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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00002 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00003 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47280 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00004 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47281 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00005 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47282 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 reporting periods beginning on or after 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: VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00006 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47283 • 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00007 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47284 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00008 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47285 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00009 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47286 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00010 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47287 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00011 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47288 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00012 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47289 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00013 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47290 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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: Number of Average Average 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00014 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47291 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00015 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47292 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00016 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47293 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 517 Cases Without CC ..................................................................................................... 13,062 1.5 28,113 DRG 526—All Cases ................................................................................................................. 51,431 4.36 45,924 DRG 526 Cases With CC .......................................................................................................... 32,904 5.2 49,751 DRG 526 Cases Without CC ..................................................................................................... 18,527 2.8 39,126 DRG 527—All Cases ................................................................................................................. 176,956 2.23 36,087 DRG 527 Cases With CC .......................................................................................................... 137,641 2.4 37,142 DRG 527 Cases Without CC ..................................................................................................... 39,315 1.3 32,392 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00017 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47294 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00018 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47295 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00019 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47296 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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: Number of Average length Average DRG cases of stay charges 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: Number of Average Average 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00020 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47297 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). VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00021 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47298 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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: Number of Average length Average DRG cases of stay charges 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00022 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47299 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00023 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47300 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00024 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47301 infarction) to reflect the clinical trial The following chart shows our criteria. findings: Number of Average Average 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00025 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47302 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00026 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47303 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00027 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47304 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00028 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47305 $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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00029 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47306 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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) VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00030 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47307 • 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00031 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47308 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00032 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47309 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 CHARITETM. ´ 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 CHARITETM 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00033 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47310 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations (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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00034 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47311 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00035 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47312 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00036 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47313 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00037 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47314 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00038 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47315 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00039 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47316 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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: VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00040 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47317 • 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00041 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47318 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00042 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47319 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00043 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47320 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00044 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47321 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00045 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47322 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00046 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47323 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00047 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47324 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00048 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47325 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00049 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47326 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00050 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47327 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00051 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47328 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00052 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47329 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00053 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47330 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006—Continued LTC–DRG Description 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00054 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47331 COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006—Continued LTC–DRG Description 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00055 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47332 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2006—Continued LTC–DRG Description 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00056 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47333 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00057 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47334 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00058 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47335 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00059 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47336 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00060 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47337 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00061 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47338 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00062 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47339 NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006—Continued Low-volume Cross-walked LTC–DRG Description quintile as- 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00063 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47340 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations NO VOLUME LTC–DRG CROSSWALK AND QUINTILE ASSIGNMENT FOR FY 2006—Continued Low-volume Cross-walked LTC–DRG Description quintile as- 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- VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00064 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47341 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00065 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47342 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations (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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00066 