric) ................................................................................... N PRE 482
3 73, 74
327.24 ...... Idiopathic sleep related non-obstructive alveolar hypoventilation ................................................. N PRE 482
3 73, 74
327.25 * .... Congenital central alveolar hypoventilation syndrome .................................................................. N PRE 482
1 34, 35
327.26 ...... Sleep related hypoventilation/hypoxemia in conditions classifiable elsewhere ............................ N PRE 482
3 73, 74
327.27 ...... Central sleep apnea in conditions classified elsewhere ............................................................... N PRE 482
1 34, 35
327.29 ...... Other organic sleep apnea ............................................................................................................ N PRE 482
3 73, 74
327.30 * .... Circadian rhythm sleep disorder, unspecified ............................................................................... N PRE 482
1 34, 35
327.31 * .... Circadian rhythm sleep disorder, delayed sleep phase type ........................................................ N PRE 482
1 34, 35
327.32 * .... Circadian rhythm sleep disorder, advanced sleep phase type ..................................................... N PRE 482
1 34, 35
327.33 * .... Circadian rhythm sleep disorder, irregular sleep-wake type ......................................................... N PRE 482
1 34, 35
327.34 * .... Circadian rhythm sleep disorder, free-running type ...................................................................... N PRE 482
1 34, 35
327.35 * .... Circadian rhythm sleep disorder, jet lag type ................................................................................ N PRE 482
1 34, 35
327.36 * .... Circadian rhythm sleep disorder, shift work type .......................................................................... N PRE 482
1 34, 35
327.37 * .... Circadian rhythm sleep disorder in conditions classified elsewhere ............................................. N PRE 482
1 34, 35
327.39 * .... Other circadian rhythm sleep disorder .......................................................................................... N PRE 482
1 34, 35
327.40 * .... Organic parasomnia, unspecified .................................................................................................. N PRE 482
3 73, 74
327.41 * .... Confusional arousals ..................................................................................................................... N PRE 482
1 34, 35
327.42 * .... REM sleep behavior disorder ........................................................................................................ N PRE 482
3 73, 74
327.43 * .... Recurrent isolated sleep paralysis ................................................................................................ N PRE 482
1 34, 35
327.44 * .... Parasomnia in conditions classified elsewhere ............................................................................. N PRE 482
3 73, 74

code
327.49 * .... Other organic parasomnia ............................................................................................................. N PRE 482

3 73, 74
327.51 * .... Periodic limb movement disorder .................................................................................................. N PRE 482
1 34, 35
327.52 * .... Sleep related leg cramps ............................................................................................................... N PRE 482
1 34, 35
327.53 * .... Sleep related bruxism .................................................................................................................... N PRE 482
3 73, 74
327.59 * .... Other organic sleep related movement disorders ......................................................................... N PRE 482
3 73, 74
327.8 * ...... Other organic sleep disorders ....................................................................................................... N PRE 482
3 73, 74
362.03 ...... Nonproliferative diabetic retinopathy NOS .................................................................................... N 2 46, 47, 48
362.04 ...... Mild nonproliferative diabetic retinopathy ...................................................................................... N 2 46, 47, 48
362.05 ...... Moderate nonproliferative diabetic retinopathy ............................................................................. N 2 46, 47, 48
362.06 ...... Severe nonproliferative diabetic retinopathy ................................................................................. N 2 46, 47, 48
362.07 ...... Diabetic macular edema ................................................................................................................ N 2 46, 47, 48
426.82 ...... Long QT syndrome ........................................................................................................................ N 5 138, 139
443.82 ...... Erythromelalgia .............................................................................................................................. N 5 130, 131
525.40 ...... Complete edentulism, unspecified ................................................................................................. N PRE 482
3 185, 186, 187
525.41 ...... Complete edentulism, class I ........................................................................................................ N PRE 482
3 185, 186, 187
525.42 ...... Complete edentulism, class II ....................................................................................................... N PRE 482
3 185, 186, 187
525.43 ...... Complete edentulism, class III ...................................................................................................... N PRE 482
3 185, 186, 187
525.44 ...... Complete edentulism, class IV ...................................................................................................... N PRE 482
3 185, 186, 187
525.50 ...... Partial edentulism, unspecified ...................................................................................................... N PRE 482
3 185, 186, 187
525.51 ...... Partial edentulism, class I .............................................................................................................. N PRE 482
3 185, 186, 187
525.52 ...... Partial edentulism, class II ............................................................................................................. N PRE 482
3 185, 186, 187
525.53 ...... Partial edentulism, class III ............................................................................................................ N PRE 482
3 185, 186, 187
525.54 ...... Partial edentulism, class IV ........................................................................................................... N PRE 482
3 185, 186, 187
567.21 ...... Peritonitis (acute) generalized ....................................................................................................... Y 6 188, 189, 190
15 387 1, 389 1
567.22 ...... Peritoneal abscess ........................................................................................................................ Y 6 188, 189, 190
15 387 1, 389 1
567.23 ...... Spontaneous bacterial peritonitis .................................................................................................. Y 6 188, 189, 190
15 387 1, 389 1
567.29 ...... Other suppurative peritonitis .......................................................................................................... Y 6 188, 189, 190
15 387 1, 389 1
567.31 * .... Psoas muscle abscess .................................................................................................................. Y 6 188, 189, 190
15 387 1, 389 1
567.38 ...... Other retroperitoneal abscess ....................................................................................................... Y 6 188, 189, 190
15 387 1, 389 1
567.39 ...... Other retroperitoneal infections ..................................................................................................... Y 6 188, 189, 190
15 387 1, 389 1
567.81 ...... Choleperitonitis .............................................................................................................................. Y 6 188, 189, 190
15 387 1, 389 1
567.82 ...... Sclerosing mesenteritis .................................................................................................................. Y 6 188, 189, 190
15 387 1, 389 1
567.89 ...... Other specified peritonitis .............................................................................................................. Y 6 188, 189, 190
15 387 1, 389 1
585.1 ........ Chronic kidney disease, Stage I .................................................................................................... Y PRE 512, 513
11 315, 316
585.2 ........ Chronic kidney disease, Stage II (mild) ........................................................................................ Y PRE 512, 513
11 315, 316
585.3 ........ Chronic kidney disease, Stage III (moderate) ............................................................................... Y PRE 512, 513
11 315, 316
585.4 ........ Chronic kidney disease, Stage IV (severe) ................................................................................... Y PRE 512, 513
11 315, 316
585.5 ........ Chronic kidney disease, Stage V .................................................................................................. Y PRE 512, 513
11 315, 316
585.6 ........ End stage renal disease ................................................................................................................ Y PRE 512, 513
11 315, 316

code
585.9 ........ Chronic kidney disease, unspecified ............................................................................................. Y PRE 512, 513
11 315, 316
599.60 ...... Urinary obstruction, unspecified .................................................................................................... Y 11 331, 332, 333
15 387 1, 389 1
599.69 ...... Urinary obstruction, not elsewhere classified ................................................................................ Y 11 331, 332, 333
15 387 1, 389 1
651.70 ...... Multiple gestation following (elective) fetal reduction, unspecified as to episode of care or not N 14 469
applicable.
651.71 ...... Multiple gestation following (elective) fetal reduction, delivered, with or without mention of N 14 370, 371, 372,
antepartum condition. 373, 374, 375
651.73 ...... Multiple gestation following (elective) fetal reduction, antepartum condition or complication ...... N 14 383, 384
760.77 ...... Anticonvulsants .............................................................................................................................. N 15 390
760.78 ...... Antimetabolic agents ..................................................................................................................... N 15 390
763.84 ...... Meconium passage during delivery ............................................................................................... N 15 390
770.10 ...... Fetal and newborn aspiration, unspecified .................................................................................... N 15 387 3, 389 3
770.11 ...... Meconium aspiration without respiratory symptoms ..................................................................... N 15 387 3, 389 3
770.12 ...... Meconium aspiration with respiratory symptoms .......................................................................... Y 15 387 3, 389 3
770.13 * .... Aspiration of clear amniotic fluid without respiratory symptoms ................................................... N 15 387 3, 389 3
770.14 * .... Aspiration of clear amniotic fluid with respiratory symptoms ........................................................ Y 15 387 3, 389 3
770.15 * .... Aspiration of blood without respiratory symptoms ........................................................................ N 15 387 3, 389 3
770.16 * .... Aspiration of blood with respiratory symptoms ............................................................................. Y 15 387 3, 389 3
770.17 ...... Other fetal and newborn aspiration without respiratory symptoms ............................................... N 15 387 3, 389 3
770.18 ...... Other fetal and newborn aspiration with respiratory symptoms .................................................... Y 15 387 3, 389 3
770.85 * .... Aspiration of postnatal stomach contents without respiratory symptoms ..................................... N 15 387 3, 389 3
770.86 * .... Aspiration of postnatal stomach contents with respiratory symptoms .......................................... Y 15 387 3, 389 3
779.84 ...... Meconium staining ......................................................................................................................... N 15 390
780.95 ...... Other excessive crying .................................................................................................................. N 23 463, 464
799.01 ...... Asphyxia ........................................................................................................................................ Y 4 101, 102
799.02 ...... Hypoxemia ..................................................................................................................................... Y 4 101, 102
996.40 ...... Unspecified mechanical complication of internal orthopedic device, implant, and graft .............. Y 8 249
996.41 ...... Mechanical loosening of prosthetic joint ....................................................................................... Y 8 249
996.42 ...... Dislocation of prosthetic joint ......................................................................................................... Y 8 249
996.43 ...... Prosthetic joint implant failure ....................................................................................................... Y 8 249
996.44 ...... Peri-prosthetic fracture around prosthetic joint ............................................................................. Y 8 249
996.45 ...... Peri-prosthetic osteolysis ............................................................................................................... Y 8 249
996.46 ...... Articular bearing surface wear of prosthetic joint .......................................................................... Y 8 249
996.47 ...... Other mechanical complication of prosthetic joint implant ............................................................ Y 8 249
996.49 ...... Other mechanical complication of other internal orthopedic device, implant, and graft ............... Y 8 249
V12.42 ..... Personal history, Infections of the central nervous system .......................................................... N 23 467
V12.60 ..... Personal history, Unspecified disease of respiratory system ....................................................... N 23 467
V12.61 ..... Personal history, Pneumonia (recurrent) ....................................................................................... N 23 467
V12.69 ..... Personal history, Other diseases of respiratory system ............................................................... N 23 467
V13.02 ..... Personal history, Urinary (tract) infection ...................................................................................... N 23 467
V13.03 ..... Personal history, Nephrotic syndrome .......................................................................................... N 23 467
V15.88 ..... History of fall .................................................................................................................................. N 23 467
V17.81 ..... Family history, Osteoporosis ......................................................................................................... N 23 467
V17.89 ..... Family history, Other musculoskeletal diseases ........................................................................... N 23 467
V18.9 ....... Family history, Genetic disease carrier ......................................................................................... N 23 467
V26.31 ..... Testing for genetic disease carrier status ..................................................................................... N 23 467
V26.32 ..... Other genetic testing ..................................................................................................................... N 23 467
V26.33 ..... Genetic counseling ........................................................................................................................ N 23 467
V46.13 ..... Encounter for weaning from respirator [ventilator] ........................................................................ Y 23 467
V46.14 ..... Mechanical complication of respirator [ventilator] ......................................................................... Y 23 467
V49.84 ..... Bed confinement status ................................................................................................................. N 23 467
V58.11 * ... Encounter for antineoplastic chemotherapy .................................................................................. N 17 410, 492
V58.12 * ... Encounter for immunotherapy for neoplastic condition ................................................................. N 17 410, 492
V59.70 ..... Egg (oocyte) (ovum) donor, unspecified ....................................................................................... N 23 467
V59.71 ..... Egg (oocyte) (ovum) donor, under age 35,anonymous recipient ................................................. N 23 467
V59.72 ..... Egg (oocyte) (ovum) donor, under age 35, designated recipient ................................................. N 23 467
V59.73 ..... Egg (oocyte) (ovum) donor, age 35 and over, anonymous recipient ........................................... N 23 467
V59.74 ..... Egg (oocyte) (ovum) donor, age 35 and over, designated recipient ............................................ N 23 467
V62.84 ..... Suicidal ideation ............................................................................................................................. N 19 425
V64.00 ..... Vaccination not carried out, unspecified reason ........................................................................... N 23 467
V64.01 ..... Vaccination not carried out because of acute illness .................................................................... N 23 467
V64.02 ..... Vaccination not carried out because of chronic illness or condition ............................................. N 23 467
V64.03 ..... Vaccination not carried out because of immune compromised state ........................................... N 23 467
V64.04 ..... Vaccination not carried out because of allergy to vaccine or component .................................... N 23 467
V64.05 ..... Vaccination not carried out because of caregiver refusal ............................................................. N 23 467
V64.06 ..... Vaccination not carried out because of patient refusal ................................................................. N 23 467
V64.07 ..... Vaccination not carried out for religious reasons .......................................................................... N 23 467
V64.08 ..... Vaccination not carried out because patient had disease being vaccinated against ................... N 23 467

code
V64.09 ..... Vaccination not carried out for other reason ................................................................................. N 23 467
V69.5 ....... Behavioral insomnia of childhood .................................................................................................. N 23 467
V72.42 * ... Pregnancy examination or test, positive result ............................................................................. N 23 467
V72.86 ..... Encounter for blood typing ............................................................................................................ N 23 467
V85.0 ....... Body Mass Index less than 19, adult ............................................................................................ N 23 467
V85.1 ....... Body Mass Index between 19–24, adult ....................................................................................... N 23 467
V85.21 ..... Body Mass Index 25.0–25.9, adult ................................................................................................ N 23 467
V85.4 ....... Body Mass Index 40 and over, adult ............................................................................................ N 10 296, 297, 298
1 Secondary diagnosis of major problem in DRGs 387 and 389.
2 Principaldiagnosis of significant HIV-related condition.
3 Principalor secondary diagnosis of major problem.
* These diagnosis codes were discussed at the March 31–April 1, 2005 ICD–9–CM Coordination and Maintenance Committee meeting and
were not finalized in time to include in the proposed rule.
TABLE 6B.—NEW PROCEDURE CODES

Procedure Description OR MDC DRG
code
00.18 * ...... Infusion of immunosuppressive antibody therapy during induction phase of solid organ trans- N
plantation.
00.40 ........ Procedure on single vessel ........................................................................................................... N
00.41 ........ Procedure on two vessels ............................................................................................................. N
00.42 ........ Procedure on three vessels ........................................................................................................... N
00.43 ........ Procedure on four or more vessels ............................................................................................... N
00.45 ........ Insertion of one vascular stent ...................................................................................................... N
00.46 ........ Insertion of two vascular stents ..................................................................................................... N
00.47 ........ Insertion of three vascular stents .................................................................................................. N
00.48 ........ Insertion of four or more vascular stents ...................................................................................... N
00.66 * ...... Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy .................... Y 5 106, 518, 555,
556, 557, 558
00.70 ........ Revision of hip replacement, both acetabular and femoral components ...................................... Y 8 471, 545
10 292, 293
21 442, 443
24 485
00.71 ........ Revision of hip replacement, acetabular component .................................................................... Y 8 471, 545
10 292, 293
21 442, 443
24 485
00.72 ........ Revision of hip replacement, femoral component ......................................................................... Y 8 471, 545
10 292, 293
21 442, 443
24 485
00.73 ........ Revision of hip replacement, acetabular liner and/or femoral head only ..................................... Y 8 471, 545
10 292, 293
21 442, 443
24 485
00.74 * ...... Hip replacement bearing surface, metal on polyethylene ............................................................. N
00.75 * ...... Hip replacement bearing surface, metal-on-metal ........................................................................ N
00.76 * ...... Hip replacement bearing surface, ceramic-on-ceramic ................................................................. N
00.80 ........ Revision of knee replacement, total (all components) .................................................................. Y 8 471, 545
21 442, 443
24 486
00.81 ........ Revision of knee replacement, tibial component .......................................................................... Y 8 471, 545
21 442, 443
24 486
TABLE 6B.—NEW PROCEDURE CODES—Continued

code
00.82 ........ Revision of knee replacement, femoral component ...................................................................... Y 8 471, 545
21 442, 443
24 486
00.83 ........ Revision of knee replacement, patellar component ...................................................................... Y 8 471, 545
21 442, 443
24 486
00.84 ........ Revision of total knee replacement, tibial insert (liner) ................................................................. Y 8 471, 545
21 442, 443
24 486
01.26 * ...... Insertion of catheter into cranial cavity .......................................................................................... N
01.27 * ...... Removal of catheter from cranial cavity ........................................................................................ N
37.41 ........ Implantation of prosthetic cardiac support device around the heart ............................................. Y 5 110, 111
37.49 ........ Other repair of heart and pericardium ........................................................................................... Y 5 110, 111
21 442, 443
24 486
39.73 * ...... Endovascular implantation of graft in thoracic aorta ..................................................................... Y 5 110, 111
11 315
21 442, 443
24 486
81.18 * ...... Subtalar joint arthroereisis ............................................................................................................. Y 8 233, 234
21 442, 443
24 486
84.56 ........ Insertion of (cement) spacer .......................................................................................................... N
84.57 ........ Removal of (cement) spacer ......................................................................................................... N
84.58 * ...... Implantation of interspinous process decompression device ........................................................ Y 1 531, 532
8 499, 500
21 442, 443
24 486
84.71 * ...... Application of external fixator device, monoplanar system ........................................................... N
84.72 * ...... Application of external fixator device, ring system ........................................................................ N
84.73 * ...... Application of hybrid external fixator device .................................................................................. N
86.97 ........ Insertion or replacement of single array rechargeable neurostimulator pulse generator ............. Y 1 7, 8
86.98 ........ Insertion or replacement of dual array rechargeable neurostimulator pulse generator ................ Y 1 7, 8
92.20 * ...... Infusion of liquid brachytherapy radioisotope ................................................................................ N
* These procedure codes were discussed at the March 31–April 1, 2005 ICD–9–CM Coordination and Maintenance Committee meeting and
were not finalized in time to include with the proposed rule.
TABLE 6C.—INVALID DIAGNOSIS CODES

code
276.5 ........ Volume depletion ........................................................................................................................... Y 10 296, 297, 298

15 387 1, 389 1
25 2 490
287.3 ........ Primary thrombocytopenia ............................................................................................................. Y 16 397
567.2 ........ Other suppurative peritonitis .......................................................................................................... Y 6 188, 189, 190
15 387 1, 389 1
567.8 ........ Other specified peritonitis .............................................................................................................. Y 6 188, 189, 190
15 387 1, 389 1
585 ........... Chronic renal failure ...................................................................................................................... Y PRE 512, 513
11 315, 316
599.6 ........ Urinary obstruction, unspecified .................................................................................................... Y 11 331, 332, 333
15 387 1, 389 1
770.1 ........ Meconium aspiration syndrome ..................................................................................................... Y 15 387 3, 389 3
799.0 ........ Asphyxia ........................................................................................................................................ N 4 101, 102
996.4 ........ Mechanical complication of internal orthopedic device, implant, and graft .................................. Y 8 249
V12.6 ....... Diseases of the respiratory system ............................................................................................... N 23 467
V17.8 ....... Other musculoskeletal diseases .................................................................................................... N 23 467
V26.3 ....... Genetic counseling and testing ..................................................................................................... N 23 467
V58.1 * ..... Chemotherapy ............................................................................................................................... N 17 410, 492
V64.0 ....... Vaccination not carried out because of contradiction ................................................................... N 23 467
1 Secondary Diagnosis of Major Problem.
2 Principal diagnosis of Significant HIV Related Condition.
3 Principal or Secondary Diagnosis of Major Problem.
* This diagnosis code was discussed at the March 31–April 1, 2005 ICD–9–CM Coordination and Maintenance Committee meeting, but not fi-
nalized in time to include in the FY 2006 IPPS proposed rule.
TABLE 6D.—INVALID PROCEDURE CODES

code
36.01 * 1 .... Single vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary Y 5 106, 516, 517,
atherectomy without mention of thrombolytic agent. 518, 526, 527
36.02 ........ Single vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary Y 5 106, 516, 517,
atherectomy with mention of thrombolytic agent. 518, 526, 527
36.05 ........ Multiple vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary Y 5 106, 516, 517,
atherectomy performed during the same operation, with or without mention of thrombolytic 518, 526, 527
agent.
37.4 .......... Repair of heart and pericardium .................................................................................................... Y 5 110, 111
21 442, 443
24 486
81.61 * ...... 360 degree spinal fusion, single incision approach ...................................................................... Y 1 531, 532
8 497, 498
21 442, 443
24 486
1 Code 36.01 was listed as a revised code in Table 6F of the proposed rule. We are deleting this code and creating new code 00.66 instead.
Code 00.66 is listed on Table 6B.
TABLE 6E.—REVISED DIAGNOSIS CODE TITLES

code
285.21 * .... Anemia in chronic kidney disease ................................................................................................. Y 16 395, 396

307.45 * .... Circadian rhythm sleep disorder of nonorganic origin .................................................................. N 19 432
403.00 ...... Hypertensive kidney disease, malignant, without chronic kidney disease ................................... Y 11 331, 332, 333
403.01 ...... Hypertensive kidney disease, malignant, with chronic kidney disease ........................................ Y 11 315, 316
403.10 ...... Hypertensive kidney disease, benign, without chronic kidney disease ........................................ N 11 331, 332, 333
403.11 ...... Hypertensive kidney disease, benign, with chronic kidney disease ............................................. Y 11 315, 316
403.90 ...... Hypertensive kidney disease, unspecified, without chronic kidney disease ................................. N 11 331, 332, 333
403.91 ...... Hypertensive kidney disease, unspecified, with chronic kidney disease ...................................... Y 11 315, 316
404.00 ...... Hypertensive heart and kidney disease, malignant, without heart failure or chronic kidney dis- Y 5 134
ease.
404.01 ...... Hypertensive heart and kidney disease, malignant, with heart failure ......................................... Y 5 121, 124, 127,
15 535, 547, 549,
551, 553, 555,
557,
387, 389 1
404.02 ...... Hypertensive heart and kidney disease, malignant, with chronic kidney disease ........................ Y 11 315, 316
404.03 ...... Hypertensive heart and kidney disease, malignant, with heart failure and chronic kidney dis- Y 5 121, 124, 127,
ease. 15 535, 547, 549,
551, 553, 555,
557
387, 389 1
404.10 ...... Hypertensive heart and kidney disease, benign, without heart failure or chronic kidney disease N 5 134
404.11 ...... Hypertensive heart and kidney disease, benign, with heart failure .............................................. Y 5 121, 124, 127,
15 535, 547, 549,
551, 553, 555,
557
387, 389 1
404.12 ...... Hypertensive heart and kidney disease, benign, with chronic kidney disease ............................. Y 11 315, 316
404.13 ...... Hypertensive heart and kidney disease, benign, with heart failure and chronic kidney disease Y 5 121, 124, 127,
15 535, 547, 549,
551, 553, 555,
557
387, 389 1
404.90 ...... Hypertensive heart and kidney disease, unspecified, without heart failure or chronic kidney N 5 134
disease.
404.91 ...... Hypertensive heart and kidney disease, unspecified, with heart failure ....................................... Y 5 121, 124, 127,
15 535, 547, 549,
551, 553, 555,
557
387, 389 1
404.92 ...... Hypertensive heart and kidney disease, unspecified, with chronic kidney disease ..................... Y 11 315, 316
404.93 ...... Hypertensive heart and kidney disease, unspecified, with heart failure and chronic kidney dis- Y 5 121, 124, 127,
ease. 15 535, 547, 549,
551, 553, 555,
557
387, 389 1
TABLE 6E.—REVISED DIAGNOSIS CODE TITLES—Continued

code
728.87 ...... Muscle weakness (generalized) .................................................................................................... N 8 247

780.51 ...... Insomnia with sleep apnea, unspecified ....................................................................................... N PRE 482
3 73, 74
780.52 ...... Insomnia, unspecified .................................................................................................................... N 19 432
780.53 ...... Hypersomnia with sleep apnea, unspecified ................................................................................. N PRE 482
3 73, 74
780.54 ...... Hypersomnia, unspecified ............................................................................................................. N 19 432
780.55 * .... Disruption of 24 hour sleep wake cycle, unspecified .................................................................... N 19 432
780.57 ...... Unspecified sleep apnea ............................................................................................................... N PRE 482
3 73, 74
780.58 * .... Sleep related movement disorder, unspecified ............................................................................. N 19 432
1 Major Problem in DRG 387 & 389.
* These diagnosis codes were discussed at the March 31–April 1, 2005 ICD–9–CM Coordination and Maintenance Committee meeting and
TABLE 6F.—REVISED PROCEDURE CODE TITLES

code
37.79 ........ Revision or relocation of cardiac device pocket ............................................................................ Y 1 7, 8

5 117
9 269, 270
21 442, 443
24 486
78.10 * ...... Application of external fixator device, unspecified site ................................................................. Y 8 233, 234
21 442, 443
24 486
78.11 * ...... Application of external fixator device, scapula, clavicle, and thorax [ribs and sternum] .............. Y 4 76, 77
8 233, 234
21 442, 443
24 486
78.12 * ...... Application of external fixator device, humerus ............................................................................ Y 8 218, 219, 220
21 442, 443
24 486
78.13 * ...... Application of external fixator device, radius and ulna ................................................................. Y 8 233, 234
21 442, 443
24 486
78.14 * ...... Application of external fixator device, carpals and metacarpals ................................................... Y 8 228, 229
21 441
24 486
78.15 * ...... Application of external fixator device, femur ................................................................................. Y 8 210, 211, 212
21 442, 443
24 485
78.16 * ...... Application of external fixator device, patella ................................................................................ Y 8 501, 502, 503
21 442, 443
24 486
78.17 * ...... Application of external fixator device, tibia and fibula ................................................................... Y 8 218, 219, 220
21 442, 443
24 486
78.18 * ...... Application of external fixator device, tarsals and metatarsals ..................................................... Y 8 225
21 442, 443
24 486
78.19 * ...... Application of external fixator device, other .................................................................................. Y 8 233, 234
21 442, 443
24 486
81.53 ........ Revision of hip replacement, not otherwise specified ................................................................... Y 8 471, 545
10 292, 293
21 442, 443
24 485
81.55 ........ Revision of knee replacement, not otherwise specified ................................................................ Y 8 471, 545
21 442, 443
24 486
86.94 ........ Insertion or replacement of single array neurostimulator pulse generator, not specified as re- Y 1 7, 8
chargeable.
86.95 ........ Insertion or replacement of dual array neurostimulator pulse generator, not specified as re- Y 1 7, 8
chargeable.
TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC

EXCLUSIONS LIST EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued
[CCs that are added to the list are included in [CCs that are added to the list are included in [CCs that are added to the list are included in
this table. Each of the principal diagnoses is this table. Each of the principal diagnoses is this table. Each of the principal diagnoses is
shown with an asterisk, and the revisions to shown with an asterisk, and the revisions to shown with an asterisk, and the revisions to
the CC Exclusions List are provided in an the CC Exclusions List are provided in an the CC Exclusions List are provided in an
indented column immediately following the indented column immediately following the indented column immediately following the
affected principal diagnosis.] affected principal diagnosis.] affected principal diagnosis.]
*185 5853 5856

59960 5854 5859
59969 5855 *25093
*1880 5856 5851
59960 5859 5852
59969 *25043 5853
*1881 5851 5854
59960 5852 5855
59969 5853 5856
*1882 5854 5859
59960 5855 *2595
59969 5856 24200
*1883 5859 24201
59960 *25080 24210
59969 5851 24211
*1884 5852 24220
59960 5853 24221
59969 5854 24230
*1885 5855 24231
59960 5856 24240
59969 5859 24241
*1886 *25081 24280
59960 5851 24281
59969 5852 24290
*1887 5853 24291
59960 5854 25001
59969 5855 25002
*1888 5856 25003
59960 5859 25011
59969 *25082 25012
*1889 5851 25013
59960 5852 25021
59969 5853 25022
*1892 5854 25023
59960 5855 25031
59969 5856 25032
*1893 5859 25033
59960 *25083 25041
59969 5851 25042
*1894 5852 25043
59960 5853 25051
59969 5854 25052
*1898 5855 25053
59960 5856 25061
59969 5859 25062
*1899 *25090 25063
59960 5851 25071
59969 5852 25072
*25040 5853 25073
5851 5854 25081
5852 5855 25082
5853 5856 25083
5854 5859 25091
5855 *25091 25092
5856 5851 25093
5859 5852 2510
*25041 5853 2513
5851 5854 2521
5852 5855 2532
5853 5856 2535
5854 5859 2541
5855 *25092 2550
5856 5851 2553
5859 5852 2554
*25042 5853 2555
5851 5854 2556
5852 5855 2580

EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued
2581 *27652 28732

2588 2760 28733
2589 2761 28739
2592 2762 *2867
*27410 2763 28730
5851 2764 28731
5852 27650 28732
5853 27651 28733
5854 27652 28739
5855 2766 *2869
5856 2767 28730
5859 2769 28731
*27411 *2766 28732
59960 27650 28733
59969 27651 28739
*27419 27652 *2870
5851 *2767 28730
5852 27650 28731
5853 27651 28732
5854 27652 28733
5855 *2768 28739
5856 27650 *2871
5859 27651 28730
*2760 27652 28731
27650 *2769 28732
27651 27650 28733
27652 27651 28739
*2761 27652 *2872
27650 *2860 28730
27651 28730 28731
27652 28731 28732
*2762 28732 28733
27650 28733 28739
27651 28739 *28730
27652 *2861 2860
*2763 28730 2861
27650 28731 2862
27651 28732 2863
27652 28733 2864
*2764 28739 2865
27650 *2862 2866
27651 28730 2867
27652 28731 2869
*27650 28732 2870
2760 28733 2871
2761 28739 2872
2762 *2863 28730
2763 28730 28731
2764 28731 28732
27650 28732 28733
27651 28733 28739
27652 28739 2874
2766 *2864 2875
2767 28730 2878
2769 28731 2879
*27651 28732 *28731
2760 28733 2860
2761 28739 2861
2762 *2865 2862
2763 28730 2863
2764 28731 2864
27650 28732 2865
27651 28733 2866
27652 28739 2867
2766 *2866 2869
2767 28730 2870
2769 28731 2871

2872 28730 29211

28730 28731 29212
28731 28732 2922
28732 28733 29281
28733 28739 29282
28739 2874 29283
2874 2875 29284
2875 2878 29289
2878 2879 2929
2879 *2874 29381
*28732 28730 29382
2860 28731 29383
2861 28732 29384
2862 28733 30300
2863 28739 30301
2864 *2875 30302
2865 28730 30390
2866 28731 30391
2867 28732 30392
2869 28733 30400
2870 28739 30401
2871 *2878 30402
2872 28730 30410
28730 28731 30411
28731 28732 30412
28732 28733 30420
28733 28739 30421
28739 *2879 30422
2874 28730 30440
2875 28731 30441
2878 28732 30442
2879 28733 30450
*28733 28739 30451
2860 *28981 30452
2861 28730 30460
2862 28731 30461
2863 28732 30462
2864 28733 30470
2865 28739 30471
2866 *28982 30472
2867 28730 30480
2869 28731 30481
2870 28732 30482
2871 28733 30490
2872 28739 30491
28730 *28989 30492
28731 28730 30500
28732 28731 30501
28733 28732 30502
28739 28733 30530
2874 28739 30531
2875 *2899 30532
2878 28730 30540
2879 28731 30541
*28739 28732 30542
2860 28733 30550
2861 28739 30551
2862 *29182 30552
2863 2910 30560
2864 2911 30561
2865 2912 30562
2866 2913 30570
2867 2914 30571
2869 29181 30572
2870 29189 30590
2871 2919 30591
2872 2920 30592

*29285 30552 56721

2910 30560 56722
2911 30561 56723
2912 30562 56729
2913 30570 56738
2914 30571 56739
29181 30572 56781
29189 30590 56782
2919 30591 56789
2920 30592 5679
29211 7105 *56722
29212 *34461 5670
2922 59960 5671
29281 59969 56721
29282 *42682 56722
29283 4260 56723
29284 42612 56729
29289 42613 56738
2929 42653 56739
29381 42654 56781
29382 4266 56782
29383 4267 56789
29384 42681 5679
30300 42689 *56723
30301 4269 5670
30302 4270 5671
30390 4271 56721
30391 4272 56722
30392 42731 56723
30400 42732 56729
30401 42741 56738
30402 42742 56739
30410 *51881 56781
30411 79901 56782
30412 79902 56789
30420 *51882 5679
30421 79901 *56729
30422 79902 5670
30440 *51883 5671
30441 79901 56721
30442 79902 56722
30450 *51884 56723
30451 79901 56729
30452 79902 56738
30460 *5670 56739
30461 56721 56781
30462 56722 56782
30470 56723 56789
30471 56729 5679
30472 56738 *56731
30480 56739 56731
30481 56781 7280
30482 56782 72886
30490 56789 72888
30491 *5671 *56738
30492 56721 5670
30500 56722 5671
30501 56723 56721
30502 56729 56722
30530 56738 56723
30531 56739 56729
30532 56781 56738
30540 56782 56739
30541 56789 56781
30542 *56721 56782
30550 5670 56789
30551 5671 5679

*56739 56738 5854

5670 56739 5855
5671 56781 5856
56721 56782 5859
56722 56789 *5812
56723 *5699 5851
56729 56721 5852
56738 56722 5853
56739 56723 5854
56781 56729 5855
56782 56738 5856
56789 56739 5859
5679 56781 *5813
*56781 56782 5851
5670 56789 5852
5671 *5800 5853
56721 5851 5854
56722 5852 5855
56723 5853 5856
56729 5854 5859
56738 5855 *58181
56739 5856 5851
56781 5859 5852
56782 *5804 5853
56789 5851 5854
5679 5852 5855
*56782 5853 5856
5670 5854 5859
5671 5855 *58189
56721 5856 5851
56722 5859 5852
56723 *58081 5853
56729 5851 5854
56738 5852 5855
56739 5853 5856
56781 5854 5859
56782 5855 *5819
56789 5856 5851
5679 5859 5852
*56789 *58089 5853
5670 5851 5854
5671 5852 5855
56721 5853 5856
56722 5854 5859
56723 5855 *5820
56729 5856 5851
56738 5859 5852
56739 *5809 5853
56781 5851 5854
56782 5852 5855
56789 5853 5856
5679 5854 5859
*5679 5855 *5821
56721 5856 5851
56722 5859 5852
56723 *5810 5853
56729 5851 5854
56738 5852 5855
56739 5853 5856
56781 5854 5859
56782 5855 *5822
56789 5856 5851
*56989 5859 5852
56721 *5811 5853
56722 5851 5854
56723 5852 5855
56729 5853 5856

5859 5852 5855

*5824 5853 5856
5851 5854 5859
5852 5855 *5849
5853 5856 5851
5854 5859 5852
5855 *5837 5853
5856 5851 5854
5859 5852 5855
*58281 5853 5856
5851 5854 5859
5852 5855 *5851
5853 5856 5800
5854 5859 5804
5855 *58381 58081
5856 5851 58089
5859 5852 5809
*58289 5853 5810
5851 5854 5811
5852 5855 5812
5853 5856 5813
5854 5859 58181
5855 *58389 58189
5856 5851 5819
5859 5852 5834
*5829 5853 5845
5851 5854 5846
5852 5855 5847
5853 5856 5848
5854 5859 5849
5855 *5839 5851
5856 5851 5852
5859 5852 5853
*5830 5853 5854
5851 5854 5855
5852 5855 5856
5853 5856 5859
5854 5859 59010
5855 *5845 59011
5856 5851 5902
5859 5852 5903
*5831 5853 59080
5851 5854 59081
5852 5855 5909
5853 5856 591
5854 5859 *5852
5855 *5846 5800
5856 5851 5804
5859 5852 58081
*5832 5853 58089
5851 5854 5809
5852 5855 5810
5853 5856 5811
5854 5859 5812
5855 *5847 5813
5856 5851 58181
5859 5852 58189
*5834 5853 5819
5851 5854 5834
5852 5855 5845
5853 5856 5846
5854 5859 5847
5855 *5848 5848
5856 5851 5849
5859 5852 5851
*5836 5853 5852
5851 5854 5853

5854 5853 5852

5855 5854 5853
5856 5855 5854
5859 5856 5855
59010 5859 5856
59011 59010 5859
5902 59011 59010
5903 5902 59011
59080 5903 5902
59081 59080 5903
5909 59081 59080
591 5909 59081
*5853 591 5909
5800 *5855 591
5804 5800 *5859
58081 5804 5800
58089 58081 5804
5809 58089 58081
5810 5809 58089
5811 5810 5809
5812 5811 5810
5813 5812 5811
58181 5813 5812
58189 58181 5813
5819 58189 58181
5834 5819 58189
5845 5834 5819
5846 5845 5834
5847 5846 5845
5848 5847 5846
5849 5848 5847
5851 5849 5848
5852 5851 5849
5853 5852 5851
5854 5853 5852
5855 5854 5853
5856 5855 5854
5859 5856 5855
59010 5859 5856
59011 59010 5859
5902 59011 59010
5903 5902 59011
59080 5903 5902
59081 59080 5903
5909 59081 59080
591 5909 59081
*5854 591 5909
5800 *5856 591
5804 5800 *586
58081 5804 5851
58089 58081 5852
5809 58089 5853
5810 5809 5854
5811 5810 5855
5812 5811 5856
5813 5812 5859
58181 5813 *587
58189 58181 5851
5819 58189 5852
5834 5819 5853
5845 5834 5854
5846 5845 5855
5847 5846 5856
5848 5847 5859
5849 5848 *5880
5851 5849 5851
5852 5851 5852

5853 5856 5851

5854 5859 5852
5855 *59001 5853
5856 5851 5854
5859 5852 5855
*5881 5853 5856
5851 5854 5859
5852 5855 *5921
5853 5856 59960
5854 5859 59969
5855 *59010 *5929
5856 5851 59960
5859 5852 59969
*58881 5853 *5930
5851 5854 5851
5852 5855 5852
5853 5856 5853
5854 5859 5854
5855 *59011 5855
5856 5851 5856
5859 5852 5859
*58889 5853 *5931
5851 5854 5851
5852 5855 5852
5853 5856 5853
5854 5859 5854
5855 *5902 5855
5856 5851 5856
5859 5852 5859
*5889 5853 *5932
5851 5854 5851
5852 5855 5852
5853 5856 5853
5854 5859 5854
5855 *5903 5855
5856 5851 5856
5859 5852 5859
*5890 5853 *5933
5851 5854 59960
5852 5855 59969
5853 5856 *5934
5854 5859 59960
5855 *59080 59969
5856 5851 *5935
5859 5852 59960
*5891 5853 59969
5851 5854 *59389
5852 5855 5851
5853 5856 5852
5854 5859 5853
5855 *59081 5854
5856 5851 5855
5859 5852 5856
*5899 5853 5859
5851 5854 59960
5852 5855 59969
5853 5856 *5939
5854 5859 5851
5855 *5909 5852
5856 5851 5853
5859 5852 5854
*59000 5853 5855
5851 5854 5856
5852 5855 5859
5853 5856 59960
5854 5859 59969
5855 *591 *5940

59960 59969 78820

59969 *5970 78829
*5941 59960 *59969
59960 59969 5921
59969 *59780 5935
*5942 59960 5950
59960 59969 5951
59969 *59781 5952
*5948 59960 5954
59960 59969 59581
59969 *59789 59582
*5949 59960 59589
59960 59969 5959
59969 *59800 5970
*5950 59960 5981
59960 59969 5982
59969 *59801 5990
*5951 59960 5994
59960 59969 59960
59969 *5981 59969
*5952 59960 78820
59960 59969 78829
59969 *5982 *5997
*5953 59960 5851
59960 59969 5852
59969 *5988 5853
*5954 59960 5854
59960 59969 5855
59969 *5989 5856
*59581 59960 5859
59960 59969 59960
59969 *5990 59969
*59582 59960 *59981
59960 59969 5851
59969 *5991 5852
*59589 59960 5853
59960 59969 5854
59969 *5992 5855
*5959 59960 5856
59960 59969 5859
59969 *5993 59960
*5960 59960 59969
59960 59969 *59982
59969 *5994 5851
*59651 59960 5852
59960 59969 5853
59969 *5995 5854
*59652 59960 5855
59960 59969 5856
59969 *59960 5859
*59653 5921 59960
59960 5935 59969
59969 5950 *59983
*59654 5951 5851
59960 5952 5852
59969 5954 5853
*59655 59581 5854
59960 59582 5855
59969 59589 5856
*59659 5959 5859
59960 5970 59960
59969 5981 59969
*5968 5982 *59984
59960 5990 5851
59969 5994 5852
*5969 59960 5853
59960 59969 5854

5855 *6018 5855

5856 59960 5856
5859 59969 5859
59960 *6019 59960
59969 59960 59969
*59989 59969 *75312
5851 *6020 5851
5852 59960 5852
5853 59969 5853
5854 *6021 5854
5855 59960 5855
5856 59969 5856
5859 *6022 5859
59960 59960 59960
59969 59969 59969
*5999 *6023 *75313
5851 59960 5851
5852 59969 5852
5853 *6028 5853
5854 59960 5854
5855 59969 5855
5856 *6029 5856
5859 59960 5859
59960 59969 59960
59969 *7280 59969
*60000 56731 *75314
59960 *72811 5851
59969 56731 5852
*60001 *72812 5853
59960 56731 5854
59969 *72813 5855
*60010 56731 5856
59960 *72819 5859
59969 56731 59960
*60011 *7282 59969
59960 56731 *75315
59969 *7283 5851
*60020 56731 5852
59960 *72881 5853
59969 56731 5854
*60021 *72886 5855
59960 56731 5856
59969 *7530 5859
*6003 5851 59960
59960 5852 59969
59969 5853 *75316
*60090 5854 5851
59960 5855 5852
59969 5856 5853
*60091 5859 5854
59960 59960 5855
59969 59969 5856
*6010 *75310 5859
59960 5851 59960
59969 5852 59969
*6011 5853 *75317
59960 5854 5851
59969 5855 5852
*6012 5856 5853
59960 5859 5854
59969 59960 5855
*6013 59969 5856
59960 *75311 5859
59969 5851 59960
*6014 5852 59969
59960 5853 *75319
59969 5854 5851

5852 59969 7705

5853 *7534 7707
5854 59960 77084
5855 59969 77086
5856 *7535 *77011
5859 59960 7685
59960 59969 769
59969 *7536 7700
*75320 59960 77012
5851 59969 77014
5852 *7537 77016
5853 59960 77018
5854 59969 7702
5855 *7538 7703
5856 59960 7704
5859 59969 7705
59960 *7539 7707
59969 5851 77084
*75321 5852 77086
5851 5853 *77012
5852 5854 7685
5853 5855 769
5854 5856 7700
5855 5859 77012
5856 59960 77014
5859 59969 77016
59960 *7685 77018
59969 77012 7702
*75322 77014 7703
5851 77016 7704
5852 77018 7705
5853 77086 7707
5854 *7686 77084
5855 77012 77086
5856 77014 *77013
5859 77016 7685
59960 77018 769
59969 77086 7700
*75323 *7689 77012
5851 77012 77014
5852 77014 77016
5853 77016 77018
5854 77018 7702
5855 77086 7703
5856 *769 7704
5859 77012 7705
59960 77014 7707
59969 77016 77084
*75329 77018 77086
5851 77086 *77014
5852 *7700 7685
5853 77012 769
5854 77014 7700
5855 77016 77012
5856 77018 77014
5859 77086 77016
59960 *77010 77018
59969 7685 7702
*7533 769 7703
5851 7700 7704
5852 77012 7705
5853 77014 7707
5854 77016 77084
5855 77018 77086
5856 7702 *77015
5859 7703 7685
59960 7704 769

7700 77018 769

77012 77086 7700
77014 *7704 77012
77016 77012 77014
77018 77014 77016
7702 77016 77018
7703 77018 7702
7704 77086 7703
7705 *7705 7704
7707 77012 7705
77084 77014 7707
77086 77016 77084
*77016 77018 77086
7685 77086 *77089
769 *7706 77012
7700 77012 77014
77012 77014 77016
77014 77016 77018
77016 77018 77086
77018 77086 *7709
7702 *7707 77012
7703 77012 77014
7704 77014 77016
7705 77016 77018
7707 77018 77086
77084 77086 *77981
77086 *77081 77012
*77017 77012 77014
7685 77014 77016
769 77016 77018
7700 77018 77086
77012 77086 *77982
77014 *77082 77012
77016 77012 77014
77018 77014 77016
7702 77016 77018
7703 77018 77086
7704 77086 *77983
7705 *77083 77012
7707 77012 77014
77084 77014 77016
77086 77016 77018
*77018 77018 77086
7685 77086 *77984
769 *77084 76501
7700 77012 76502
77012 77014 76503
77014 77016 76504
77016 77018 76505
77018 77086 76506
7702 *77085 76507
7703 7685 76508
7704 769 7670
7705 7700 76711
7707 77012 7685
77084 77014 769
77086 77016 7700
*7702 77018 77012
77012 7702 77014
77014 7703 77016
77016 7704 77018
77018 7705 7702
77086 7707 7703
*7703 77084 7704
77012 77086 7705
77014 *77086 7707
77016 7685 77084

77086 44024 99679

7710 78001 *99641
7711 78003 99640
7713 7801 99641
77181 78031 99642
77183 78039 99643
77210 7817 99644
77211 7854 99645
77212 78550 99646
77213 78551 99647
77214 78552 99649
7722 78559 99657
7724 7863 99660
7725 78820 99666
7730 78829 99667
7731 7895 99669
7732 7907 99670
7733 7911 99677
7734 7913 99678
7740 79901 99679
7741 79902 *99642
7742 7991 99640
77430 7994 99641
77431 *78099 99642
77439 79901 99643
7744 79902 99644
7745 *7881 99645
7747 59960 99646
7751 59969 99647
7752 *7980 99649
7753 79901 99657
7754 79902 99660
7755 *79901 99666
7756 79901 99667
7757 79902 99669
7760 7991 99670
7761 *79902 99677
7762 79901 99678
7763 79902 99679
7771 7991 *99643
7772 *7991 99640
7775 79901 99641
7776 79902 99642
7780 *79981 99643
7790 79901 99644
7791 79902 99645
7797 *79989 99646
*77989 79901 99647
77012 79902 99649
77014 *99640 99657
77016 99640 99660
77018 99641 99666
77086 99642 99667
*78091 99643 99669
79901 99644 99670
79902 99645 99677
*78092 99646 99678
79901 99647 99679
79902 99649 *99644
*78093 99657 99640
79901 99660 99641
79902 99666 99642
*78094 99667 99643
79901 99669 99644
79902 99670 99645
*78095 99677 99646
04082 99678 99647

99649 *99649 99647

99657 99640 99649
99660 99641 *99799
99666 99642 99640
99667 99643 99641
99669 99644 99642
99670 99645 99643
99677 99646 99644
99678 99647 99645
99679 99649 99646
*99645 99657 99647
99640 99660 99649
99641 99666 *99881
99642 99667 99640
99643 99669 99641
99644 99670 99642
99645 99677 99643
99646 99678 99644
99647 99679 99645
99649 *99666 99646
99657 99640 99647
99660 99641 99649
99666 99642 *99883
99667 99643 99640
99669 99644 99641
99670 99645 99642
99677 99646 99643
99678 99647 99644
99679 99649 99645
*99646 *99667 99646
99640 99640 99647
99641 99641 99649
99642 99642 *99889
99643 99643 99640
99644 99644 99641
99645 99645 99642
99646 99646 99643
99647 99647 99644
99649 99649 99645
99657 *99677 99646
99660 99640 99647
99666 99641 99649
99667 99642 *9989
99669 99643 99640
99670 99644 99641
99677 99645 99642
99678 99646 99643
99679 99647 99644
*99647 99649 99645
99640 *99678 99646
99641 99640 99647
99642 99641 99649
99643 99642 *V460
99644 99643 V4613
99645 99644 V4614
99646 99645 *V4611
99647 99646 V4613
99649 99647 V4614
99657 99649 *V4612
99660 *99791 V4613
99666 99640 V4614
99667 99641 *V4613
99669 99642 V4611
99670 99643 V4612
99677 99644 V4613
99678 99645 V4614
99679 99646 *V4614
TABLE 6G.—ADDITIONS TO THE CC TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC
[CCs that are added to the list are included in [CCs that are deleted from the list are in- [CCs that are deleted from the list are in-
this table. Each of the principal diagnoses is cluded in this table. Each of the principal di- cluded in this table. Each of the principal di-
shown with an asterisk, and the revisions to agnoses is shown with an asterisk, and the agnoses is shown with an asterisk, and the
the CC Exclusions List are provided in an revisions to the CC Exclusions List are pro- revisions to the CC Exclusions List are pro-
indented column immediately following the vided in an indented column immediately vided in an indented column immediately
affected principal diagnosis.] following the affected principal diagnosis.] following the affected principal diagnosis.]
V4611 *25082 2873

V4612 585 *2872
V4613 *25083 2873
V4614 585 *2873
*V462 *25090 2860
V4613 585 2861
V4614 *25091 2862
*V468 585 2863
V4613 *25092 2864
V4614 585 2865
*V469 *25093 2866
V4613 585 2867
V4614 *27410 2869
585 2870
TABLE 6H.—DELETIONS FROM THE CC *27411 2871
5996 2872
EXCLUSIONS LIST *27419 2873
[CCs that are deleted from the list are in- 585 2874
cluded in this table. Each of the principal di- *2760 2875
agnoses is shown with an asterisk, and the 2765 2878
revisions to the CC Exclusions List are pro-
vided in an indented column immediately *2761 2879
following the affected principal diagnosis.] 2765 *2874
*2762 2873
*185 2765 *2875
5996 *2763 2873
*1880 2765 *2878
5996 *2764 2873
*1881 2765 *2879
5996 *2765 2873
*1882 2760 *28981
5996 2761 2873
*1883 2762 *28982
5996 2763 2873
*1884 2764 *28989
5996 2765 2873
*1885 2766 *2899
5996 2767 2873
*1886 2769 *34461
5996 *2766 5996
*1887 2765 *5670
5996 *2767 5672
*1888 2765 5678
5996 *2768 *5671
*1889 2765 5672
5996 *2769 5678
*1892 2765 *5672
5996 *2860 5670
*1893 2873 5671
5996 *2861 5672
*1894 2873 5678
5996 *2862 5679
*1898 2873 *5678
5996 *2863 5670
*1899 2873 5671
5996 *2864 5672
*25040 2873 5678
585 *2865 5679
*25041 2873 *5679
585 *2866 5672
*25042 2873 5678
585 *2867 *56989
*25043 2873 5672
585 *2869 5678
*25080 2873 *5699
585 *2870 5672
*25081 2873 5678
585 *2871 *5800
TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC
[CCs that are deleted from the list are in- [CCs that are deleted from the list are in- [CCs that are deleted from the list are in-
cluded in this table. Each of the principal di- cluded in this table. Each of the principal di- cluded in this table. Each of the principal di-
agnoses is shown with an asterisk, and the agnoses is shown with an asterisk, and the agnoses is shown with an asterisk, and the
revisions to the CC Exclusions List are pro- revisions to the CC Exclusions List are pro- revisions to the CC Exclusions List are pro-
vided in an indented column immediately vided in an indented column immediately vided in an indented column immediately
following the affected principal diagnosis.] following the affected principal diagnosis.] following the affected principal diagnosis.]
585 5804 5996

*5804 58081 *5929
585 58089 5996
*58081 5809 *5930
585 5810 585
*58089 5811 *5931
585 5812 585
*5809 5813 *5932
585 58181 585
*5810 58189 *5933
585 5819 5996
*5811 5834 *5934
585 5845 5996
*5812 5846 *5935
585 5847 5996
*5813 5848 *59389
585 5849 585
*58181 585 5996
585 59010 *5939
*58189 59011 585
585 5902 5996
*5819 5903 *5940
585 59080 5996
*5820 59081 *5941
585 5909 5996
*5821 591 *5942
585 *586 5996
*5822 585 *5948
585 *587 5996
*5824 585 *5949
585 *5880 5996
*58281 585 *5950
585 *5881 5996
*58289 585 *5951
585 *58881 5996
*5829 585 *5952
585 *58889 5996
*5830 585 *5953
585 *5889 5996
*5831 585 *5954
585 *5890 5996
*5832 585 *59581
585 *5891 5996
*5834 585 *59582
585 *5899 5996
*5836 585 *59589
585 *59000 5996
*5837 585 *5959
585 *59001 5996
*58381 585 *5960
585 *59010 5996
*58389 585 *59651
585 *59011 5996
*5839 585 *59652
585 *5902 5996
*5845 585 *59653
585 *5903 5996
*5846 585 *59654
585 *59080 5996
*5847 585 *59655
585 *59081 5996
*5848 585 *59659
585 *5909 5996
*5849 585 *5968
585 *591 5996
*585 585 *5969
5800 *5921 5996
*5970 585 *75315

5996 5996 585
*59780 *5999 5996
5996 585 *75316
*59781 5996 585
5996 *60000 5996
*59789 5996 *75317
5996 *60001 585
*59800 5996 5996
5996 *60010 *75319
*59801 5996 585
5996 *60011 5996
*5981 5996 *75320
5996 *60020 585
*5982 5996 5996
5996 *60021 *75321
*5988 5996 585
5996 *6003 5996
*5989 5996 *75322
5996 *60090 585
*5990 5996 5996
5996 *60091 *75323
*5991 5996 585
5996 *6010 5996
*5992 5996 *75329
5996 *6011 585
*5993 5996 5996
5996 *6012 *7533
*5994 5996 585
5996 *6013 5996
*5995 5996 *7534
5996 *6014 5996
*5996 5996 *7535
5921 *6018 5996
5935 5996 *7536
5950 *6019 5996
5951 5996 *7537
5952 *6020 5996
5954 5996 *7538
59581 *6021 5996
59582 5996 *7539
59589 *6022 585
5959 5996 5996
5970 *6023 *7685
5981 5996 7701
5982 *6028 *7686
5990 5996 7701
5994 *6029 *7689
5996 5996 7701
78820 *7530 *769
78829 585 7701
*5997 5996 *7700
585 *75310 7701
5996 585 *7701
*59981 5996 7685
585 *75311 769
5996 585 7700
*59982 5996 7701
585 *75312 7702
5996 585 7703
*59983 5996 7704
585 *75313 7705
5996 585 7707
*59984 5996 77084
585 *75314 *7702
5996 585 7701
*59989 5996 *7703
7701 7701 *99666

*7704 *77982 9964
7701 7701 *99667
*7705 *77983 9964
7701 7701 *99677
*7706 *77989
7701 7701 9964
*7707 *7881 *99678
7701 5996 9964
*77081 *7990 *99791
7701 7991 9964
*77082 *9964 *99799
7701 9964 9964
*77083 99657 *99881
7701 99660
9964
*77084 99666
*99883
7701 99667
*77089 99669 9964
7701 99670 *99889
*7709 99677 9964
7701 99678 *9989
*77981 99679 9964
TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY

[FY 2004 MedPAR Update March 2005 GROUPER V22.0]
Number Arithmetic 10th 25th 50th 75th 90th

DRG discharges mean LOS percentile percentile percentile percentile percentile
1 ............................................................... 23,402 9.8463 3 5 8 13 19

2 ............................................................... 10,428 4.5661 1 2 4 6 9
3 ............................................................... 4 9.5000 1 1 8 14 15
6 ............................................................... 413 3.0363 1 1 2 4 7
7 ............................................................... 15,700 9.3193 2 4 7 12 19
8 ............................................................... 3,735 2.8600 1 1 2 4 7
9 ............................................................... 1,970 6.2162 1 3 4 7 12
10 ............................................................. 19,627 6.0182 2 3 5 8 12
11 ............................................................. 3,290 3.7620 1 2 3 5 7
12 ............................................................. 54,743 5.3802 2 3 4 6 10
13 ............................................................. 7,425 4.9494 2 3 4 6 8
14 ............................................................. 238,142 5.6618 2 3 4 7 11
15 ............................................................. 76,495 4.5219 1 2 4 6 8
16 ............................................................. 16,350 6.3544 2 3 5 8 12
17 ............................................................. 3,024 3.2183 1 2 2 4 6
18 ............................................................. 33,332 5.2661 2 3 4 7 10
19 ............................................................. 8,625 3.4419 1 2 3 4 6
20 ............................................................. 6,591 9.8490 3 5 8 13 19
21 ............................................................. 2,218 6.3120 2 3 5 8 13
22 ............................................................. 3,333 5.2187 2 2 4 7 10
23 ............................................................. 10,801 3.8931 1 2 3 5 7
24 ............................................................. 64,348 4.7323 1 2 4 6 9
25 ............................................................. 28,409 3.1271 1 2 3 4 6
26 ............................................................. 18 6.2778 1 2 3 4 8
27 ............................................................. 5,462 5.1531 1 1 3 6 11
28 ............................................................. 17,705 5.7497 1 3 4 7 12
29 ............................................................. 6,356 3.3211 1 1 3 4 6
30 ............................................................. 1 19.0000 19 19 19 19 19
31 ............................................................. 5,189 3.9726 1 2 3 5 8
32 ............................................................. 2,030 2.3975 1 1 2 3 5
34 ............................................................. 28,017 4.7706 1 2 4 6 9
35 ............................................................. 7,947 3.0042 1 1 3 4 6
36 ............................................................. 1,477 1.6019 1 1 1 1 3
37 ............................................................. 1,253 4.1564 1 1 3 5 9
38 ............................................................. 56 3.5179 1 1 2 4 6
39 ............................................................. 449 2.3742 1 1 1 2 5
40 ............................................................. 1,395 4.1004 1 1 4 5 8
42 ............................................................. 1,156 2.7578 1 1 2 4 6
TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued


43 ............................................................. 125 3.1440 1 1 2 4 6

44 ............................................................. 1,171 4.7976 2 3 4 6 8
45 ............................................................. 2,819 3.0816 1 2 2 4 6
46 ............................................................. 3,837 4.1780 1 2 3 5 8
47 ............................................................. 1,346 2.8886 1 1 2 4 5
49 ............................................................. 2,490 4.3831 1 2 3 5 8
50 ............................................................. 2,183 1.8140 1 1 1 2 3
51 ............................................................. 191 2.7539 1 1 1 3 6
52 ............................................................. 166 1.9759 1 1 1 2 4
53 ............................................................. 2,241 3.9487 1 1 2 5 9
54 ............................................................. 1 7.0000 7 7 7 7 7
55 ............................................................. 1,364 3.1239 1 1 2 4 7
56 ............................................................. 445 2.5730 1 1 1 3 6
57 ............................................................. 705 4.1447 1 1 2 5 9
59 ............................................................. 104 2.6058 1 1 1 3 6
60 ............................................................. 8 3.2500 1 1 2 4 4
61 ............................................................. 222 5.3694 1 1 3 7 12
63 ............................................................. 2,880 4.4705 1 2 3 5 9
64 ............................................................. 3,370 6.0576 1 2 4 8 13
65 ............................................................. 41,607 2.7731 1 1 2 3 5
66 ............................................................. 8,052 3.1333 1 1 2 4 6
67 ............................................................. 420 3.6810 1 2 3 4 7
68 ............................................................. 17,401 3.9725 1 2 3 5 7
69 ............................................................. 4,841 3.0283 1 2 3 4 5
70 ............................................................. 26 2.3462 1 2 2 3 3
71 ............................................................. 68 4.0000 1 2 3 5 7
72 ............................................................. 1,073 3.4418 1 2 3 4 7
73 ............................................................. 7,996 4.3779 1 2 3 6 9
74 ............................................................. 4 2.5000 2 2 2 3 3
75 ............................................................. 45,262 9.8107 3 5 7 12 20
76 ............................................................. 47,617 10.8370 3 5 8 13 21
77 ............................................................. 2,173 4.6558 1 2 4 6 9
78 ............................................................. 45,896 6.2537 2 4 6 8 10
79 ............................................................. 171,263 8.2002 3 4 7 10 15
80 ............................................................. 7,757 5.3673 2 3 4 7 10
81 ............................................................. 5 9.8000 3 3 11 13 14
82 ............................................................. 65,516 6.6893 2 3 5 9 13
83 ............................................................. 7,091 5.2293 2 3 4 7 10
84 ............................................................. 1,502 3.1478 1 2 3 4 6
85 ............................................................. 21,990 6.2299 2 3 5 8 12
86 ............................................................. 1,868 3.6156 1 2 3 5 7
87 ............................................................. 83,132 6.4294 2 3 5 8 12
88 ............................................................. 415,743 4.9005 2 3 4 6 9
89 ............................................................. 553,059 5.6479 2 3 5 7 10
90 ............................................................. 46,079 3.8094 2 2 3 5 7
91 ............................................................. 48 4.3542 1 2 3 5 9
92 ............................................................. 16,584 5.9982 2 3 5 8 11
93 ............................................................. 1,613 3.8407 1 2 3 5 7
94 ............................................................. 13,459 6.1299 2 3 5 8 12
95 ............................................................. 1,631 3.6297 1 2 3 5 7
96 ............................................................. 59,418 4.3758 2 2 4 5 8
97 ............................................................. 27,175 3.3845 1 2 3 4 6
98 ............................................................. 9 2.5556 1 2 3 3 3
99 ............................................................. 21,688 3.1166 1 1 2 4 6
100 ........................................................... 7,002 2.1133 1 1 2 3 4
101 ........................................................... 23,315 4.2565 1 2 3 5 8
102 ........................................................... 5,292 2.4934 1 1 2 3 5
103 ........................................................... 748 37.8115 8 12 23 49 79
104 ........................................................... 21,097 14.4820 6 8 12 18 25
105 ........................................................... 31,872 9.9383 4 6 8 12 18
106 ........................................................... 3,549 11.1972 5 7 9 13 19
107 ........................................................... 70,700 10.4839 5 7 9 12 17
108 ........................................................... 8,933 9.8282 1 5 8 12 19
109 ........................................................... 51,135 7.7541 4 5 6 9 13
110 ........................................................... 57,502 8.3925 1 3 7 11 17
111 ........................................................... 10,144 3.4310 1 1 3 5 7
113 ........................................................... 37,476 12.6142 4 6 10 16 24
114 ........................................................... 8,583 8.4620 2 4 7 11 16
115 ........................................................... 22,284 6.8149 1 2 5 9 14
116 ........................................................... 119,388 4.2595 1 1 3 6 9


117 ........................................................... 5,173 4.2295 1 1 2 5 10

118 ........................................................... 7,652 3.0387 1 1 2 4 7
119 ........................................................... 998 5.4920 1 1 3 7 13
120 ........................................................... 36,527 9.0471 1 3 6 12 20
121 ........................................................... 160,225 6.2477 2 3 5 8 12
122 ........................................................... 62,124 3.3835 1 2 3 4 6
123 ........................................................... 33,796 4.8114 1 1 3 6 11
124 ........................................................... 131,668 4.3935 1 2 3 6 9
125 ........................................................... 96,650 2.7212 1 1 2 3 5
126 ........................................................... 5,867 11.3414 3 6 9 14 21
127 ........................................................... 699,142 5.1265 2 3 4 6 10
128 ........................................................... 5,201 5.1650 2 3 5 6 9
129 ........................................................... 3,781 2.6006 1 1 1 3 6
130 ........................................................... 89,637 5.4262 1 3 5 7 10
131 ........................................................... 23,960 3.8028 1 2 4 5 7
132 ........................................................... 117,958 2.8045 1 1 2 3 5
133 ........................................................... 7,345 2.1799 1 1 2 3 4
134 ........................................................... 42,681 3.1055 1 2 2 4 6
135 ........................................................... 7,481 4.2929 1 2 3 5 8
136 ........................................................... 1,137 2.7502 1 1 2 3 5
138 ........................................................... 208,073 3.9146 1 2 3 5 7
139 ........................................................... 79,030 2.4358 1 1 2 3 5
140 ........................................................... 38,463 2.4369 1 1 2 3 5
141 ........................................................... 122,553 3.4612 1 2 3 4 6
142 ........................................................... 52,544 2.4784 1 1 2 3 5
143 ........................................................... 250,910 2.0938 1 1 2 3 4
144 ........................................................... 100,554 5.7002 1 2 4 7 12
145 ........................................................... 6,244 2.6099 1 1 2 3 5
146 ........................................................... 10,816 9.8879 5 6 8 12 17
147 ........................................................... 2,652 5.8111 3 4 6 7 9
148 ........................................................... 136,357 12.0947 5 7 9 15 22
149 ........................................................... 20,021 5.9451 3 4 6 7 9
150 ........................................................... 22,835 10.8915 4 6 9 14 20
151 ........................................................... 5,389 5.1297 1 2 5 7 10
152 ........................................................... 5,038 8.0369 3 5 7 9 14
153 ........................................................... 2,104 4.9729 2 3 5 6 8
154 ........................................................... 28,656 13.0578 3 6 10 16 25
155 ........................................................... 6,190 4.1359 1 2 3 6 8
156 ........................................................... 6 24.1667 1 5 9 27 27
157 ........................................................... 8,309 5.7232 1 2 4 7 12
158 ........................................................... 4,131 2.6069 1 1 2 3 5
159 ........................................................... 19,267 5.1221 1 2 4 7 10
160 ........................................................... 12,067 2.6627 1 1 2 3 5
161 ........................................................... 10,462 4.3990 1 2 3 6 9
162 ........................................................... 5,528 2.0801 1 1 1 3 4
163 ........................................................... 10 2.9000 1 1 2 3 6
164 ........................................................... 5,986 7.9820 3 5 7 10 14
165 ........................................................... 2,541 4.2082 2 3 4 5 7
166 ........................................................... 4,973 4.5025 1 2 3 5 9
167 ........................................................... 4,682 2.2179 1 1 2 3 4
168 ........................................................... 1,557 4.9030 1 2 3 6 10
169 ........................................................... 767 2.2934 1 1 2 3 5
170 ........................................................... 17,580 10.7956 2 5 8 14 22
171 ........................................................... 1,494 4.1031 1 2 3 5 8
172 ........................................................... 33,081 6.8370 2 3 5 9 14
173 ........................................................... 2,410 3.5921 1 1 3 5 7
174 ........................................................... 269,091 4.7026 2 3 4 6 9
175 ........................................................... 32,812 2.8895 1 2 2 4 5
176 ........................................................... 14,625 5.1424 2 3 4 6 10
177 ........................................................... 8,603 4.4328 2 2 4 5 8
178 ........................................................... 2,924 3.1211 1 2 3 4 5
179 ........................................................... 14,542 5.8548 2 3 5 7 11
180 ........................................................... 92,648 5.3227 2 3 4 7 10
181 ........................................................... 26,045 3.3267 1 2 3 4 6
182 ........................................................... 293,770 4.4295 1 2 3 5 8
183 ........................................................... 87,104 2.8668 1 1 2 4 5
184 ........................................................... 81 3.2840 1 2 2 4 6
185 ........................................................... 5,754 4.4944 1 2 3 5 9
186 ........................................................... 4 2.0000 1 1 1 3 3
187 ........................................................... 634 4.1514 1 2 3 5 8


188 ........................................................... 91,501 5.5437 1 2 4 7 11

189 ........................................................... 13,270 3.0916 1 1 2 4 6
190 ........................................................... 70 4.3286 1 2 3 5 8
191 ........................................................... 10,475 12.7179 3 6 9 16 26
192 ........................................................... 1,329 5.6764 1 3 5 7 10
193 ........................................................... 4,535 12.0485 5 7 10 15 22
194 ........................................................... 524 6.6660 3 4 6 8 11
195 ........................................................... 3,262 10.6125 4 6 9 13 19
196 ........................................................... 703 5.7070 2 4 5 7 9
197 ........................................................... 17,409 9.1025 3 5 7 11 17
198 ........................................................... 4,664 4.3216 2 3 4 6 7
199 ........................................................... 1,430 9.5203 2 4 7 13 19
200 ........................................................... 942 9.7187 1 4 7 13 20
201 ........................................................... 2,684 13.7299 3 6 10 18 28
202 ........................................................... 27,484 6.1745 2 3 5 8 12
203 ........................................................... 31,852 6.4862 2 3 5 8 13
204 ........................................................... 73,333 5.5299 2 3 4 7 11
205 ........................................................... 31,719 5.9002 2 3 4 7 12
206 ........................................................... 2,095 3.8788 1 2 3 5 8
207 ........................................................... 35,947 5.2368 1 2 4 7 10
208 ........................................................... 9,830 2.9347 1 1 2 4 6
209 ........................................................... 464,512 4.5650 3 3 4 5 7
210 ........................................................... 129,184 6.6984 3 4 6 8 11
211 ........................................................... 26,872 4.6683 3 3 4 5 7
212 ........................................................... 10 2.9000 1 1 3 4 4
213 ........................................................... 10,326 9.1100 2 4 7 12 18
216 ........................................................... 17,774 5.7605 1 1 3 8 14
217 ........................................................... 17,790 12.4693 3 5 9 15 26
218 ........................................................... 29,029 5.4549 2 3 4 7 10
219 ........................................................... 21,589 3.1095 1 2 3 4 5
220 ........................................................... 4 2.7500 2 2 3 3 3
223 ........................................................... 13,562 3.2145 1 1 2 4 6
224 ........................................................... 11,013 1.8900 1 1 1 2 3
225 ........................................................... 6,609 5.1607 1 2 4 7 11
226 ........................................................... 6,717 6.3484 1 2 4 8 13
227 ........................................................... 5,138 2.6086 1 1 2 3 5
228 ........................................................... 2,665 4.1403 1 1 3 5 9
229 ........................................................... 1,217 2.5094 1 1 2 3 5
230 ........................................................... 2,591 5.5832 1 2 4 7 12
232 ........................................................... 736 2.8139 1 1 1 3 6
233 ........................................................... 15,214 6.6706 1 2 5 9 14
234 ........................................................... 7,745 2.7898 1 1 2 4 6
235 ........................................................... 5,010 4.6415 1 2 4 6 9
236 ........................................................... 42,665 4.4765 1 3 4 5 8
237 ........................................................... 2,035 3.6644 1 2 3 4 7
238 ........................................................... 9,940 8.3339 3 4 6 10 16
239 ........................................................... 43,175 6.0614 2 3 5 7 11
240 ........................................................... 12,753 6.6181 2 3 5 8 13
241 ........................................................... 2,717 3.7004 1 2 3 5 7
242 ........................................................... 2,758 6.6164 2 3 5 8 13
243 ........................................................... 102,299 4.5163 1 2 4 6 8
244 ........................................................... 15,863 4.4900 1 2 4 6 8
245 ........................................................... 5,870 3.1295 1 1 3 4 6
246 ........................................................... 1,437 3.5783 1 2 3 4 7
247 ........................................................... 21,831 3.3168 1 2 3 4 6
248 ........................................................... 15,210 4.8406 1 3 4 6 9
249 ........................................................... 14,161 3.8764 1 1 3 5 8
250 ........................................................... 4,194 3.8884 1 2 3 5 7
251 ........................................................... 2,168 2.7495 1 1 3 3 5
252 ........................................................... 1 1.0000 1 1 1 1 1
253 ........................................................... 25,052 4.5304 2 3 4 5 8
254 ........................................................... 10,503 3.0475 1 2 3 4 5
255 ........................................................... 1 7.0000 7 7 7 7 7
256 ........................................................... 7,214 5.0349 1 2 4 6 10
257 ........................................................... 13,587 2.6109 1 1 2 3 5
258 ........................................................... 12,118 1.7490 1 1 1 2 3
259 ........................................................... 2,910 2.7680 1 1 1 3 7
260 ........................................................... 3,001 1.4045 1 1 1 1 2
261 ........................................................... 1,630 2.2092 1 1 1 2 4
262 ........................................................... 641 4.8222 1 2 4 7 10


263 ........................................................... 23,953 10.7683 3 5 8 13 21

264 ........................................................... 3,948 6.2497 2 3 5 8 12
265 ........................................................... 4,335 6.6046 1 2 4 8 14
266 ........................................................... 2,335 3.1764 1 1 2 4 7
267 ........................................................... 272 4.1838 1 1 3 5 10
268 ........................................................... 1,038 3.5308 1 1 2 4 7
269 ........................................................... 10,761 8.3312 2 4 6 11 16
270 ........................................................... 2,661 3.8200 1 1 3 5 8
271 ........................................................... 21,218 6.8298 2 3 5 8 13
272 ........................................................... 5,964 5.8273 2 3 4 7 11
273 ........................................................... 1,358 3.6406 1 2 3 5 7
274 ........................................................... 2,303 6.2731 2 3 5 8 12
275 ........................................................... 228 3.2500 1 1 2 4 7
276 ........................................................... 1,451 4.4590 1 2 4 6 8
277 ........................................................... 113,037 5.5031 2 3 5 7 10
278 ........................................................... 34,072 4.0544 2 2 3 5 7
279 ........................................................... 8 4.3750 1 1 5 6 6
280 ........................................................... 19,468 4.0057 1 2 3 5 7
281 ........................................................... 7,192 2.8411 1 1 2 4 5
283 ........................................................... 6,300 4.5775 1 2 3 6 9
284 ........................................................... 1,847 3.0238 1 1 2 4 6
285 ........................................................... 7,696 10.0444 3 5 8 12 19
286 ........................................................... 2,715 5.4748 2 2 4 6 10
287 ........................................................... 6,162 9.9081 3 5 7 12 19
288 ........................................................... 10,604 4.1167 2 2 3 4 7
289 ........................................................... 6,923 2.5524 1 1 1 2 5
290 ........................................................... 10,937 2.1306 1 1 1 2 4
291 ........................................................... 67 2.7761 1 1 1 2 4
292 ........................................................... 7,377 10.0538 2 4 8 13 20
293 ........................................................... 370 4.4568 1 2 3 6 9
294 ........................................................... 99,631 4.2903 1 2 3 5 8
295 ........................................................... 4,143 3.6667 1 2 3 4 7
296 ........................................................... 256,039 4.7212 1 2 4 6 9
297 ........................................................... 45,622 3.0707 1 2 3 4 6
298 ........................................................... 86 3.9302 1 1 2 4 7
299 ........................................................... 1,497 5.1670 1 2 4 6 10
300 ........................................................... 21,447 5.8676 2 3 5 7 11
301 ........................................................... 3,916 3.4068 1 2 3 4 6
302 ........................................................... 9,903 8.1703 4 5 6 9 14
303 ........................................................... 23,854 7.3928 3 4 6 9 14
304 ........................................................... 13,932 8.4913 2 3 6 11 18
305 ........................................................... 3,110 3.2077 1 2 3 4 6
306 ........................................................... 6,364 5.4788 1 2 3 8 13
307 ........................................................... 2,075 2.0733 1 1 2 2 3
308 ........................................................... 7,123 6.1189 1 2 4 8 14
309 ........................................................... 3,585 2.0006 1 1 1 2 4
310 ........................................................... 26,164 4.5252 1 2 3 6 10
311 ........................................................... 6,530 1.8778 1 1 1 2 3
312 ........................................................... 1,464 4.8347 1 1 3 6 11
313 ........................................................... 514 2.2082 1 1 2 3 4
314 ........................................................... 1 2.0000 2 2 2 2 2
315 ........................................................... 36,882 6.7594 1 1 4 9 16
316 ........................................................... 182,009 6.2874 2 3 5 8 12
317 ........................................................... 2,798 3.4578 1 1 2 4 7
318 ........................................................... 5,961 5.7412 1 2 4 7 11
319 ........................................................... 388 2.7784 1 1 2 3 6
320 ........................................................... 219,838 5.0956 2 3 4 6 9
321 ........................................................... 31,579 3.5951 1 2 3 4 6
322 ........................................................... 65 3.4462 2 2 3 4 6
323 ........................................................... 20,616 3.0939 1 1 2 4 6
324 ........................................................... 5,451 1.8835 1 1 1 2 3
325 ........................................................... 9,685 3.6823 1 2 3 5 7
326 ........................................................... 2,596 2.6221 1 1 2 3 5
327 ........................................................... 5 2.6000 1 1 2 3 5
328 ........................................................... 611 3.4583 1 1 3 5 7
329 ........................................................... 72 1.8333 1 1 1 2 3
331 ........................................................... 55,177 5.4326 1 2 4 7 11
332 ........................................................... 4,439 3.1246 1 1 2 4 6
333 ........................................................... 260 5.3923 1 2 3 6 13
334 ........................................................... 9,878 4.2963 2 2 3 5 7


335 ........................................................... 12,049 2.6821 1 2 3 3 4

336 ........................................................... 31,389 3.2999 1 2 2 4 7
337 ........................................................... 25,268 1.9183 1 1 2 2 3
338 ........................................................... 653 6.1884 1 2 3 9 14
339 ........................................................... 1,259 5.1096 1 1 3 7 11
340 ........................................................... 2 5.0000 4 4 6 6 6
341 ........................................................... 3,196 3.1621 1 1 2 3 7
342 ........................................................... 566 3.4223 1 2 2 4 7
344 ........................................................... 2,702 2.7028 1 1 1 2 6
345 ........................................................... 1,465 4.8007 1 1 3 6 11
346 ........................................................... 3,993 5.7250 1 3 4 7 11
347 ........................................................... 250 3.0640 1 1 2 4 7
348 ........................................................... 4,202 4.0888 1 2 3 5 8
349 ........................................................... 579 2.3523 1 1 2 3 4
350 ........................................................... 7,188 4.4509 2 2 4 5 8
352 ........................................................... 984 4.0061 1 2 3 5 8
353 ........................................................... 2,745 6.3100 2 3 4 7 12
354 ........................................................... 7,648 5.6951 2 3 4 6 10
355 ........................................................... 4,958 3.0621 2 2 3 4 4
356 ........................................................... 24,123 1.9262 1 1 2 2 3
357 ........................................................... 5,589 8.1313 3 4 6 10 15
358 ........................................................... 20,933 3.9643 2 2 3 4 7
359 ........................................................... 28,972 2.4053 1 2 2 3 4
360 ........................................................... 14,861 2.5888 1 1 2 3 4
361 ........................................................... 276 3.0072 1 1 2 3 7
362 ........................................................... 2 1.0000 1 1 1 1 1
363 ........................................................... 2,144 3.7733 1 2 2 4 8
364 ........................................................... 1,464 4.1858 1 2 3 5 9
365 ........................................................... 1,628 7.7279 2 3 5 9 17
366 ........................................................... 4,822 6.4942 1 3 5 8 13
367 ........................................................... 459 2.9891 1 1 2 4 6
368 ........................................................... 3,941 6.6420 2 3 5 8 13
369 ........................................................... 3,645 3.2483 1 1 2 4 6
370 ........................................................... 1,892 5.1723 2 3 4 5 8
371 ........................................................... 2,309 3.4171 2 3 3 4 5
372 ........................................................... 1,179 3.1688 2 2 2 3 5
373 ........................................................... 4,967 2.2350 1 2 2 3 3
374 ........................................................... 160 2.7688 2 2 2 3 5
375 ........................................................... 6 4.0000 1 2 2 6 6
376 ........................................................... 403 3.3945 1 2 2 4 7
377 ........................................................... 78 4.5000 1 1 3 4 8
378 ........................................................... 197 2.3147 1 1 2 3 4
379 ........................................................... 511 2.8043 1 1 2 3 6
380 ........................................................... 93 2.0860 1 1 1 2 4
381 ........................................................... 217 2.2396 1 1 1 2 4
382 ........................................................... 43 1.4419 1 1 1 2 2
383 ........................................................... 2,515 3.6509 1 1 2 4 7
384 ........................................................... 134 2.5522 1 1 1 3 5
385 ........................................................... 1 1.0000 1 1 1 1 1
389 ........................................................... 2 87.5000 21 21 154 154 154
390 ........................................................... 2 2.5000 1 1 4 4 4
392 ........................................................... 2,223 9.1939 2 4 6 11 19
393 ........................................................... 1 4.0000 4 4 4 4 4
394 ........................................................... 2,840 7.3718 1 2 5 9 16
395 ........................................................... 116,839 4.2599 1 2 3 5 8
396 ........................................................... 10 4.2000 1 2 2 3 6
397 ........................................................... 18,586 5.1464 1 2 4 6 10
398 ........................................................... 18,416 5.7084 2 3 4 7 11
399 ........................................................... 1,659 3.3207 1 2 3 4 6
401 ........................................................... 6,364 11.0506 2 5 9 14 22
402 ........................................................... 1,414 4.0304 1 1 3 5 9
403 ........................................................... 32,036 7.9373 2 3 6 10 16
404 ........................................................... 3,825 4.1485 1 2 3 5 8
406 ........................................................... 2,235 9.8868 2 4 7 12 21
407 ........................................................... 589 3.8200 1 2 3 5 7
408 ........................................................... 2,183 8.2171 1 2 5 10 19
409 ........................................................... 1,818 5.7948 1 3 4 6 12
410 ........................................................... 28,563 3.8313 1 2 3 5 6
411 ........................................................... 12 3.2500 1 2 2 4 4
412 ........................................................... 12 2.7500 1 1 1 3 4


413 ........................................................... 5,229 6.7569 2 3 5 9 13