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47343 • 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00067 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47344 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00068 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47345 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00069 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47346 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00070 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47347 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00071 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47348 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00072 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47349 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00073 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47350 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00074 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47351 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00075 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47352 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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- VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00076 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47353 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 CHARITETM meets charge to the thresholds of DRGs 499 c. CHARITETM Artificial Disc ´ the cost criterion because the average and 500 where these cases are grouped. (CHARITETM) 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 CHARITETM 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 CHARITETM maintained that the CHARITETM 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 CHARITETM Artificial ´ cases of CHARITETM 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 CHARITETM 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 CHARITETM Artificial As noted above, cases using the commenter noted that the average ´ CHARITETM device group to the DRGs Disc for single level spinal arthroplasty 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 ´ the CHARITETM could be a substitute stated that DDD is defined as discogenic 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 CHARITETM meets the cost ´ CHARITETM represents a substantial mm of spondylolisthesis at an involved criterion and to argue that procedures clinical improvement over existing level. Patients receiving the CHARITETM ´ using the technology should be grouped ´ technology. Use of the CHARITETM 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 CHARITETM ´ $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 ´ CHARITETM 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 CHARITETM ´ tracking purposes. The code assigned to DRG 498. Based on the actual cases Artificial Disc were discharged from the ´ the CHARITETM 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 ´ CHARITETM was $20,033. The applicant that patients who received the applicant submitted two sets of data: estimated that charges have grown by 15 ´ CHARITETM 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 CHARITETM 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 CHARITETM 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 ´ CHARITETM. 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 CHARITETM 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00077 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47354 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations ´ the CHARITETM Artificial Disc returned We finally noted that the applicant ´ • The CHARITETM 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 CHARITETM 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 CHARITETM 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 CHARITETM has the potential ´ CHARITETM Artificial Disc. Also, CC) and 498 (Spinal Fusion Except to reduce second surgical procedures for patients who received the CHARITETM ´ 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 ´ • The CHARITETM provides early spinal fusion and inclusion in DRGs 497 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, ´ CHARITETM Artificial Disc may reduce prostheses (codes 84.60 through 84.69). and 12 months. ´ • The CHARITETM provides the risk of increase of degenerative disc In the FY 2005 IPPS proposed rule and 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. ´ • The CHARITETM provides patients (minimum 10 years) who assignments from DRGs 499 and 500 in ´ received the CHARITETM 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 ´ CHARITETM Artificial Disc would ´ be generalized to the Medicare CHARITETM 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 ´ CHARITETM, noting that the under 65 definitively substantiate whether the ´ CHARITETM and the DRG assignment ´ CHARITETM 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. ´ CHARITETM 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 ´ • The CHARITETM obviates the iliac clinical improvement criterion. of activity compared to their Despite the issues mentioned above, crest bone graft donor site morbidity. preoperative status; and 100 percent of ´ • The CHARITETM preserves we noted in the FY 2006 IPPS proposed the surgeons recommended the rule that we were still considering segmental motion in flexion/extension ´ CHARITETM 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 ´ for the CHARITETM Artificial Disc for 3 A. Blumenthal et al., ‘‘A Prospective, studies and the IDE trial demonstrate FY 2006. If approved for add-on Randomized, Multi Center FDA IDE Study of ´ that CHARITETM offers a substantial Lumbar Total Disc Replacement with the payments, hospitals would be ´ CHARITETM 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 CHARITETM Artificial Disc ´ CHARITETM Artificial Disc would be make up 21.8 percent of all discharges vs. Lumbar Fusion: Part II—Evaluation of $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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00078 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47355 patients could benefit from the studies 4 5 6 demonstrated excellent or further suggested that the CHARITETM ´ ´ CHARITETM. In response to CMS’ good results, but did not explicitly should be considered experimental until ´ concern that CHARITETM 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 ´ acknowledges that the CHARITETM may addition, aside from a lack of long-term nearly 98,000 spinal fusions in FY 2004. 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 ´ CHARITETM 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 caused mainly by disc degeneration on ´ CHARITETM, including the lack of long- results, combined with the benefits of 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 CHARITETM implanted supported eliminating the need for harvesting bone ´ approving the CHARITETM for new from the iliac crest, the CHARITETM´ 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 CHARITETM, indicating that the [Fr]. 2002;14:271–285, cited in DePuy Spine, Inc. pain and function and earlier return to ´ Charite 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 CHARITETM ´ 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 CHARITETM 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 ´ CHARITETM (some of the studies ´ of Charite 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 CHARITETM, we remain VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00079 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47356 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 ´ CHARITETM 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 CHARITETM. 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 CHARITETM 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00080 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47357 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00081 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47358 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00082 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47359 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00083 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47360 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00084 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47361 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00085 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47362 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00086 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47363 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/ VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00087 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47364 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00088 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47365 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00089 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47366 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations ER12AU05.000 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00090 Fmt 4701 Sfmt 4725 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47367 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 the suggestion. We do not believe that weighted average hourly rate for an SOC categories. If the hospital’s adjusted rate VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00091 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47368 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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). VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00092 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47369 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00093 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47370 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00094 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47371 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00095 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47372 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00096 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47373 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00097 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47374 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00098 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47375 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00099 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47376 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00100 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47377 