414 ........................................................... 576 4.0260 1 2 3 5 8
415 ........................................................... 51,153 14.0354 4 6 11 18 28
416 ........................................................... 240,311 7.3872 2 3 6 9 14
417 ........................................................... 22 4.0455 1 2 3 5 7
418 ........................................................... 28,788 6.1952 2 3 5 8 12
419 ........................................................... 16,399 4.3887 1 2 3 5 8
420 ........................................................... 2,961 3.3810 1 2 3 4 6
421 ........................................................... 11,952 4.0628 1 2 3 5 7
422 ........................................................... 53 3.7358 1 1 2 5 7
423 ........................................................... 8,704 8.2135 2 3 6 10 17
424 ........................................................... 1,078 12.4017 2 4 8 14 22
425 ........................................................... 14,887 3.4519 1 1 3 4 7
426 ........................................................... 4,353 4.1358 1 2 3 5 8
427 ........................................................... 1,519 4.7110 1 2 3 5 9
428 ........................................................... 777 7.2844 1 2 5 8 15
429 ........................................................... 25,617 5.4610 2 3 4 6 10
430 ........................................................... 71,987 7.6793 2 3 6 9 15
431 ........................................................... 309 5.8576 1 2 4 7 12
432 ........................................................... 422 4.2583 1 2 3 5 8
433 ........................................................... 5,227 2.9629 1 1 2 3 6
439 ........................................................... 1,756 8.8844 1 3 5 10 19
440 ........................................................... 5,670 8.8106 2 3 6 10 18
441 ........................................................... 786 3.3804 1 1 2 4 7
442 ........................................................... 18,167 8.6812 2 3 6 11 18
443 ........................................................... 3,422 3.3928 1 1 3 4 7
444 ........................................................... 5,949 4.0309 1 2 3 5 8
445 ........................................................... 2,376 2.8283 1 1 2 4 5
447 ........................................................... 6,296 2.5681 1 1 2 3 5
448 ........................................................... 1 2.0000 2 2 2 2 2
449 ........................................................... 39,204 3.6748 1 1 3 4 7
450 ........................................................... 7,880 1.9868 1 1 1 2 4
451 ........................................................... 3 1.6667 1 1 1 3 3
452 ........................................................... 27,882 4.9010 1 2 3 6 10
453 ........................................................... 5,499 2.7978 1 1 2 3 5
454 ........................................................... 3,874 4.1033 1 2 3 5 8
455 ........................................................... 855 2.2187 1 1 2 3 4
461 ........................................................... 2,752 5.1286 1 1 3 6 12
462 ........................................................... 7,839 10.2341 4 6 8 13 19
463 ........................................................... 31,249 3.8966 1 2 3 5 7
464 ........................................................... 7,700 2.9153 1 1 2 4 5
465 ........................................................... 226 3.7566 1 1 2 5 8
466 ........................................................... 1,429 5.2645 1 1 2 5 10
467 ........................................................... 1,023 2.6755 1 1 2 3 5
468 ........................................................... 50,812 12.8282 3 6 10 16 25
471 ........................................................... 15,754 5.0523 3 3 4 5 8
473 ........................................................... 8,839 12.4395 2 3 7 18 32
475 ........................................................... 117,173 11.0464 2 5 9 15 22
476 ........................................................... 3,040 10.4967 2 4 9 14 21
477 ........................................................... 29,601 8.5271 1 3 6 11 18
478 ........................................................... 114,427 7.0983 1 2 5 9 15
479 ........................................................... 24,838 2.7842 1 1 2 4 6
480 ........................................................... 823 17.9380 7 8 13 22 36
481 ........................................................... 1,099 21.7543 9 16 20 25 35
482 ........................................................... 5,100 11.5082 4 6 9 14 21
484 ........................................................... 468 12.7906 2 6 10 17 25
485 ........................................................... 3,476 9.6530 4 5 7 12 18
486 ........................................................... 2,662 12.3681 2 5 10 16 25
487 ........................................................... 4,804 7.0760 1 3 5 9 14
488 ........................................................... 798 16.3972 4 7 13 22 35
489 ........................................................... 13,587 8.3522 2 3 6 10 17
490 ........................................................... 5,255 5.3753 1 2 4 7 11
491 ........................................................... 19,972 3.1398 1 2 3 3 5
492 ........................................................... 4,033 13.6677 3 5 6 23 31
493 ........................................................... 61,926 6.0526 1 3 5 8 12
494 ........................................................... 25,786 2.6794 1 1 2 4 5
495 ........................................................... 315 17.4127 8 9 13 20 31
496 ........................................................... 3,319 8.9708 3 4 6 11 18
497 ........................................................... 29,820 6.0519 3 4 5 7 10
498 ........................................................... 19,770 3.7891 2 3 3 5 6


499 ........................................................... 35,931 4.3194 1 2 3 5 9

500 ........................................................... 48,926 2.2388 1 1 2 3 4
501 ........................................................... 3,144 9.9078 4 5 8 13 18
502 ........................................................... 721 5.7406 2 3 5 7 9
503 ........................................................... 5,983 3.8369 1 2 3 5 7
504 ........................................................... 189 27.2116 8 16 23 36 49
505 ........................................................... 181 4.6354 1 1 1 6 11
506 ........................................................... 1,010 15.8822 3 7 13 21 33
507 ........................................................... 311 8.4662 1 3 7 11 18
508 ........................................................... 645 7.2341 1 3 5 9 16
509 ........................................................... 171 5.1345 1 2 3 6 11
510 ........................................................... 1,770 6.4068 1 2 4 8 14
511 ........................................................... 640 4.0531 1 1 2 4 8
512 ........................................................... 539 12.7737 7 8 10 13 23
513 ........................................................... 233 9.9356 5 7 8 12 16
515 ........................................................... 27,658 4.2880 1 1 2 6 11
516 ........................................................... 38,925 4.7852 2 2 4 6 9
517 ........................................................... 66,832 2.5758 1 1 1 3 6
518 ........................................................... 41,407 3.4769 1 1 2 4 8
519 ........................................................... 11,642 4.8104 1 1 3 6 11
520 ........................................................... 15,531 2.0012 1 1 1 2 4
521 ........................................................... 32,416 5.4724 2 3 4 7 11
522 ........................................................... 5,684 9.3895 3 4 7 12 19
523 ........................................................... 16,002 3.8933 1 2 3 5 7
524 ........................................................... 119,564 3.1912 1 2 3 4 6
525 ........................................................... 323 13.2477 1 3 8 15 31
526 ........................................................... 56,224 4.3526 1 2 3 5 8
527 ........................................................... 194,348 2.2279 1 1 1 2 5
528 ........................................................... 1,777 17.1486 6 10 15 22 30
529 ........................................................... 4,046 7.9983 1 2 5 10 18
530 ........................................................... 2,370 3.1224 1 1 2 4 6
531 ........................................................... 4,846 9.4191 2 4 7 12 20
532 ........................................................... 2,659 3.7131 1 1 3 5 8
533 ........................................................... 47,840 3.7569 1 1 2 4 9
534 ........................................................... 45,532 1.7911 1 1 1 2 3
535 ........................................................... 13,099 8.2594 1 3 7 11 17
536 ........................................................... 19,770 5.4062 1 2 4 7 12
537 ........................................................... 8,711 6.7751 1 3 5 8 14
538 ........................................................... 5,655 2.8233 1 1 2 3 6
539 ........................................................... 5,041 10.8242 2 4 7 14 23
540 ........................................................... 1,518 3.5870 1 1 3 4 7
541 ........................................................... 22,675 43.1644 17 25 36 52 77
542 ........................................................... 24,573 32.6658 12 18 27 40 58
543 ........................................................... 5,471 12.0068 2 5 10 16 24
12,216,080
TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY


DRG discharges Mean LOS percentile percentile percentile percentile percentile
1 ............................................................... 23,407 9.8451 3 5 8 13 19

2 ............................................................... 10,422 4.5659 1 2 4 6 9
3 ............................................................... 4 9.5 1 1 8 14 15
6 ............................................................... 413 3.0363 1 1 2 4 7
7 ............................................................... 15,520 9.3891 2 4 7 12 19
8 ............................................................... 3,497 2.9548 1 1 2 4 7
9 ............................................................... 1,970 6.2162 1 3 4 7 12
10 ............................................................. 19,633 6.0172 2 3 5 8 12
11 ............................................................. 3,284 3.7643 1 2 3 5 8
12 ............................................................. 54,743 5.3802 2 3 4 6 10
13 ............................................................. 7,425 4.9494 2 3 4 6 8
14 ............................................................. 235,884 5.6478 2 3 4 7 11
15 ............................................................. 76,495 4.5219 1 2 4 6 8
16 ............................................................. 16,366 6.3522 2 3 5 8 12
17 ............................................................. 3,008 3.2134 1 2 2 4 6
18 ............................................................. 33,343 5.2655 2 3 4 7 10
TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued


19 ............................................................. 8,614 3.4418 1 2 3 4 6

20 ............................................................. 6,591 9.849 3 5 8 13 19
21 ............................................................. 2,218 6.312 2 3 5 8 13
22 ............................................................. 3,333 5.2187 2 2 4 7 10
23 ............................................................. 10,801 3.8931 1 2 3 5 7
24 ............................................................. 64,424 4.7297 1 2 4 6 9
25 ............................................................. 28,333 3.1286 1 2 3 4 6
26 ............................................................. 18 6.2778 1 2 3 4 8
27 ............................................................. 5,462 5.1531 1 1 3 6 11
28 ............................................................. 17,714 5.749 1 3 4 7 12
29 ............................................................. 6,347 3.3198 1 1 3 4 6
30 ............................................................. 1 19 19 19 19 19 19
31 ............................................................. 5,190 3.9726 1 2 3 5 8
32 ............................................................. 2,029 2.3967 1 1 2 3 5
34 ............................................................. 26,697 4.7673 1 2 4 6 9
35 ............................................................. 7,689 3.0061 1 1 3 4 6
36 ............................................................. 1,477 1.6019 1 1 1 1 3
37 ............................................................. 1,253 4.1564 1 1 3 5 9
38 ............................................................. 56 3.5179 1 1 2 4 6
39 ............................................................. 449 2.3742 1 1 1 2 5
40 ............................................................. 1,395 4.1004 1 1 4 5 8
42 ............................................................. 1,156 2.7578 1 1 2 4 6
43 ............................................................. 125 3.144 1 1 2 4 6
44 ............................................................. 1,171 4.7976 2 3 4 6 8
45 ............................................................. 2,819 3.0816 1 2 2 4 6
46 ............................................................. 3,837 4.178 1 2 3 5 8
47 ............................................................. 1,346 2.8886 1 1 2 4 5
49 ............................................................. 2,491 4.3826 1 2 3 5 8
50 ............................................................. 2,183 1.814 1 1 1 2 3
51 ............................................................. 191 2.7539 1 1 1 3 6
52 ............................................................. 333 1.9129 1 1 1 2 3
53 ............................................................. 2,259 3.9354 1 1 2 5 9
54 ............................................................. 1 7 7 7 7 7 7
55 ............................................................. 1,367 3.1207 1 1 2 4 7
56 ............................................................. 447 2.5682 1 1 1 3 6
57 ............................................................. 920 3.5989 1 1 2 4 8
59 ............................................................. 105 2.5905 1 1 1 3 6
60 ............................................................. 9 3 1 1 2 4 4
61 ............................................................. 222 5.3694 1 1 3 7 12
63 ............................................................. 2,902 4.501 1 2 3 5 9
64 ............................................................. 3,370 6.0576 1 2 4 8 13
65 ............................................................. 41,607 2.7731 1 1 2 3 5
66 ............................................................. 8,052 3.1333 1 1 2 4 6
67 ............................................................. 420 3.681 1 2 3 4 7
68 ............................................................. 17,478 3.9693 1 2 3 5 7
69 ............................................................. 4,764 3.0246 1 2 3 4 5
70 ............................................................. 26 2.3462 1 2 2 3 3
71 ............................................................. 68 4 1 2 3 5 7
72 ............................................................. 1,073 3.4418 1 2 3 4 7
73 ............................................................. 9,574 4.4027 1 2 3 6 9
74 ............................................................. 4 2.5 2 2 2 3 3
75 ............................................................. 45,259 9.8105 3 5 7 12 20
76 ............................................................. 47,648 10.8335 3 5 8 13 21
77 ............................................................. 2,142 4.6438 1 2 4 6 9
78 ............................................................. 45,896 6.2537 2 4 6 8 10
79 ............................................................. 171,506 8.1955 3 4 7 10 15
80 ............................................................. 7,514 5.383 2 3 4 7 10
81 ............................................................. 5 9.8 3 3 11 13 14
82 ............................................................. 65,516 6.6893 2 3 5 9 13
83 ............................................................. 7,121 5.2219 2 3 4 7 10
84 ............................................................. 1,472 3.1413 1 2 3 4 6
85 ............................................................. 22,034 6.2247 2 3 5 8 12
86 ............................................................. 1,824 3.6151 1 2 3 5 7
87 ............................................................. 83,132 6.4294 2 3 5 8 12
88 ............................................................. 415,743 4.9005 2 3 4 6 9
89 ............................................................. 554,672 5.6426 2 3 5 7 10
90 ............................................................. 44,466 3.8085 2 2 3 5 7
91 ............................................................. 48 4.3542 1 2 3 5 9
92 ............................................................. 16,675 5.9867 2 3 5 8 11
93 ............................................................. 1,522 3.8371 1 2 3 5 7


94 ............................................................. 13,468 6.1288 2 3 5 8 12

95 ............................................................. 1,622 3.6245 1 2 3 5 7
96 ............................................................. 60,100 4.3643 2 2 4 5 8
97 ............................................................. 26,493 3.385 1 2 3 4 6
98 ............................................................. 9 2.5556 1 2 3 3 3
99 ............................................................. 21,768 3.1137 1 1 2 4 6
100 ........................................................... 6,922 2.1108 1 1 2 3 4
101 ........................................................... 23,407 4.2505 1 2 3 5 8
102 ........................................................... 5,200 2.4892 1 1 2 3 5
103 ........................................................... 755 37.6159 8 12 23 48 79
104 ........................................................... 21,072 14.4891 6 8 12 18 25
105 ........................................................... 31,848 9.94 4 6 8 12 18
106 ........................................................... 3,544 11.2015 5 7 9 13 19
108 ........................................................... 9,311 10.8565 4 6 9 13 20
110 ........................................................... 56,311 8.3074 1 3 6 10 17
111 ........................................................... 10,039 3.4017 1 1 3 5 7
113 ........................................................... 37,476 12.6142 4 6 10 16 24
114 ........................................................... 8,583 8.462 2 4 7 11 16
117 ........................................................... 5,173 4.2295 1 1 2 5 10
118 ........................................................... 7,652 3.0387 1 1 2 4 7
119 ........................................................... 998 5.492 1 1 3 7 13
120 ........................................................... 36,527 9.0471 1 3 6 12 20
121 ........................................................... 160,170 6.2471 2 3 5 8 12
122 ........................................................... 62,110 3.383 1 2 3 4 6
123 ........................................................... 33,796 4.8114 1 1 3 6 11
124 ........................................................... 131,668 4.3935 1 2 3 6 9
125 ........................................................... 96,650 2.7212 1 1 2 3 5
126 ........................................................... 5,867 11.3414 3 6 9 14 21
127 ........................................................... 699,142 5.1265 2 3 4 6 10
128 ........................................................... 5,201 5.165 2 3 5 6 9
129 ........................................................... 3,781 2.6006 1 1 1 3 6
130 ........................................................... 89,660 5.4256 1 3 5 7 10
131 ........................................................... 23,937 3.8036 1 2 4 5 7
132 ........................................................... 117,968 2.8045 1 1 2 3 5
133 ........................................................... 7,335 2.1793 1 1 2 3 4
134 ........................................................... 42,681 3.1055 1 2 2 4 6
135 ........................................................... 7,482 4.2926 1 2 3 5 8
136 ........................................................... 1,136 2.7509 1 1 2 3 5
138 ........................................................... 208,165 3.914 1 2 3 5 7
139 ........................................................... 78,938 2.4356 1 1 2 3 5
140 ........................................................... 38,463 2.4369 1 1 2 3 5
141 ........................................................... 122,656 3.4603 1 2 3 4 6
142 ........................................................... 52,441 2.4785 1 1 2 3 5
143 ........................................................... 250,910 2.0938 1 1 2 3 4
144 ........................................................... 100,597 5.6989 1 2 4 7 12
145 ........................................................... 6,201 2.6093 1 1 2 3 5
146 ........................................................... 10,816 9.8879 5 6 8 12 17
147 ........................................................... 2,652 5.8111 3 4 6 7 9
148 ........................................................... 136,377 12.094 5 7 9 15 22
149 ........................................................... 20,001 5.9437 3 4 6 7 9
150 ........................................................... 22,841 10.8905 4 6 9 14 20
151 ........................................................... 5,383 5.1274 1 2 5 7 10
152 ........................................................... 5,039 8.0367 3 5 7 9 14
153 ........................................................... 2,103 4.9719 2 3 5 6 8
154 ........................................................... 28,663 13.0553 3 6 10 16 25
155 ........................................................... 6,182 4.1349 1 2 3 6 8
156 ........................................................... 6 24.1667 1 5 9 27 27
157 ........................................................... 8,313 5.7218 1 2 4 7 12
158 ........................................................... 4,127 2.6067 1 1 2 3 5
159 ........................................................... 19,282 5.1208 1 2 4 7 10
160 ........................................................... 12,052 2.6618 1 1 2 3 5
161 ........................................................... 10,467 4.3978 1 2 3 6 9
162 ........................................................... 5,523 2.0802 1 1 1 3 4
163 ........................................................... 10 2.9 1 1 2 3 6
164 ........................................................... 5,991 7.9806 3 5 7 10 14
165 ........................................................... 2,536 4.2039 2 3 4 5 7
166 ........................................................... 4,978 4.5026 1 2 3 5 9
167 ........................................................... 4,677 2.2153 1 1 2 3 4
168 ........................................................... 1,565 4.8907 1 2 3 6 10
169 ........................................................... 778 2.2969 1 1 2 3 5


170 ........................................................... 17,581 10.7952 2 5 8 14 22

171 ........................................................... 1,493 4.1025 1 2 3 5 8
172 ........................................................... 33,087 6.8372 2 3 5 9 14
173 ........................................................... 2,404 3.5815 1 1 3 5 7
174 ........................................................... 269,113 4.7025 2 3 4 6 9
175 ........................................................... 32,790 2.8894 1 2 2 4 5
176 ........................................................... 14,625 5.1424 2 3 4 6 10
177 ........................................................... 8,605 4.4335 2 2 4 5 8
178 ........................................................... 2,922 3.1181 1 2 3 4 5
179 ........................................................... 14,542 5.8548 2 3 5 7 11
180 ........................................................... 92,667 5.3223 2 3 4 7 10
181 ........................................................... 26,026 3.3268 1 2 3 4 6
182 ........................................................... 293,882 4.4288 1 2 3 5 8
183 ........................................................... 86,992 2.8669 1 1 2 4 5
184 ........................................................... 81 3.284 1 2 2 4 6
185 ........................................................... 5,754 4.4944 1 2 3 5 9
186 ........................................................... 4 2 1 1 1 3 3
187 ........................................................... 634 4.1514 1 2 3 5 8
188 ........................................................... 91,507 5.5436 1 2 4 7 11
189 ........................................................... 13,264 3.0913 1 1 2 4 6
190 ........................................................... 70 4.3286 1 2 3 5 8
191 ........................................................... 10,476 12.7174 3 6 9 16 26
192 ........................................................... 1,328 5.6755 1 3 5 7 10
193 ........................................................... 4,536 12.0476 5 7 10 15 22
194 ........................................................... 523 6.6635 3 4 6 8 11
195 ........................................................... 3,262 10.6125 4 6 9 13 19
196 ........................................................... 703 5.707 2 4 5 7 9
197 ........................................................... 17,419 9.0995 3 5 7 11 17
198 ........................................................... 4,653 4.3215 2 3 4 6 7
199 ........................................................... 1,430 9.5203 2 4 7 13 19
200 ........................................................... 942 9.7187 1 4 7 13 20
201 ........................................................... 2,684 13.7299 3 6 10 18 28
202 ........................................................... 27,484 6.1745 2 3 5 8 12
203 ........................................................... 31,852 6.4862 2 3 5 8 13
204 ........................................................... 73,333 5.5299 2 3 4 7 11
205 ........................................................... 31,724 5.8998 2 3 4 7 12
206 ........................................................... 2,090 3.8804 1 2 3 5 8
207 ........................................................... 35,951 5.2367 1 2 4 7 10
208 ........................................................... 9,826 2.9341 1 1 2 4 6
210 ........................................................... 129,253 6.6973 3 4 6 8 11
211 ........................................................... 26,803 4.6683 3 3 4 5 7
212 ........................................................... 10 2.9 1 1 3 4 4
213 ........................................................... 10,326 9.11 2 4 7 12 18
216 ........................................................... 17,774 5.7605 1 1 3 8 14
217 ........................................................... 17,790 12.4693 3 5 9 15 26
218 ........................................................... 29,060 5.4537 2 3 4 7 10
219 ........................................................... 21,558 3.1077 1 2 3 4 5
220 ........................................................... 4 2.75 2 2 3 3 3
223 ........................................................... 13,578 3.2155 1 1 2 4 6
224 ........................................................... 10,998 1.8869 1 1 1 2 3
225 ........................................................... 6,609 5.1607 1 2 4 7 11
226 ........................................................... 6,725 6.3486 1 2 4 8 13
227 ........................................................... 5,130 2.6025 1 1 2 3 5
228 ........................................................... 2,665 4.1403 1 1 3 5 9
229 ........................................................... 1,217 2.5094 1 1 2 3 5
230 ........................................................... 2,591 5.5832 1 2 4 7 12
232 ........................................................... 735 2.815 1 1 1 3 6
233 ........................................................... 15,221 6.6695 1 2 5 9 14
234 ........................................................... 7,738 2.7886 1 1 2 4 6
235 ........................................................... 5,010 4.6415 1 2 4 6 9
236 ........................................................... 42,665 4.4765 1 3 4 5 8
237 ........................................................... 2,035 3.6644 1 2 3 4 7
238 ........................................................... 9,940 8.3339 3 4 6 10 16
239 ........................................................... 43,175 6.0614 2 3 5 7 11
240 ........................................................... 12,757 6.6172 2 3 5 8 13
241 ........................................................... 2,713 3.7003 1 2 3 5 7
242 ........................................................... 2,758 6.6164 2 3 5 8 13
243 ........................................................... 102,299 4.5163 1 2 4 6 8
244 ........................................................... 15,871 4.4895 1 2 4 6 8
245 ........................................................... 5,862 3.129 1 1 3 4 6


246 ........................................................... 1,437 3.5783 1 2 3 4 7

247 ........................................................... 21,831 3.3168 1 2 3 4 6
248 ........................................................... 15,210 4.8406 1 3 4 6 9
249 ........................................................... 14,161 3.8764 1 1 3 5 8
250 ........................................................... 4,199 3.8876 1 2 3 5 7
251 ........................................................... 2,163 2.7485 1 1 3 3 5
252 ........................................................... 1 1 1 1 1 1 1
253 ........................................................... 25,073 4.5295 2 3 4 5 8
254 ........................................................... 10,482 3.0467 1 2 3 4 5
255 ........................................................... 1 7 7 7 7 7 7
256 ........................................................... 7,214 5.0349 1 2 4 6 10
257 ........................................................... 13,593 2.6106 1 1 2 3 5
258 ........................................................... 12,112 1.7488 1 1 1 2 3
259 ........................................................... 2,912 2.7679 1 1 1 3 7
260 ........................................................... 2,999 1.4038 1 1 1 1 2
261 ........................................................... 1,630 2.2092 1 1 1 2 4
262 ........................................................... 641 4.8222 1 2 4 7 10
263 ........................................................... 23,959 10.7669 3 5 8 13 21
264 ........................................................... 3,942 6.2511 2 3 5 8 12
265 ........................................................... 4,339 6.6036 1 2 4 8 14
266 ........................................................... 2,331 3.1725 1 1 2 4 7
267 ........................................................... 272 4.1838 1 1 3 5 10
268 ........................................................... 1,038 3.5308 1 1 2 4 7
269 ........................................................... 10,763 8.3298 2 4 6 11 16
270 ........................................................... 2,658 3.8209 1 1 3 5 8
271 ........................................................... 21,218 6.8298 2 3 5 8 13
272 ........................................................... 5,966 5.8265 2 3 4 7 11
273 ........................................................... 1,356 3.6409 1 2 3 5 7
274 ........................................................... 2,304 6.2708 2 3 5 8 12
275 ........................................................... 227 3.2599 1 1 2 4 7
276 ........................................................... 1,451 4.459 1 2 4 6 8
277 ........................................................... 113,079 5.5031 2 3 5 7 10
278 ........................................................... 34,030 4.0527 2 2 3 5 7
279 ........................................................... 8 4.375 1 1 5 6 6
280 ........................................................... 19,491 4.0045 1 2 3 5 7
281 ........................................................... 7,169 2.8407 1 1 2 4 5
283 ........................................................... 6,303 4.5766 1 2 3 6 9
284 ........................................................... 1,844 3.0244 1 1 2 4 6
285 ........................................................... 7,696 10.0444 3 5 8 12 19
286 ........................................................... 2,715 5.4748 2 2 4 6 10
287 ........................................................... 6,162 9.9081 3 5 7 12 19
288 ........................................................... 10,604 4.1167 2 2 3 4 7
289 ........................................................... 6,923 2.5524 1 1 1 2 5
290 ........................................................... 10,937 2.1306 1 1 1 2 4
291 ........................................................... 67 2.7761 1 1 1 2 4
292 ........................................................... 7,378 10.0529 2 4 8 13 20
293 ........................................................... 369 4.4607 1 2 3 6 9
294 ........................................................... 99,631 4.2903 1 2 3 5 8
295 ........................................................... 4,143 3.6667 1 2 3 4 7
296 ........................................................... 256,121 4.7208 1 2 4 6 9
297 ........................................................... 45,540 3.0703 1 2 3 4 6
298 ........................................................... 86 3.9302 1 1 2 4 7
299 ........................................................... 1,497 5.167 1 2 4 6 10
300 ........................................................... 21,452 5.8669 2 3 5 7 11
301 ........................................................... 3,911 3.4076 1 2 3 4 6
302 ........................................................... 9,903 8.1703 4 5 6 9 14
303 ........................................................... 23,854 7.3928 3 4 6 9 14
304 ........................................................... 13,937 8.4896 2 3 6 11 18
305 ........................................................... 3,105 3.2068 1 2 3 4 6
306 ........................................................... 6,364 5.4788 1 2 3 8 13
307 ........................................................... 2,075 2.0733 1 1 2 2 3
308 ........................................................... 7,124 6.1186 1 2 4 8 14
309 ........................................................... 3,584 2 1 1 1 2 4
310 ........................................................... 26,169 4.5248 1 2 3 6 10
311 ........................................................... 6,525 1.8775 1 1 1 2 3
312 ........................................................... 1,464 4.8347 1 1 3 6 11
313 ........................................................... 514 2.2082 1 1 2 3 4
314 ........................................................... 1 2 2 2 2 2 2
315 ........................................................... 36,882 6.7594 1 1 4 9 16
316 ........................................................... 182,009 6.2874 2 3 5 8 12


317 ........................................................... 2,798 3.4578 1 1 2 4 7

318 ........................................................... 5,962 5.7404 1 2 4 7 11
319 ........................................................... 387 2.7829 1 1 2 3 6
320 ........................................................... 219,971 5.0946 2 3 4 6 9
321 ........................................................... 31,446 3.5956 1 2 3 4 6
322 ........................................................... 65 3.4462 2 2 3 4 6
323 ........................................................... 20,619 3.0937 1 1 2 4 6
324 ........................................................... 5,448 1.8834 1 1 1 2 3
325 ........................................................... 9,686 3.6822 1 2 3 5 7
326 ........................................................... 2,595 2.622 1 1 2 3 5
327 ........................................................... 5 2.6 1 1 2 3 5
328 ........................................................... 611 3.4583 1 1 3 5 7
329 ........................................................... 72 1.8333 1 1 1 2 3
331 ........................................................... 55,181 5.4324 1 2 4 7 11
332 ........................................................... 4,435 3.1256 1 1 2 4 6
333 ........................................................... 260 5.3923 1 2 3 6 13
334 ........................................................... 9,887 4.2956 2 2 3 5 7
335 ........................................................... 12,040 2.6815 1 2 3 3 4
336 ........................................................... 31,395 3.2997 1 2 2 4 7
337 ........................................................... 25,262 1.9182 1 1 2 2 3
338 ........................................................... 653 6.1884 1 2 3 9 14
339 ........................................................... 1,259 5.1096 1 1 3 7 11
340 ........................................................... 2 5 4 4 6 6 6
341 ........................................................... 3,196 3.1621 1 1 2 3 7
342 ........................................................... 566 3.4223 1 2 2 4 7
344 ........................................................... 2,702 2.7028 1 1 1 2 6
345 ........................................................... 1,465 4.8007 1 1 3 6 11
346 ........................................................... 3,993 5.725 1 3 4 7 11
347 ........................................................... 250 3.064 1 1 2 4 7
348 ........................................................... 4,202 4.0888 1 2 3 5 8
349 ........................................................... 579 2.3523 1 1 2 3 4
350 ........................................................... 7,188 4.4509 2 2 4 5 8
352 ........................................................... 984 4.0061 1 2 3 5 8
353 ........................................................... 2,745 6.31 2 3 4 7 12
354 ........................................................... 7,655 5.6933 2 3 4 6 10
355 ........................................................... 4,951 3.0612 2 2 3 4 4
356 ........................................................... 24,123 1.9262 1 1 2 2 3
357 ........................................................... 5,589 8.1313 3 4 6 10 15
358 ........................................................... 20,954 3.9633 2 2 3 4 7
359 ........................................................... 28,951 2.4049 1 2 2 3 4
360 ........................................................... 14,861 2.5888 1 1 2 3 4
361 ........................................................... 276 3.0072 1 1 2 3 7
362 ........................................................... 2 1 1 1 1 1 1
363 ........................................................... 2,144 3.7733 1 2 2 4 8
364 ........................................................... 1,464 4.1858 1 2 3 5 9
365 ........................................................... 1,628 7.7279 2 3 5 9 17
366 ........................................................... 4,822 6.4942 1 3 5 8 13
367 ........................................................... 459 2.9891 1 1 2 4 6
368 ........................................................... 3,941 6.642 2 3 5 8 13
369 ........................................................... 3,645 3.2483 1 1 2 4 6
370 ........................................................... 1,892 5.1723 2 3 4 5 8
371 ........................................................... 2,309 3.4171 2 3 3 4 5
372 ........................................................... 1,179 3.1688 2 2 2 3 5
373 ........................................................... 4,967 2.235 1 2 2 3 3
374 ........................................................... 160 2.7688 2 2 2 3 5
375 ........................................................... 5 4.6 2 2 3 6 10
376 ........................................................... 403 3.3945 1 2 2 4 7
377 ........................................................... 78 4.5 1 1 3 4 8
378 ........................................................... 197 2.3147 1 1 2 3 4
379 ........................................................... 511 2.8043 1 1 2 3 6
380 ........................................................... 93 2.086 1 1 1 2 4
381 ........................................................... 217 2.2396 1 1 1 2 4
382 ........................................................... 43 1.4419 1 1 1 2 2
383 ........................................................... 2,515 3.6509 1 1 2 4 7
384 ........................................................... 134 2.5522 1 1 1 3 5
385 ........................................................... 1 1 1 1 1 1 1
389 ........................................................... 2 87.5 21 21 154 154 154
390 ........................................................... 2 2.5 1 1 4 4 4
392 ........................................................... 2,223 9.1939 2 4 6 11 19
393 ........................................................... 1 4 4 4 4 4 4


394 ........................................................... 2,840 7.3718 1 2 5 9 16

395 ........................................................... 116,839 4.2599 1 2 3 5 8
396 ........................................................... 10 4.2 1 2 2 3 6
397 ........................................................... 18,586 5.1464 1 2 4 6 10
398 ........................................................... 18,422 5.7074 2 3 4 7 11
399 ........................................................... 1,653 3.323 1 2 3 4 6
401 ........................................................... 6,366 11.0485 2 5 9 14 22
402 ........................................................... 1,412 4.0297 1 1 3 5 9
403 ........................................................... 32,042 7.9368 2 3 6 10 16
404 ........................................................... 3,819 4.1464 1 2 3 5 8
406 ........................................................... 2,236 9.8837 2 4 7 12 20
407 ........................................................... 588 3.8214 1 2 3 5 7
408 ........................................................... 2,183 8.2171 1 2 5 10 19
409 ........................................................... 1,818 5.7948 1 3 4 6 12
410 ........................................................... 28,563 3.8313 1 2 3 5 6
411 ........................................................... 12 3.25 1 2 2 4 4
412 ........................................................... 12 2.75 1 1 1 3 4
413 ........................................................... 5,230 6.7558 2 3 5 9 13
414 ........................................................... 575 4.0313 1 2 3 5 8
415 ........................................................... 51,152 14.0356 4 6 11 18 28
416 ........................................................... 240,311 7.3872 2 3 6 9 14
417 ........................................................... 22 4.0455 1 2 3 5 7
418 ........................................................... 28,788 6.1952 2 3 5 8 12
419 ........................................................... 16,428 4.389 1 2 3 5 8
420 ........................................................... 2,932 3.3697 1 2 3 4 6
421 ........................................................... 11,952 4.0628 1 2 3 5 7
422 ........................................................... 53 3.7358 1 1 2 5 7
423 ........................................................... 8,704 8.2135 2 3 6 10 17
424 ........................................................... 1,078 12.4017 2 4 8 14 22
425 ........................................................... 14,887 3.4519 1 1 3 4 7
426 ........................................................... 4,353 4.1358 1 2 3 5 8
427 ........................................................... 1,519 4.711 1 2 3 5 9
428 ........................................................... 777 7.2844 1 2 5 8 15
429 ........................................................... 25,617 5.461 2 3 4 6 10
430 ........................................................... 71,987 7.6793 2 3 6 9 15
431 ........................................................... 309 5.8576 1 2 4 7 12
432 ........................................................... 4.2583 1 2 3 5 8
433 ........................................................... 5,227 2.9629 1 1 2 3 6
439 ........................................................... 1,756 8.8844 1 3 5 10 19
440 ........................................................... 5,670 8.8106 2 3 6 10 18
441 ........................................................... 786 3.3804 1 1 2 4 7
442 ........................................................... 18,171 8.68 2 3 6 11 18
443 ........................................................... 3,416 3.3929 1 1 3 4 7
444 ........................................................... 5,955 4.0316 1 2 3 5 8
445 ........................................................... 2,370 2.8236 1 1 2 4 5
447 ........................................................... 6,296 2.5681 1 1 2 3 5
448 ........................................................... 1 2 2 2 2 2 2
449 ........................................................... 39,246 3.6741 1 1 3 4 7
450 ........................................................... 7,838 1.9815 1 1 1 2 4
451 ........................................................... 3 1.6667 1 1 1 3 3
452 ........................................................... 27,889 4.9002 1 2 3 6 10
453 ........................................................... 5,492 2.799 1 1 2 3 5
454 ........................................................... 3,876 4.1019 1 2 3 5 8
455 ........................................................... 853 2.2204 1 1 2 3 4
461 ........................................................... 2,752 5.1286 1 1 3 6 12
462 ........................................................... 7,839 10.2341 4 6 8 13 19
463 ........................................................... 31,272 3.8962 1 2 3 5 7
464 ........................................................... 7,677 2.9139 1 1 2 4 5
465 ........................................................... 226 3.7566 1 1 2 5 8
466 ........................................................... 1,429 5.2645 1 1 2 5 10
467 ........................................................... 1,023 2.6755 1 1 2 3 5
468 ........................................................... 50,777 12.8319 3 6 10 16 25
471 ........................................................... 15,754 5.0523 3 3 4 5 8
473 ........................................................... 8,839 12.4395 2 3 7 18 32
475 ........................................................... 117,173 11.0464 2 5 9 15 22
476 ........................................................... 3,040 10.4967 2 4 9 14 21
477 ........................................................... 29,602 8.5325 1 3 6 11 18
479 ........................................................... 24,830 2.7834 1 1 2 4 6
480 ........................................................... 823 17.938 7 8 13 22 36
481 ........................................................... 1,099 21.7543 9 16 20 25 35


482 ........................................................... 5,211 11.4558 4 6 9 14 21

484 ........................................................... 468 12.7906 2 6 10 17 25
485 ........................................................... 3,476 9.653 4 5 7 12 18
486 ........................................................... 2,662 12.3681 2 5 10 16 25
487 ........................................................... 4,804 7.076 1 3 5 9 14
488 ........................................................... 798 16.3972 4 7 13 22 35
489 ........................................................... 13,587 8.3522 2 3 6 10 17
490 ........................................................... 5,255 5.3753 1 2 4 7 11
491 ........................................................... 19,972 3.1398 1 2 3 3 5
492 ........................................................... 4,033 13.6677 3 5 6 23 31
493 ........................................................... 61,968 6.0511 1 3 5 8 12
494 ........................................................... 25,744 2.6775 1 1 2 4 5
495 ........................................................... 312 17.3173 8 9 13 19 31
496 ........................................................... 3,542 8.7572 3 4 6 10 18
497 ........................................................... 27,884 5.8094 3 3 5 7 9
498 ........................................................... 19,238 3.7597 2 3 3 5 6
499 ........................................................... 35,954 4.3187 1 2 3 5 9
500 ........................................................... 48,903 2.2383 1 1 2 3 4
501 ........................................................... 3,144 9.9078 4 5 8 13 18
502 ........................................................... 721 5.7406 2 3 5 7 9
503 ........................................................... 5,983 3.8369 1 2 3 5 7
504 ........................................................... 189 27.2116 8 16 23 36 49
505 ........................................................... 181 4.6354 1 1 1 6 11
506 ........................................................... 1,010 15.8822 3 7 13 21 33
507 ........................................................... 311 8.4662 1 3 7 11 18
508 ........................................................... 645 7.2341 1 3 5 9 16
509 ........................................................... 171 5.1345 1 2 3 6 11
510 ........................................................... 1,774 6.3968 1 2 4 8 14
511 ........................................................... 636 4.066 1 1 2 5 8
512 ........................................................... 539 12.7737 7 8 10 13 23
513 ........................................................... 233 9.9356 5 7 8 12 16
515 ........................................................... 44,944 4.3382 1 1 2 6 10
518 ........................................................... 25,988 2.4905 1 1 1 3 5
519 ........................................................... 11,650 4.8095 1 1 3 6 11
520 ........................................................... 15,523 2.0005 1 1 1 2 4
521 ........................................................... 32,428 5.4713 2 3 4 7 11
522 ........................................................... 5,684 9.3895 3 4 7 12 19
523 ........................................................... 15,979 3.8937 1 2 3 5 7
524 ........................................................... 119,564 3.1912 1 2 3 4 6
525 ........................................................... 314 13.242 1 3 8 15 29
528 ........................................................... 1,777 17.1486 6 10 15 22 30
529 ........................................................... 4,046 7.9983 1 2 5 10 18
530 ........................................................... 2,370 3.1224 1 1 2 4 6
531 ........................................................... 4,846 9.4191 2 4 7 12 20
532 ........................................................... 2,659 3.7131 1 1 3 5 8
533 ........................................................... 47,870 3.7563 1 1 2 4 9
534 ........................................................... 45,500 1.7902 1 1 1 2 3
535 ........................................................... 7,459 10.273 3 5 8 13 20
536 ........................................................... 8,124 7.64 2 4 6 9 14
537 ........................................................... 8,715 6.7733 1 3 5 8 14
538 ........................................................... 5,651 2.8234 1 1 2 3 6
539 ........................................................... 5,041 10.8242 2 4 7 14 23
540 ........................................................... 1,518 3.587 1 1 3 4 7
541 ........................................................... 22,715 43.1055 17 24 35 52 77
542 ........................................................... 24,492 32.7431 12 18 27 40 58
543 ........................................................... 5,471 12.0068 2 5 10 16 24
544 ........................................................... 421,851 4.5075 3 3 4 5 7
545 ........................................................... 42,661 5.1333 3 3 4 6 8
546 ........................................................... 2,245 8.8272 3 4 7 11 17
547 ........................................................... 35,664 12.0587 6 8 10 14 20
548 ........................................................... 34,868 8.8612 5 6 8 10 14
549 ........................................................... 14,483 10.1284 5 6 8 12 17
550 ........................................................... 36,445 6.7982 4 5 6 8 10
551 ........................................................... 56,978 6.359 1 2 5 8 13
552 ........................................................... 84,699 3.5196 1 1 3 5 7
553 ........................................................... 38,754 9.4977 2 4 7 12 20
554 ........................................................... 75,681 5.8694 1 2 4 8 13
555 ........................................................... 72,121 4.6626 1 2 3 6 9
556 ........................................................... 49,952 2.0677 1 1 1 2 4
557 ........................................................... 95,324 4.0908 1 2 3 5 8


558 ........................................................... 155,257 1.854 1 1 1 2 4

559 ........................................................... 2,258 7.1165 3 4 6 9 13
12,215,613
TABLE 8A.—STATEWIDE AVERAGE OP- TABLE 8B.—STATEWIDE AVERAGE TABLE 9A.—HOSPITAL RECLASSIFICA-
ERATING COST-TO-CHARGE RA- CAPITAL COST-TO-CHARGE RA- TIONS AND REDESIGNATIONS BY IN-
TIOS—JULY 2005 TIOS—JULY 2005 DIVIDUAL HOSPITAL AND CBSA—FY
2006
State Urban Rural State Ratio
Geo-
Provider Reclassi-
Alabama .................... 0.271 0.344 Alabama ........................................ 0.026 graphic Lugar
No. fied CBSA
Alaska ....................... 0.454 0.678 Alaska ........................................... 0.044 CBSA
Arizona ...................... 0.292 0.391 Arizona .......................................... 0.028
010008 ..... 01 33860
Arkansas ................... 0.348 0.38 Arkansas ....................................... 0.029
010012 ..... 01 16860
California ................... 0.247 0.349 California ....................................... 0.018 010022 ..... 01 40660 Lugar
Colorado ................... 0.326 0.475 Colorado ....................................... 0.03 010025 ..... 01 17980
Connecticut ............... 0.442 0.52 Connecticut ................................... 0.033 010029 ..... 12220 17980
Delaware ................... 0.529 0.509 Delaware ....................................... 0.042 010035 ..... 01 13820
District of Columbia .. 0.377 ................ District of Columbia ...................... 0.027 010044 ..... 01 13820
Florida ....................... 0.256 0.294 Florida ........................................... 0.026 010045 ..... 01 13820
Georgia ..................... 0.367 0.418 Georgia ......................................... 0.034 010065 ..... 01 33860
Hawaii ....................... 0.396 0.44 Hawaii ........................................... 0.034 010072 ..... 01 11500 Lugar
010083 ..... 01 37860
Idaho ......................... 0.481 0.532 Idaho ............................................. 0.038
010100 ..... 01 37860
Illinois ........................ 0.333 0.432 Illinois ............................................ 0.029 010101 ..... 01 11500 Lugar
Indiana ...................... 0.437 0.469 Indiana .......................................... 0.04 010118 ..... 01 33860
Iowa .......................... 0.393 0.486 Iowa .............................................. 0.031 010120 ..... 01 33660
Kansas ...................... 0.304 0.473 Kansas .......................................... 0.032 010126 ..... 01 33860
Kentucky ................... 0.391 0.4 Kentucky ....................................... 0.032 010143 ..... 01 13820
Louisiana .................. 0.31 0.378 Louisiana ...................................... 0.032 010158 ..... 01 19460
Maine ........................ 0.504 0.489 Maine ............................................ 0.036 010164 ..... 01 11500 Lugar
Maryland ................... 0.762 0.884 Maryland ....................................... 0.013 030007 ..... 03 22380
030033 ..... 03 22380
Massachusetts .......... 0.484 ................ Massachusetts .............................. 0.037
040014 ..... 04 30780
Michigan ................... 0.386 0.486 Michigan ....................................... 0.034 040017 ..... 04 44180
Minnesota ................. 0.404 0.531 Minnesota ..................................... 0.034 040019 ..... 04 32820
Mississippi ................ 0.349 0.389 Mississippi .................................... 0.032 040020 ..... 27860 32820
Missouri .................... 0.342 0.406 Missouri ........................................ 0.029 040027 ..... 04 44180
Montana .................... 0.437 0.485 Montana ........................................ 0.039 040039 ..... 04 27860
Nebraska .................. 0.356 0.494 Nebraska ...................................... 0.039 040041 ..... 04 30780
Nevada ..................... 0.249 0.494 Nevada ......................................... 0.02 040047 ..... 04 26
New Hampshire ........ 0.464 0.5 New Hampshire ............................ 0.039 040069 ..... 04 32820
New Jersey ............... 0.201 ................ New Jersey ................................... 0.015 040072 ..... 04 30780
040076 ..... 04 26300 Lugar
New Mexico .............. 0.411 0.407 New Mexico .................................. 0.034
040080 ..... 04 27860
New York .................. 0.374 0.529 New York ...................................... 0.033 040088 ..... 04 43340
North Carolina .......... 0.45 0.439 North Carolina .............................. 0.038 040091 ..... 04 45500
North Dakota ............ 0.418 0.469 North Dakota ................................ 0.042 040100 ..... 04 30780
Ohio .......................... 0.39 0.548 Ohio .............................................. 0.032 040119 ..... 04 30780
Oklahoma ................. 0.328 0.43 Oklahoma ..................................... 0.031 050006 ..... 05 39820
Oregon ...................... 0.487 0.471 Oregon .......................................... 0.036 050009 ..... 34900 46700
Pennsylvania ............ 0.293 0.46 Pennsylvania ................................ 0.025 050013 ..... 34900 46700
Puerto Rico ............... 0.444 ................ Puerto Rico ................................... 0.033 050014 ..... 05 40900
Rhode Island ............ 0.439 ................ Rhode Island ................................ 0.022 050022 ..... 40140 42044
050042 ..... 05 39820
South Carolina .......... 0.31 0.34 South Carolina .............................. 0.03
050054 ..... 40140 42044
South Dakota ............ 0.382 0.485 South Dakota ................................ 0.039 050065 ..... 42044 31084
Tennessee ................ 0.331 0.397 Tennessee .................................... 0.033 050069 ..... 42044 31084
Texas ........................ 0.294 0.377 Texas ............................................ 0.028 050071 ..... 41940 36084
Utah .......................... 0.433 0.583 Utah .............................................. 0.039 050073 ..... 46700 36084
Vermont .................... 0.577 0.621 Vermont ........................................ 0.045 050076 ..... 41884 36084
Virginia ...................... 0.385 0.383 Virginia .......................................... 0.039 050089 ..... 40140 31084
Washington ............... 0.444 0.494 Washington ................................... 0.036 050090 ..... 42220 41884
West Virginia ............ 0.49 0.476 West Virginia ................................ 0.034 050099 ..... 40140 31084
Wisconsin ................. 0.45 0.493 Wisconsin ..................................... 0.038 050102 ..... 40140 42044
Wyoming ................... 0.442 0.615 Wyoming ....................................... 0.046 050118 ..... 44700 33700
050129 ..... 40140 31084
TABLE 9A.—HOSPITAL RECLASSIFICA- TABLE 9A.—HOSPITAL RECLASSIFICA- TABLE 9A.—HOSPITAL RECLASSIFICA-

TIONS AND REDESIGNATIONS BY IN- TIONS AND REDESIGNATIONS BY IN- TIONS AND REDESIGNATIONS BY IN-
DIVIDUAL HOSPITAL AND CBSA—FY DIVIDUAL HOSPITAL AND CBSA—FY DIVIDUAL HOSPITAL AND CBSA—FY
2006—Continued 2006—Continued 2006—Continued
Geo- Geo- Geo-
Provider Reclassi- Provider Reclassi- Provider Reclassi-
graphic Lugar graphic Lugar graphic Lugar
No. fied CBSA No. fied CBSA No. fied CBSA
CBSA CBSA CBSA
050136 ..... 42220 41884 060001 ..... 24540 19740 140058 ..... 14 41180
050140 ..... 40140 31084 060003 ..... 14500 19740 140061 ..... 14 41180
050150 ..... 05 40900 060027 ..... 14500 19740 140064 ..... 14 37900
050168 ..... 42044 31084 060044 ..... 06 19740 140093 ..... 19180 16580
050173 ..... 42044 31084 060049 ..... 06 22660 140110 ..... 14 16974
050174 ..... 42220 41884 060096 ..... 06 19740 140143 ..... 14 37900
050193 ..... 42044 31084 060103 ..... 14500 19740 140160 ..... 14 40420
050224 ..... 42044 31084 070003 ..... 07 25540 Lugar 140161 ..... 14 16974
050226 ..... 42044 31084 070015 ..... 25540 35644 140164 ..... 14 41180
050228 ..... 41884 36084 070021 ..... 07 25540 Lugar 140189 ..... 14 16580
050230 ..... 42044 31084 070033 ..... 14860 35644 140233 ..... 40420 16974
050243 ..... 40140 42044 080004 ..... 20100 48864 140234 ..... 14 37900
050245 ..... 40140 31084 080007 ..... 08 36140 140236 ..... 14 28100 Lugar
050251 ..... 05 39900 100022 ..... 33124 22744 140291 ..... 29404 16974
050272 ..... 40140 31084 100023 ..... 10 36740 150002 ..... 23844 16974
050279 ..... 40140 31084 100024 ..... 10 33124 150004 ..... 23844 16974
050291 ..... 42220 41884 100045 ..... 19660 36740 150006 ..... 33140 43780
050292 ..... 40140 42044 100049 ..... 10 29460 150008 ..... 23844 16974
050298 ..... 40140 31084 100081 ..... 10 23020 Lugar 150011 ..... 15 26900
050300 ..... 40140 31084 100109 ..... 10 36740 150015 ..... 33140 16974
050327 ..... 40140 31084 100118 ..... 10 27260 150030 ..... 15 26900 Lugar
050329 ..... 40140 42044 100139 ..... 10 23540 Lugar 150048 ..... 15 17140
050331 ..... 42220 41884 100150 ..... 10 33124 150065 ..... 15 26900
050348 ..... 42044 31084 100157 ..... 29460 45300 150069 ..... 15 17140
050385 ..... 42220 41884 100176 ..... 48424 38940 150076 ..... 15 43780
050390 ..... 40140 42044 100217 ..... 46940 38940 150088 ..... 11300 26900
050419 ..... 05 39820 100239 ..... 45300 42260 150090 ..... 23844 16974
050423 ..... 40140 42044 100249 ..... 10 36100 150102 ..... 15 23844 Lugar
050426 ..... 42044 31084 100252 ..... 10 38940 150112 ..... 18020 26900
050430 ..... 05 39900 100292 ..... 10 23020 Lugar 150113 ..... 11300 26900
050510 ..... 41884 36084 110001 ..... 19140 12060 150125 ..... 23844 16974
050517 ..... 40140 31084 110002 ..... 11 12060 150126 ..... 23844 16974
050526 ..... 42044 31084 110003 ..... 11 27260 150132 ..... 23844 16974
050534 ..... 40140 42044 110023 ..... 11 12060 150133 ..... 15 23060
050535 ..... 42044 31084 110025 ..... 15260 27260 150146 ..... 15 23060
050541 ..... 41884 36084 110029 ..... 23580 12060 150147 ..... 23844 16974
050543 ..... 42044 31084 110038 ..... 11 10 160001 ..... 16 11180
050547 ..... 42220 41884 110040 ..... 11 12060 Lugar 160016 ..... 16 19780
050548 ..... 42044 31084 110041 ..... 11 12020 160026 ..... 16 11180 Lugar
050550 ..... 42044 31084 110052 ..... 11 16860 Lugar 160057 ..... 16 26980
050551 ..... 42044 31084 110054 ..... 40660 12060 160080 ..... 16 40420
050567 ..... 42044 31084 110069 ..... 47580 31420 160089 ..... 16 19780
050569 ..... 05 42220 110075 ..... 11 42340 160147 ..... 16 19780
050570 ..... 42044 31084 110088 ..... 11 12060 Lugar 170006 ..... 17 27900
050573 ..... 40140 42044 110095 ..... 11 46660 170010 ..... 17 46140
050580 ..... 42044 31084 110117 ..... 11 12060 Lugar 170012 ..... 17 48620
050584 ..... 40140 31084 110125 ..... 11 31420 170013 ..... 17 48620
050585 ..... 42044 31084 110128 ..... 11 42340 170020 ..... 17 48620
050586 ..... 40140 31084 110150 ..... 11 31420 170022 ..... 17 28140
050589 ..... 42044 31084 110153 ..... 47580 31420 170023 ..... 17 48620
050592 ..... 42044 31084 110168 ..... 40660 12060 170033 ..... 17 48620
050594 ..... 42044 31084 110187 ..... 11 12060 Lugar 170058 ..... 17 28140
050603 ..... 42044 31084 110189 ..... 11 12060 170068 ..... 17 111100
050609 ..... 42044 31084 110205 ..... 11 12060 170120 ..... 17 27900
050667 ..... 34900 46700 120028 ..... 12 26180 170142 ..... 17 45820
050668 ..... 41884 36084 130002 ..... 13 14260 170175 ..... 17 48620
050678 ..... 42044 31084 130003 ..... 30300 50 180005 ..... 18 26580
050684 ..... 40140 42044 130018 ..... 13 38540 180011 ..... 18 30460
050686 ..... 40140 42044 130049 ..... 17660 44060 180012 ..... 21060 31140
050690 ..... 42220 41884 130067 ..... 13 26820 Lugar 180013 ..... 14540 34980
050693 ..... 42044 31084 140012 ..... 14 16974 180017 ..... 18 21060
050694 ..... 40140 42044 140015 ..... 14 41180 180018 ..... 18 30460
050701 ..... 40140 42044 140032 ..... 14 41180 180019 ..... 18 17140
050709 ..... 40140 31084 140034 ..... 14 41180 180024 ..... 18 31140
050718 ..... 40140 42044 140040 ..... 14 37900 180027 ..... 18 17300
050720 ..... 42044 31084 140043 ..... 14 40420 180028 ..... 18 26580
050728 ..... 42220 41884 140046 ..... 14 41180 180029 ..... 18 28700

Geo- Geo- Geo-
CBSA CBSA CBSA
180044 ..... 18 26580 230204 ..... 47644 19804 280065 ..... 28 24540
180048 ..... 18 31140 230208 ..... 23 24340 Lugar 280077 ..... 28 36540
180066 ..... 18 34980 230217 ..... 12980 29620 290002 ..... 29 16180 Lugar
180069 ..... 18 26580 230227 ..... 47644 19804 290006 ..... 29 39900
180075 ..... 18 14540 Lugar 230235 ..... 23 40980 Lugar 290008 ..... 29 29820
180078 ..... 18 26580 230257 ..... 47644 19804 290019 ..... 16180 39900
180080 ..... 18 30460 230264 ..... 47644 19804 300005 ..... 30 31700
180093 ..... 18 21780 230279 ..... 47644 22420 300011 ..... 31700 15764
180102 ..... 18 17300 230295 ..... 23 26100 Lugar 300012 ..... 31700 15764
180104 ..... 18 17300 240013 ..... 24 33460 300019 ..... 30 15764
180116 ..... 18 14 240018 ..... 24 33460 300020 ..... 31700 15764
180124 ..... 14540 34980 240030 ..... 24 41060 300034 ..... 31700 15764
180127 ..... 18 31140 240031 ..... 41060 33460 310002 ..... 35084 35644
180132 ..... 18 30460 240036 ..... 41060 33460 310009 ..... 35084 35644
180139 ..... 18 30460 240052 ..... 24 22020 310013 ..... 35084 35644
190001 ..... 19 35380 240064 ..... 24 20260 310015 ..... 35084 35644
190003 ..... 19 29180 240069 ..... 24 40340 310018 ..... 35084 35644
190015 ..... 19 35380 240071 ..... 24 40340 310031 ..... 15804 20764
190086 ..... 19 43340 240075 ..... 24 41060 310032 ..... 47220 48864
190099 ..... 19 12940 240088 ..... 24 41060 310038 ..... 20764 35644
190106 ..... 19 10780 240093 ..... 24 33460 310048 ..... 20764 35084
190131 ..... 12940 35380 240105 ..... 24 40340 Lugar 310054 ..... 35084 35644
190155 ..... 19 12940 Lugar 240150 ..... 24 40340 Lugar 310070 ..... 20764 35644
190164 ..... 19 10780 240152 ..... 24 33460 310076 ..... 35084 35644
190191 ..... 19 12940 240187 ..... 24 33460 310078 ..... 35084 35644
190223 ..... 19 12940 Lugar 240211 ..... 24 33460 310083 ..... 35084 35644
200002 ..... 20 38860 250004 ..... 25 32820 310093 ..... 35084 35644
200020 ..... 38860 40484 250006 ..... 25 32820 310096 ..... 35084 35644
200024 ..... 30340 38860 250009 ..... 25 27180 310119 ..... 35084 35644
200034 ..... 30340 38860 250023 ..... 25 25060 Lugar 320005 ..... 22140 10740
200039 ..... 20 38860 250031 ..... 25 27140 320006 ..... 32 42140
200050 ..... 20 12620 250034 ..... 25 32820 320013 ..... 32 42140
200063 ..... 20 38860 250040 ..... 37700 25060 320014 ..... 32 29740
220001 ..... 49340 14484 250042 ..... 25 32820 320033 ..... 32 42140 Lugar
220003 ..... 49340 14484 250069 ..... 25 46220 320063 ..... 32 36220
220010 ..... 21604 14484 250079 ..... 25 27140 320065 ..... 32 36220
220019 ..... 49340 14484 250081 ..... 25 27140 330001 ..... 39100 35644
220025 ..... 49340 14484 250082 ..... 25 38220 330004 ..... 28740 39100
220028 ..... 49340 14484 250094 ..... 25620 25060 330008 ..... 33 15380 Lugar
220029 ..... 21604 14484 250097 ..... 25 12940 330027 ..... 35004 35644
220033 ..... 21604 14484 250099 ..... 25 27140 330038 ..... 33 40380 Lugar
220035 ..... 21604 14484 250100 ..... 25 46220 330062 ..... 33 27060 Lugar
220058 ..... 49340 14484 250104 ..... 25 27140 330073 ..... 33 40380 Lugar
220060 ..... 14484 12700 250117 ..... 25 25060 Lugar 330085 ..... 33 45060
220062 ..... 49340 14484 260009 ..... 26 28140 330094 ..... 33 28740
220077 ..... 44140 25540 260017 ..... 26 41180 330136 ..... 33 45060
220080 ..... 21604 14484 260022 ..... 26 16 330157 ..... 33 45060
220090 ..... 49340 14484 260025 ..... 26 41180 330181 ..... 35004 35644
220095 ..... 49340 14484 260047 ..... 27620 17860 330182 ..... 35004 35644
220163 ..... 49340 14484 260049 ..... 26 44180 Lugar 330191 ..... 24020 10580
220174 ..... 21604 14484 260064 ..... 26 17860 330229 ..... 27460 21500
230022 ..... 23 11460 260074 ..... 26 17860 330235 ..... 33 45060 Lugar
230030 ..... 23 40980 260094 ..... 26 44180 330239 ..... 27460 21500
230035 ..... 23 24340 Lugar 260110 ..... 26 41180 330250 ..... 33 15540
230037 ..... 23 11460 260113 ..... 26 14 330277 ..... 33 27060
230047 ..... 47644 19804 260116 ..... 26 14 330359 ..... 33 39100 Lugar
230054 ..... 23 24580 260183 ..... 26 41180 330386 ..... 33 39100 Lugar
230069 ..... 47644 22420 260186 ..... 26 17860 340008 ..... 34 16740
230077 ..... 40980 22420 270003 ..... 27 24500 340010 ..... 24140 39580
230080 ..... 23 40980 270011 ..... 27 24500 340013 ..... 34 16740
230093 ..... 23 24340 270017 ..... 27 33540 340018 ..... 34 43900 Lugar
230096 ..... 23 28020 270051 ..... 27 33540 340021 ..... 34 16740
230099 ..... 33780 11460 280009 ..... 28 30700 340023 ..... 11700 24860
230105 ..... 23 13020 280023 ..... 28 30700 340027 ..... 34 24780
230121 ..... 23 29620 Lugar 280032 ..... 28 30700 340039 ..... 34 16740
230134 ..... 23 26100 Lugar 280057 ..... 28 30700 340050 ..... 34 22180
230195 ..... 47644 19804 280061 ..... 28 53 340051 ..... 34 25860

Geo- Geo- Geo-
CBSA CBSA CBSA
340068 ..... 34 48900 380050 ..... 38 32780 450032 ..... 45 43340

340069 ..... 39580 20500 390006 ..... 39 25420 450039 ..... 23104 19124
340071 ..... 34 39580 Lugar 390013 ..... 39 25420 450059 ..... 41700 12420
340073 ..... 39580 20500 390030 ..... 39 10900 450064 ..... 23104 19124
340109 ..... 34 47260 390031 ..... 39 39740 Lugar 450073 ..... 45 10180
340114 ..... 39580 20500 390048 ..... 39 25420 450080 ..... 45 30980
340115 ..... 34 20500 390052 ..... 39 11020 450087 ..... 23104 19124
340124 ..... 34 39580 Lugar 390065 ..... 39 47894 450098 ..... 45 30980
340126 ..... 34 39580 390066 ..... 30140 25420 450099 ..... 45 11100
340127 ..... 34 20500 Lugar 390071 ..... 39 48700 Lugar 450121 ..... 23104 19124
340129 ..... 34 16740 390079 ..... 39 13780 450135 ..... 23104 19124
340131 ..... 34 24780 390086 ..... 39 44300 450137 ..... 23104 19124
340136 ..... 34 20500 Lugar 390091 ..... 39 49660 450144 ..... 45 36220
340138 ..... 39580 20500 390093 ..... 39 38300 450148 ..... 23104 19124
340144 ..... 34 16740 390110 ..... 27780 38300 450187 ..... 45 26420
340145 ..... 34 16740 Lugar 390113 ..... 39 49660 450192 ..... 45 19124
340147 ..... 40580 39580 390133 ..... 10900 37964 450194 ..... 45 19124
340173 ..... 39580 20500 390138 ..... 39 47894 450196 ..... 45 19124
350009 ..... 35 22020 390150 ..... 39 38300 Lugar 450211 ..... 45 26420
360008 ..... 36 26580 390151 ..... 39 47894 450214 ..... 45 26420
360010 ..... 36 10420 390224 ..... 39 13780 Lugar 450224 ..... 45 46340
360011 ..... 36 18140 390246 ..... 39 48700 450283 ..... 45 19124 Lugar
360013 ..... 36 30620 400048 ..... 25020 41980 450286 ..... 45 17780 Lugar
360014 ..... 36 18140 410001 ..... 39300 14484 450347 ..... 45 26420
360019 ..... 10420 17460 410004 ..... 39300 14484 450351 ..... 45 23104
360020 ..... 10420 17460 410005 ..... 39300 14484 450389 ..... 45 19124 Lugar
360025 ..... 41780 17460 410006 ..... 39300 14484 450400 ..... 45 47380
360027 ..... 10420 17460 410007 ..... 39300 14484 450419 ..... 23104 19124
360036 ..... 36 17460 410008 ..... 39300 14484 450438 ..... 45 26420
360039 ..... 36 18140 410009 ..... 39300 14484 450447 ..... 45 19124
360054 ..... 36 16620 410011 ..... 39300 14484 450451 ..... 45 23104
360065 ..... 36 17460 410012 ..... 39300 14484 450484 ..... 45 26420
360078 ..... 10420 17460 410013 ..... 39300 14484 450508 ..... 45 46340
360079 ..... 19380 17140 420009 ..... 42 24860 Lugar 450547 ..... 45 19124
360086 ..... 44220 19380 420020 ..... 42 16700 450563 ..... 23104 19124
360095 ..... 36 30620 420028 ..... 42 44940 Lugar 450623 ..... 45 19124 Lugar
360096 ..... 36 49660 Lugar 420030 ..... 42 16700 450639 ..... 23104 19124
360107 ..... 36 17460 420036 ..... 42 16740 450653 ..... 45 33260
360112 ..... 45780 11460 420039 ..... 42 43900 Lugar 450656 ..... 45 46340
360121 ..... 36 11460 420067 ..... 42 42340 450672 ..... 23104 19124
360125 ..... 36 17460 Lugar 420068 ..... 42 16700 450675 ..... 23104 19124
360150 ..... 10420 17460 420069 ..... 42 44940 Lugar 450677 ..... 23104 19124
360159 ..... 36 18140 420070 ..... 44940 17900 450694 ..... 45 26420
360175 ..... 36 18140 420071 ..... 42 24860 450747 ..... 45 19124
360185 ..... 36 49660 Lugar 420080 ..... 42 42340 450755 ..... 45 31180
360187 ..... 44220 19380 420085 ..... 34820 48900 450770 ..... 45 12420 Lugar
360197 ..... 36 18140 430012 ..... 43 43620 450779 ..... 23104 19124
360211 ..... 48260 38300 430014 ..... 43 22020 450830 ..... 45 36220
360238 ..... 36 49660 Lugar 430094 ..... 43 53 450839 ..... 45 43340
360241 ..... 10420 17460 440008 ..... 44 21780 450858 ..... 23104 19124
360245 ..... 36 17460 Lugar 440020 ..... 44 26620 450872 ..... 23104 19124
370004 ..... 37 27900 440035 ..... 17300 34980 450880 ..... 23104 19124
370014 ..... 37 43300 440050 ..... 44 11700 460004 ..... 36260 41620
370015 ..... 37 46140 440058 ..... 44 16860 460005 ..... 36260 41620
370018 ..... 37 46140 440059 ..... 44 34980 460007 ..... 46 41100
370022 ..... 37 30020 440060 ..... 44 27180 460011 ..... 46 39340
370025 ..... 37 46140 440067 ..... 34100 28940 460021 ..... 41100 29820
370034 ..... 37 22900 440068 ..... 44 16860 460036 ..... 46 39340
370047 ..... 37 43300 440072 ..... 44 32820 460039 ..... 46 36260
370049 ..... 37 36420 440073 ..... 44 34980 460041 ..... 36260 41620
370099 ..... 37 46140 440148 ..... 44 34980 460042 ..... 36260 41620
370103 ..... 37 45 440151 ..... 44 34980 470001 ..... 47 30
370113 ..... 37 22220 440175 ..... 44 34980 470011 ..... 47 15764
370179 ..... 37 46140 440180 ..... 44 28940 470012 ..... 47 38340
380001 ..... 38 38900 440185 ..... 17420 16860 490004 ..... 25500 16820
380008 ..... 38 18700 Lugar 440192 ..... 44 34980 490005 ..... 49020 47894
380027 ..... 38 21660 450007 ..... 45 41700 490006 ..... 49 49020 Lugar

Geo- Geo- Geo-
CBSA CBSA CBSA
490013 ..... 49 31340 510006 ..... 51 38300 520071 ..... 52 33340 Lugar
490018 ..... 49 16820 510018 ..... 51 16620 Lugar 520076 ..... 52 31540
490047 ..... 49 25500 Lugar 510024 ..... 34060 38300 520088 ..... 22540 33340
490079 ..... 49 49180 510028 ..... 51 16620 520094 ..... 39540 33340
490092 ..... 49 40060 510030 ..... 51 34060
520095 ..... 52 31540
490105 ..... 49 28700 510046 ..... 51 16620
490106 ..... 49 16820 510047 ..... 51 38300 520096 ..... 39540 33340
490109 ..... 47260 40060 510070 ..... 51 16620 520102 ..... 52 33340 Lugar
500002 ..... 50 28420 510071 ..... 51 16620 520107 ..... 52 24580
500003 ..... 34580 42644 510077 ..... 51 26580 520113 ..... 52 24580
500016 ..... 48300 42644 520002 ..... 52 48140 520116 ..... 52 33340 Lugar
500031 ..... 50 36500 520021 ..... 29404 16974 520152 ..... 52 24580
500039 ..... 14740 42644 520028 ..... 52 31540 Lugar 520173 ..... 52 20260
500041 ..... 31020 38900 520037 ..... 52 48140 520189 ..... 29404 16974
500072 ..... 50 42644 520059 ..... 39540 29404 530002 ..... 53 16220
510001 ..... 34060 38300 520060 ..... 52 22540 Lugar 530025 ..... 53 22660
510002 ..... 51 40220 520066 ..... 27500 31540
TABLE 9B.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS BY INDIVIDUAL HOSPITAL UNDER SECTION 508 OF PUB.
L. 108–173—FY 2006
Wage index
Geographic CBSA Sec. Own wage
Provider No. Note CBSA 508 reclassi- index
fication
010150 ............................................................................................................................ 01 17980

020008 ............................................................................................................................ 02 ........................ 1.2828
050494 ............................................................................................................................ 05 42220
050549 ............................................................................................................................ 37100 42220
060057 ............................................................................................................................ 06 19740
060075 ............................................................................................................................ 06 ........................ 1.1697
070001 ............................................................................................................................ 35300 35004
070005 ............................................................................................................................ 35300 35004
070006 ............................................................................................................................ * 14860 35644
070010 ............................................................................................................................ 14860 35644
070016 ............................................................................................................................ 35300 35004
070017 ............................................................................................................................ 35300 35004
070018 ............................................................................................................................ * 14860 35644
070019 ............................................................................................................................ 35300 35004
070022 ............................................................................................................................ 35300 35004
070028 ............................................................................................................................ 14860 35644
070031 ............................................................................................................................ 35300 35004
070034 ............................................................................................................................ * 14860 35644
070036 ............................................................................................................................ 25540 ........................ 1.2913
070039 ............................................................................................................................ 35300 35004
120025 ............................................................................................................................ 12 26180
150034 ............................................................................................................................ 23844 16974
160040 ............................................................................................................................ 47940 16300
160064 ............................................................................................................................ 16 ........................ 1.0218
160067 ............................................................................................................................ 47940 16300
160110 ............................................................................................................................ 47940 16300
190218 ............................................................................................................................ 19 43340
220046 ............................................................................................................................ 38340 14484
230003 ............................................................................................................................ 26100 28020
230004 ............................................................................................................................ 34740 28020
230013 ............................................................................................................................ 47644 22420
230019 ............................................................................................................................ 47644 22420
230020 ............................................................................................................................ 19804 11460
230024 ............................................................................................................................ 19804 11460
230029 ............................................................................................................................ 47644 22420
230036 ............................................................................................................................ 23 22420
230038 ............................................................................................................................ 24340 28020
230053 ............................................................................................................................ 19804 11460
230059 ............................................................................................................................ 24340 28020
230066 ............................................................................................................................ 34740 28020
230071 ............................................................................................................................ 47644 22420
L. 108–173—FY 2006—Continued
Wage index
fication
230072 ............................................................................................................................ 26100 28020

230089 ............................................................................................................................ 19804 11460
230097 ............................................................................................................................ 23 28020
230104 ............................................................................................................................ 19804 11460
230106 ............................................................................................................................ 24340 28020
230119 ............................................................................................................................ 19804 11460
230130 ............................................................................................................................ 47644 22420
230135 ............................................................................................................................ 19804 11460
230146 ............................................................................................................................ 19804 11460
230151 ............................................................................................................................ 47644 22420
230165 ............................................................................................................................ 19804 11460
230174 ............................................................................................................................ 26100 28020
230176 ............................................................................................................................ 19804 11460
230207 ............................................................................................................................ 47644 22420
230223 ............................................................................................................................ 47644 22420
230236 ............................................................................................................................ 24340 28020
230254 ............................................................................................................................ 47644 22420
230269 ............................................................................................................................ 47644 22420
230270 ............................................................................................................................ 19804 11460
230273 ............................................................................................................................ 19804 11460
230277 ............................................................................................................................ 47644 22420
250002 ............................................................................................................................ 25 25060
250078 ............................................................................................................................ * 25620 25060
250122 ............................................................................................................................ 25 25060
270002 ............................................................................................................................ * 27 33540
270012 ............................................................................................................................ * 24500 33540
270021 ............................................................................................................................ 27 13740
270023 ............................................................................................................................ 33540 13740
270032 ............................................................................................................................ 27 13740
270050 ............................................................................................................................ 27 13740
270057 ............................................................................................................................ 27 13740
270084 ............................................................................................................................ * 27 33540
310021 ............................................................................................................................ 45940 35644
310028 ............................................................................................................................ 35084 35644
310050 ............................................................................................................................ 35084 35644
310051 ............................................................................................................................ 35084 35644
310060 ............................................................................................................................ 10900 35644
310115 ............................................................................................................................ 10900 35644
310120 ............................................................................................................................ 35084 35644
330023 ............................................................................................................................ * 39100 35644
330049 ............................................................................................................................ 39100 35644
330067 ............................................................................................................................ * 39100 35644
330106 ............................................................................................................................ 35004 ........................ 1.4804
330126 ............................................................................................................................ 39100 35644
330135 ............................................................................................................................ 39100 35644
330205 ............................................................................................................................ 39100 35644
330209 ............................................................................................................................ 39100 35004
330264 ............................................................................................................................ 39100 35004
340002 ............................................................................................................................ 11700 16740
350002 ............................................................................................................................ 13900 22020
350003 ............................................................................................................................ 35 22020
350006 ............................................................................................................................ 35 22020
350010 ............................................................................................................................ 35 22020
350014 ............................................................................................................................ 35 22020
350015 ............................................................................................................................ 13900 22020
350017 ............................................................................................................................ 35 22020
350019 ............................................................................................................................ * 24220 22020
350030 ............................................................................................................................ 35 22020
350061 ............................................................................................................................ 35 22020
380090 ............................................................................................................................ 38 ........................ 1.2303
390001 ............................................................................................................................ 42540 10900
390003 ............................................................................................................................ 39 10900
390054 ............................................................................................................................ 42540 29540
390072 ............................................................................................................................ 39 10900
390095 ............................................................................................................................ 42540 10900
390109 ............................................................................................................................ 42540 10900
390119 ............................................................................................................................ 42540 10900
390137 ............................................................................................................................ 42540 10900
L. 108–173—FY 2006—Continued
Wage index
fication
390169 ............................................................................................................................ 42540 10900