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00101 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47378 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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’ VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00102 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47379 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00103 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47380 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00104 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47381 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00105 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47382 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00106 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47383 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00107 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47384 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00108 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47385 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00109 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47386 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00110 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47387 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00111 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47388 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00112 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47389 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00113 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47390 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00114 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47391 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). VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00115 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47392 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00116 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47393 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00117 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47394 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00118 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47395 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00119 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47396 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00120 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47397 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00121 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47398 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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.) VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00122 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47399 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00123 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47400 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00124 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47401 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00125 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47402 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00126 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47403 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00127 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47404 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00128 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47405 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00129 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47406 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 especially over shorter time spans. As VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00130 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47407 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00131 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47408 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00132 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47409 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00133 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47410 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00134 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47411 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00135 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47412 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00136 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47413 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: VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00137 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47414 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00138 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47415 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00139 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47416 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00140 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47417 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00141 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47418 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00142 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47419 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00143 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47420 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00144 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47421 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00145 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47422 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00146 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47423 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00147 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47424 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00148 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47425 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00149 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47426 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00150 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47427 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00151 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47428 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00152 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47429 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00153 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47430 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00154 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47431 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 reporting periods beginning on or after 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00155 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47432 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations (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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00156 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47433 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00157 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47434 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00158 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47435 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00159 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47436 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00160 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47437 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). VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00161 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47438 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 Medicaid fractions. With respect to both file against its Medicare Part A VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00162 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47439 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00163 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47440 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00164 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47441 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00165 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47442 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00166 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47443 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00167 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47444 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00168 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47445 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.) VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00169 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47446 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00170 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47447 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00171 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47448 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00172 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47449 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00173 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47450 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00174 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47451 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00175 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47452 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00176 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47453 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00177 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47454 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00178 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47455 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00179 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47456 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00180 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47457 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00181 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47458 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00182 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47459 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00183 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47460 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00184 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47461 