390185 ............................................................................................................................ 42540 29540
390192 ............................................................................................................................ 42540 10900
390237 ............................................................................................................................ 42540 10900
390270 ............................................................................................................................ 42540 29540
410010 ............................................................................................................................ 39300 ........................ 1.1734
430005 ............................................................................................................................ 43 39660
430008 ............................................................................................................................ * 43 43620
430013 ............................................................................................................................ * 43 43620
430015 ............................................................................................................................ 43 43620
430031 ............................................................................................................................ * 43 43620
430048 ............................................................................................................................ 43 43620
430060 ............................................................................................................................ 43 43620
430064 ............................................................................................................................ 43 43620
430077 ............................................................................................................................ 39660 43620
430091 ............................................................................................................................ 39660 43620
450010 ............................................................................................................................ 48660 32580
450072 ............................................................................................................................ 26420 26420
450591 ............................................................................................................................ 26420 26420
470003 ............................................................................................................................ 15540 14484
490001 ............................................................................................................................ 49 31340
490024 ............................................................................................................................ 40220 19260
530008 ............................................................................................................................ * 53 16220
530010 ............................................................................................................................ * 53 16220
530015 ............................................................................................................................ 53 ........................ 0.9887
*These hospitals are assigned a wage index value under a special exceptions policy (see FY 2005 IPPS final rule, 69 FR 49105).
TABLE 9C.—HOSPITALS REDESIG- TABLE 10.—GEOMETRIC MEAN PLUS TABLE 10.—GEOMETRIC MEAN PLUS
NATED AS RURAL UNDER SECTION THE LESSER OF .75 OF THE NA- THE LESSER OF .75 OF THE NA-
1886(D)(8)(E)OF THE ACT—FY TIONAL ADJUSTED OPERATING TIONAL ADJUSTED OPERATING
2006 STANDARDIZED PAYMENT AMOUNT STANDARDIZED PAYMENT AMOUNT
(INCREASED TO REFLECT THE DIF- (INCREASED TO REFLECT THE DIF-
Provider Geographic Redesignated FERENCE BETWEEN COSTS AND FERENCE BETWEEN COSTS AND
No. CBSA rural area
CHARGES) OR .75 OF ONE STAND- CHARGES) OR .75 OF ONE STAND-
040075 ...... 22220 04 ARD DEVIATION OF MEAN CHARGES ARD DEVIATION OF MEAN CHARGES
050192 ...... 23420 05 BY DIAGNOSIS-RELATED GROUP BY DIAGNOSIS-RELATED GROUP
050469 ...... 40140 05 (DRG)—JULY 2005 1 (DRG)—JULY 2005 1—Continued
050528 ...... 32900 05
050618 ...... 40140 05 Number of Number of
070004 ...... 25540 07 DRG Threshold DRG Threshold
Cases Cases
100048 ...... 37860 10
100134 ...... 27260 10 1 ................ 23,405 $50,112 27 .............. 5,461 $23,116
140167 ...... 00014 14 2 ................ 10,422 $34,822 28 .............. 17,707 $23,770
150051 ...... 14020 15 3 ................ 4 $45,382 29 .............. 6,341 $14,627
170137 ...... 29940 17 6 ................ 413 $15,921 31 .............. 5,188 $19,178
190048 ...... 26380 19 7 ................ 15,520 $38,797 32 .............. 2,029 $12,777
230042 ...... 26100 23 8 ................ 3,497 $28,679 34 .............. 26,693 $19,711
230078 ...... 35660 23 9 ................ 1,970 $23,976 35 .............. 7,684 $12,809
260006 ...... 41140 26 10 .............. 19,629 $23,222 36 .............. 1,474 $14,633
260195 ...... 44180 26 11 .............. 3,284 $17,958 37 .............. 1,252 $22,719
330268 ...... 10580 33 12 .............. 54,701 $17,426 38 .............. 56 $14,203
370054 ...... 36420 37 13 .............. 7,421 $16,770 39 .............. 449 $14,256
380040 ...... 13460 38 14 .............. 235,814 $23,807 40 .............. 1,394 $19,743
390181 ...... 00039 39 15 .............. 76,451 $18,831 42 .............. 1,155 $16,308
390183 ...... 00039 39 16 .............. 16,361 $24,322 43 .............. 125 $11,917
440135 ...... 34980 44 17 .............. 3,005 $14,704 44 .............. 1,170 $13,746
450052 ...... 00045 45 18 .............. 33,326 $19,739 45 .............. 2,817 $15,155
450078 ...... 10180 45 19 .............. 8,606 $14,443 46 .............. 3,835 $15,193
450243 ...... 10180 45 20 .............. 6,590 $38,390 47 .............. 1,346 $10,774
450276 ...... 48660 45 21 .............. 2,218 $25,462 49 .............. 2,490 $29,091
450348 ...... 00045 45 22 .............. 3,332 $21,992 50 .............. 2,176 $17,333
500122 ...... 00050 50 23 .............. 10,796 $15,560 51 .............. 191 $18,125
500147 ...... 42644 50 24 .............. 64,403 $19,693 52 .............. 332 $16,799
500148 ...... 48300 50 25 .............. 28,327 $12,640 53 .............. 2,257 $24,659
26 .............. 18 $22,199 55 .............. 1,367 $18,802
TABLE 10.—GEOMETRIC MEAN PLUS TABLE 10.—GEOMETRIC MEAN PLUS TABLE 10.—GEOMETRIC MEAN PLUS
THE LESSER OF .75 OF THE NA- THE LESSER OF .75 OF THE NA- THE LESSER OF .75 OF THE NA-
TIONAL ADJUSTED OPERATING TIONAL ADJUSTED OPERATING TIONAL ADJUSTED OPERATING
STANDARDIZED PAYMENT AMOUNT STANDARDIZED PAYMENT AMOUNT STANDARDIZED PAYMENT AMOUNT
(INCREASED TO REFLECT THE DIF- (INCREASED TO REFLECT THE DIF- (INCREASED TO REFLECT THE DIF-
FERENCE BETWEEN COSTS AND FERENCE BETWEEN COSTS AND FERENCE BETWEEN COSTS AND
CHARGES) OR .75 OF ONE STAND- CHARGES) OR .75 OF ONE STAND- CHARGES) OR .75 OF ONE STAND-
ARD DEVIATION OF MEAN CHARGES ARD DEVIATION OF MEAN CHARGES ARD DEVIATION OF MEAN CHARGES
BY DIAGNOSIS-RELATED GROUP BY DIAGNOSIS-RELATED GROUP BY DIAGNOSIS-RELATED GROUP
(DRG)—JULY 2005 1—Continued (DRG)—JULY 2005 1—Continued (DRG)—JULY 2005 1—Continued
Number of Number of Number of
DRG Threshold DRG Threshold DRG Threshold
Cases Cases Cases
56 .............. 447 $17,749 123 ............ 33,782 $24,266 184 ............ 81 $10,486
57 .............. 920 $20,414 124 ............ 131,638 $27,647 185 ............ 5,753 $17,250
59 .............. 105 $15,664 125 ............ 96,574 $22,049 186 ............ 4 $6,238
60 .............. 9 $15,242 126 ............ 5,866 $39,226 187 ............ 634 $16,858
61 .............. 222 $24,062 127 ............ 698,888 $20,488 188 ............ 91,481 $21,540
63 .............. 2,902 $24,985 128 ............ 5,197 $13,933 189 ............ 13,256 $12,410
64 .............. 3,369 $21,134 129 ............ 3,774 $20,262 190 ............ 70 $12,478
65 .............. 41,598 $12,272 130 ............ 89,628 $18,627 191 ............ 10,469 $51,233
66 .............. 8,051 $11,767 131 ............ 23,926 $11,214 192 ............ 1,328 $30,378
67 .............. 420 $15,477 132 ............ 117,924 $12,607 193 ............ 4,532 $47,362
68 .............. 17,469 $13,293 133 ............ 7,325 $10,996 194 ............ 523 $29,931
69 .............. 4,762 $9,900 134 ............ 42,673 $12,392 195 ............ 3,262 $46,669
70 .............. 26 $8,627 135 ............ 7,482 $17,703 196 ............ 703 $30,967
71 .............. 68 $15,085 136 ............ 1,136 $12,755 197 ............ 17,408 $38,874
72 .............. 1,073 $15,217 138 ............ 208,101 $16,588 198 ............ 4,645 $23,923
73 .............. 9,571 $17,094 139 ............ 78,893 $10,661 199 ............ 1,430 $35,852
74 .............. 4 $7,591 140 ............ 38,450 $10,389 200 ............ 942 $36,898
75 .............. 45,250 $45,002 141 ............ 122,639 $15,323 201 ............ 2,684 $48,681
76 .............. 47,634 $40,725 142 ............ 52,421 $12,025 202 ............ 27,457 $23,443
77 .............. 2,142 $24,059 143 ............ 250,830 $11,593 203 ............ 31,842 $24,227
78 .............. 45,875 $24,834 144 ............ 100,553 $22,549 204 ............ 73,292 $21,594
79 .............. 171,419 $27,473 145 ............ 6,198 $11,859 205 ............ 31,701 $21,723
80 .............. 7,512 $17,867 146 ............ 10,813 $41,925 206 ............ 2,087 $14,915
81 .............. 5 $28,450 147 ............ 2,652 $29,209 207 ............ 35,943 $22,789
82 .............. 65,487 $24,675 148 ............ 136,334 $48,373 208 ............ 9,819 $14,213
83 .............. 7,120 $19,618 149 ............ 19,988 $28,480 210 ............ 129,152 $33,582
84 .............. 1,472 $11,829 150 ............ 22,833 $42,103 211 ............ 26,760 $24,523
85 .............. 22,028 $23,434 151 ............ 5,382 $25,607 212 ............ 10 $26,859
86 .............. 1,824 $14,267 152 ............ 5,039 $31,655 213 ............ 10,325 $31,192
87 .............. 83,068 $24,812 153 ............ 2,102 $21,743 216 ............ 17,773 $33,187
88 .............. 415,631 $17,720 154 ............ 28,654 $52,974 217 ............ 17,785 $39,754
89 .............. 554,469 $20,598 155 ............ 6,182 $25,854 218 ............ 29,053 $29,997
90 .............. 44,452 $12,328 156 ............ 6 $49,288 219 ............ 21,541 $20,902
91 .............. 48 $16,648 157 ............ 8,312 $24,166 220 ............ 4 $28,868
92 .............. 16,675 $23,136 158 ............ 4,126 $13,492 223 ............ 13,572 $22,491
93 .............. 1,522 $14,651 159 ............ 19,277 $26,228 224 ............ 10,977 $16,523
94 .............. 13,466 $22,215 160 ............ 12,043 $17,157 225 ............ 6,608 $23,901
95 .............. 1,621 $12,301 161 ............ 10,464 $23,437 226 ............ 6,725 $26,967
96 .............. 60,087 $14,799 162 ............ 5,515 $13,832 227 ............ 5,124 $16,694
97 .............. 26,487 $10,920 163 ............ 10 $14,000 228 ............ 2,665 $23,174
98 .............. 9 $8,159 164 ............ 5,991 $36,827 229 ............ 1,216 $14,213
99 .............. 21,760 $14,405 165 ............ 2,534 $23,727 230 ............ 2,590 $24,625
100 ............ 6,914 $11,047 166 ............ 4,976 $27,347 232 ............ 733 $19,423
101 ............ 23,399 $17,489 167 ............ 4,668 $17,898 233 ............ 15,220 $32,286
102 ............ 5,199 $11,159 168 ............ 1,565 $23,385 234 ............ 7,736 $25,343
103 ............ 755 $213,786 169 ............ 776 $14,845 235 ............ 5,006 $14,886
104 ............ 21,060 $114,683 170 ............ 17,580 $41,447 236 ............ 42,644 $14,237
105 ............ 31,833 $86,722 171 ............ 1,492 $24,444 237 ............ 2,034 $12,297
106 ............ 3,543 $105,479 172 ............ 33,073 $24,521 238 ............ 9,936 $24,709
108 ............ 9,310 $83,192 173 ............ 2,401 $15,446 239 ............ 43,167 $21,069
110 ............ 56,310 $55,494 174 ............ 268,990 $20,257 240 ............ 12,749 $22,928
111 ............ 10,039 $41,761 175 ............ 32,775 $11,560 241 ............ 2,711 $13,362
113 ............ 37,457 $41,919 176 ............ 14,617 $22,349 242 ............ 2,758 $21,468
114 ............ 8,582 $28,228 177 ............ 8,603 $18,603 243 ............ 102,278 $15,522
117 ............ 5,172 $23,613 178 ............ 2,920 $14,351 244 ............ 15,860 $14,400
118 ............ 7,643 $30,997 179 ............ 14,538 $21,599 245 ............ 5,857 $9,430
119 ............ 998 $23,563 180 ............ 92,638 $19,327 246 ............ 1,437 $12,113
120 ............ 36,523 $33,864 181 ............ 26,020 $11,449 247 ............ 21,824 $11,771
121 ............ 160,146 $27,836 182 ............ 293,794 $16,910 248 ............ 15,208 $17,231
122 ............ 62,100 $19,640 183 ............ 86,966 $12,054 249 ............ 14,157 $13,978
Cases Cases Cases
250 ............ 4,195 $13,885 313 ............ 513 $14,111 377 ............ 78 $23,287
251 ............ 2,162 $9,734 315 ............ 36,881 $32,144 378 ............ 196 $15,726
253 ............ 25,058 $15,138 316 ............ 181,946 $22,863 379 ............ 510 $7,170
254 ............ 10,478 $9,255 317 ............ 2,793 $16,038 380 ............ 93 $7,850
256 ............ 7,212 $16,727 318 ............ 5,961 $21,867 381 ............ 217 $12,532
257 ............ 13,582 $17,867 319 ............ 386 $13,276 382 ............ 43 $4,116
258 ............ 12,093 $14,253 320 ............ 219,905 $17,094 383 ............ 2,514 $9,798
259 ............ 2,908 $19,367 321 ............ 31,443 $11,415 384 ............ 134 $6,368
260 ............ 2,991 $14,161 322 ............ 65 $11,006 389 ............ 2 $193,336
261 ............ 1,630 $19,578 323 ............ 20,612 $16,786 390 ............ 2 $20,529
262 ............ 641 $19,774 324 ............ 5,447 $10,404 392 ............ 2,223 $42,569
263 ............ 23,955 $30,672 325 ............ 9,685 $13,024 394 ............ 2,839 $28,560
264 ............ 3,942 $20,869 326 ............ 2,595 $9,061 395 ............ 116,763 $16,487
265 ............ 4,338 $26,784 327 ............ 5 $5,735 396 ............ 10 $14,834
266 ............ 2,331 $17,512 328 ............ 611 $14,623 397 ............ 18,541 $21,173
267 ............ 272 $18,006 329 ............ 71 $10,100 398 ............ 18,411 $22,559
268 ............ 1,038 $22,965 331 ............ 55,165 $20,706 399 ............ 1,648 $13,702
269 ............ 10,762 $28,834 332 ............ 4,433 $12,522 401 ............ 6,365 $40,602
270 ............ 2,658 $16,899 333 ............ 259 $18,296 402 ............ 1,412 $23,453
271 ............ 21,209 $19,563 334 ............ 9,884 $28,157 403 ............ 32,022 $27,810
272 ............ 5,962 $19,175 335 ............ 12,033 $21,864 404 ............ 3,817 $18,926
273 ............ 1,356 $11,513 336 ............ 31,389 $16,654 406 ............ 2,235 $39,723
274 ............ 2,304 $21,476 337 ............ 25,251 $11,414 407 ............ 587 $24,616
275 ............ 227 $11,209 338 ............ 653 $24,778 408 ............ 2,183 $30,932
276 ............ 1,450 $13,973 339 ............ 1,259 $22,426 409 ............ 1,817 $22,452
277 ............ 113,024 $17,133 340 ............ 2 $18,747 410 ............ 28,552 $22,154
278 ............ 34,015 $10,875 341 ............ 3,196 $23,840 411 ............ 12 $7,098
279 ............ 8 $16,892 342 ............ 565 $17,333 412 ............ 12 $16,529
280 ............ 19,484 $14,549 344 ............ 2,702 $24,952 413 ............ 5,226 $23,470
281 ............ 7,168 $10,009 345 ............ 1,465 $21,814 414 ............ 574 $16,033
283 ............ 6,300 $14,577 346 ............ 3,991 $20,384 415 ............ 51,145 $48,904
284 ............ 1,840 $9,181 347 ............ 250 $12,534 416 ............ 240,228 $26,693
285 ............ 7,694 $32,910 348 ............ 4,202 $14,652 417 ............ 22 $17,612
286 ............ 2,714 $32,554 349 ............ 579 $8,745 418 ............ 28,775 $20,650
287 ............ 6,159 $29,259 350 ............ 7,188 $14,636 419 ............ 16,423 $17,053
288 ............ 10,593 $34,864 352 ............ 984 $14,886 420 ............ 2,930 $12,337
289 ............ 6,917 $18,263 353 ............ 2,736 $29,499 421 ............ 11,946 $14,869
290 ............ 10,909 $17,602 354 ............ 7,651 $27,759 422 ............ 53 $10,931
291 ............ 67 $18,276 355 ............ 4,945 $17,497 423 ............ 8,701 $26,984
292 ............ 7,378 $38,188 356 ............ 24,093 $14,919 424 ............ 1,078 $33,194
293 ............ 368 $24,998 357 ............ 5,584 $35,120 425 ............ 14,886 $12,559
294 ............ 99,610 $15,030 358 ............ 20,938 $22,649 426 ............ 4,353 $9,541
295 ............ 4,138 $14,600 359 ............ 28,904 $15,871 427 ............ 1,519 $10,475
296 ............ 256,061 $16,155 360 ............ 14,850 $17,215 428 ............ 776 $13,581
297 ............ 45,533 $9,891 361 ............ 276 $22,374 429 ............ 25,609 $15,540
298 ............ 86 $10,485 362 ............ 2 $11,740 430 ............ 71,973 $12,801
299 ............ 1,497 $19,326 363 ............ 2,143 $19,913 431 ............ 309 $10,477
300 ............ 21,444 $21,582 364 ............ 1,464 $17,689 432 ............ 422 $12,749
301 ............ 3,908 $12,527 365 ............ 1,628 $30,015 433 ............ 5,225 $5,600
302 ............ 9,900 $49,840 366 ............ 4,820 $22,232 439 ............ 1,756 $27,865
303 ............ 23,847 $36,195 367 ............ 459 $11,968 440 ............ 5,669 $27,803
304 ............ 13,937 $35,431 368 ............ 3,939 $22,092 441 ............ 786 $18,799
305 ............ 3,103 $23,608 369 ............ 3,643 $12,841 442 ............ 18,168 $34,984
306 ............ 6,363 $23,807 370 ............ 1,888 $17,385 443 ............ 3,415 $20,268
307 ............ 2,074 $12,380 371 ............ 2,304 $11,896 444 ............ 5,954 $14,880
308 ............ 7,123 $27,016 372 ............ 1,177 $9,775 445 ............ 2,369 $10,345
309 ............ 3,582 $18,603 373 ............ 4,955 $7,031 447 ............ 6,294 $10,673
310 ............ 26,165 $23,337 374 ............ 160 $13,121 449 ............ 39,238 $16,570
311 ............ 6,522 $12,993 375 ............ 5 $22,537 450 ............ 7,826 $8,664
312 ............ 1,464 $22,392 376 ............ 403 $10,215 451 ............ 3 $5,773
Cases Cases Cases
452 ............ 27,878 $20,075 494 ............ 25,682 $20,733 531 ............ 4,846 $42,213
453 ............ 5,492 $10,737 495 ............ 311 $106,522 532 ............ 2,659 $26,414
454 ............ 3,876 $15,906 496 ............ 3,537 $87,344 533 ............ 47,837 $28,289
455 ............ 853 $9,747 497 ............ 27,848 $55,870 534 ............ 45,427 $20,389
461 ............ 2,752 $24,473 498 ............ 19,209 $46,173 535 ............ 7,457 $120,243
462 ............ 7,828 $16,918 499 ............ 35,943 $26,528 536 ............ 8,117 $105,754
463 ............ 31,267 $13,853 500 ............ 48,831 $18,113 537 ............ 8,715 $30,405
464 ............ 7,673 $10,274 501 ............ 3,143 $40,031 538 ............ 5,648 $19,992
465 ............ 226 $12,400 502 ............ 721 $27,568 539 ............ 5,040 $41,927
466 ............ 1,429 $13,649 503 ............ 5,980 $24,309 540 ............ 1,517 $24,005
467 ............ 1,023 $9,734 504 ............ 189 $134,049 541 ............ 22,708 $240,567
468 ............ 50,764 $52,876 505 ............ 181 $24,546 542 ............ 24,483 $153,747
470 ............ 502 $64,232 506 ............ 1,010 $48,681 543 ............ 5,468 $59,942
471 ............ 15,627 $52,323 507 ............ 311 $29,068 544 ............ 420,959 $36,819
473 ............ 8,835 $35,986 508 ............ 645 $21,865 545 ............ 42,611 $41,350
475 ............ 117,155 $48,272 509 ............ 171 $14,860 546 ............ 2,241 $74,614
476 ............ 3,038 $34,031 510 ............ 1,774 $20,128 547 ............ 35,636 $90,627
477 ............ 29,597 $30,919 511 ............ 636 $12,654 548 ............ 34,824 $74,108
479 ............ 24,817 $28,352 512 ............ 539 $78,167 549 ............ 14,479 $74,286
480 ............ 821 $117,571 513 ............ 233 $94,790 550 ............ 36,399 $58,866
481 ............ 1,098 $82,815 515 ............ 44,891 $85,654 551 ............ 56,969 $49,706
482 ............ 5,206 $46,279 518 ............ 25,965 $31,491 552 ............ 84,578 $38,275
484 ............ 468 $72,010 519 ............ 11,647 $40,559 553 ............ 38,749 $44,392
485 ............ 3,471 $48,251 520 ............ 15,488 $32,459 554 ............ 75,669 $34,300
486 ............ 2,662 $63,364 521 ............ 32,428 $13,578 555 ............ 72,073 $40,910
487 ............ 4,802 $29,883 522 ............ 5,680 $9,558 556 ............ 49,856 $35,707
488 ............ 798 $55,257 523 ............ 15,979 $7,628 557 ............ 95,205 $48,043
489 ............ 13,579 $26,429 524 ............ 119,534 $14,814 558 ............ 154,831 $40,079
490 ............ 5,254 $20,265 525 ............ 314 $134,845 559 ............ 2,258 $37,803
491 ............ 19,917 $32,894 528 ............ 1,777 $99,303
492 ............ 4,032 $41,888 529 ............ 4,046 $35,002 1 Cases taken from the FY 2004 MedPAR
493 ............ 61,952 $31,960 530 ............ 2,369 $24,213 file; DRGs are from GROUPER Version 23.0.
TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE
GEOMETRIC AVERAGE LENGTH OF STAY
5/6th of the
Geometric geometric
Relative average
LTC-DRG Description average
weight length of length of
stay stay
1 ............... 5 CRANIOTOMY AGE >17 W CC ..................................................................................... 1.7034 38.5 32.1

2 ............... 7 CRANIOTOMY AGE > 17 W/O CC ................................................................................ 1.7034 38.5 32.1
3 ............... 7 CRANIOTOMY AGE 0–17 .............................................................................................. 1.7034 38.5 32.1
6 ............... 7 CARPAL TUNNEL RELEASE ......................................................................................... 0.4499 19.0 15.8
7 ............... PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC .............................. 1.3984 37.7 31.4
8 ............... 3 PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC ........................ 0.7637 24.8 20.7
9 ............... SPINAL DISORDERS & INJURIES .................................................................................. 0.9720 33.7 28.1
10 ............. NERVOUS SYSTEM NEOPLASMS W CC ...................................................................... 0.7554 24.5 20.4
11 ............. 2 NERVOUS SYSTEM NEOPLASMS W/O CC ................................................................ 0.5837 21.3 17.8
12 ............. DEGENERATIVE NERVOUS SYSTEM DISORDERS ..................................................... 0.6851 25.5 21.3
13 ............. MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA ......................................................... 0.6531 23.1 19.3
14 ............. INTERCRANIAL HEMORRHAGE OR STROKE WITH INFARCT ................................... 0.7783 26.0 21.7
15 ............. NONSPECIFIC CVA & PRECEREBRAL OCCULUSION WITHOUT INFARCT .............. 0.7314 26.8 22.3
16 ............. NONSPECIFIC CEREBROVASCULAR DISORDERS W CC .......................................... 0.7471 23.5 19.6
17 ............. 1NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC ..................................... 0.4499 19.0 15.8
18 ............. CRANIAL & PERIPHERAL NERVE DISORDERS W CC ................................................ 0.7197 23.6 19.7
19 ............. CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC ............................................. 0.4773 21.2 17.7
20 ............. NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS ................................... 1.0277 27.2 22.7
GEOMETRIC AVERAGE LENGTH OF STAY—Continued
5/6th of the
Geometric geometric
Relative average
stay stay
21 ............. 3 VIRAL MENINGITIS ........................................................................................................ 0.7637 24.8 20.7

22 ............. 4 HYPERTENSIVE ENCEPHALOPATHY ......................................................................... 1.1820 29.6 24.7
23 ............. NONTRAUMATIC STUPOR & COMA .............................................................................. 0.8054 25.4 21.2
24 ............. SEIZURE & HEADACHE AGE >17 W CC ....................................................................... 0.6251 22.6 18.8
25 ............. 1 SEIZURE & HEADACHE AGE >17 W/O CC ................................................................. 0.4499 19.0 15.8
26 ............. 7 SEIZURE & HEADACHE AGE 0–17 .............................................................................. 0.4499 19.0 15.8
27 ............. TRAUMATIC STUPOR & COMA, COMA >1 HR ............................................................. 0.9444 27.1 22.6
28 ............. TRAUMATIC STUPOR & COMA, COMA <1 HR AGE ≤17 W CC .................................. 0.8890 30.2 25.2
29 ............. 2 TRAUMATIC STUPOR & COMA, COMA <1 HR AGE ≤17 W/O CC ............................ 0.5837 21.3 17.8
30 ............. 7 TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0–17 ......................................... 0.5837 21.3 17.8
31 ............. 3 CONCUSSION AGE >17 W CC ..................................................................................... 0.7637 24.8 20.7
32 ............. 7 CONCUSSION AGE >17 W/O CC ................................................................................. 0.4499 19.0 15.8
33 ............. 7 CONCUSSION AGE 0–17 .............................................................................................. 0.4499 19.0 15.8
34 ............. OTHER DISORDERS OF NERVOUS SYSTEM W CC ................................................... 0.8004 25.3 21.1
35 ............. OTHER DISORDERS OF NERVOUS SYSTEM W/O CC ................................................ 0.5698 24.2 20.2
36 ............. 7 RETINAL PROCEDURES ............................................................................................... 1.1820 29.6 24.7
37 ............. 7 ORBITAL PROCEDURES ............................................................................................... 1.1820 29.6 24.7
38 ............. 7 PRIMARY IRIS PROCEDURES ..................................................................................... 1.1820 29.6 24.7
39 ............. 7 LENS PROCEDURES WITH OR WITHOUT VITRECTOMY ......................................... 1.1820 29.6 24.7
40 ............. 4 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17 ....................................... 1.1820 29.6 24.7
41 ............. 7 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0–17 ..................................... 1.1820 29.6 24.7
42 ............. 7 INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS ............................... 1.1820 29.6 24.7
43 ............. 7 HYPHEMA ....................................................................................................................... 1.1820 29.6 24.7
44 ............. 2 ACUTE MAJOR EYE INFECTIONS ............................................................................... 0.5837 21.3 17.8
45 ............. 7 NEUROLOGICAL EYE DISORDERS ............................................................................. 1.1820 29.6 24.7
46 ............. 2 OTHER DISORDERS OF THE EYE AGE >17 W CC ................................................... 0.5837 21.3 17.8
47 ............. 7 OTHER DISORDERS OF THE EYE AGE >17 W/O CC ................................................ 1.1820 29.6 24.7
48 ............. 7 OTHER DISORDERS OF THE EYE AGE 0–17 ............................................................ 1.1820 29.6 24.7
49 ............. 7 MAJOR HEAD & NECK PROCEDURES ....................................................................... 1.1820 29.6 24.7
50 ............. S7 IALOADENECTOMY .................................................................................................... 1.1820 29.6 24.7
51 ............. 7 SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY .......................... 1.1820 29.6 24.7
52 ............. 7 CLEFT LIP & PALATE REPAIR ..................................................................................... 1.1820 29.6 24.7
53 ............. 7 SINUS & MASTOID PROCEDURES AGE >17 .............................................................. 1.1820 29.6 24.7
54 ............. 7 SINUS & MASTOID PROCEDURES AGE 0–17 ............................................................ 1.1820 29.6 24.7
55 ............. 7 MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES ........................ 1.1820 29.6 24.7
56 ............. 7 RHINOPLASTY ............................................................................................................... 1.1820 29.6 24.7
57 ............. 7 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 0.4499 19.0 15.8
58 ............. 7 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0– 0.4499 19.0 15.8
17.
59 ............. 7 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 ................................... 0.4499 19.0 15.8
60 ............. 7 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0–17 ................................. 0.4499 19.0 15.8
61 ............. 3 MYRINGOTOMY W TUBE INSERTION AGE >17 ......................................................... 0.7637 24.8 20.7
62 ............. 7 MYRINGOTOMY W TUBE INSERTION AGE 0–17 ....................................................... 0.4499 19.0 15.8
63 ............. 4 OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES ................................. 1.1820 29.6 24.7
64 ............. EAR, NOSE, MOUTH & THROAT MALIGNANCY ........................................................... 1.1480 26.2 21.8
65 ............. 1 DYSEQUILIBRIUM .......................................................................................................... 0.4499 19.0 15.8
66 ............. 7 EPISTAXIS ...................................................................................................................... 0.4499 19.0 15.8
67 ............. 3 EPIGLOTTITIS ................................................................................................................ 0.7637 24.8 20.7
68 ............. OTITIS MEDIA & URI AGE >17 W CC ........................................................................ 0.5111 18.0 15
69 ............. 1 OTITIS MEDIA & URI AGE >17 W/O CC .................................................................. 0.4499 19.0 15.8
70 ............. 7 OTITIS MEDIA & URI AGE 0–17 ................................................................................... 0.4499 19.0 15.8
71 ............. 7 LARYNGOTRACHEITIS .................................................................................................. 0.5837 21.3 17.8
72 ............. 7 NASAL TRAUMA & DEFORMITY .................................................................................. 0.7637 24.8 20.7
73 ............. OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE >17 ................................ 0.7535 21.9 18.3
74 ............. 7 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0–17 ............................ 0.4499 19.0 15.8
75 ............. 5 MAJOR CHEST PROCEDURES .................................................................................... 1.7034 38.5 32.1
76 ............. OTHER RESP SYSTEM O.R. PROCEDURES W CC ..................................................... 2.5523 43.9 36.6
77 ............. 5 OTHER RESP SYSTEM O.R. PROCEDURES W/O CC ............................................... 1.7034 38.5 32.1
78 ............. PULMONARY EMBOLISM ................................................................................................ 0.6900 21.9 18.3
79 ............. RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC ............................. 0.8280 22.9 19.1
80 ............. RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W/O CC ......................... 0.5986 21.7 18.1
81 ............. 7 RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0–17 .................................... 0.4499 19.0 15.8
82 ............. RESPIRATORY NEOPLASMS ......................................................................................... 0.7174 20.1 16.8
83 ............. 2 MAJOR CHEST TRAUMA W CC ................................................................................... 0.5837 21.3 17.8
84 ............. 7 MAJOR CHEST TRAUMA W/O CC ............................................................................... 0.5837 21.3 17.8
85 ............. PLEURAL EFFUSION W CC ............................................................................................ 0.7264 21.2 17.7
86 ............. 1 PLEURAL EFFUSION W/O CC ...................................................................................... 0.4499 19.0 15.8
5/6th of the
Geometric geometric
Relative average
stay stay
87 ............. PULMONARY EDEMA & RESPIRATORY FAILURE ....................................................... 1.0816 25.4 21.2
88 ............. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ...................................................... 0.6585 19.6 16.3
89 ............. SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC ..................................................... 0.6987 20.8 17.3
90 ............. SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC ................................................. 0.4970 17.8 14.8
91 ............. 7 SIMPLE PNEUMONIA & PLEURISY AGE 0–17 ............................................................ 0.4499 19.0 15.8
92 ............. INTERSTITIAL LUNG DISEASE W CC ............................................................................ 0.6704 20.2 16.8
93 ............. 2 INTERSTITIAL LUNG DISEASE W/O CC ...................................................................... 0.5837 21.3 17.8
94 ............. PNEUMOTHORAX W CC ................................................................................................. 0.5880 17.0 14.2
95 ............. 1 PNEUMOTHORAX W/O CC ........................................................................................... 0.4499 19.0 15.8
96 ............. BRONCHITIS & ASTHMA AGE >17 W CC ...................................................................... 0.6417 19.4 16.2
97 ............. 2 BRONCHITIS & ASTHMA AGE >17 W/O CC ................................................................ 0.5837 21.3 17.8
98 ............. 7 BRONCHITIS & ASTHMA AGE 0–17 ............................................................................. 0.5837 21.3 17.8
99 ............. RESPIRATORY SIGNS & SYMPTOMS W CC ................................................................ 0.9219 23.2 19.3
100 ........... 3 RESPIRATORY SIGNS & SYMPTOMS W/O CC .......................................................... 0.7637 24.8 20.7
101 ........... OTHER RESPIRATORY SYSTEM DIAGNOSES W CC .................................................. 0.8147 21.1 17.6
102 ........... 1 OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC ............................................ 0.4499 19.0 15.8
103 ........... 6 HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM ........................... 0.0000 0.0 0
104 ........... 7 CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W CARDIAC 0.7637 24.8 20.7
CATH.
105 ........... 7 CARDIAC VALVE & OTHER MAJOR CARDIOTHORACIC PROC W/O CARDIAC 0.7637 24.8 20.7
CATH.
106 ........... 7 CORONARY BYPASS W PTCA ..................................................................................... 0.7637 24.8 20.7
108 ........... 7 OTHER CARDIOTHORACIC PROCEDURES ................................................................ 0.7637 24.8 20.7
110 ........... 3 MAJOR CARDIOVASCULAR PROCEDURES W CC .................................................... 0.7637 24.8 20.7
111 ........... 7 MAJOR CARDIOVASCULAR PROCEDURES W/O CC ................................................ 0.7637 24.8 20.7
113 ........... AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE ....... 1.4887 39.3 32.8
114 ........... UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS ...................... 1.2389 33.2 27.7
117 ........... 4 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT .................... 1.1820 29.6 24.7
118 ........... 4 CARDIAC PACEMAKER DEVICE REPLACEMENT ...................................................... 1.1820 29.6 24.7
119 ........... 3 VEIN LIGATION & STRIPPING ...................................................................................... 0.7637 24.8 20.7
120 ........... OTHER CIRCULATORY SYSTEM O.R. PROCEDURES ................................................ 1.0979 31.7 26.4
121 ........... CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE ........... 0.8429 23.2 19.3
122 ........... 2 CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE .... 0.5837 21.3 17.8
123 ........... CIRCULATORY DISORDERS W AMI, EXPIRED ............................................................ 1.1811 20.4 17
124 ........... 4 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG ..... 1.1820 29.6 24.7
125 ........... 3 CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG 0.7637 24.8 20.7
126 ........... ACUTE & SUBACUTE ENDOCARDITIS .......................................................................... 0.8386 25.3 21.1
127 ........... HEART FAILURE & SHOCK ............................................................................................. 0.6857 21.2 17.7
128 ........... 2 DEEP VEIN THROMBOPHLEBITIS ............................................................................... 0.5837 21.3 17.8
129 ........... 7 CARDIAC ARREST, UNEXPLAINED ............................................................................. 0.7637 24.8 20.7
130 ........... PERIPHERAL VASCULAR DISORDERS W CC .............................................................. 0.6741 23.2 19.3
131 ........... PERIPHERAL VASCULAR DISORDERS W/O CC .......................................................... 0.4675 20.4 17
132 ........... ATHEROSCLEROSIS W CC ............................................................................................ 0.6565 21.8 18.2
133 ........... 1 ATHEROSCLEROSIS W/O CC ...................................................................................... 0.4499 19.0 15.8
134 ........... HYPERTENSION .............................................................................................................. 0.6354 24.8 20.7
135 ........... CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC ......................... 0.7211 23.7 19.8
136 ........... 2 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC ................... 0.5837 21.3 17.8
137 ........... 7 CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0–17 ................................ 0.5837 21.3 17.8
138 ........... CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC ................................... 0.6201 20.5 17.1
139 ........... 2 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC ............................. 0.5837 21.3 17.8
140 ........... 1 ANGINA PECTORIS ....................................................................................................... 0.4499 19.0 15.8
141 ........... 8 SYNCOPE & COLLAPSE W CC .................................................................................... 0.4271 18.3 15.3
142 ........... 8 SYNCOPE & COLLAPSE W/O CC ................................................................................ 0.4271 18.3 15.3
143 ........... 1 CHEST PAIN ................................................................................................................... 0.4499 19.0 15.8
144 ........... OTHER CIRCULATORY SYSTEM DIAGNOSES W CC .................................................. 0.7413 21.7 18.1
145 ........... OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC .............................................. 0.4568 18.2 15.2
146 ........... 7 RECTAL RESECTION W CC ......................................................................................... 1.7034 38.5 32.1
147 ........... 7 RECTAL RESECTION W/O CC ..................................................................................... 1.7034 38.5 32.1
148 ........... MAJOR SMALL & LARGE BOWEL PROCEDURES W CC ............................................ 1.8616 40.9 34.1
149 ........... 7 MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC ....................................... 0.7637 24.8 20.7
150 ........... 4 PERITONEAL ADHESIOLYSIS W CC ........................................................................... 1.1820 29.6 24.7
151 ........... 2 PERITONEAL ADHESIOLYSIS W/O CC ....................................................................... 0.5837 21.3 17.8
152 ........... 3 MINOR SMALL & LARGE BOWEL PROCEDURES W CC ........................................... 0.7637 24.8 20.7
153 ........... 7 MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC ....................................... 0.7637 24.8 20.7
154 ........... 5 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC ............. 1.7034 38.5 32.1
155 ........... 7 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC .......... 1.7034 38.5 32.1
156 ........... 7 STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0–17 ....................... 1.7034 38.5 32.1
5/6th of the
Geometric geometric
Relative average
stay stay
157 ........... 4 ANAL & STOMAL PROCEDURES W CC ...................................................................... 1.1820 29.6 24.7
158 ........... 7 ANAL & STOMAL PROCEDURES W/O CC .................................................................. 1.1820 29.6 24.7
159 ........... 7 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC ............. 0.7637 24.8 20.7
160 ........... 7 HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC .......... 0.7637 24.8 20.7
161 ........... 5 INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC ............................. 1.7034 38.5 32.1
162 ........... 7 INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC ......................... 0.7637 24.8 20.7
163 ........... 7 HERNIA PROCEDURES AGE 0–17 .............................................................................. 0.7637 24.8 20.7
164 ........... 1 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC .................................. 1.7034 38.5 32.1
165 ........... 7 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC .............................. 1.7034 38.5 32.1
166 ........... 7 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC .............................. 1.7034 38.5 32.1
167 ........... 7 APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC .......................... 1.7034 38.5 32.1
168 ........... 4 MOUTH PROCEDURES W CC ...................................................................................... 1.1820 29.6 24.7
169 ........... 7 MOUTH PROCEDURES W/O CC .................................................................................. 0.7637 24.8 20.7
170 ........... OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC ............................................ 1.6271 35.9 29.9
171 ........... 1 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC ...................................... 0.4499 19.0 15.8
172 ........... DIGESTIVE MALIGNANCY W CC .................................................................................... 0.8553 21.8 18.2
173 ........... 2 DIGESTIVE MALIGNANCY W/O CC .............................................................................. 0.5837 21.3 17.8
174 ........... G.I. HEMORRHAGE W CC ............................................................................................... 0.7119 22.2 18.5
175 ........... 1 G.I. HEMORRHAGE W/O CC ......................................................................................... 0.4499 19.0 15.8
176 ........... COMPLICATED PEPTIC ULCER ..................................................................................... 0.8426 21.5 17.9
177 ........... 3 UNCOMPLICATED PEPTIC ULCER W CC ................................................................... 0.7637 24.8 20.7
178 ........... 3 UNCOMPLICATED PEPTIC ULCER W/O CC ............................................................... 0.7637 24.8 20.7
179 ........... INFLAMMATORY BOWEL DISEASE ............................................................................... 0.9675 24.0 20
180 ........... G.I. OBSTRUCTION W CC ............................................................................................... 0.9375 23.5 19.6
181 ........... 3 G.I. OBSTRUCTION W/O CC ......................................................................................... 0.7637 24.8 20.7
182 ........... ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC ............ 0.7745 22.6 18.8
183 ........... ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC ........ 0.3870 16.8 14
184 ........... 7 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0–17 ................... 0.4499 19.0 15.8
185 ........... 3 DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17 ........ 0.7637 24.8 20.7
186 ........... 7 DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0–17 ...... 0.7637 24.8 20.7
187 ........... 7 DENTAL EXTRACTIONS & RESTORATIONS .............................................................. 0.7637 24.8 20.7
188 ........... OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC ........................................ 0.9952 24.0 20
189 ........... OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O CC .................................... 0.4707 18.2 15.2
190 ........... 7 OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0–17 ............................................... 0.4499 19.0 15.8
191 ........... 4 PANCREAS, LIVER & SHUNT PROCEDURES W CC .................................................. 1.1820 29.6 24.7
192 ........... 7 PANCREAS, LIVER & SHUNT PROCEDURES W/O CC .............................................. 1.1820 29.6 24.7
193 ........... 3 BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC ...... 0.7637 24.8 20.7
194 ........... 7 BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC .. 0.7637 24.8 20.7
195 ........... 3 CHOLECYSTECTOMY W C.D.E. W CC ........................................................................ 0.7637 24.8 20.7
196 ........... 7 CHOLECYSTECTOMY W C.D.E. W/O CC .................................................................... 0.7637 24.8 20.7
197 ........... 3 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC .................. 0.7637 24.8 20.7
198 ........... 7 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC .............. 0.7637 24.8 20.7
199 ........... 7 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY ........................... 1.7034 38.5 32.1
200 ........... 5 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY ................. 1.7034 38.5 32.1
201 ........... OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES .................................. 2.0371 36.1 30.1
202 ........... CIRRHOSIS & ALCOHOLIC HEPATITIS ......................................................................... 0.6610 20.6 17.2
203 ........... MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS ................................... 0.7896 19.5 16.3
204 ........... DISORDERS OF PANCREAS EXCEPT MALIGNANCY .................................................. 0.9441 22.7 18.9
205 ........... DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC ................................ 0.6642 20.5 17.1
206 ........... 2 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC .......................... 0.5837 21.3 17.8
207 ........... DISORDERS OF THE BILIARY TRACT W CC ................................................................ 0.7570 21.5 17.9
208 ........... 2 DISORDERS OF THE BILIARY TRACT W/O CC .......................................................... 0.5837 21.3 17.8
210 ........... 5 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC .................. 1.7034 38.5 32.1
211 ........... 4 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC ............... 1.1820 29.6 24.7
212 ........... 7 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0–17 ............................ 1.7034 38.5 32.1
213 ........... AMPUTATION FOR MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS 1.1948 34.0 28.3
216 ........... 4 BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE .................. 1.1820 29.6 24.7
217 ........... WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS 1.2927 38.0 31.7
218 ........... 5 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC ... 1.7034 38.5 32.1
219 ........... 1 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC 0.4499 19.0 15.8
220 ........... 7 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0–17 ............ 1.7034 38.5 32.1
223 ........... 3 MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W 0.7637 24.8 20.7
CC.
224 ........... 7 SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC .... 0.7637 24.8 20.7
225 ........... FOOT PROCEDURES ...................................................................................................... 0.9869 28.4 23.7
226 ........... SOFT TISSUE PROCEDURES W CC ............................................................................. 0.9443 29.5 24.6
227 ........... 3 SOFT TISSUE PROCEDURES W/O CC ....................................................................... 0.7637 24.8 20.7
5/6th of the
Geometric geometric
Relative average
stay stay
228 ........... 4 MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC ............ 1.1820 29.6 24.7
229 ........... 7 HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC .......................... 0.4499 19.0 15.8
230 ........... 5 LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR ................ 1.7034 38.5 32.1
232 ........... 7 ARTHROSCOPY ............................................................................................................. 0.4499 19.0 15.8
233 ........... OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC ............................. 1.3522 34.6 28.8
234 ........... 7 OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC ....................... 0.4499 19.0 15.8
235 ........... 3 FRACTURES OF FEMUR .............................................................................................. 0.7637 24.8 20.7
236 ........... FRACTURES OF HIP & PELVIS ...................................................................................... 0.6531 25.2 21
237 ........... 1 SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH .......................... 0.4499 19.0 15.8
238 ........... OSTEOMYELITIS .............................................................................................................. 0.8278 28.3 23.6
239 ........... PATHOLOGICAL FRACTURES & MUSCULOSKELETAL & CONN TISS MALIG- 0.6935 23.6 19.7
NANCY.
240 ........... CONNECTIVE TISSUE DISORDERS W CC ................................................................... 0.7310 24.8 20.7
241 ........... 1 CONNECTIVE TISSUE DISORDERS W/O CC .............................................................. 0.4499 19.0 15.8
242 ........... SEPTIC ARTHRITIS .......................................................................................................... 0.7864 26.5 22.1
243 ........... MEDICAL BACK PROBLEMS ........................................................................................... 0.6061 23.4 19.5
244 ........... BONE DISEASES & SPECIFIC ARTHROPATHIES W CC ............................................. 0.5259 22.2 18.5
245 ........... BONE DISEASES & SPECIFIC ARTHROPATHIES W/O CC ......................................... 0.4635 20.4 17
246 ........... 1 NON-SPECIFIC ARTHROPATHIES ............................................................................... 0.4499 19.0 15.8
247 ........... SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE ............. 0.5548 21.9 18.3
248 ........... TENDONITIS, MYOSITIS & BURSITIS ............................................................................ 0.6574 22.6 18.8
249 ........... AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE .................... 0.6577 24.7 20.6
250 ........... 2 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC .................. 0.5837 21.3 17.8
251 ........... 1 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/O CC .............. 0.4499 19.0 15.8
252 ........... 7 FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0–17 ........................... 0.7637 24.8 20.7
253 ........... FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC ................ 0.6802 26.3 21.9
254 ........... 2 FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W/O CC .......... 0.5837 21.3 17.8
255 ........... 7 FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0–17 ....................... 0.7637 24.8 20.7
256 ........... OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES ........ 0.7924 25.3 21.1
257 ........... 7 TOTAL MASTECTOMY FOR MALIGNANCY W CC ...................................................... 0.7637 24.8 20.7
258 ........... 7 TOTAL MASTECTOMY FOR MALIGNANCY W/O CC .................................................. 0.7637 24.8 20.7
259 ........... 2 SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC .............................................. 0.5837 21.3 17.8
260 ........... 7 SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC ........................................... 0.7637 24.8 20.7
261 ........... 7 BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION ... 0.7637 24.8 20.7
262 ........... 1 BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY .............................. 0.4499 19.0 15.8
263 ........... SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC ...................... 1.3222 39.5 32.9
264 ........... SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W/O CC ................... 0.9584 32.0 26.7
265 ........... SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC ...... 1.0398 33.1 27.6
266 ........... 3 SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC 0.7637 24.8 20.7
267 ........... 7 PERIANAL & PILONIDAL PROCEDURES ..................................................................... 0.7637 24.8 20.7
268 ........... 5 SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES .................... 1.7034 38.5 32.1
269 ........... OTHER SKIN, SUBCUT TISS & BREAST PROC W CC ................................................. 1.3037 36.1 30.1
270 ........... 3 OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC ........................................... 0.7637 24.8 20.7
271 ........... SKIN ULCERS ................................................................................................................... 0.8720 27.7 23.1
272 ........... MAJOR SKIN DISORDERS W CC ................................................................................... 0.7420 22.6 18.8
273 ........... 1 MAJOR SKIN DISORDERS W/O CC ............................................................................. 0.4499 19.0 15.8
274 ........... 3 MALIGNANT BREAST DISORDERS W CC .................................................................. 0.7637 24.8 20.7
275 ........... 7 MALIGNANT BREAST DISORDERS W/O CC ............................................................... 0.7637 24.8 20.7
276 ........... 2 NON-MALIGANT BREAST DISORDERS ....................................................................... 0.5837 21.3 17.8
277 ........... CELLULITIS AGE >17 W CC ............................................................................................ 0.6264 21.0 17.5
278 ........... CELLULITIS AGE >17 W/O CC ........................................................................................ 0.4420 17.8 14.8
279 ........... 7 CELLULITIS AGE 0–17 .................................................................................................. 0.4499 19.0 15.8
280 ........... TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC ........................... 0.6698 24.3 20.3
281 ........... 1 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC ..................... 0.4499 19.0 15.8
282 ........... 7 TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0–17 .................................. 0.4499 19.0 15.8
283 ........... MINOR SKIN DISORDERS W CC .................................................................................... 0.6935 23.9 19.9
284 ........... 1 MINOR SKIN DISORDERS W/O CC .............................................................................. 0.4499 19.0 15.8
285 ........... AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DISORDERS 1.3501 35.6 29.7
286 ........... 7 ADRENAL & PITUITARY PROCEDURES ..................................................................... 1.7034 38.5 32.1
287 ........... SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS ... 1.1387 33.9 28.3
288 ........... 4 O.R. PROCEDURES FOR OBESITY ............................................................................. 1.1820 29.6 24.7
289 ........... 7 PARATHYROID PROCEDURES .................................................................................... 1.1820 29.6 24.7
290 ........... 5 THYROID PROCEDURES .............................................................................................. 1.7034 38.5 32.1
291 ........... 7 THYROGLOSSAL PROCEDURES ................................................................................. 1.1820 29.6 24.7
292 ........... OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC ........................................ 1.3409 31.7 26.4
293 ........... 2 OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC .................................. 0.5837 21.3 17.8
294 ........... DIABETES AGE >35 ......................................................................................................... 0.7293 25.0 20.8
5/6th of the
Geometric geometric
Relative average
stay stay
295 ........... 3 DIABETES AGE 0–35 ..................................................................................................... 0.7637 24.8 20.7

296 ........... NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC ............................. 0.7212 23.1 19.3
297 ........... NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W/O CC .......................... 0.5227 18.4 15.3
298 ........... 7 NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0–17 .................................... 0.5837 21.3 17.8
299 ........... 4 INBORN ERRORS OF METABOLISM ........................................................................... 1.1820 29.6 24.7
300 ........... ENDOCRINE DISORDERS W CC .................................................................................... 0.6376 21.2 17.7
301 ........... 1 ENDOCRINE DISORDERS W/O CC .............................................................................. 0.4499 19.0 15.8
302 ........... 6 KIDNEY TRANSPLANT .................................................................................................. 0.0000 0.0 0
303 ........... 4 KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM ............... 1.1820 29.6 24.7
304 ........... 5 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC .................. 1.7034 38.5 32.1
305 ........... 1 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O CC .............. 0.4499 19.0 15.8
306 ........... 2 PROSTATECTOMY W CC ............................................................................................. 0.5837 21.3 17.8
307 ........... 7 PROSTATECTOMY W/O CC ......................................................................................... 0.5837 21.3 17.8
308 ........... 3 MINOR BLADDER PROCEDURES W CC ..................................................................... 0.7637 24.8 20.7
309 ........... 7 MINOR BLADDER PROCEDURES W/O CC ................................................................. 0.7637 24.8 20.7
310 ........... 4 TRANSURETHRAL PROCEDURES W CC .................................................................... 1.1820 29.6 24.7
311 ........... 7 TRANSURETHRAL PROCEDURES W/O CC ................................................................ 1.1820 29.6 24.7
312 ........... 1 URETHRAL PROCEDURES, AGE >17 W CC ............................................................... 0.4499 19.0 15.8
313 ........... 7 URETHRAL PROCEDURES, AGE >17 W/O CC ........................................................... 0.4499 19.0 15.8
314 ........... 7 URETHRAL PROCEDURES, AGE 0–17 ........................................................................ 0.4499 19.0 15.8
315 ........... OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES .......................................... 1.4055 31.6 26.3
316 ........... RENAL FAILURE .............................................................................................................. 0.8219 22.7 18.9
317 ........... ADMIT FOR RENAL DIALYSIS ........................................................................................ 0.9852 25.2 21
318 ........... KIDNEY & URINARY TRACT NEOPLASMS W CC ......................................................... 0.7586 20.2 16.8
319 ........... 1 KIDNEY & URINARY TRACT NEOPLASMS W/O CC ................................................... 0.4499 19.0 15.8
320 ........... KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC ......................................... 0.6179 22.2 18.5
321 ........... KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC ..................................... 0.4792 19.0 15.8
322 ........... 7 KIDNEY & URINARY TRACT INFECTIONS AGE 0–17 ................................................ 0.4499 19.0 15.8
323 ........... 4 URINARY STONES W CC, &/OR ESW LITHOTRIPSY ................................................ 1.1820 29.6 24.7
324 ........... 7 URINARY STONES W/O CC .......................................................................................... 0.4499 19.0 15.8
325 ........... 2 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC ........................ 0.5837 21.3 17.8
326 ........... 7 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC .................... 0.4499 19.0 15.8
327 ........... 7 KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0–17 ................................. 0.4499 19.0 15.8
328 ........... 1 URETHRAL STRICTURE AGE >17 W CC .................................................................... 0.4499 19.0 15.8
329 ........... 7 URETHRAL STRICTURE AGE >17 W/O CC ................................................................. 0.4499 19.0 15.8
330 ........... 7 URETHRAL STRICTURE AGE 0–17 ............................................................................. 0.4499 19.0 15.8
331 ........... OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC ............................ 0.8010 23.1 19.3
332 ........... 2 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC ...................... 0.5837 21.3 17.8
333 ........... 7 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0–17 ................................... 0.5837 21.3 17.8
334 ........... 2 MAJOR MALE PELVIC PROCEDURES W CC .............................................................. 0.5837 21.3 17.8
335 ........... 7 MAJOR MALE PELVIC PROCEDURES W/O CC .......................................................... 1.7034 38.5 32.1
336 ........... 2 TRANSURETHRAL PROSTATECTOMY W CC ............................................................. 0.5837 21.3 17.8
337 ........... 7 TRANSURETHRAL PROSTATECTOMY W/O CC ......................................................... 0.5837 21.3 17.8
338 ........... 7 TESTES PROCEDURES, FOR MALIGNANCY ............................................................. 0.5837 21.3 17.8
339 ........... 4 TESTES PROCEDURES, NON-MALIGNANCY AGE >17 ............................................. 1.1820 29.6 24.7
340 ........... 7 TESTES PROCEDURES, NON-MALIGNANCY AGE 0–17 ........................................... 1.1820 29.6 24.7
341 ........... 4 PENIS PROCEDURES ................................................................................................... 1.1820 29.6 24.7
342 ........... 7 CIRCUMCISION AGE >17 .............................................................................................. 1.1820 29.6 24.7
343 ........... 7 CIRCUMCISION AGE 0–17 ............................................................................................ 1.1820 29.6 24.7
344 ........... 1 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY 0.4499 19.0 15.8
345 ........... 5 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIG- 1.7034 38.5 32.1
NANCY.
346 ........... MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC ............................................. 0.6060 20.6 17.2
347 ........... 2 MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC ....................................... 0.5837 21.3 17.8
348 ........... 2 BENIGN PROSTATIC HYPERTROPHY W CC .............................................................. 0.5837 21.3 17.8
349 ........... 7 BENIGN PROSTATIC HYPERTROPHY W/O CC .......................................................... 1.1820 29.6 24.7
350 ........... INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM ........................................ 0.6798 21.9 18.3
351 ........... 7 STERILIZATION, MALE .................................................................................................. 1.1820 29.6 24.7
352 ........... OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES ............................................... 0.6375 23.4 19.5
353 ........... 7 PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY 1.1820 29.6 24.7
354 ........... 7 UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC ................. 1.1820 29.6 24.7
355 ........... 7 UTERINE, ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC ............ 1.1820 29.6 24.7
356 ........... 7 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES ............... 1.1820 29.6 24.7
357 ........... 7 UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY .............. 1.1820 29.6 24.7
358 ........... 7 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC .................................... 1.1820 29.6 24.7
359 ........... 7 UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC ................................ 1.1820 29.6 24.7
360 ........... 4 VAGINA, CERVIX & VULVA PROCEDURES ................................................................ 1.1820 29.6 24.7
5/6th of the
Geometric geometric
Relative average
stay stay
361 ........... 7 LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION ........................................... 0.7637 24.8 20.7
362 ........... 7 ENDOSCOPIC TUBAL INTERRUPTION ....................................................................... 0.7637 24.8 20.7
363 ........... 7 D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY ..................................... 0.7637 24.8 20.7
364 ........... 5 D&C, CONIZATION EXCEPT FOR MALIGNANCY ....................................................... 1.7034 38.5 32.1
365 ........... 5 OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES ............................ 1.7034 38.5 32.1
366 ........... MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC .......................................... 0.7072 20.3 16.9
367 ........... 7 MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC .................................... 0.7637 24.8 20.7
368 ........... INFECTIONS, FEMALE REPRODUCTIVE SYSTEM ....................................................... 0.6416 20.7 17.3
369 ........... 3 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS ............. 0.7637 24.8 20.7
370 ........... 7 CESAREAN SECTION W CC ......................................................................................... 0.7637 24.8 20.7
371 ........... 7 CESAREAN SECTION W/O CC ..................................................................................... 0.5837 21.3 17.8
372 ........... 7 VAGINAL DELIVERY W COMPLICATING DIAGNOSES .............................................. 0.7637 24.8 20.7
373 ........... 7 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES ........................................... 0.7637 24.8 20.7
374 ........... 7 VAGINAL DELIVERY W STERILIZATION &/OR D&C ................................................... 0.7637 24.8 20.7
375 ........... 7 VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C ............................. 0.7637 24.8 20.7
376 ........... 7 POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE ............. 0.7637 24.8 20.7
377 ........... 7 POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE ................. 0.7637 24.8 20.7
378 ........... 7 ECTOPIC PREGNANCY ................................................................................................. 0.7637 24.8 20.7
379 ........... 7 THREATENED ABORTION ............................................................................................ 0.7637 24.8 20.7
380 ........... 7 ABORTION W/O D&C ..................................................................................................... 0.7637 24.8 20.7
381 ........... 7 ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY ...................... 0.7637 24.8 20.7
382 ........... 7 FALSE LABOR ................................................................................................................ 0.7637 24.8 20.7
383 ........... 7 OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS ....................... 0.7637 24.8 20.7
384 ........... 7 OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS ................... 0.7637 24.8 20.7
385 ........... 7 NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY ..... 0.7637 24.8 20.7
386 ........... 7 EXTREME IMMATURITY ................................................................................................ 1.1820 29.6 24.7
387 ........... 7 PREMATURITY W MAJOR PROBLEMS ....................................................................... 1.1820 29.6 24.7
388 ........... 7 PREMATURITY W/O MAJOR PROBLEMS ................................................................... 0.7637 24.8 20.7
389 ........... 7 FULL TERM NEONATE W MAJOR PROBLEMS .......................................................... 1.1820 29.6 24.7
390 ........... 7 NEONATE W OTHER SIGNIFICANT PROBLEMS ........................................................ 1.1820 29.6 24.7
391 ........... 7 NORMAL NEWBORN ..................................................................................................... 0.7637 24.8 20.7
392 ........... 7 SPLENECTOMY AGE >17 ............................................................................................. 0.7637 24.8 20.7
393 ........... 7 SPLENECTOMY AGE 0–17 ........................................................................................... 0.7637 24.8 20.7
394 ........... 5 OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS ... 1.7034 38.5 32.1
395 ........... RED BLOOD CELL DISORDERS AGE >17 ..................................................................... 0.6581 22.0 18.3
396 ........... 7 RED BLOOD CELL DISORDERS AGE 0–17 ................................................................ 0.5837 21.3 17.8
397 ........... COAGULATION DISORDERS .......................................................................................... 0.8675 22.9 19.1
398 ........... RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC ....................................... 0.8240 23.7 19.8
399 ........... 2 RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC .................................. 0.5837 21.3 17.8
401 ........... 5 LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC ..................... 1.7034 38.5 32.1
402 ........... 7 LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC ................. 0.5837 21.3 17.8
403 ........... LYMPHOMA & NON-ACUTE LEUKEMIA W CC .............................................................. 0.8757 21.3 17.8
404 ........... 2 LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC ........................................................ 0.5837 21.3 17.8
405 ........... 7 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0–17 ................................ 0.5837 21.3 17.8
406 ........... 4 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC DW CC ..... 1.1820 29.6 24.7
407 ........... 7 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC .... 1.1820 29.6 24.7
408 ........... 4 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC ............. 1.1820 29.6 24.7
409 ........... RADIOTHERAPY .............................................................................................................. 0.8642 23.5 19.6
410 ........... CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS ................ 1.1684 26.4 22
411 ........... 7 HISTORY OF MALIGNANCY W/O ENDOSCOPY ......................................................... 0.7637 24.8 20.7
412 ........... 7 HISTORY OF MALIGNANCY W ENDOSCOPY ............................................................. 0.7637 24.8 20.7
413 ........... OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC .......................... 0.8920 20.5 17.1
414 ........... 7 OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC .................... 0.5837 21.3 17.8
415 ........... O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES ................................ 1.4251 35.6 29.7
416 ........... SEPTICEMIA AGE >17 ..................................................................................................... 0.8241 23.5 19.6
417 ........... 7 SEPTICEMIA AGE 0–17 ................................................................................................. 0.7637 24.8 20.7
418 ........... POSTOPERATIVE & POST-TRAUMATIC INFECTIONS ................................................. 0.8252 24.7 20.6
419 ........... 4 FEVER OF UNKNOWN ORIGIN AGE >17 W CC ......................................................... 1.1820 29.6 24.7
420 ........... 7 FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC ..................................................... 1.1820 29.6 24.7
421 ........... VIRAL ILLNESS AGE >17 ................................................................................................ 0.9441 27.3 22.8
422 ........... 7 VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0–17 ................................... 1.1820 29.6 24.7
423 ........... OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES ...................................... 0.9505 21.8 18.2
424 ........... 3 O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS .................... 0.7637 24.8 20.7
425 ........... 2 ACUTE ADJUSTMENT REACTION & PSYCHOLOGICAL DYSFUNCTION ................. 0.5837 21.3 17.8
426 ........... DEPRESSIVE NEUROSES .............................................................................................. 0.4113 20.7 17.3
427 ........... NEUROSES EXCEPT DEPRESSIVE ............................................................................... 0.4653 23.8 19.8
428 ........... 1 DISORDERS OF PERSONALITY & IMPULSE CONTROL ........................................... 0.4499 19.0 15.8
5/6th of the
Geometric geometric
Relative average
stay stay
429 ........... ORGANIC DISTURBANCES & MENTAL RETARDATION .............................................. 0.5813 26.8 22.3
430 ........... PSYCHOSES .................................................................................................................... 0.4330 24.2 20.2
431 ........... 1 CHILDHOOD MENTAL DISORDERS ............................................................................. 0.4499 19.0 15.8
432 ........... 2 OTHER MENTAL DISORDER DIAGNOSES .................................................................. 0.5837 21.3 17.8
433 ........... 2 ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA .......................................... 0.5837 21.3 17.8
439 ........... SKIN GRAFTS FOR INJURIES ........................................................................................ 1.3677 35.6 29.7
440 ........... WOUND DEBRIDEMENTS FOR INJURIES ..................................................................... 1.3442 36.1 30.1
441 ........... 1 HAND PROCEDURES FOR INJURIES ......................................................................... 0.4499 19.0 15.8
442 ........... OTHER O.R. PROCEDURES FOR INJURIES W CC ...................................................... 1.3937 33.4 27.8
443 ........... 3 OTHER O.R. PROCEDURES FOR INJURIES W/O CC ................................................ 0.7637 24.8 20.7
444 ........... TRAUMATIC INJURY AGE >17 W CC ............................................................................. 0.7584 26.3 21.9
445 ........... 1 TRAUMATIC INJURY AGE >17 W/O CC ....................................................................... 0.4499 19.0 15.8
446 ........... 7 TRAUMATIC INJURY AGE 0–17 ................................................................................... 0.4499 19.0 15.8
447 ........... 2 ALLERGIC REACTIONS AGE >17 ................................................................................. 0.5837 21.3 17.8
448 ........... 7 ALLERGIC REACTIONS AGE 0–17 ............................................................................... 0.5837 21.3 17.8
449 ........... 3 POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC ................................... 0.7637 24.8 20.7
450 ........... 7 POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC ................................ 0.7637 24.8 20.7
451 ........... 7 POISONING & TOXIC EFFECTS OF DRUGS AGE 0–17 ............................................. 0.7637 24.8 20.7
452 ........... COMPLICATIONS OF TREATMENT W CC ..................................................................... 0.9265 25.3 21.1
453 ........... COMPLICATIONS OF TREATMENT W/O CC ................................................................. 0.5871 23.8 19.8
454 ........... 3 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC ................................... 0.7637 24.8 20.7
455 ........... 7 OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC ................................ 0.7637 24.8 20.7
461 ........... O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES ............... 1.2245 34.0 28.3
462 ........... REHABILITATION ............................................................................................................. 0.5787 22.4 18.7
463 ........... SIGNS & SYMPTOMS W CC ........................................................................................... 0.6258 23.8 19.8
464 ........... SIGNS & SYMPTOMS W/O CC ....................................................................................... 0.5554 24.1 20.1
465 ........... AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS ............. 0.6958 21.9 18.3
466 ........... AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS ......... 0.6667 21.9 18.3
467 ........... 3 OTHER FACTORS INFLUENCING HEALTH STATUS ................................................. 0.7637 24.8 20.7
468 ........... EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS ............... 2.1478 40.2 33.5
469 ........... 6 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS ................................ 0.0000 0.0 0
470 ........... 6 UNGROUPABLE ............................................................................................................. 0.0000 0.0 0
471 ........... 5 BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY .......... 1.7034 38.5 32.1
473 ........... ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 .................................... 0.8537 20.0 16.7
475 ........... RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT ....................... 2.0831 34.6 28.8
476 ........... 4 PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS ............. 1.1820 29.6 24.7
477 ........... NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS ...... 1.5836 35.3 29.4
479 ........... 7 OTHER VASCULAR PROCEDURES W/O CC .............................................................. 0.7637 24.8 20.7
480 ........... 6 LIVER TRANSPLANT ..................................................................................................... 0.0000 0.0 0
481 ........... 7 BONE MARROW TRANSPLANT ................................................................................... 1.7034 38.5 32.1
482 ........... 5 TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES ................................... 1.7034 38.5 32.1
484 ........... 2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA ............................................ 0.5837 21.3 17.8
485 ........... 7 LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT 1.1820 29.6 24.7
TR.
486 ........... 5 OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA ..................... 1.7034 38.5 32.1
487 ........... OTHER MULTIPLE SIGNIFICANT TRAUMA ................................................................... 0.8992 26.0 21.7
488 ........... 5 HIV W EXTENSIVE O.R. PROCEDURE ........................................................................ 1.7034 38.5 32.1
489 ........... HIV W MAJOR RELATED CONDITION ........................................................................... 0.8535 21.4 17.8
490 ........... HIV W OR W/O OTHER RELATED CONDITION ............................................................ 0.4919 16.6 13.8
491 ........... 5 MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY 1.7034 38.5 32.1
492 ........... 7 CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS .................. 1.1820 29.6 24.7
493 ........... 5 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC ....................................... 1.7034 38.5 32.1
494 ........... 7 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC ................................... 1.7034 38.5 32.1
495 ........... 6 LUNG TRANSPLANT ...................................................................................................... 0.0000 0.0 0
496 ........... 7 COMBINED ANTERIOR/POSTERIOR SPINAL FUSION ............................................... 1.1820 29.6 24.7
497 ........... 4 SPINAL FUSION W CC .................................................................................................. 1.1820 29.6 24.7
498 ........... 7 SPINAL FUSION W/O CC .............................................................................................. 1.1820 29.6 24.7
499 ........... 5 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC .............................. 1.7034 38.5 32.1
500 ........... 4 BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC .......................... 1.1820 29.6 24.7
501 ........... 5 KNEE PROCEDURES W PDX OF INFECTION W CC ................................................. 1.7034 38.5 32.1
502 ........... 4 KNEE PROCEDURES W PDX OF INFECTION W/O CC .............................................. 1.1820 29.6 24.7
503 ........... 2 KNEE PROCEDURES W/O PDX OF INFECTION ......................................................... 0.5837 21.3 17.8
504 ........... 7 EXTENSIVE BURN OR FULL THICKNESS BURNS WITH MECH VENT 96+ HOURS 1.7034 38.5 32.1
WITH SKIN GRAFT.
505 ........... 4 EXTENSIVE BURN OR FULL THICKNESS BURNS WITH MECH VENT 96+ HOURS 1.1820 29.6 24.7
WITHOUT SKIN GRAFT.
506 ........... 4 FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA 1.1820 29.6 24.7
5/6th of the
Geometric geometric
Relative average
stay stay
507 ........... 3 FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA 0.7637 24.8 20.7
508 ........... FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA .. 0.8367 29.4 24.5
509 ........... 1 FULL THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA 0.4499 19.0 15.8
510 ........... NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA ...................................... 0.7709 24.6 20.5
511 ........... 1 NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA ................................ 0.4499 19.0 15.8
512 ........... 6 SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT ................................................ 0.0000 0.0 0
513 ........... 6 PANCREAS TRANSPLANT ............................................................................................ 0.0000 0.0 0
515 ........... 5 CARDIAC DEFIBRILATOR IMPLANT W/O CARDIAC CATH ........................................ 1.7034 38.5 32.1
518 ........... 7 PERCUTANEOUS CARDIVASCULAR PROC W/O CORONARY ARTERY STENT 0.7637 24.8 20.7
OR AMI.
519 ........... 5 CERVICAL SPINAL FUSION W CC ............................................................................... 1.7034 38.5 32.1
520 ........... 7 CERVICAL SPINAL FUSION W/O CC ........................................................................... 1.1820 29.6 24.7
521 ........... ALCOHOL/DRUG ABUSE OR DEPENDENCE W CC ..................................................... 0.4457 19.4 16.2
522 ........... 7 ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY W/O 0.4499 19.0 15.8
CC.
523 ........... 7 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/ 0.4499 19.0 15.8
O CC.
524 ........... TRANSIENT ISCHEMIA .................................................................................................... 0.5043 21.1 17.6
525 ........... 7 OTHER HEART ASSIST SYSTEM IMPLANT ................................................................ 1.7034 38.5 32.1
528 ........... 7 INTRACRANIAL VASCULAR PROC W PDX HEMORRHAGE ...................................... 1.7034 38.5 32.1
529 ........... 5 VENTRICULAR SHUNT PROCEDURES W CC ............................................................ 1.7034 38.5 32.1
530 ........... 7 VENTRICULAR SHUNT PROCEDURES W/O CC ........................................................ 1.7034 38.5 32.1
531 ........... 3 SPINAL PROCEDURES WITH CC ................................................................................ 0.7637 24.8 20.7
532 ........... 3 SPINAL PROCEDURES WITHOUT CC ......................................................................... 0.7637 24.8 20.7
533 ........... 5 EXTRACRANIAL VASCULAR PROCEDURES WITH CC ............................................. 1.7034 38.5 32.1
534 ........... 7 EXTRACRANIAL VASCULAR PROCEDURES WITHOUT CC ...................................... 1.1820 29.6 24.7
535 ........... 7 CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK ........................... 1.7034 38.5 32.1
536 ........... 7 CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK ....................... 1.7034 38.5 32.1
537 ........... LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP 1.1615 34.7 28.9
AND FEMUR WITH CC.
538 ........... 7 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT 1.1820 29.6 24.7
HIP AND FEMUR WITHOUT CC.
539 ........... 4 LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITH CC .............. 1.1820 29.6 24.7
540 ........... 7 LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITHOUT CC ....... 0.5837 21.3 17.8
541 ........... ECMO OR TRACH W MECH VENT 96+ HRS OR PDX EXCEPT FACE,MOUTH & 4.2287 65.6 54.7
NECK DIAG WITH MAJOR OR.
542 ........... TRACH W MECH VENT 96+ HRS OR PDX EXCEPT FACE,MOUTH & NECK DIAG 3.1869 48.2 40.2
WITHOUT MAJOR OR.
543 ........... 5 CRANIOTOMY W IMPLANT OF CHEMO AGENT OR ACUTE COMPLEX CNS PDX 1.7034 38.5 32.1
544 ........... 5 MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY ..... 1.7034 38.5 32.1
545 ........... 5 REVISION OF HIP OR KNEE REPLACEMENT ............................................................ 1.7034 38.5 32.1
546 ........... 7 SPINAL FUSION EXCEPT CERVICAL WITH CURVATURE OF SPINE OR MALIG- 1.7034 38.5 32.1
NANCY.
547 ........... 7 CORONARY BYPASS WITH CARDIAC CATH WITH MAJOR CV DIAGNOSIS .......... 1.7034 38.5 32.1
548 ........... 7 CORONARY BYPASS WITH CARDIAC CATH WITHOUT MAJOR CV DIAGNOSIS .. 1.7034 38.5 32.1
549 ........... 7 CORONARY BYPASS WITHOUT CARDIAC CATH WITH MAJOR CV DIAGNOSIS .. 1.7034 38.5 32.1
550 ........... 7 CORONARY BYPASS WITHOUT CARDIAC CATH WITHOUT MAJOR CV DIAG- 1.7034 38.5 32.1
NOSIS.
551 ........... 4 PERMANENT CARDIAC PACEMAKER IMPLANT WITH MAJOR CV DIAGNOSIS 1.1820 29.6 24.7
OR AICD LEAD OR GNRTR.
552 ........... 4 OTHER PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT MAJOR CV DI- 1.1820 29.6 24.7
AGNOSIS.
553 ........... 8 OTHER VASCULAR PROCEDURES WITH CC WITH MAJOR CV DIAGNOSIS ......... 1.3255 30.6 25.5
554 ........... 8 OTHER VASCULAR PROCEDURES WITH CC WITHOUT MAJOR CV DIAGNOSIS 1.3255 30.6 25.5
555 ........... 4 PERCUTANEOUS CARDIOVASCULAR PROC WITH MAJOR CV DIAGNOSIS ......... 1.1820 29.6 24.7
556 ........... 8 PERCUTANEOUS CARDIOVASCULAR PROC WITH NON-DRUG-ELUTING STENT 1.1820 29.6 24.7
WITHOUT MAJOR CV DIAGNOSIS.
557 ........... 8 PERCUTANEOUS CARDIOVASCULAR PROC WITH DRUG-ELUTING STENT 1.1820 29.6 24.7
WITH MAJOR CV DIAGNOSIS.
558 ........... 7 PERCUTANEOUS CARDIOVASCULAR PROC WITH DRUG-ELUTING STENT 1.1820 29.6 24.7
WITHOUT MAJOR CV DIAGNOSIS.
559 ........... 7 ACUTE ISCHEMIC STROKE WITH USE OF THROMBOLYTIC AGENT ..................... 0.7637 24.8 20.7
1 Relative weights for these LTC-DRGs were determined by assigning these cases to low-volume quintile 1.
6 Relative weights for these LTC-DRGs were assigned a value of 0.0000.