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; VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00185 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47462 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations • 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00186 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47463 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00187 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47464 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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, VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00188 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47465 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00189 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47466 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00190 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47467 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00191 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47468 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00192 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47469 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00193 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47470 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00194 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47471 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00195 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47472 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00196 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47473 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00197 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47474 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00198 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47475 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00199 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47476 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00200 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47477 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00201 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47478 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00202 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47479 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00203 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47480 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00204 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47481 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00205 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47482 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00206 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47483 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00207 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47484 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 I 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. I B. Part 412 is amended as follows: DRG Definitions Manual (FY 2006): Fax (202) 395–6974. I 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; I 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, I 3. In § 412.2— (d)(3)(i)(A) and (d)(3)(ii)(B) of this Puerto Rico, Reporting and I 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, I 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 I 4. Section 412.4 is amended by— postacute care in the DRG must equal or Hospitals, Medicare, Reporting and I a. Revising the introductory text of exceed the 55th percentile for all DRGs; recordkeeping requirements. paragraph (d)(1). (B) The proportion of short-stay I b. Revising paragraph (d)(1)(v). discharges to postacute care to total 42 CFR Part 422 discharges in the DRG exceeds the 55th I c. Adding a new paragraph (d)(3). Health maintenance organizations I 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 I 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 * * * * * I 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 I A. Part 405 is amended as follows: (v) To initially qualify, the DRG must transfer is assigned to DRGs 209, 210, or I 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00208 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47485 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 I 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. I 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. I 5. Section 412.64 is amended by— § 412.73 Determination of the hospital- adjusts the rural Federal payment I a. Adding a new paragraph (b)(5). specific rate based on a Federal fiscal year amounts for inpatient operating costs for I b. Revising paragraph (i)(3)(iv). 1982 base period. hospitals located in geographic areas I 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 I 10. Section 412.92 is amended by— operating costs for Federal fiscal year 2005 recalibrations of the DRG relative I 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 I b Revising paragraph (d)(1)(i). I 7. Section 412.75 is amended by more separately located inpatient I 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. I 8. Section 412.77 is amended by— account a significant decrease in the * * * * * I a. Revising paragraph (a)(1). number of discharges, as described in (k) Midyear corrections to the wage I b. Adding a new paragraph (j). paragraph (e) of this section. index. The revision and addition read as follows: * * * * * * * * * * I 11. Section 412.96 is amended by— (2)(i) Except as provided in paragraph § 412.77 Determination of the hospital- I 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 I 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 I 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 I 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)’’. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00209 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47486 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations I e. Revising paragraph (g)(1). the U.S. Department of Health and under paragraph (f)(1)(xiii) of this I 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 I g. In paragraph (h)(2), removing the continuous years and then subsequently I 13. Section 412.105 is amended by— reference ‘‘(g)(1)’’ and adding in its place elects to revert back to urban I a. Adding a new paragraph the reference ‘‘(h)(1)’’. classification will not be allowed to I h. Removing paragraph (h)(4). (f)(1)(iv)(D). I b. Adding a new paragraph (f)(1)(xiii). retain the adjustment to its IME FTE I i. In paragraph (i)(2), removing the resident cap that it received as a result reference ‘‘(h)(1)’’ and adding in its place I c. Adding a new paragraph (f)(1)(xiv). I d. Adding a new paragraph (f)(1)(xv). of being reclassified as rural. the reference ‘‘(i)(1)’’. The additions read as follows: * * * * * I j. Removing paragraph (i)(4). The revisions read as follows: I 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 I 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 I 16. In § 412.113— (g) Hospital cancellation of referral payment system, the limit on the total I 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. I 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. I 12. Section 412.103 is amended by system and an acute care hospital revising paragraph (a)(1) to read as § 412.115 [Amended] subject to the hospital inpatient follows: I 17. In § 412.115— prospective payment system, if the § 412.103 Special treatment: Hospitals surviving hospital is a hospital subject I 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 I 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 I 18. Section 412.230 is amended by— Services Administration, which is (f)(1)(ii)(B) of this section and the limit I a. Revising paragraph (a)(5)(iv) available via the ORHP Web site at: on the total number of FTE residents for I b. Redesignating paragraph (d)(2)(iii) http://www.ruralhealth.hrsa.gov or from the excluded hospital as determined as paragraph (d)(2)(iv). VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00210 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47487 I 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: * * * * * I 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. I 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 I 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 I 4. Section 413.65 is amended by— (iii) For applications submitted for prospective payment system for each I 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 I 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 I c. Revising paragraphs (b)(3)(i) and campus is seeking reclassification to a determined under subpart D of this part. (b)(3)(ii). I 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). I e. Revising paragraph (e)(3). submit the composite wage data for the I 22. In § 412.521— I f. Revising paragraph (g)(7). entire multicampus hospital as its I 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 I 19. Section 412.234 is amended by— reference ‘‘§§ 413.75 through 413.83, § 413.65 Requirements for a determination I 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. I b. Adding a new paragraph (a)(3)(iii). I b. Under paragraph (b)(2)(ii), the (a) Scope and definitions. * * * I 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 I C. Part 413 is amended as follows: (2) Definitions. * * * OMB on June 6, 2003) as the urban area I 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 I 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 I 3. Section 413.40 is amended by— as the site of services of a type for which definitions announced by the OMB on I 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00211 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47488 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00212 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47489 consistent with the laws of both States, § 413.77 [Amended] result of the most recent census data in adjacent States. I 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 I 7. Section 413.79 is amended by— of this section while it was located in a main provider’s campus, the treatment I a. Revising paragraph (a)(10). rural area. is not required to be provided by the I 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 I 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: I d. Adding a new paragraph (c)(6). for an adjustment to its FTE cap under (i) The hospital must provide written I e. Revising paragraph (e)(1)(iv). paragraph (e)(1) of this section is notice to the beneficiary, before the I 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 I 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 I 5. Section 413.75 is amended in eligibility associated with the specialty I 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 I 9. In § 413.178— (b) * * * paragraphs (c)(3) through (c)(6) of this Medicare GME affiliated group section and § 413.81, for purposes of I 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 I 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00213 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47490 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations PART 415—SERVICES FURNISHED BY ‘‘§§ 413.75 through 413.83’’ is added in § 422.216 [Amended] PHYSICIANS IN PROVIDERS, its place. I 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 I 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. I D. Part 415 is amended as follows: ‘‘§§ 413.75 through 413.83’’ is added in I 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 I 11. In § 415.206(a), the reference 1395hh). I G. Part 485 is amended as follows: ‘‘§ 413.86(f)(1)(iii)’’ is removed and the I 1. The authority citation for Part 485 reference ‘‘§ 413.78’’ is added in its § 415.55 [Amended] continues to read as follows: place. I 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 I 12. In § 415.208— its place. I 2. Section 485.610 is amended by— I a. In paragraph (b)(1), the reference I 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), I 3. In § 415.70(a)(2), the reference its place. excluding paragraph (b)(3).’’ ‘‘§ 413.86’’ is removed and the reference I b. In paragraph (b)(4), the reference I 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. I c. Adding a new paragraph (d). The revisions and additions read as I 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. I F. Part 419 is amended as follows: * * * * * § 415.150 [Amended] I 1. The authority citation for part 419 (d) Standard: Relocation of CAHs with I 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 I 6. In § 415.152— I 2. In § 419.2— requirement of paragraph (c) of this I a. In paragraph (2) of the definition of I 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 I b. In paragraph (c)(6), the reference I 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— I 7. In § 415.160— (i) Serves at least 75 percent of the I a. In paragraph (c)(2), the reference same service area that it served prior to ‘‘§ 413.86’’ is removed and the reference I G. Part 422 is amended as follows: I 1. The authority citation of part 422 its relocation; ‘‘§ 413.78’’ is added in its place. (ii) Provides at least 75 percent of the I 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. I 8. In § 415.174(a)(1), the reference I 2. In § 422.214— (2) If a CAH that has been designated ‘‘§ 413.86.’’ is removed and the phrase I 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] I b. In paragraph (b), the phrase ‘‘Section (d)(1) of this section, the action will be I 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). VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00214 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47491 (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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00215 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47492 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00216 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47493 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00217 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47494 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00218 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47495 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: VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00219 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47496 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00220 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47497 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00221 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47498 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00222 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47499 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00223 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47500 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00224 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47501 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00225 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47502 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 separately from the effects of other changes geographic reclassification has on the other after January 1, 2005, established in the VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00226 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47503 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00227 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47504 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00228 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47505 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) VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00229 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47506 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00230 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47507 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 VerDate jul<14>2003 20:00 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00231 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47508 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00232 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47509 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00233 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47510 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00234 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47511 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00235 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47512 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00236 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47513 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00237 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47514 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00238 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47515 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00239 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47516 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 * * * * * VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00240 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47517 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00241 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47518 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00242 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47519 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00243 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47520 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00244 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47521 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—Continued 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) 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 * * * * VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00245 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47522 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00246 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47523 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00247 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47524 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00248 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47525 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00249 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47526 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00250 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47527 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00251 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47528 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00252 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47529 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00253 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47530 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00254 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47531 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00255 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47532 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00256 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47533 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—Continued 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) 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 * * * * VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00257 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47534 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00258 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47535 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00259 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47536 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00260 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47537 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00261 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47538 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00262 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47539 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00263 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47540 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00264 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47541 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00265 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47542 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00266 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47543 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00267 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47544 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00268 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47545 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00269 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47546 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00270 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47547 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00271 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47548 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00272 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47549 