7 Relative weights for these LTC-DRGs were determined by assigning these cases to the appropriate low-volume quintile because there are no
LTCH cases in the FY 2004 MedPAR file.
8 Relative weights for these LTC-DRGs were determined after adjusting to account for nonmonotonicity (see step 5 above).
Appendix A—Regulatory Analysis of continue to classify these hospitals as urban not make adjustments for future changes in
Impacts hospitals. such variables as admissions, lengths of stay,
Section 202 of the Unfunded Mandates or case-mix. As we have done in the previous
I. Background and Summary Reform Act of 1995 (Pub. L. 104–4) also proposed rules, in the FY 2006 IPPS
We have examined the impacts of this final requires that agencies assess anticipated costs proposed rule, we solicited comments and
rule as required by Executive Order 12866 and benefits before issuing any final rule that information about the anticipated effects of
(September 1993, Regulatory Planning and has been preceded by a proposed rule that the changes on hospitals and our
Review) and the Regulatory Flexibility Act may result in an expenditure in any one year methodology for estimating them. Any
(RFA) (September 19, 1980, Pub. L. 96–354), by State, local, or tribal governments, in the comments that we received in response to the
section 1102(b) of the Social Security Act, the aggregate, or by the private sector, of $110 FY 2006 IPPS proposed rule are addressed
Unfunded Mandates Reform Act of 1995 million. This final rule will not mandate any below under the appropriate heading in the
(Pub. L. 104–4), and Executive Order 13132. requirements for State, local, or tribal final rule.
Executive Order 12866 directs agencies to governments.
assess all costs and benefits of available Executive Order 13132 establishes certain IV. Hospitals Included In and Excluded
regulatory alternatives and, if regulation is requirements that an agency must meet when From the IPPS
necessary, to select regulatory approaches it promulgates a proposed rule (and The prospective payment systems for
that maximize net benefits (including subsequent final rule) that imposes hospital inpatient operating and capital-
potential economic, environmental, public substantial direct requirement costs on State related costs encompass nearly all general
health and safety effects, distributive and local governments, preempts State law, short-term, acute care hospitals that
impacts, and equity). A regulatory impact or otherwise has Federalism implications. participate in the Medicare program. There
analysis (RIA) must be prepared for major We have reviewed this final rule in light of were 34 Indian Health Service hospitals in
rules with economically significant effects Executive Order 13132 and have determined our database, which we excluded from the
($100 million or more in any 1 year). that it will not have any negative impact on analysis due to the special characteristics of
We have determined that this final rule is the rights, roles, and responsibilities of State, the prospective payment method for these
a major rule as defined in 5 U.S.C. 804(2). We local, or tribal governments. hospitals. Among other short-term, acute care
estimate that the total impact of the changes In accordance with the provisions of hospitals, only the 46 such hospitals in
for FY 2006 operating and capital payments Executive Order 12866, this final rule was Maryland remain excluded from the IPPS
compared to FY 2005 operating and capital reviewed by the Office of Management and under the waiver at section 1814(b)(3) of the
payments to be approximately a $3.33 billion Budget. Act.
increase. This amount does not reflect The following analysis, in conjunction As of July 2005, there are 3,744 IPPS
changes in hospital admissions or case-mix with the remainder of this document, hospitals to be included in our analysis. This
intensity, which would also affect overall demonstrates that this final rule is consistent represents about 63 percent of all Medicare-
payment changes. with the regulatory philosophy and participating hospitals. The majority of this
The RFA requires agencies to analyze principles identified in Executive Order impact analysis focuses on this set of
options for regulatory relief of small 12866, the RFA, and section 1102(b) of the hospitals. There are also approximately 1,123
businesses. For purposes of the RFA, small Act. The final rule will affect payments to a critical access hospitals (CAHs). These small,
entities include small businesses, nonprofit substantial number of small rural hospitals, limited service hospitals are paid on the basis
organizations, and government agencies. as well as other classes of hospitals, and the of reasonable costs rather than under the
Most hospitals and most other providers and effects on some hospitals may be significant. IPPS. There are also 1,150 specialty hospitals
suppliers are small entities, either by and units that are excluded from the IPPS.
nonprofit status or by having revenues of $5 II. Objectives These specialty hospitals include psychiatric
million to $25 million in any 1 year. For The primary objective of the IPPS is to hospitals and units, rehabilitation hospitals
purposes of the RFA, all hospitals and other create incentives for hospitals to operate and units, long-term care hospitals,
providers and suppliers are considered to be efficiently and minimize unnecessary costs children’s hospitals, and cancer hospitals.
small entities. Individuals and States are not while at the same time ensuring that The impacts of our policy changes on these
included in the definition of a small entity. payments are sufficient to adequately hospitals are discussed below.
In addition, section 1102(b) of the Act compensate hospitals for their legitimate
requires us to prepare a regulatory impact costs. In addition, we share national goals of V. Impact on Excluded Hospitals and
analysis for any rule that may have a preserving the Medicare Trust Fund. Hospital Units
significant impact on the operations of a We believe the changes in this final rule As of July 2005, there were 1,150 specialty
substantial number of small rural hospitals. will further each of these goals while hospitals excluded from the IPPS. Of these
This analysis must conform to the provisions maintaining the financial viability of the 1,150 specialty hospitals, 469 psychiatric
of section 604 of the RFA. With the exception hospital industry and ensuring access to high hospitals, 81 children’s, 11 cancer hospitals,
of hospitals located in certain New England quality health care for Medicare and 12 LTCHs that are paid under the LTCH
counties, for purposes of section 1102(b) of beneficiaries. We expect that these changes PPS blend methodology are being paid, in
the Act, we previously defined a small rural will ensure that the outcomes of this whole or in part, on a reasonable cost basis
hospital as a hospital with fewer than 100 payment system are reasonable and equitable subject to the rate-of-increase ceiling under
beds that is located outside of a Metropolitan while avoiding or minimizing unintended § 413.40. The remaining providers—216 IRFs
Statistical Area (MSA) or New England adverse consequences. and 361 LTCHs are paid 100 percent of the
County Metropolitan Area (NECMA). Federal prospective rate under the IRF PPS
However, under the new labor market III. Limitations of Our Analysis and the LTCH PPS, respectively. In addition,
definitions, we no longer employ NECMAs to The following quantitative analysis there were 1,330 psychiatric units (paid on
define urban areas in New England. presents the projected effects of our policy a blend of the IPF PPS per diem payment and
Therefore, we now define a small rural changes, as well as statutory changes the TEFRA reasonable cost-based payment)
hospital as a hospital with fewer than 100 effective for FY 2006, on various hospital and 1,010 rehabilitation units (paid under the
beds that is located outside of a MSA. groups. We estimate the effects of individual IRF PPS) in hospitals otherwise subject to the
Section 601(g) of the Social Security policy changes by estimating payments per IPPS. Under § 413.40(a)(2)(i)(A), the rate-of-
Amendments of 1983 (Pub. L. 98–21) case while holding all other payment policies increase ceiling is not applicable to the 46
designated hospitals in certain New England constant. We use the best data available, but specialty hospitals and units in Maryland
counties as belonging to the adjacent we do not attempt to predict behavioral that are paid in accordance with the waiver
NECMA. Thus, for purposes of the IPPS, we responses to our policy changes, and we do at section 1814(b)(3) of the Act.
In the past, hospitals and units excluded update in their rate-of-increase limits, the sources for the data used to categorize
from the IPPS have been paid based on their major effect is the amount of excess costs that hospitals in the tables. In some cases,
reasonable costs subject to limits as will not be reimbursed. particularly the number of beds, there is a
established by the Tax Equity and Fiscal We note that, under § 413.40(d)(3), an fair degree of variation in the data from
Responsibility Act of 1982 (TEFRA). excluded hospital or unit whose costs exceed different sources. We have attempted to
Hospitals that continue to be paid fully on a 110 percent of its rate-of-increase limit construct these variables with the best
reasonable cost basis are subject to TEFRA receives its rate-of-increase limit plus 50 available source overall. However, for
limits for FY 2006. For these hospitals percent of the difference between its individual hospitals, some
(cancer and children’s hospitals and reasonable costs and 110 percent of the limit, miscategorizations are possible.
RNHCIs), the update is the percentage not to exceed 110 percent of its limit. In Using cases from the March 2005 update of
increase in the FY 2006 IPPS operating addition, under the various provisions set the FY 2004 MedPAR file, we simulated
market basket of 3.7 percent. forth in § 413.40, certain excluded hospitals payments under the operating IPPS given
Inpatient rehabilitation facilities (IRFs) are and hospital units can obtain payment various combinations of payment parameters.
paid under a prospective payment system adjustments for justifiable increases in Any short-term, acute care hospitals not paid
(IRF PPS) for cost reporting periods operating costs that exceed the limit. under the IPPS (Indian Health Service
beginning on or after January 1, 2002. For However, at the same time, by generally hospitals and hospitals in Maryland) were
cost reporting periods beginning during FY limiting payment increases, we continue to excluded from the simulations. The impact of
2006, the IRF PPS is based on 100 percent provide an incentive for excluded hospitals payments under the capital IPPS, or the
of the adjusted Federal IRF prospective and hospital units to restrain the growth in impact of payments for costs other than
payment amount, updated annually. their spending for patient services. inpatient operating costs, are not analyzed in
Therefore, these hospitals are not impacted this section. Estimated payment impacts of
by this final rule. VI. Quantitative Impact Analysis of the
FY 2006 changes to the capital IPPS are
Effective for cost reporting periods Policy Changes Under the IPPS for
discussed in section VIII of this Appendix.
beginning on or after October 1, 2002, LTCHs Operating Costs
The changes discussed separately below
are paid under a LTCH PPS, based on a A. Basis and Methodology of Estimates are the following:
Federal prospective payment amount that is In this final rule, we are announcing policy • The effects of the annual reclassification
updated annually. Existing LTCHs will changes and payment rate updates for the of diagnoses and procedures and the
receive a blended payment that consists of IPPS for operating costs. Changes to the recalibration of the DRG relative weights
the Federal prospective payment rate and a capital payments are discussed in section required by section 1886(d)(4)(C) of the Act.
reasonable cost-based payment rate over a 5- VIII. of this Appendix. Based on the overall • The effects of the changes in hospitals’
year transition period. However, under the percentage change in payments per case wage index values reflecting wage data from
LTCH PPS, an existing LTCH may also elect estimated using our payment simulation hospitals’ cost reporting periods beginning
to be paid at 100 percent of the Federal model (a 3.5 percent increase), we estimate during FY 2002, compared to the FY 2001
prospective rate at the beginning of any of its the total impact of the changes for FY 2006 wage data.
cost reporting periods during the 5-year operating and capital payments compared to • The effect of the change in the way we
transition period. For purposes of the update FY 2005 operating and capital payments to use the wage data for hospitals that reclassify
factor, the portion of the LTCH PPS transition be approximately a $3.33 billion increase. as rural under section 401 of the BBRA to
blend payment based on reasonable costs for This amount does not reflect changes in compute wage indexes.
inpatient operating services would be hospital admissions or case-mix intensity, • The effect of the wage and recalibration
determined by updating the LTCH’s TEFRA which would also affect overall payment budget neutrality factors, including the
target amount by the excluded hospital changes. rebased labor share for both the national and
market basket percentage increase, which is We have prepared separate impact analyses Puerto Rico standardized amounts.
3.8 percent. of the changes to each system. This section • The effect of the remaining labor market
Section 124 of the Medicare, Medicaid, and deals with changes to the operating area transition for those hospitals that were
SCHIP Balanced Budget Refinement Act of prospective payment system. Our payment urban under the old labor market area
1999 (BBRA) required the development of a simulation model relies on the most recent designations and are now considered rural
per diem prospective payment system (PPS) available data to enable us to estimate the hospitals.
for payment of inpatient hospital services impacts on payments per case of certain • The effects of geographic
furnished in psychiatric hospitals and changes we are making in this final rule. reclassifications by the MGCRB that will be
psychiatric units of acute care hospitals and However, there are other changes for which effective in FY 2006.
CAHs (inpatient psychiatric facilities (IPFs)). we do not have data available that would • The effects of section 505 of Pub. L. 108–
We published a final rule to implement the allow us to estimate the payment impacts 173, which provides for an increase in a
IPF PPS on November 15, 2004 (69 FR using this model. For those changes, we have hospital’s wage index if the hospital qualifies
66922). The final rule established a 3-year attempted to predict the payment impacts of by meeting a threshold percentage of
transition to the IPF PPS during which some those changes based upon our experience residents of the county where the hospital is
providers will receive a blend of the IPF PPS and other more limited data. located who commute to work at hospitals in
per diem payment and the TEFRA reasonable The data used in developing the counties with higher wage indexes.
cost-based payment. For purposes of quantitative analyses of changes in payments • The total change in payments based on
determining what the TEFRA payment to the per case presented below are taken from the FY 2006 policies and MMA-imposed changes
IPF will be, we updated the IPF’s TEFRA FY 2004 MedPAR file and the most current relative to payments based on FY 2005
target amount by the excluded hospital Provider-Specific File that is used for policies.
market basket percentage increase of 3.8 payment purposes. Although the analyses of To illustrate the impacts of the FY 2006
percent. the changes to the operating PPS do not changes, our analysis begins with a FY 2006
The impact on excluded hospitals and incorporate cost data, data from the most baseline simulation model using: The update
hospital units of the update in the rate-of- recently available hospital cost report were of 3.7 percent; the FY 2005 DRG GROUPER
increase limit depends on the cumulative used to categorize hospitals. Our analysis has (version 22.0); the CBSA designations for
cost increases experienced by each excluded several qualifications. First, we do not make hospitals based on OMB’s June 2003 MSA
hospital or unit since its applicable base adjustments for behavioral changes that definitions; the FY 2005 wage index; and no
period. For excluded hospitals and units that hospitals may adopt in response to the policy MGCRB reclassifications. Outlier payments
have maintained their cost increases at a changes, and we do not adjust for future are set at 5.1 percent of total operating DRG
level below the rate-of-increase limits since changes in such variables as admissions, and outlier payments.
their base period, the major effect is on the lengths of stay, or case-mix. Second, due to Section 1886(b)(3)(B)(vii) of the Act, as
level of incentive payments these hospitals the interdependent nature of the IPPS added by section 501(b) of Pub. L. 108–173,
and hospital units receive. Conversely, for payment components, it is very difficult to provides that, for FYs 2005 through 2007, the
excluded hospitals and hospital units with precisely quantify the impact associated with update factors will be reduced by 0.4
per-case cost increases above the cumulative each change. Third, we draw upon various percentage points for any hospital that does
not submit quality data. At the time this Act, which provides that reclassifications for the Act. For example, the rows labeled urban,
impact was prepared, the quality data were purposes of the wage index are for a 3-year large urban, other urban, and rural show that
still under review. Since early results period. the number of hospitals paid based on these
indicated that very few providers would fail A third significant factor is that we categorizations after consideration of
the quality edits, for purposes of the FY 2006 currently estimate that actual outlier geographic reclassifications are 2,651, 1,451,
simulations in this impact analysis, we have payments during FY 2005 will be 4.1 percent 1,200, and 1,093, respectively.
assumed that all hospitals will qualify for the of total DRG payments. When the FY 2005 The next three groupings examine the
full update. Subsequent analysis of the final rule was published, we projected FY impacts of the changes on hospitals grouped
quality data indicate that 2.0 percent of 2005 outlier payments would be 5.1 percent by whether or not they have GME residency
hospitals will fail the quality edits and the of total DRG plus outlier payments; the programs (teaching hospitals that receive an
impact of this finding is discussed in section average standardized amounts were offset
IME adjustment) or receive DSH payments, or
C of this addendum. correspondingly. The effects of the lower
some combination of these two adjustments.
Each policy change is then added than expected outlier payments during FY
incrementally to this baseline model, finally 2005 (as discussed in the Addendum to this There are 2,661 nonteaching hospitals in our
arriving at an FY 2006 model incorporating final rule) are reflected in the analyses below analysis, 845 teaching hospitals with fewer
all of the changes. This allows us to isolate comparing our current estimates of FY 2005 than 100 residents, and 238 teaching
the effects of each change. payments per case to estimated FY 2006 hospitals with 100 or more residents.
Our final comparison illustrates the payments per case (with outlier payments In the DSH categories, hospitals are
percent change in payments per case from FY projected to equal 5.1 percent of total DRG grouped according to their DSH payment
2005 to FY 2006. Three factors not discussed payments). status, and whether they are considered
separately have significant impacts here. The urban or rural for DSH purposes. The next
first is the update to the standardized B. Analysis of Table I category groups hospitals considered urban
amount. In accordance with section Table I displays the results of our analysis after geographic reclassification, in terms of
1886(b)(3)(B)(i) of the Act, we have updated of changes for FY 2006. The table categorizes whether they receive the IME adjustment, the
standardized amounts for FY 2006 using the hospitals by various geographic and special DSH adjustment, both, or neither.
most recently forecasted hospital market payment consideration groups to illustrate The next five rows examine the impacts of
basket increase for FY 2006 of 3.7 percent. the varying impacts on different types of the changes on rural hospitals by special
(Hospitals that fail to comply with the quality hospitals. The top row of the table shows the payment groups (sole community hospitals
data submission requirement to receive the overall impact on the 3,744 hospitals (SCHs), rural referral centers (RRCs), and
full update will receive an update reduced by included in the analysis. There are 153 fewer Medicare dependent hospitals (MDHs)), as
0.4 percentage points to 3.3 percent.) Under hospitals than were included in the impact well as rural hospitals not receiving a special
section 1886(b)(3)(B)(iv) of the Act, the analysis in the FY 2005 final rule (69 FR payment designation. There were 136 RRCs,
updates to the hospital-specific amounts for 49758). 389 SCHs, 146 MDHs, and 77 hospitals that
sole community hospitals (SCHs) and for The next four rows of Table I contain are both SCHs and RRCs.
Medicare-dependent small rural hospitals hospitals categorized according to their The next two groupings are based on type
(MDHs) are also equal to the market basket geographic location: All urban, which is of ownership and the hospital’s Medicare
increase, or 3.7 percent. further divided into large urban and other
utilization expressed as a percent of total
A second significant factor that impacts urban; and rural. There are 2,616 hospitals
patient days. These data are taken primarily
changes in hospitals’ payments per case from located in urban areas included in our
from the FY 2002 Medicare cost reports, if
FY 2005 to FY 2006 is the change in MGCRB analysis. Among these, there are 1,440
status from one year to the next. That is, hospitals located in large urban areas available (otherwise FY 2001 data are used).
hospitals reclassified in FY 2005 that are no (populations over 1 million), and 1,176 The next series of groupings concern the
longer reclassified in FY 2006 may have a hospitals in other urban areas (populations of geographic reclassification status of
negative payment impact going from FY 2005 1 million or fewer). In addition, there are hospitals. The first grouping displays all
to FY 2006. Conversely, hospitals not 1,128 hospitals in rural areas. The next two hospitals that were reclassified by the
reclassified in FY 2005 that are reclassified groupings are by bed-size categories, shown MGCRB for FY 2006. The next two groupings
in FY 2006 may have a positive impact. In separately for urban and rural hospitals. The separate the hospitals in the first group by
some cases, these impacts can be quite final groupings by geographic location are by urban and rural status. The final two rows in
substantial, so if a relatively small number of census divisions, also shown separately for Table I contain hospitals located in rural
hospitals in a particular category lose their urban and rural hospitals. counties but deemed to be urban under
reclassification status, the percentage change The second part of Table I shows hospital section 1886(d)(8)(B) of the Act and hospitals
in payments for the category may be below groups based on hospitals’ FY 2006 payment located in urban counties, but deemed to be
the national mean. However, this effect is classifications, including any rural under section 1886(d)(8)(E) of the Act.
alleviated by section 1886(d)(10)(D)(v) of the reclassifications under section 1886(d)(10) of BILLING CODE 4120–01–P
ER12AU05.005</GPH>
ER12AU05.006</GPH>
ER12AU05.007</GPH>
ER12AU05.008</GPH>
C. Impact of the Changes to the Postacute urban and rural hospitals. There is only small malignancy from DRGs 497 and 498 to new
Care Transfer Policy (Column 2) variation among all of the hospital categories DRG 546 (Spinal Fusions Except Cervical
In Column 2 of Table I, we present the from the ¥0.9 percent impact. The areas that with Curvature of the Spine or Malignancy);
effects of the expansion of the postacute care are most dramatically affected are urban • Reassigning procedure code 39.65
transfer policy, as discussed in section V.A. areas, with urban New England experiencing (Extracorporeal membrane oxygenation
of the preamble to this final rule. We a 1.6 percent decline in payments and the [ECMO]) from DRGs 104 and 105 to DRG 541
compared aggregate payments using the FY East North Central experiencing a 1.1 percent (ECMO or Tracheostomy with Mechanical
2005 DRG relative weights (GROUPER decline. Although none of the rural regions Ventilation 96+ Hours or Principal Diagnosis
version 22.0) and the expansion of the show an increase in payments, all rural Except Face, Mouth and Neck Diagnoses
postacute care transfer policy to aggregate regions lose less than 1 percent from this With Major Operating Room Procedure); and
payments using the FY 2005 DRG relative policy change. Urban areas tend to have a • Creating a new DRG 559 (Acute Ischemic
weights (GROUPER version 22.0) and the FY greater concentration of postacute care Stroke With Use of Thrombolytic Agent) that
2005 postacute care transfer policy. The facilities to which to discharge patients than identifies embolic stroke combined with tPA
changes we are making are estimated to do rural areas and are, therefore, more likely treatment.
result in a 0.9 percent decrease in payments to be affected by this policy. Of the changes described above, the most
to hospitals overall. We estimate the total significant change we are making results
D. Impact of the Changes to the DRG
savings at approximately $780 million in FY from our focused review of the
Reclassifications and Recalibration of
2006. cardiovascular DRGs for FY 2006. The
Relative Weights (Column 3)
To simulate the impact of this final policy, approach we are adopting provides a sound
we calculated two sets of transfer-adjusted In Column 3 of Table I, we present the analytical basis for replacing 9 cardiovascular
discharges and case-mix index values for combined effects of the DRG reclassifications DRGs that account for nearly 700,000 cases
hospitals. The first set was based on the FY and recalibration, as discussed in section II. with 12 new DRGs that better recognize
2005 postacute care transfer policy and the of the preamble to this final rule. Section severity of illness. These nine DRGs are
second was based on the expanded postacute 1886(d)(4)(C)(i) of the Act requires us commonly billed by specialty hospitals.
care transfer policy discussed in the annually to make appropriate classification While these changes do not appear to have
preamble to this final rule. Estimated changes and to recalibrate the DRG weights a significant impact among any of the
payments were computed for both sets of in order to reflect changes in treatment categories of hospitals listed below, we
data and were then compared. The transfer- patterns, technology, and any other factors believe the changes will address a portion of
adjusted discharge fraction is calculated in that may change the relative use of hospital the inappropriately higher payments that are
one of two ways, depending on the transfer resources. accruing to specialty hospitals under the
payment methodology. Under the postacute We compared aggregate payments using current DRG system. We have analyzed a
care transfer payment methodology in place the FY 2005 DRG relative weights (GROUPER sample of specialty hospitals and found that
in FY 2005, for all but the three DRGs version 22.0) to aggregate payments using the the effect of the DRG changes alone may
receiving special payment consideration FY 2006 DRG relative weights (GROUPER decrease the case-mix index (and the
(DRGs 209, 210, and 211), this adjustment is version 23.0). We note that, consistent with resulting payments) by an average 1 percent.
made by adding 1 to the length of stay and section 1886(d)(4)(C)(iii) of the Act, we have While we expect to complete a
dividing that amount by the geometric mean applied a budget neutrality factor to ensure comprehensive analysis of the MedPAC
length of stay for the DRG (with the resulting that the overall payment impact of the DRG recommendations over the next year and will
fraction not to exceed 1.0). For example, a changes (combined with the wage index consider making further changes to the DRG
postacute care transfer after 3 days from a changes) is budget neutral. This budget system for FY 2007, the changes we are
DRG with a geometric mean length of stay of neutrality factor of 1.002271 is applied to making to the cardiovascular DRGs for FY
6 days would have a transfer-adjusted payments in Column 6. Because this is a 2006 represent an excellent interim step for
discharge fraction of 0.667 ((3+1)/6). combined DRG reclassification and beginning the improvements to the DRG
For postacute care transfers from any one recalibration and wage index budget system.
of the three DRGs receiving the alternative neutrality factor, it is not applied to In the aggregate, these changes will have
payment methodology, the transfer-adjusted payments in Column 3. no impact on overall payments to hospitals.
discharge fraction is 0.5 (to reflect that these The major DRG classification changes we
cases receive half the full DRG amount the On average, the impacts of these changes on
are making include— any particular hospital group are very small,
first day), plus one-half of the result of
• The creation of several new DRGs with urban hospitals experiencing a 0.1
dividing 1 plus the length of stay prior to
designed to better reflect severity among percent increase and rural hospitals
transfer by the geometric mean length of stay
cardiac DRG cases, experiencing a 0.1 percent decrease. The
for the DRG. There are 12 DRGs (including
210 and 211) that would qualify to receive • Reassigning procedure code 35.52 largest impact is a 0.3 percent increase
the special payment consideration. DRG 209 (Repair of atrial septal defect with prosthesis, among urban hospitals in New England. This
which formerly received the special payment closed technique) from DRG 108 to DRG 518 impact is in part due to the residual effects
has been split into two new DRGs 544 and (Percutaneous Cardiovascular Procedure of the change to the postacute care transfer
545. Both DRG 544 and DRG 545 are Without Coronary Artery Stent or AMI); policy on the relative weights. Including a
included in the 13 special payment DRGs: • Reassigning procedure code 37.26 DRG in the postacute care transfer policy
Accordingly, these cases continue to qualify (Cardiac electrophysiologic stimulation and reduces the number of cases in the DRG
to receive the alternative payment recording studies) from DRGs 535 and 536 to (cases that qualify as transfers are only
methodology. As with the above adjustment, DRG 515 (Cardiac Defibrillator Implant counted as a fraction of a case) which in turn
the result is equal to the lesser of the transfer- Without Cardiac Catheterization); increases the average charge for the DRG and
adjusted discharge fraction or 1. • Splitting DRG 209 into two new DRGs the weight.
The transfer-adjusted case-mix index based on the presence or absence of the
procedure codes for major joint replacement E. Impact of Wage Index Changes (Column 4)
values are calculated by summing the
transfer-adjusted DRG weights and dividing or reattachment of lower extremity and Section 1886(d)(3)(E) of the Act requires
by the transfer-adjusted discharges. The revision of hip or knee replacement, DRG 545 that, beginning October 1, 1993, we annually
transfer-adjusted DRG weights are calculated (Revision of Hip or Knee Replacement) and update the wage data used to calculate the
by multiplying the DRG weight by the lesser DRG 544 (Major Joint Replacement or wage index. In accordance with this
of 1 or the transfer-adjusted discharge Reattachment of Lower Extremity); requirement, the wage index for FY 2006 is
fraction for the case, divided by the • Reassigning procedure code 26.12 (Open based on data submitted for hospital cost
geometric mean length of stay for the DRG. biopsy of salivary gland or duct) from DRG reporting periods beginning on or after
In this way, simulated payments per case can 468 to DRG 477 (Non-Extensive O.R. October 1, 2001 and before October 1, 2002.
be compared before and after the change to Procedure Unrelated To Principal Diagnosis); The impact of the new data on hospital
the postacute care transfer policy. • Reassigning the principal or secondary payments is isolated in Column 4 by holding
This expansion of the policy has a ¥0.9 diagnosis codes for curvature of the spine the other payment parameters constant in
percent payment impact overall among both and the principal diagnosis code for this simulation. That is, Column 4 shows the
percentage changes in payments when going Number of combination with the budget neutrality
from a model using the FY 2005 wage index, Percentage change in hospitals factor, are budget neutral. In Table I, the
based on FY 2001 wage data, to a model area wage index values combined overall impacts of the effects of
using the FY 2006 pre-reclassification wage Urban Rural both the DRG reclassifications and
index, based on FY 2002 wage data. The FY recalibration and the updated wage index are
2005 wage index baseline incorporated a Decrease more than 5 shown in Column 6. The changes in this
blended wage index of 50 percent of the MSA percent and less than column are the sum of the changes in
wage index and 50 percent of the CBSA wage 10 percent ..................... 46 12 Columns 3, 4, and 5, combined with the
index in areas where the CBSA wage index Decrease more than 10 budget neutrality factor and the wage index
was lower than the MSA wage index to percent .......................... 15 0 floor for urban areas required by section 4410
reflect the transition policy that was in effect of Pub. L. 105–33 to be budget neutral. There
in FY 2005. The wage data collected on the F. Impact of Change in Treatment of Section also may be some variation of plus or minus
FY 2002 cost report is the same as the FY 1886(d)(8)(E) Wage Data (Column 5) 0.1 percentage point due to rounding.
2001 wage data that were used to calculate For the FY 2006 wage index, we are Among urban regions, the largest impacts
the FY 2005 wage index. leaving the wage data for a hospital are in the West North Central region and
Column 4 shows the impacts of updating redesignated as rural under section Puerto Rico, with 0.4 and 1.0 percent
the wage data using FY 2002 cost reports. 1886(d)(8)(E) of the Act in the urban area in declines, respectively. The Pacific region
Overall, the new wage data will lead to a 0.2 which the hospital is geographically located experiences the largest increase of 1.1
percent decrease for all hospitals and for for purposes of calculating the wage index of percent. Among rural regions, the New
hospitals in urban areas. This decrease is due those areas. We are moving the wage data for England region benefits the most with a 1.5
to both fluctuations in the wage data itself these hospitals into the rural wage index only percent increase, while the Mountain region
if it increases the wage index in the rural experiences the largest decline (1.2 percent).
and full implementation of the new labor
market areas in FY 2006. Hospitals that area. In this way, the rural floor is only H. Impact of Allowing Urban Hospitals That
experienced a decline in the wage index due affected by the wage data for these Were Converted to Rural as a Result of the
to the new labor market areas received a redesignated hospitals if it would increase CBSA Designations to Maintain the Wage
transition blended wage index in FY 2006. the rural wage index and thus reset the rural Index of the MSA Where They Are Located
The labor market transition is no longer in floor at a higher value. Previously, the wage (Column 7)
effect for FY 2006 resulting in a payment data for these redesignated hospitals was
moved into the rural area wage index To help alleviate the decreased payments
reduction for hospitals that benefited in FY for urban hospitals that became rural under
2005 from the transition. Among regions, the calculations regardless of whether it
increased or decreased the rural wage index, the new labor market area definitions, for
largest increase is in the rural New England purposes of the wage index, we adopted a
and this caused the rural floor for several
region, which is experiencing a 1.3 percent policy in FY 2005 to allow them to maintain
States to be lower than it would have been
increase. The largest decline from updating the wage index assignment of the MSA where
had the redesignated providers’ data not been
the wage data is seen in the urban Puerto they were located for the 3-year period FY
included.
Rico region (a 1.2 percent decrease). Column 5 shows the impact of adopting 2005, FY 2006, and FY 2007. Column 7
In looking at the wage data itself, the this policy. In aggregate, this policy has no shows the impact of the remaining labor
national average hourly wage increased 6.2 effect on payments to providers. Hospitals in market area transition, for those hospitals
percent compared to FY 2005. Therefore, the the urban New England region experience an that were urban under the old labor market
only manner in which to maintain or exceed increase in payments of 0.2 percent, which area designations and are now considered
the previous year’s wage index was to match indicates that CBSAs in that region that rural hospitals. Section 1886(d)(3)(E) of the
the national 6.2 increase in average hourly receive the rural floor are now receiving a Act specifies that any updates or adjustments
wage. Of the 3,681 hospitals with wage data higher wage index. Rural hospitals in the to the wage index are to be budget neutral.
for both FYs 2005 and 2006, 1,647, or 44.7 Mountain region are shown to experience a Therefore, we applied an adjustment of
percent, also experienced an average hourly 0.3 percent decline. However, when the 0.998859 to ensure that the effects of
wage increase of 6.2 percent or more. redesignated data are added to the rural wage reclassification are budget neutral as
The following chart compares the shifts in index, their rural floor increases and they do indicated by the zero effect on payments to
wage index values for hospitals for FY 2006 not actually experience a loss from this hospitals overall. The rural hospital row
relative to FY 2005. Among urban hospitals, policy. Hospitals reclassified as rural under shows a 0.3 percent benefit from this
56 will experience an increase of between 5 section 1886(d)(8)(E) of the Act will provision as these hold harmless hospitals
percent and 10 percent and 20 will experience a 0.9 percent increase. are now considered geographically rural.
experience an increase of more than 10
percent. A total of 35 rural hospitals will G. Combined Impact of DRG and Wage Index I. Impact of MGCRB Reclassifications
Changes, Including Budget Neutrality (Column 8)
experience increases greater than 5 percent,
but none will experience increases of greater Adjustment (Column 6) Our impact analysis to this point has
than 10 percent. On the negative side, 46 The impact of the DRG reclassifications assumed hospitals are paid on the basis of
urban hospitals will experience decreases in and recalibration on aggregate payments is their actual geographic location (with the
their wage index values of at least 5 percent, required by section 1886(d)(4)(C)(iii) of the exception of ongoing policies that provide
but less than 10 percent. Fifteen urban Act to be budget neutral. In addition, section that certain hospitals receive payments on
hospitals will experience decreases in their 1886(d)(3)(E) of the Act specifies that any basis other than where they are
wage index values greater than 10 percent. updates or adjustments to the wage index are geographically located, such as hospitals in
The following chart shows the projected to be budget neutral. As noted in the rural counties that are deemed urban under
impact for urban and rural hospitals. Addendum to this final rule, in determining section 1886(d)(8)(B) of the Act). The changes
the budget neutrality factor, we compared in Column 8 reflect the per case payment
Number of simulated aggregate payments using the FY impact of moving from this baseline to a
Percentage change in hospitals 2005 DRG relative weights, the blended wage simulation incorporating the MGCRB
area wage index values index, and labor share percentage to decisions for FY 2006. These decisions affect
Urban Rural simulated aggregate payments using the FY hospitals’ wage index area assignments.
2006 DRG relative weights and wage index By February 28 of each year, the MGCRB
Increase more than 10 and the rebased labor share percentage (69.7 makes reclassification determinations that
percent .......................... 20 0 percent for the national rate, 58.7 percent for will be effective for the next fiscal year,
Increase more than 5 per- the Puerto Rico specific rate). which begins on October 1. The MGCRB may
cent and less than 10 We computed a wage and DRG approve a hospital’s reclassification request
percent .......................... 56 35 recalibration budget neutrality factor of for the purpose of using another area’s wage
Increase or decrease less 1.002271. The 0.0 percent impact for all index value. The FY 2006 wage index values
than 5 percent ............... 2,375 1,102 hospitals demonstrates that these changes, in incorporate all of the MGCRB’s
reclassification decisions for FY 2006. The Due to the statutory formula to calculate isolate. For these reasons, the values in
wage index values also reflect any decisions the adjustment and the small number of Column 10 may not equal the sum of the
made by the CMS Administrator through the counties that qualify, the impact on hospitals changes described above.
appeals and review process through February is minimal, with an overall impact on all The overall change in payments per case
28, 2005, or a request by a hospital to hospitals of 0.1 percent. for hospitals in FY 2006 will increase by 3.5
withdraw its application. percent. Hospitals in urban areas will
The overall effect of geographic K. All Changes (Column 10)
experience a 3.5 percent increase in
reclassification is required by section Column 10 compares our estimate of payments per case compared to FY 2005.
1886(d)(8)(D) of the Act to be budget neutral. payments per case, incorporating all changes Hospitals in rural areas, meanwhile, will
Therefore, we applied an adjustment of reflected in this final rule for FY 2006 experience a 3.3 percent payment increase.
0.992521 to ensure that the effects of (including statutory changes), to our estimate Hospitals in large urban areas will experience
reclassification are budget neutral. (See of payments per case in FY 2005. This
a 3.4 percent increase in payments and
section II.A.4.b. of the Addendum to this column includes all of the policy changes.
hospitals in other urban areas will experience
final rule.) Column 10 reflects all FY 2006 changes
a 3.6 percent increase in payments.
As a group, rural hospitals benefit from relative to FY 2005, shown in Columns 2
through 9 and those not applied until the Among urban census divisions, the largest
geographic reclassification. We estimate that
final rates are calculated. The average payment increase will be 5.1 percent in the
their payments will rise 2.1 percent in
increase for all hospitals is approximately 3.5 Pacific region. Hospitals in the West South
Column 8. Payments to urban hospitals will
decline by 0.3 percent. Hospitals in other percent. This increase includes the effects of Central region will experience the next
urban areas will experience an overall the 3.7 percent market basket update. It also largest overall increase of 3.9 percent. The
decrease in payments of 0.2 percent, while reflects the 1.0 percentage point difference smallest urban increase would occur in the
large urban hospitals will lose 0.4 percent. between the projected outlier payments in FY New England region, with an increase of 2.3
Among urban hospital groups (that is, bed 2005 (5.1 percent of total DRG payments) and percent.
size, census division, and special payment the current estimate of the percentage of Among rural regions in Column 10, no
status), payments generally would decline. actual outlier payments in FY 2005 (4.1 hospital category will experience overall
A positive impact is evident among all of percent), as described in the introduction to payment decreases. The Pacific and New
the rural hospital groups. The smallest this Appendix and the Addendum to this England regions will benefit the most, with
increase among the rural census divisions is final rule. As a result, payments are projected 4.3 and 4.7 percent increases, respectively.
0.5 for the Mountain region. The largest to be 1.0 percentage point lower in FY 2005 The smallest increase will occur in the South
increases are in the rural East South Central than originally estimated, resulting in a 1.0 Atlantic and East North Central regions, with
region, with an increase of 3.0 percent and percentage point greater increase for FY 2006 2.0 percent increases in payments.
in the West South Central region, which than would otherwise occur. In addition, the Among special categories of rural hospitals
would experience an increase of 2.6 percent. impact of section 505 adjustments accounted in Column 10, those hospitals receiving
Urban hospitals reclassified for FY 2006 for a 0.1 percent increase. Payment decreases payment under the hospital-specific
are expected to receive an increase of 2.8 of 1.3 percent are primarily attributable to the methodology (SCHs, MDHs, and SCH/RRCs)
percent, while rural reclassified hospitals are impact of expanding the postacute care will experience payment increases of 3.8
expected to benefit from the MGCRB changes transfer policy (¥0.9 percent). Indirect percent, 3.2 percent, and 3.5 percent,
with a 3.8 percent increase in payments. medical education formula changes for respectively.
Payments to urban and rural hospitals that teaching hospitals under section 502 of Pub. Urban hospitals reclassified for FY 2006
did not reclassify are expected to decrease L. 108–173, changes in payments due to the are anticipated to receive an increase of 4.2
slightly due to the MGCRB changes, difference between the FY 2005 and FY 2006 percent, while rural reclassified hospitals are
decreasing by 0.6 percent for urban hospitals wage index values assigned to providers
expected to benefit from reclassification with
and 0.3 percent for rural hospitals. reclassified under section 508 of Pub. L. 108–
a 3.3 percent increase in payments. Those
173, and changes in the incremental increase
J. Impacts of the Wage Index Adjustment for hospitals located in rural counties, but
in payments from section 505 of Pub. L. 108–
Out-Migration (Column 9) 173 out-migration adjustments account for deemed to be urban under section
Section 1886(d)(13) of the Act, as added by the remaining ¥0.4 percent. 1886(d)(8)(B) of the Act, are expected to
section 505 of Pub. L. 108–173, provides for Section 213 of Pub. L. 106–554 provides receive an increase in payments of 2.5
an increase in the wage index for hospitals that all SCHs may receive payment on the percent.
located in certain counties that have a basis of their costs per case during their cost L. Impact Analysis of Table II
relatively high percentage of hospital reporting period that began during 1996. For
employees who reside in the county, but FY 2006, eligible SCHs receive 100 percent Table II presents the projected impact of
work in a different area with a higher wage of their 1996 hospital-specific rate. In the changes for FY 2006 for urban and rural
index. Hospitals located in counties that addition, in this final rule we are revising the hospitals and for the different categories of
qualify for the payment adjustment are to budget neutrality adjustment applied to the hospitals shown in Table I. It compares the
receive an increase in the wage index that is hospital-specific rates to reflect only the estimated payments per case for FY 2005
equal to a weighted average of the difference payment changes resulting from DRG with the average estimated per case payments
between the wage index of the resident recalibration. Previously, we had also for FY 2006, as calculated under our models.
county and the higher wage index work adjusted the hospital-specific rates to reflect Thus, this table presents, in terms of the
area(s), weighted by the overall percentage of payment changes based on area wage levels. average dollar amounts paid per discharge,
workers who are employed in an area with The impact of this provision is modeled in the combined effects of the changes
a higher wage index. Using our established Column 10 as well. presented in Table I. The percentage changes
criteria, 308 counties and 592 hospitals There might also be interactive effects shown in the last column of Table II equal
qualify to receive a commuting adjustment in among the various factors comprising the the percentage changes in average payments
FY 2006. payment system that we are not able to from Column 10 of Table I.
TABLE II.—IMPACT ANALYSIS OF CHANGES FOR FY 2006 OPERATING PROSPECTIVE PAYMENT SYSTEM
[Payments per case]
Aver- Aver-
Num- age FY age FY All FY
ber of 2005 pay- 2006 pay- 2006
hospitals ment per ment per changes
case 1 case 1
(1) (2) (3) (4)
All hospitals ...................................................................................................................................... 3,744 8,257 8,542 3.5

By Geographic Location
Urban hospitals ................................................................................................................................ 2,616 8,580 8,878 3.5
Large urban areas (populations over 1 million) .............................................................................. 1,440 8,961 9,267 3.4
Other urban areas (populations of 1 million or fewer) .................................................................... 1,176 8,123 8,412 3.6
Rural hospitals ................................................................................................................................. 1,128 6,534 6,750 3.3
Bed Size (Urban):
0–99 beds ................................................................................................................................. 676 6,480 6,726 3.8
100–199 beds ........................................................................................................................... 884 7,187 7,439 3.5
200–299 beds ........................................................................................................................... 485 8,127 8,417 3.6
300–499 beds ........................................................................................................................... 410 9,075 9,380 3.4
500 or more beds ..................................................................................................................... 161 10,866 11,238 3.4
Bed Size (Rural):
0–49 beds ................................................................................................................................. 452 5,629 5,814 3.3
50–99 beds ............................................................................................................................... 379 6,021 6,214 3.2
100–149 beds ........................................................................................................................... 188 6,490 6,706 3.3
150–199 beds ........................................................................................................................... 61 7,703 7,931 3.0
200 or more beds ..................................................................................................................... 48 7,788 8,079 3.7
Urban by Region:
New England ............................................................................................................................ 129 9,225 9,437 2.3
Middle Atlantic .......................................................................................................................... 368 9,342 9,626 3.0
South Atlantic ........................................................................................................................... 396 8,148 8,430 3.5
East North Central .................................................................................................................... 405 8,251 8,491 2.9
East South Central ................................................................................................................... 171 7,809 8,101 3.7
West North Central ................................................................................................................... 159 8,653 8,925 3.1
West South Central .................................................................................................................. 370 8,115 8,432 3.9
Mountain ................................................................................................................................... 146 8,455 8,770 3.7
Pacific ....................................................................................................................................... 420 10,089 10,603 5.1
Puerto Rico ............................................................................................................................... 52 3,998 4,118 3.0
Rural by Region:
New England ............................................................................................................................ 25 8,397 8,787 4.7
Middle Atlantic .......................................................................................................................... 73 6,200 6,460 4.2
South Atlantic ........................................................................................................................... 180 6,419 6,593 2.7
East North Central .................................................................................................................... 145 6,474 6,651 2.7
East South Central ................................................................................................................... 197 5,807 6,019 3.7
West North Central ................................................................................................................... 160 6,889 7,110 3.2
West South Central .................................................................................................................. 210 6,149 6,348 3.2
Mountain ................................................................................................................................... 87 7,399 7,658 3.5
Pacific ....................................................................................................................................... 51 9,904 10,328 4.3
By Payment Classification
Urban hospitals ................................................................................................................................ 2,651 8,544 8,840 3.5
Large urban areas (populations over 1 million) .............................................................................. 1,451 8,940 9,245 3.4
Other urban areas (populations of 1 million or fewer) .................................................................... 1,200 8,070 8,355 3.5
Rural areas ...................................................................................................................................... 1,093 6,675 6,898 3.3
Teaching Status:
Non-teaching ............................................................................................................................ 2,661 6,958 7,216 3.7
Fewer than 100 Residents ....................................................................................................... 845 8,379 8,665 3.4
100 or more Residents ............................................................................................................. 238 12,175 12,544 3.0
Urban DSH:
Non-DSH .................................................................................................................................. 1,026 7,462 7,715 3.4
100 or more beds ..................................................................................................................... 1,505 9,035 9,350 3.5
Less than 100 beds .................................................................................................................. 350 5,945 6,181 4.0
Rural DSH:
SCH .......................................................................................................................................... 404 6,941 7,201 3.7
RRC .......................................................................................................................................... 182 7,278 7,499 3.0
Other Rural:
100 or more beds .............................................................................................................. 63 5,580 5,743 2.9
Less than 100 beds ........................................................................................................... 214 4,904 5,044 2.9
Urban Teaching and DSH:
Both teaching and DSH ............................................................................................................ 811 9,971 10,301 3.3
Teaching and no DSH .............................................................................................................. 207 8,424 8,683 3.1
No teaching and DSH .............................................................................................................. 1,044 7,271 7,554 3.9
No teaching and no DSH ......................................................................................................... 589 6,893 7,143 3.6
Rural Hospital Types:
TABLE II.—IMPACT ANALYSIS OF CHANGES FOR FY 2006 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued
[Payments per case]
Aver- Aver-
Num- age FY age FY All FY
ber of 2005 pay- 2006 pay- 2006
hospitals ment per ment per changes
case 1 case 1
(1) (2) (3) (4)
Non special status hospitals ..................................................................................................... 334 5,149 5,305 3.0