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00273 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47550 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 * * * * VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00274 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47551 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00275 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47552 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00276 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47553 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00277 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47554 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 * * * * VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00278 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47555 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00279 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47556 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00280 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47557 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00281 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47558 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00282 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47559 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00283 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47560 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00284 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47561 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00285 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47562 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00286 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47563 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00287 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47564 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00288 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47565 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00289 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47566 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00290 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47567 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—Continued 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) 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 * * * * VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00291 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47568 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00292 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47569 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00293 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47570 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00294 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47571 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00295 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47572 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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—Continued 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) 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00296 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47573 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—Continued 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) 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00297 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47574 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 Sebastian, 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00298 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47575 TABLE 3A.—FY 2006 AND 3-YEAR AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00299 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47576 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 3A.—FY 2006 AND 3-YEAR AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00300 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47577 TABLE 3A.—FY 2006 AND 3-YEAR AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*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 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 ....... ¨ Mayaguez, 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00301 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47578 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 3A.—FY 2006 AND 3-YEAR AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*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 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 German-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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00302 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47579 TABLE 3A.—FY 2006 AND 3-YEAR AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*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 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] FY 2006 av- 3-Year aver- 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00303 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47580 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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] FY 2006 av- 3-Year aver- 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 Sebastian, PR ............................................................................................................... 0.4732 0.5991 Aguada Municipio, PR. Aguadilla Municipio, PR. ˜ Anasco Municipio, PR. Isabela Municipio, PR. Lares Municipio, PR. Moca Municipio, PR. ´ Rinc0n Municipio, PR. ´ San Sebastian 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00304 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47581 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00305 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47582 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00306 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47583 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00307 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47584 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00308 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47585 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00309 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47586 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00310 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47587 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00311 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47588 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00312 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47589 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00313 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47590 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00314 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47591 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00315 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47592 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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 ....... ¨ Mayaguez, PR .................................................................................................................................................. 0.4019 0.5357 Hormigueros Municipio, PR. ¨ Mayaguez Municipio, PR. 32580 ....... McAllen-Edinburg-Mission, TX .......................................................................................................................... 0.8936 0.9259 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00316 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47593 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00317 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47594 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00318 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47595 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00319 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47596 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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 Dıaz 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00320 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47597 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00321 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47598 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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 German-Cabo Rojo, PR ............................................................................................................................ 0.4641 0.5911 Cabo Rojo Municipio, PR. Lajas Municipio, PR. Sabana Grande Municipio, PR. ´ San German 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. ´ Bayamon Municipio, PR. Caguas Municipio, PR. Camuy Municipio, PR. ´ Canovanas Municipio, PR. Carolina Municipio, PR. ˜ Catano Municipio, PR. Cayey Municipio, PR. Ciales Municipio, PR. Cidra Municipio, PR. ´ Comerıo Municipio, PR. Corozal Municipio, PR. Dorado Municipio, PR. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00322 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47599 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF index Florida Municipio, PR. Guaynabo Municipio, PR. Gurabo Municipio, PR. Hatillo Municipio, PR. Humacao Municipio, PR. Juncos Municipio, PR. Las Piedras Municipio, PR. ´ Loıza Municipio, PR. ´ Manatı Municipio, PR. Maunabo Municipio, PR. Morovis Municipio, PR. Naguabo Municipio, PR. Naranjito Municipio, PR. Orocovis Municipio, PR. Quebradillas Municipio, PR. ´ Rıo 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00323 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47600 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00324 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47601 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00325 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47602 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00326 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47603 TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA— Continued Wage CBSA code Urban area (constituent counties) GAF index 49500 ....... Yauco, PR ......................................................................................................................................................... 