RRC .......................................................................................................................................... 136 6,754 6,943 2.8
SCH .......................................................................................................................................... 389 7,548 7,837 3.8
MDH .......................................................................................................................................... 146 4,824 4,980 3.2
SCH and RRC .......................................................................................................................... 77 8,467 8,760 3.5
Type of Ownership:
Voluntary ................................................................................................................................... 2,217 8,374 8,655 3.4
Proprietary ................................................................................................................................ 857 7,545 7,819 3.6
Government .............................................................................................................................. 670 8,481 8,803 3.8
Medicare Utilization as a Percent of Inpatient Days:
0–25 .......................................................................................................................................... 280 11,238 11,670 3.8
25–50 ........................................................................................................................................ 1,427 9,272 9,595 3.5
50–65 ........................................................................................................................................ 1,534 7,326 7,573 3.4
Over 65 ..................................................................................................................................... 403 6,555 6,759 3.1
Hospitals Reclassified by the Medicare Geographic Classification Review Board
FY 2005 Reclassifications:
All Urban Reclassified Hospitals .............................................................................................. 263 8,522 8,882 4.2
Urban Nonreclassified Hospitals .............................................................................................. 2,329 8,576 8,867 3.4
All Reclassified Rural Hospitals ............................................................................................... 355 7,052 7,284 3.3
Rural Nonreclassified Hospitals ............................................................................................... 702 6,066 6,274 3.4
Other Reclassified Hospitals (Section 1886(d)(8)(E)) .............................................................. 64 5,717 5,857 2.5
Other Reclassified Hospitals (Section 1886(d)(8)(B)) .............................................................. 31 10,164 10,481 3.1
1 These payment amounts per case do not reflect any estimates of annual case-mix increase.
VII. Impact of Other Policy Changes cases in the March 2005 update of the FY not treat a broad spectrum of patients in their
In addition to those changes discussed 2004 MedPAR files, we estimate that the facilities with many different diagnoses.
above that we are able to model using our changes to the LTC–DRG classifications and While there are 526 valid Grouper version 23
IPPS payment simulation model, we are relative weights for FY 2006 will result in an LTC–DRGs, 196 LTC–DRGs have no LTCH
aggregate decrease in LTCH PPS payments of cases. In addition, another 171 LTC–DRGs
making various other changes in this final
approximately 4.2 percent. are categorized as ‘‘low volume’’ (that is,
rule. Generally, we have limited or no
When we compared the Grouper version 22 have less than 25 cases annually).
specific data available with which to estimate (FY 2005) LTC–DRG relative weights to the Consequently, only about 159 LTC–DRGs are
the impacts of these changes. Our estimates Grouper version 23 (FY 2006) LTC–DRG used by most LTCHs on a ‘‘regular basis’’
of the likely impacts associated with these relative weights, we found that (that is, nationally LTCHs discharge, in total,
other changes are discussed below. approximately 71 percent of the LTC–DRGs average 25 or more of these cases annually).
A. Impact of LTC–DRG Reclassifications and had higher relative weights under version 22. Of these 159 LTC–DRGs that are used on a
Relative Weights for LTCHs We also found that the Grouper version 22 ‘‘regular basis,’’ we found that approximately
LTC–DRG relative weights were, on average, 80 percent of the LTC–DRGs had higher
In section II.D. of the preamble of this final approximately 15 percent higher than the relative weights under Grouper version 22 in
rule, we discuss the changes in the LTC–DRG Grouper version 23 LTC–DRG relative comparison to Grouper version 23. About 33
relative weights for FY 2006, which is based weights. In addition, based on an analysis of percent of the159 LTC–DRGs that are used on
on the version 23.0 of the CMS GROUPER the most recent available LTCH claims data a ‘‘regular basis’’ (53 LTC–DRGs) will
(including the changes in the classifications, from the FY 2004 MedPAR file, we continue experience a decrease in the average charge
relative weights and geometric mean length to observe that the average LTC–DRG relative per case as compared to the average charge
of stay for each LTC–DRG). As also discussed weight decreases due to an increase of per case in that DRG based on FY 2003 data,
in that same section of this final rule, relatively lower charge cases being assigned which generally results in a lower relative
currently, there is no statutory or regulatory to LTC–DRGs with higher relative weights in weight. We also found that there has been an
requirement that the annual update to the the prior year. Contributing to this increase increase of approximately 16 percent in the
LTC–DRG classifications and relative weights in these relatively lower charge cases being average LTCH charge across all LTC–DRGs
be done in a budget neutral manner. As assigned to LTC–DRGs with higher relative from FY 2003 to FY 2004. In addition, about
discussed above in section II.D.4. of the weights in the prior year are improvements 42 percent of the 159 LTC–DRGs that are
preamble to this final rule, the LTCH PPS is in coding practices, which are typical when used on a ‘‘regular basis’’ (66 LTC–DRGs)
still in the midst of a transition from a moving from a reasonable cost-based will experience an increase in the average
reasonable cost-based payment system to payment system to a PPS. The impact of charge that is less than the increase in the
fully Federal PPS payments, during which including additional cases with relatively overall average charge across all LTC–DRGs
time LTCH coding and data are still in flux. lower charges into LTC–DRGs that had a (about 16 percent, as noted above).
The LTCH PPS was implemented for cost relatively higher relative weight in the Accordingly, those LTC–DRGs will also have
reporting periods beginning on or after Grouper version 22.0 (FY 2005) is a decrease a reduction in their relative weight as
October 1, 2002 (FY 2003). Therefore, the FY in the average relative weight for those LTC– compared to the relative weight in FY 2005.
2004 MedPAR data used to compute the FY DRGs in the GROUPER version 23.0. For those LTC–DRGs in which the average
2006 LTC–DRG relative weights are based on As noted above in section II.D.4 of the charge within the LTC–DRG increase is less
LTCH claims data taken from only the first preamble of this final rule, LTCHs are a than 16 percent, the relative weights for those
full year of the LTCH PPS. Based on LTCH specialized provider type that typically do LTC–DRGs will decrease because the average
charge for each of those LTC–DRGs is being full market basket update in FY 2006 was resident cap for these hospitals. Because this
divided by a larger number (that is, the May 15, 2005. Preliminary results indicate is a clarification of existing policy and
average charge across all LTC–DRGs). For the that over 98 percent of IPPS hospitals have codification of it in regulations, there is no
reasons discussed above, we believe that the submitted quality data. The QIOs are still in financial impact for FY 2006.
changes in the LTC–DRG relative weights, the process of validating that data and 2. Section 1886(d)(8)(E) Teaching Hospitals
which include a significant number of LTC– certifying those hospitals eligible to receive That Withdraw Rural Reclasssification
DRGs with lower relative weights, will result the full update for FY 2006. We have
in approximately a 4.2 percent decrease in continued our efforts to ensure that QIOs In section V.F.3. of the preamble to this
aggregate LTCH PPS payments. provide assistance to all hospitals that wish final rule, we present our policy to adjust the
to submit data. In the preamble to this final IME FTE resident caps of hospitals that
B. Impact of New Technology Add-On rule, we are providing additional validation rescind their section 1886(d)(8)(E) rural
Payments criteria to ensure that the quality data being reclassifications so that they do not continue
We are no longer required to ensure that sent to CMS are accurate. The requirement of to receive the increase in the FTE resident
any add-on payments for new technology 5 charts per hospital will result in cap that is applied for rural teaching hositals.
under section 1886(d)(5)(K) of the Act are approximately 19,000 charts per quarter total The purpose of this policy is to prevent
budget neutral (see section II.E. of the submitted to the agency. We reimburse urban hospitals from reclassifying to rural
preamble to this final rule). However, we are hospitals for the cost of sending charts to the areas under section 1886(d)(8)(E) of the Act
still providing an estimate of the payment CDAC at the rate of 12 cents per page for for a short period of time, solely as a means
increases here, as they will have an impact copying and approximately $4.00 per chart of receiving a permanent increase to their
on total payments made in FY 2006. New for postage. Our experience shows that the IME FTE caps. The impact of this policy is
technology add-on payments are limited to average chart received at the CDAC is that section 1886(d)(8)(E) hospitals may
the lower of 50 percent of the costs of the approximately 140 pages. Thus, the agency receive decreased IME payments if they
technology, or 50 percent of the costs in will have expenditures of approximately return to urban status. This impact cannot be
$380,000 per quarter to collect the charts. quantified because we are unable to
excess of the DRG payment for the case.
Given that we reimburse for the data determine the number of hospitals that
Because it is difficult to predict the actual
collection effort, we believe that a would otherwise convert to rural status
new technology add-on payment for each
requirement for five charts per hospital per solely to gain a higher IME FTE cap in the
case, we are estimating the increase in
quarter represents a minimal burden to the absence of this policy and we are not aware
payment for FY 2006 as if every claim with
participating hospital. Based on test of any teaching hospitals that became rural
these add-on payments will receive the
applications of these validation criteria to under the provision of section 1886(d)(8)(E)
maximum add-on payment. As discussed in
quality data that have been submitted thus of the Act that have subsequently reverted to
section II.E. of the preamble of this final rule,
far, we currently estimate that approximately urban status.
we are approving two of the new technology
applications, Restore Rechargable 2 percent of hospitals will fail the edits and F. Impact of Policy Relating to Geographic
Implantable Neurostimulator and GORE receive the reduced market basket update to Reclassifications of Multicampus Hospitals
TAG, that were filed for FY 2006. the standardized amount. We estimate
In section V.H.2. of the preamble of this
Additionally, we are continuing to make add- reduced market basket payments of
final rule, we discuss the impact of our
on payments in FY 2006 for an FY 2005 new approximately $8 million for FY 2006.
implementation of the new labor market
technology: KinetraTM implants. We estimate D. Impact of Policy on Payment Adjustments areas on multicampus hospital systems.
these approvals will increase overall FY 2006 for Low-Volume Hospitals Under our current policy, a multicampus
payments by $6.01 million, $16.61 million hospital with campuses located in the same
and $12.82 million, respectively. The total In section V.E. of the preamble to this final
rule, we discussed our FY 2006 labor market area receives a single wage
increase in payments for these three new index. However, if the campuses are located
technologies, approximately $35.5 million, is implementation of section 1886(d)(12) of the
Act, as added by section 406 of Pub. L. 108– in more than one labor market area, payment
not reflected in the tables. for each discharge is determined using the
173, which provides for a payment
C. Impact of Requirements for Hospital wage index value for the labor market area
adjustment to account for the higher costs per
Reporting of Quality Data for Annual in which the campus of the hospital is
discharge of low-volume hospitals under the
Hospital Payment Update located. In addition, current provisions
IPPS. For FY 2006, we are continuing to
provide that, in the case of a merger of
In section V.B. of the preamble to this final apply the low-volume adjustment criteria
hospitals, if the merged facilities operate as
rule, we discuss our implementation of that we specified in the FY 2005 IPPS final
a single institution, the institution must
section 1886(b)(3)(B)(vii) of the Act, as added rule (69 FR 49099). Currently, our fiscal
submit a single cost report, which
by section 501(b) of Pub. L. 108–173, which intermediaries have identified eight
necessitates a single provider identification
revised the mechanism used to update the providers that are eligible for the low-volume
number. This provision also does not
standardized amount of payment for adjustment. We estimate that the impact of
differentiate between merged facilities in a
inpatient hospital operating costs. these providers receiving the additional 25 single wage index area or in multiple wage
Specifically, section 1886(b)(3)(B)(vii) of the percent payment increase to be index areas. As a result, the wage index data
Act provides for a reduction of 0.4 percentage approximately $1.49 million. for the merged facility is reported for the
points to the update percentage increase (also E. Impact of Policies on Payment for Indirect entire entity on a single cost report.
known as the market basket update) for each Costs of Graduate Medical Education The current criteria for a hospital being
of FYs 2005 through 2007 for any subsection reclassified to another wage area by the
(d) hospital that does not submit data on a 1. IME Adjustment for TEFRA Hospitals
MGCRB do not address the circumstances
set of 10 quality indicators as established by Converting to IPPS Hospitals
under which a single campus of a
the Secretary as of November 1, 2003. The In section V.F.2. of the preamble of this multicampus hospital may seek
statute also provides that any reduction will final rule, we discuss the incorporation into reclassification.
apply only to the year involved, and will not regulations of our existing policy regarding Specifically, we are providing that, for
be taken into account in computing the the IME adjustment for TEFRA hospitals reclassification applications submitted for FY
applicable percentage increase for a converting to IPPS hospitals. We establish an 2006 (that is, applications received by
subsequent fiscal year. We are unable to FTE resident cap for TEFRA hospitals September 1, 2004), for FY 2007 (that is,
precisely estimate the effect of this provision converting to an IPPS hospital for IME applications received by September 1, 2005,
because, while receiving the full update for payment purposes as if the hospital had been and for FY 2008 (that is, applications
those years is conditional upon the an IPPS hospital during the base year used received by September 1, 2006), we will
submission of quality data by a hospital, the to compute the hospital’s direct GME FTE allow a campus or campuses of a
submitted data must also be validated, as resident cap. We are only aware of four multicampus hospital system to seek
described in section V.B. of the preamble to hospitals where this issue has arisen. The geographic reclassification to the labor
this final rule. The final date for submission addition to the regulations clarifies the market area where the other campus(es) is
of quality data for purposes of receiving the established policy for computing an IME FTE located on the basis of the average hourly
wage data submitted for the entire hospital H. Impact of Policy on Rural Community their facilities. For the reasons explained
system. This policy will only affect those Hospital Demonstration Program more fully in section VII.B.3, we have
multicampus hospitals that are located in In section V.K. of the preamble to this final decided to permit a necessary provider CAH
more than one labor market area that seek to rule, we discuss our implementation of to relocate its facility and begin providing
reclassify to allow the entire hospital system section 410A of Pub.L. 108–173 that required services at a new location, provided the
to be paid using a single wage index. We the Secretary to establish a demonstration necessary provider will be essentially the
estimate there are less than 10 multicampus that will modify reimbursement for inpatient same facility in its new location.
hospital systems nationwide that will seek to services for up to 15 small rural hospitals. The Health Resources Services
reclassify under the revised regulation. This Section 410A(c)(2) requires that ‘‘in Administration (HRSA) estimates that these
provision will not lead to additional program conducting the demonstration program under necessary provider CAH facility
expenditures because hospital geographic this section, the Secretary shall ensure that replacements will take place at the rate of 5
reclassifications are budget neutral under the aggregate payments made by the facilities per year, nationwide, over the next
section 1886(d)(8)(D) of the Act. Secretary do not exceed the amount which 10 years. The average cost of construction of
the Secretary would have paid if the a new 25-bed CAH is approximately $25
G. Impact of Policy on Payment for Direct million. Given a depreciation schedule based
Costs of Graduate Medical Education demonstration program under this section
was not implemented.’’ As discussed in on a 25 year useful life and Medicare
1. GME Initial Residency—Match for Second section V.K. of the preamble to this final rule, utilization of approximately 50 percent, the
Year we are satisfying this requirement by additional annual capital costs for 5 CAH
In section V.I.2. of the preamble to this adjusting national IPPS rates by a factor that facility replacements would be $2.5 million.
final rule, we discuss our changes related to is sufficient to account for the added costs of However, the actual cost to the program
the initial residency period for residents that this demonstration. We estimate that the would be further reduced since those CAH
match into an advanced residency program, average additional annual payment for FY are currently being reimbursed for their
but fail to match into a clinical base year of 2006 that will be made to each participating existing capital costs and their increased
training. We are providing that, in instances hospital under the demonstration will be operating costs that are associated with
where a hospital can document that, prior to approximately $977,410. We based this operating an aged facility. Accordingly, the
commencement of any residency training, a estimate on the recent historical experience budgetary impact for the change on the
resident matched into an advanced program of the difference between inpatient cost and affected CAHs is estimated at between $1
that begins in the second residency year, that payment for hospitals that have applied for million and $2 million. Expressed on a per-
resident’s initial residency period will be the demonstration. For 13 participating facility basis, the budgetary impact of this
determined based on the period of board hospitals, the total annual impact of the change is estimated at between $200,000 and
eligibility for the advanced program, without demonstration program is estimated to be $400,000 per CAH.
$12,706,334. We describe the budget Comment: One commenter stated that our
regard to the fact that the resident had not
neutrality adjustment required for this estimated cost of $25 to $35 million is not
matched for a clinical base year training
purpose in the Addendum to this final rule. a realistic estimate. One example given was
program. For purposes of this final rule, we
a hospital in Oklahoma with 15 beds and 2
have estimated the impact of this change for
I. Impact of Policy on Provider-Based Status complete surgical suites. The commenter
FY 2006, using assumptions about the
of Facilities and Organizations Under indicated that the cost for building the new
national average per resident amount, the
Medicare—Location Requirements for Off- facility and buying equipment was $7.5
number of affected residents, and the
Campus Facilities: Application to Certain million.
national average Medicare utilization rate.
Neonatal Intensive Care Units Response: We appreciate the commenter’s
We estimate that this provision will affect
In section V.J.2. of the preamble to this information and considered it in developing
approximately 600 residents. Using a the cost estimate for the final rule. However,
national average per resident amount of final rule, we discuss the change to the
provider-based regulations regarding the as acknowledged by the commenter, the $7.5
$92,000, and an average Medicare utilization million figure represents a single instance of
rate of 35 percent, we estimate that, for FY location requirements for off-campus
facilities as they relate to neonatal intensive construction at a single location and related
2006, the impact of treating those residents to a facility having only 15 beds. In contrast,
as a full FTE rather than 0.50 FTE, Medicare care units (NICUs). In accordance with this
final rule, NICUs meeting other applicable our estimate of $25 to $35 million is intended
payments for direct GME will increase by to be national in scope and assumes the new
approximately $9.7 million. requirements will be considered to be
qualified provider-based entities if they are facility will have 25 beds, as do the vast
2. New Teaching Hospitals’ Participation in majority of facilities now operating as CAHs.
located within a 100-mile radius of the
Medicare GME Affiliated Groups Therefore, we made no change in our cost
children’s hospitals which is the potential
In section V.I.3. of the preamble to this estimates based on this comment.
main provider and at least 35 miles from the
final rule, we discuss changes related to new nearest other NICU. We estimate that there VIII. Impact of Changes in the Capital PPS
teaching hospitals’ participation in Medicare will be fewer than five NICUs nationwide
GME affiliated groups. Under current that will be able to meet the provider-based A. General Considerations
regulations, a new teaching hospital located status as a result of this change. Given the Fiscal year (FY) 2001 was the last year of
in an urban area that establishes an FTE specialized nature of the care provided and the 10-year transition period established to
resident cap under § 413.79(e) may not their rural location, we expect that these phase in the PPS for hospital capital-related
participate in a Medicare GME affiliated types of units will not treat any Medicare costs. During the transition period, hospitals
group. We are revising the regulations to patients, though some of their patients may were paid under one of two payment
allow a new teaching hospital located in an qualify for Medicaid. As a result, we believe methodologies: Fully prospective or hold
urban area to participate in a Medicare GME that this change will have no impact on harmless. Under the fully prospective
affiliated group, but only if any adjustments Medicare. The Medicaid impact, on a methodology, hospitals were paid a blend of
made by the Medicare GME affiliation national basis, will be very small. the capital Federal rate and their hospital-
agreement result in an increase to the new specific rate (see § 412.340). Under the hold-
teaching hospital’s adjusted resident FTE J. Impact of Policy on CAH Relocation harmless methodology, unless a hospital
resident caps for purposes of IME and direct Provisions elected payment based on 100 percent of the
GME payment. There is no estimated In section VII.B.3. of the preamble to this capital Federal rate, hospitals were paid 85
increase in program payments related to this final rule, we discuss the change to the percent of reasonable costs for old capital
change because any additional residents that necessary provider provision as it applies to costs (100 percent for SCHs) plus an amount
would be counted at the new teaching CAHs. As required by statute, no additional for new capital costs based on a proportion
hospitals as a result of this change could CAHs will be certified as a necessary of the capital Federal rate (see § 412.344). As
have been counted prior to the affiliation for provider on or after January 1, 2006. We are we state in section VI. of the preamble of this
Medicare GME payment purposes at the revising the regulations to allow some final rule, with the 10-year transition period
hospital that is losing slots under the flexibility for those CAHs previously ending with hospital cost reporting periods
affiliation agreement. designated as necessary providers to replace beginning on or after October 1, 2001 (FY
2002), beginning in FY 2002 capital • We estimate that the Medicare case-mix experience a 2.5 percent increase in IPPS
prospective payment system payments for index will increase by 1.0 percent in both capital payments per case, while rural
most hospitals are based solely on the capital FYs 2005 and 2006. hospitals are only expected to experience a
Federal rate. Therefore, we no longer include • We estimate that the Medicare 1.8 percent increase in capital payments per
information on obligated capital costs or discharges will be 13.5 million in FY 2005 case. This difference is mostly due to a
projections of old capital costs and new and 13.3 million in FY 2006 for a 1.5 percent projection that urban hospitals would
capital costs, which were factors needed to decrease from FY 2005 to FY 2006. experience a larger increase in estimated
calculate payments during the transition • The capital Federal rate was updated outlier payments from FY 2005 to FY 2006
period, for our impact analysis. beginning in FY 1996 by an analytical compared to rural hospitals.
In accordance with § 412.312, the basic framework that considers changes in the All regions are estimated to receive an
methodology for determining a capital PPS prices associated with capital-related costs increase in total capital payments per case
payment is: and adjustments to account for forecast error, from FY 2005 to FY 2006. Changes by region
(Standard Federal Rate) × (DRG weight) × changes in the case-mix index, allowable vary from a minimum increase of 1.0 percent
(Geographic Adjustment Factor (GAF)) × changes in intensity, and other factors. The (Middle Atlantic rural) to a maximum
(Large Urban Add-on, if applicable) × (COLA FY 2006 update is 0.8 percent (see section increase of 4.5 percent (New England rural).
adjustment for hospitals located in Alaska III.A.1.a. of the Addendum to this final rule). The relatively small increase in projected
and Hawaii) × (1 + Disproportionate Share • In addition to the FY 2006 update factor, capital payments per discharge for hospitals
(DSH) Adjustment Factor + Indirect Medical the FY 2006 capital Federal rate was located in the Middle Atlantic region is
Education (IME) Adjustment Factor, if calculated based on a GAF/DRG budget largely attributable to the change in the GAF
applicable). neutrality factor of 1.0008, an outlier value (that is, the GAF for most of these
In addition, hospitals may also receive adjustment factor of 0.9515, and a (special) hospitals for FY 2006 are lower than the
outlier payments for those cases that qualify exceptions adjustment factor of 0.9997. weighted average of the GAFs for FY 2005).
under the threshold established for each 2. Results The relatively large increase in capital
fiscal year. payments per discharge for hospitals located
The data used in developing the impact In the past, in this impact section we in the New England rural region is largely
analysis presented below are taken from the presented the redistributive effects that were due to the changes in the GAF values (that
March 2005 update of the FY 2004 MedPAR expected to occur between ‘‘hold-harmless’’
is, the GAFs for most of these hospitals for
hospitals and ‘‘fully prospective’’ hospitals
file and the March 2005 update of the FY 2006 are higher than the average of the
and a cross-sectional summary of hospital
Provider Specific File that is used for GAFs for FY 2005) and an increase in
groupings by the capital PPS transition
payment purposes. Although the analyses of estimated outlier payments for FY 2006.
period payment methodology. We are no
the changes to the capital prospective Hospitals located in Puerto Rico are
longer including this information because all
payment system do not incorporate cost data, expected to experience an increase in total
hospitals (except new hospitals under
we used the March 2005 update of the most capital payments per case of 0.3 percent. This
§ 412.324(b) and under § 412.304(c)(2)) will
recently available hospital cost report data lower than average increase in payment per
be paid 100 percent of the capital Federal
(FY 2003) to categorize hospitals. Our case for hospitals located in Puerto Rico is
rate in FY 2006.
analysis has several qualifications. First, we largely due to the changes in the GAF values
We used the actuarial model described
do not make adjustments for behavioral above to estimate the potential impact of our (that is, the GAFs for most of these hospitals
changes that hospitals may adopt in response changes for FY 2006 on total capital for FY 2006 are lower than the average of the
to policy changes. Second, due to the payments per case, using a universe of 3,693 GAFs for FY 2005).
interdependent nature of the IPPS, it is very hospitals. As described above, the individual By type of ownership, government
difficult to precisely quantify the impact hospital payment parameters are taken from hospitals are projected to have the largest rate
associated with each change. Third, we draw the best available data, including the March of increase of total payment changes (2.6
upon various sources for the data used to 2005 update of the FY 2004 MedPAR file, the percent). Similarly, payments to voluntary
categorize hospitals in the tables. In some March 2005 update to the Provider-Specific and proprietary hospitals are expected to
cases (for instance, the number of beds), there File, and the most recent cost report data increase 2.4 percent and 2.3 percent,
is a fair degree of variation in the data from from the March 2005 update of HCRIS. In respectively. As noted above, this slightly
different sources. We have attempted to Table III, we present a comparison of total larger projected increase in capital payments
construct these variables with the best payments per case for FY 2005 compared to per case for government hospitals is mostly
available sources overall. However, for FY 2006 based on the FY 2006 payment due to a smaller than average decrease in the
individual hospitals, some policies. Column 2 shows estimates of GAF values.
miscategorizations are possible. payments per case under our model for FY Section 1886(d)(10) of the Act established
Using cases from the March 2005 update of 2005. Column 3 shows estimates of payments the MGCRB. Previously, hospitals could
the FY 2004 MedPAR file, we simulated per case under our model for FY 2006. apply for reclassification for purposes of the
payments under the capital PPS for FY 2005 Column 4 shows the total percentage change standardized amount, wage index, or both.
and FY 2006 for a comparison of total in payments from FY 2005 to FY 2006. The Section 401(c) of Pub. L. 108–173 equalized
payments per case. Any short-term, acute change represented in Column 4 includes the the standardized amounts under the
care hospitals not paid under the general 0.8 percent update to the capital Federal rate, operating IPPS. Therefore, beginning in FY
IPPS (Indian Health Service hospitals and a 0.0 percent increase in case-mix, changes 2005, there is no longer reclassification for
hospitals in Maryland) are excluded from the in the adjustments to the capital Federal rate the purposes of the standardized amounts;
simulations. (for example, the effect of the new hospital hospitals may apply for reclassification for
As we explain in section III.A.4. of the wage index on the GAF), and purposes of the wage index in FY 2006.
Addendum of this final rule, payments are no reclassifications by the MGCRB, as well as Reclassification for wage index purposes also
longer made under the regular exceptions changes in special exception payments. The affects the GAF because that factor is
provision under §§ 412.348(b) through (e). comparisons are provided by: (1) Geographic constructed from the hospital wage index.
Therefore, we no longer use the actuarial location; (2) region; and (3) payment To present the effects of the hospitals being
capital cost model (described in Appendix B classification. reclassified for FY 2006 compared to the
of the August 1, 2001 proposed rule (66 FR The simulation results show that, on effects of reclassification for FY 2005, we
40099)). We modeled payments for each average, capital payments per case can be show the average payment percentage
hospital by multiplying the capital Federal expected to increase 2.4 percent in FY 2006. increase for hospitals reclassified in each
rate by the GAF and the hospital’s case-mix. In addition to the 0.8 percent increase due to fiscal year and in total. The reclassified
We then added estimated payments for the capital market basket update, this groups are compared to all other
indirect medical education, disproportionate projected increase in capital payments per nonreclassified hospitals. These categories
share, large urban add-on, and outliers, if case is largely attributable to an estimated are further identified by urban and rural
applicable. For purposes of this impact increase in outlier payments in FY 2006. Our designation.
analysis, the model includes the following comparison by geographic location shows Hospitals reclassified for FY 2006 as a
assumptions: that urban hospitals are expected to whole are projected to experience a 2.7
percent increase in payments. Payments to in payments of 1.9 percent. Hospitals values (that is, the GAFs for most of these
nonreclassified hospitals in FY 2006 are reclassified during FY 2006 only are hospitals for FY 2006 are higher than the
expected to increase 2.4 percent. Hospitals projected to receive an increase in payments average of the GAFs for FY 2005).
reclassified during both FY 2005 and FY of 4.5 percent. This relatively large increase
2006 are projected to experience an increase is primarily due to the changes in the GAF
TABLE III.—COMPARISON OF TOTAL PAYMENTS PER CASE

[FY 2005 payments compared to FY 2006 payments]
Average Average
Number FY 2005 FY 2006
of hos- pay- pay- Change
pitals ments/ ments/
case case
By Geographic Location
All hospitals ...................................................................................................................................... 3,744 723 741 2.4

Large urban areas (populations over 1 million) .............................................................................. 1,440 807 827 2.5
Other urban areas (populations of 1 million of fewer) .................................................................... 1,176 715 732 2.4
Rural areas ...................................................................................................................................... 1,128 501 510 1.8
Urban hospitals ................................................................................................................................ 2,616 765 784 2.5
0–99 beds ................................................................................................................................. 676 587 600 2.2
100–199 beds ........................................................................................................................... 884 649 664 2.3
200–299 beds ........................................................................................................................... 485 723 740 2.3
300–499 beds ........................................................................................................................... 410 805 824 2.3
500 or more beds ..................................................................................................................... 161 961 991 3.1
Rural hospitals ................................................................................................................................. 1,128 501 510 1.8
0–49 beds ................................................................................................................................. 452 414 420 1.3
50–99 beds ............................................................................................................................... 379 463 471 1.8
100–149 beds ........................................................................................................................... 188 506 515 1.9
150–199 beds ........................................................................................................................... 61 562 572 1.8
200 or more beds ..................................................................................................................... 48 626 640 2.3
By Region
Urban by Region .............................................................................................................................. 2,616 765 784 2.5
New England ............................................................................................................................ 129 831 849 2.1
Middle Atlantic .......................................................................................................................... 368 832 854 2.6
South Atlantic ........................................................................................................................... 396 734 751 2.2
East North Central .................................................................................................................... 405 757 771 2.0
East South Central ................................................................................................................... 171 689 706 2.4
West North Central ................................................................................................................... 159 760 775 2.0
West South Central .................................................................................................................. 370 712 730 2.5
Mountain ................................................................................................................................... 146 767 786 2.5
Pacific ....................................................................................................................................... 420 864 898 4.0
Puerto Rico ............................................................................................................................... 52 338 339 0.3
Rural by Region ............................................................................................................................... 1,128 501 510 1.8
New England ............................................................................................................................ 25 647 676 4.5
Middle Atlantic .......................................................................................................................... 73 512 517 1.0
South Atlantic ........................................................................................................................... 180 491 500 1.7
East North Central .................................................................................................................... 145 532 540 1.5
East South Central ................................................................................................................... 197 460 470 2.2
West North Central ................................................................................................................... 160 526 532 1.3
West South Central .................................................................................................................. 210 454 461 1.7
Mountain ................................................................................................................................... 87 520 532 2.4
Pacific ....................................................................................................................................... 51 591 612 3.6
By Payment Classification
All hospitals ...................................................................................................................................... 3,744 723 741 2.4
Large urban areas (populations over 1 million) .............................................................................. 1,451 806 826 2.6
Other urban areas (populations of 1 million of fewer) .................................................................... 1,200 713 730 2.4
Rural areas ...................................................................................................................................... 1,093 502 511 1.9
Teaching Status:
Non-teaching ............................................................................................................................ 2,661 605 618 2.2
Fewer than 100 Residents ....................................................................................................... 845 743 760 2.2
100 or more Residents ............................................................................................................. 238 1,062 1,094 3.0
Urban DSH:
100 or more beds .............................................................................................................. 1,505 790 811 2.6
Less than 100 beds ........................................................................................................... 350 521 535 2.6
Rural DSH:
Sole Community (SCH/EACH) .......................................................................................... 404 452 459 1.7
Referral Center (RRC/EACH) ........................................................................................... 182 559 572 2.2
Other Rural:
100 or more beds ....................................................................................................... 63 471 478 1.6
Less than 100 beds ................................................................................................... 214 416 421 1.2
Urban teaching and DSH:
Both teaching and DSH ............................................................................................................ 811 870 893 2.7
TABLE III.—COMPARISON OF TOTAL PAYMENTS PER CASE—Continued

[FY 2005 payments compared to FY 2006 payments]
Average Average
Number FY 2005 FY 2006
of hos- pay- pay- Change
pitals ments/ ments/
case case
Teaching and no DSH .............................................................................................................. 207 793 810 2.1

No teaching and DSH .............................................................................................................. 1,044 641 656 2.4
No teaching and no DSH ......................................................................................................... 589 664 678 2.2
Rural Hospital Types:
Non special status hospitals ..................................................................................................... 334 441 448 1.5
RRC/EACH ............................................................................................................................... 136 570 582 2.1
SCH/EACH ............................................................................................................................... 389 470 479 1.8
Medicare-dependent hospitals (MDH) ...................................................................................... 146 418 424 1.4
SCH, RRC and EACH .............................................................................................................. 77 570 582 2.0
Hospitals Reclassified by the Medicare Geographic Classification Review Board
Reclassification Status During FY2005 and FY2006:
Reclassified During Both FY2005 and FY2006 ....................................................................... 418 632 644 1.9
Reclassified During FY2006 Only ..................................................................................... 198 705 736 4.5
Reclassified During FY2005 Only ..................................................................................... 134 678 695 2.5
FY2006 Reclassifications:
All Reclassified Hospitals .................................................................................................. 618 655 673 2.7
All Nonreclassified Hospitals ............................................................................................. 3,031 740 757 2.4
All Urban Reclassified Hospitals ....................................................................................... 263 759 782 3.0
Urban Nonreclassified Hospitals ....................................................................................... 2,329 766 785 2.4
All Reclassified Rural Hospitals ........................................................................................ 355 545 558 2.3
Rural Nonreclassified Hospitals ........................................................................................ 702 453 459 1.4
Other Reclassified Hospitals (Section 1886(D)(8)(B)) ............................................................. 71 501 502 0.2
Type of Ownership
Voluntary ................................................................................................................................... 2,189 743 760 2.4
Proprietary ................................................................................................................................ 806 654 669 2.3
Government .............................................................................................................................. 669 696 715 2.6
Medicare Utilization as a Percent of Inpatient Days:.
0–25 .......................................................................................................................................... 280 918 947 3.2
25–50 ........................................................................................................................................ 1,427 811 834 2.7
50–65 ........................................................................................................................................ 1,534 644 658 2.0
Over 65 ..................................................................................................................................... 403 587 597 1.6
Appendix B: Recommendation of Update equal to the market basket percentage hospital units excluded from the IPPS, that
Factors for Operating Cost Rates of Payment increase less 0.4 percentage points. Section is, certain psychiatric hospitals and units
for Inpatient Hospital Services 1886(b)(3)(B)(iv) of the Act sets the FY 2006 (now referred to as inpatient psychiatric
percentage increase in the hospital-specific facilities (IPFs)), certain LTCHs, cancer
I. Background rates applicable to SCHs and MDHs equal to hospitals, children’s hospitals, and RNHCIs
Section 1886(e)(4)(A) of the Act requires the rate set forth in section 1886(b)(3)(B)(i) of equal to the market basket percentage
that the Secretary, taking into consideration the Act (that is, the same update factor as for increase. In the past, hospitals and hospital
the recommendations of the Medicare all other hospitals subject to the IPPS, or the units excluded from the IPPS have been paid
Payment Advisory Commission (MedPAC), rate-of-increase in the market basket). based on their reasonable costs subject to
recommend update factors for inpatient Based on the Office of the Actuary’s TEFRA limits. However, some of these
hospital services for each fiscal year that take revised and rebased fourth quarter 2004 categories of excluded hospitals and units are
into account the amounts necessary for the forecast of the FY 2006 market basket currently, or soon will be, paid under their
efficient and effective delivery of medically increase of 3.7 percent, the update to the own prospective payment systems. Currently,
appropriate and necessary care of high standardized amounts for hospitals subject to children’s and cancer hospitals and RNHCIs
quality. Under section 1886(e)(5)(B) of the the acute inpatient prospective payment are the remaining three types of hospitals
Act, we are required to publish update system is 3.7 percent (that is, the market still reimbursed fully under reasonable costs.
factors recommended by the Secretary in the basket rate-of-increase) for hospitals in all Those psychiatric hospitals and units of
final rule. areas, provided the hospital submits quality hospitals not yet paid under a PPS are still
Consistent with section 1886(e)(5)(B) of the data in accordance with our rules, and 3.3 reimbursed fully on a reasonable cost basis
Act, in this final rule, we are publishing our percent for hospitals that do not provide the subject to TEFRA limits. In addition, those
final recommendations for updating hospitals required quality data. The update to the LTCHs and IPFs paid under a blend
payments for FY 2006. In accordance with hospital specific rate applicable to SCHs and methodology have the TEFRA portion of that
sections 1886(d)(3)(A) and MDHs is also 3.7 percent. In the proposed payment subject to the TEFRA limits.
1886(b)(3)(B)(i)(XIX) of the Act, we are rule, the most recent estimate of the market Hospitals and units that receive any
updating the standardized amount for FY basket increase was 3.2 percent. Accordingly, reasonable cost-based payments will have
2006 equal to the rate-of-increase in the we proposed an update factor of 3.2 percent those payments determined subject to the
hospital market basket for IPPS hospitals in for hospitals that submitted quality data and TEFRA limits for FY 2006.
all areas subject to the hospital submitting 2.8 percent for hospitals that did not provide As we discuss in section IV. of the
quality information under rules established the required quality data. preamble and in section IV. of the
by the Secretary under section Section 1886(b)(3)(B)(ii) of the Act sets the Addendum to this final rule, we have used
1886(b)(3)(B)(vii) of the Act. For hospitals FY 2006 percentage increase in the rate-of- the estimated FY 2006 IPPS operating market
that do not provide these data, the update is increase limits for various hospitals and basket percentage increase (3.7 percent) to
update the target limits for children’s the portion of the IPF PPS transitional blend recommendation. However, the fourth
hospitals, cancer hospitals, and RNHCIs. payment based on reasonable costs will be quarter forecast of the market basket
As described in greater detail below, under determined by updating the IPF’s TEFRA percentage increase is 3.7 for these excluded
their respective PPSs, existing LTCHs and limit by the current estimate of the FY 2002- hospitals and hospital units (up from 3.2
existing IPFs are/or will soon be in a based excluded hospital market basket (or 3.8 percent estimated in the proposed rule).
transition period during which some LTCHs percent). Thus, the Secretary’s final recommendation
and IPFs are paid a blend of reasonable cost- IRFs are paid under the IRF PPS for cost is that the update to the target limits for
based payments (subject to the TEFRA limits) reporting periods beginning on or after cancer hospitals, RNHCIs, and children’s
and a Federal prospective payment amount. January 1, 2002. For cost reporting periods hospitals is 3.7 percent.
Under the respective transition period beginning during FY 2004, and thereafter, the Further, we did not receive any comments
methodologies for the LTCH PPS and IPF Federal prospective payments to IRFs are concerning our proposed recommendations
PPS, which are described below, payment is based on 100 percent of the adjusted Federal for the update factor for LTCHs for RY 2006.
based, in part, on a decreasing percentage of IRF prospective payment amount, updated For LTCHs that currently may be paid during
the reasonable cost-based payment amount. annually. (Refer to the July 30, 2004 final rule a transition period a blend of reasonable cost-
As we discuss in section IV. of the preamble (69 FR 45721).) based payments (subject to the TEFRA limits)
of this final rule, we are rebasing the market and Federal prospective payment amounts,
basket used to determine the reasonable cost- II. Secretary’s Final Recommendation for
we are recommending a final update factor of
based payment amount for LTCHs and IPFs. Updating the Prospective Payment System
3.8 percent (up from the estimated 3.4
We are providing that the portion of Standardized Amount
percent in the proposed rule) for the portion
payments to LTCHs and IPFs that are In recommending an update, the Secretary of the payment that is based on reasonable
reasonable cost-based will be determined takes into account the factors in the update costs, subject to the TEFRA limits, consistent
using the FY 2002-based excluded hospital framework, as well as other factors, such as with our determination in section IV. of the
market basket (currently estimated at 3.8 the recommendations of MedPAC, the long- preamble of this final rule. For the Federal
percent). term solvency of the Medicare Trust funds portion of this same blended payment
Effective for cost reporting periods and the capacity of the hospital industry to amount, we are recommending a final update
beginning FY 2003, LTCHs are paid under continually provide access to high quality of 3.4 percent (up from the estimated 3.1
the LTCH PPS, which was implemented with care to Medicare beneficiaries through percent in the proposed rule and consistent
a 5-year transition period. (Refer to the adequate payment to health care providers. with determination in the FY 2006 LTGH
August 30, 2002 final rule (67 FR 55954).) An In the proposed rule, we proposed to PPS final rule (70 FR 24180)).
existing LTCH may elect to be paid on 100 recommend an update of 3.2 percent, which Because the IPF PPS was effective for cost
percent of the Federal prospective rate at the reflected the CMS Office of the Actuary’s reporting periods beginning on or after
start of any of its cost reporting periods most recent forecast of the FY 2006 market January 1, 2005, and the base rates are
during the 5-year transition period. For basket increase. We did not receive any effective until July 1, 2006, we are
purposes of the update factor for inpatient public comments regarding this issue. In this recommending a final update of zero for IPFs
operating services for FY 2006, the portion of final rule, we are recommending an update (69 FR 66922). Finally, for the IRF PPS, we
the LTCH PPS transition blend payment that for IPPS hospitals based on the forecasted proposed an update of 3.1 percent in the FY
is based on reasonable costs will be market basket increase. However, the Office 2006 IPPS proposed rule. In the FY 2006 IRF
determined by updating the LTCH’s TEFRA of the Actuary’s most recent (second quarter) PPS proposed rule (70 FR 24180), which was
limit by the current estimate of the FY 2002- 2005 forecast of the FY 2006 market basket published after the issuance of the FY 2006
based excluded hospital market basket (or 3.8 increase is 3.7 percent. Thus, the Secretary’s IPPS proposed rule, we proposed an update
percent). final recommendation for the update to the for the IRF PPS payments of 3.1 percent.
Effective for cost reporting periods IPPS standardized amount for all hospitals is Accordingly, we are finalizing our
beginning on or after January 1, 2005, IPFs 3.7 percentage points for hospitals that recommendation of an update of 3.1 percent
are paid under the IPF PPS under which they provide the required quality data. The update for IRF PPS.
receive payment based on a Federal per diem to the hospital-specific rate applicable to
rate that is based on the sum of the average SCHs and MDHs is also 3.7 percent (or IV. Secretary’s Final Recommendation for
routine operating, ancillary, and capital costs consistent with current law, the market Updating the Capital Prospective Payment
for each patient day of psychiatric care in an basket percentage increase). Amounts
IPF, adjusted for budget neutrality. During a Because the operating and capital
transition period between January 1, 2005 III. Secretary’s Final Recommendation for
prospective payment systems remain
and January 1, 2008, existing IPFs are paid Updating the Rate-of-Increase Limits for
separate, we are continuing to use separate
based on a blend of the reasonable cost-based Excluded Hospitals and Hospital Units
updates for operating and capital payments.
payments, subject to the TEFRA limit, and We did not receive any comments The final update to the capital payment rates
the Federal per diem base rate. For cost concerning our proposed recommendations is discussed in section III. of the Addendum
reporting periods beginning on or after for updating the rate-of-increase for FY 2006 to this final rule.
January 1, 2008, IPFs will be paid based on for cancer hospitals, RNHCIs, and children’s
100 percent of the Federal per diem rate. For hospitals. Our final recommendation does [FR Doc. 05–15406 Filed 8–1–05; 4:16 pm]
purposes of the update factor for FY 2006, not differ from the proposed BILLING CODE 4120–01–P

Rule: Medicare: Hospital Inpatient Prospective Payment Systems and 2006 FY Rates

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Rule: Medicare: Hospital Inpatient Prospective Payment Systems and 2006 FY Rates

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Friday,

August 12, 2005

42 CFR Parts 405, 412, 413, 415, et al.

1. General 1. Background Regulation Text

MAJOR DIAGNOSTIC CATEGORIES (MDCS)

PRE-MAJOR DIAGNOSTIC CATEGORIES (PRE-MDCS)

Number of Average length Average

DRG 480 .................................................................................................................................... 959 16.65 $165,622

Average length Average

14—All Cases ............................................................................................................................ 221,879 5.67 $18,997

Number of Average Average

515 ............................................................................................................................................... 25,236 4.32 $83,659.76

Number of Average Average

535—Cardiac Catheterization Without Code 37.26 .................................................................... 5,060 10.63 $127,130.79

Number of Average length- Average

DRG 516—All Cases ................................................................................................................. 37,325 4.79 $40,278

Number of Average length Average

Number of Average Average

DRG 110 .................................................................................................................................... 53,527 1 8.4 $66,475

Number of Average length Average

DRG 103—All cases .................................................................................................................. 633 37.5 $313,583

DRG 525—Cases with Any Diagnosis of AMI .......................................................................... 46 8.5 $195,758

Number of Average Average

DRG 533—All cases .................................................................................................................... 44,677 3.73 $24,464

4 ..................................................................................................................... 23 9 $147,766 $120,496

209—All cases ............................................................................................................................. 430,776 4.57 $30,695.41

233—All cases ............................................................................................................................. 14,066 6.66 $28,967.78

497 ............................................................................................................................................. 27,346 6.08 $64,471.82

Code Code description 2004 count

Code Code description 2004 count

424.0 ................. Mitral Valve Disorder ............................................................................................................................................ 401,359

COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006

17 ........................... NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC.

COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006—Continued

11 ........................... NERVOUS SYSTEM NEOPLASMS W/O CC.

COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006—Continued

22 ........................... HYPERTENSIVE ENCEPHALOPATHY.

COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006—Continued

555 ......................... PERCUTANEOUS CARDIOVASCULAR PROC WITH MAJOR CV DIAGNOSIS.

1 ............................. CRANIOTOMY AGE >17 W CC.

NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006

2 ................... CRANIOTOMY AGE >17 W/O CC ................................................................................................. 1 Quintile 5.

NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006—Continued

NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006—Continued

RURAL COUNTIES REDESIGNATED AS URBAN UNDER SECTION 1886(d)(8)(B) OF THE ACT

Rural county CBSA

Cherokee, AL ..................................................................................................................... Rome, GA.

RURAL COUNTIES REDESIGNATED AS URBAN UNDER SECTION 1886(d)(8)(B) OF THE ACT—Continued

Rural county CBSA

Starke, IN ........................................................................................................................... Gary, IN.

CHART 1.—MAJOR COST CATEGORIES FOUND IN MEDICARE COST REPORTS

Wages and salaries ................................................................................................................................................. 48.965 45.590

1. Compensation ........................................ 61.656 59.993

Total .................................................... 100.000 100.000

CHART 3.—ANNUAL GROWTH RATES FOR THREE POSSIBLE PRICE PROXIES

Chemicals ..................................................................... Industrial Chemicals ..................................................... ¥0.9 11.3

2000 ............................................................................................................................................. 3.2 3.3 3.2

Total—PPS02 .............................................................................................................................. 100.000 3.2 3.7

CHART 7.—LABOR-RELATED SHARE: FY 1992-BASED AND FY 2002-BASED

Wages and salaries ..................................................................................................................... 50.244 48.171 ¥2.073

Total labor-related ................................................................................................................ 71.066 69.731 ¥1.335

Total nonlabor-related ................................................................................................... 28.934 30.269 1.335

Salary Cost Weight ........................................................................................................................................ 49.486 46.278 55.263