0.4408 0.5707 ´ Guanica Municipio, PR. Guayanilla Municipio, PR. ˜ Penuelas 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00327 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47604 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00328 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47605 TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00329 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47606 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA—Continued 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00330 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47607 TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA—Continued 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 Sebastian, PR ....................................................... 1.0347 1.0236 .................... .................... 21940 ....... Fajardo, PR ................................................................................................ 0.9089 0.9367 .................... .................... 25020 ....... Guayama, PR ............................................................................................ 0.6960 0.7802 .................... .................... 32420 ....... ¨ Mayaguez, PR ........................................................................................... 0.8789 0.9154 .................... .................... 38660 ....... Ponce, PR .................................................................................................. 1.0802 1.0543 .................... .................... 41900 ....... ´ San German-Cabo Rojo, PR ..................................................................... 1.0150 1.0102 .................... .................... VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00331 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47608 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00332 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47609 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00333 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47610 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00334 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47611 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00335 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47612 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00336 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47613 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00337 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47614 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00338 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47615 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00339 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47616 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00340 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47617 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2006—Continued [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 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00341 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47618 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00342 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47619 TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00343 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47620 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. 109 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 12.1 12.1 110 ........... 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. 112 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 113 ........... 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. 115 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 15.8 15.8 116 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 9.3 9.3 117 ........... 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00344 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47621 TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00345 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47622 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. 209 ........... No ............ No ............ 08 SURG ...... NO LONGER VALID ................................ 0.0000 17.1 17.1 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00346 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47623 TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. 214 ........... No ............ No ............ 08 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 215 ........... No ............ No ............ 08 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 216 ........... 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. 221 ........... No ............ No ............ 08 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 222 ........... No ............ No ............ 08 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 223 ........... 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. 231 ........... No ............ No ............ 08 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 232 ........... 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00347 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47624 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00348 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47625 TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00349 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47626 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00350 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47627 TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00351 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47628 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. 400 ........... No ............ No ............ 17 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 401 ........... 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. 407 ........... No ............ No ............ 17 SURG ...... MYELOPROLIF DISORD OR POORLY 1.2289 3.0 3.8 DIFF NEOPL W MAJ O.R.PROC W/O CC. 408 ........... No ............ No ............ 17 SURG ...... MYELOPROLIF DISORD OR POORLY 2.2460 4.8 8.2 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00352 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47629 TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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 0.0 435 ........... No ............ No ............ 20 MED ......... NO LONGER VALID ................................ 0.0000 0.0 0.0 436 ........... No ............ No ............ 20 MED ......... NO LONGER VALID ................................ 0.0000 0.0 0.0 437 ........... 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 0.0 457 ........... No ............ No ............ 22 MED ......... NO LONGER VALID ................................ 0.0000 0.0 0.0 458 ........... No ............ No ............ 22 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 459 ........... No ............ No ............ 22 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 460 ........... No ............ No ............ 22 MED ......... 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00353 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47630 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. 472 ........... No ............ No ............ 22 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 473 ........... No ............ No ............ 17 MED ......... ACUTE LEUKEMIA W/O MAJOR O.R. 3.4231 7.4 12.7 PROCEDURE AGE >17. 474 ........... No ............ No ............ 04 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 475 ........... 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. 478 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 479 ........... 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00354 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47631 TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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 9.9 514 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 515 ........... No ............ No ............ 05 SURG ...... CARDIAC DEFIBRILLATOR IMPLANT 5.5205 2.6 4.3 W/O CARDIAC CATH. 516 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 517 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 518 ........... 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. 526 ........... No ............ No ............ 05 SURG ...... NO LONGER VALID ................................ 0.0000 0.0 0.0 527 ........... 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00355 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47632 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 5.—LIST OF DIAGNOSIS-RELATED GROUPS, RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY (LOS)—Continued 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 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. 557 ........... No ............ No ............ 05 SURG ...... PERCUTANEOUS CARDIOVASCULAR 2.8717 3.0 4.1 PROC W DRUG-ELUTING STENT W MAJOR CV DX. 558 ........... No ............ No ............ 05 SURG ...... PERCUTANEOUS CARDIOVASCULAR 2.2108 1.5 1.9 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00356 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47633 TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis Description CC MDC DRG 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00357 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47634 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis Description CC MDC DRG 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00358 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47635 TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis Description CC MDC DRG 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00359 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47636 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis Description CC MDC DRG 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 V85.22 ..... Body Mass Index 26.0–26.9, adult ................................................................................................ N 23 467 V85.23 ..... Body Mass Index 27.0–27.9, adult ................................................................................................ N 23 467 V85.24 ..... Body Mass Index 28.0–28.9, adult ................................................................................................ N 23 467 V85.25 ..... Body Mass Index 29.0–29.9, adult ................................................................................................ N 23 467 V85.30 ..... Body Mass Index 30.0–30.9, adult ................................................................................................ N 23 467 V85.31 ..... Body Mass Index 31.0–31.9, adult ................................................................................................ N 23 467 V85.32 ..... Body Mass Index 32.0–32.9, adult ................................................................................................ N 23 467 V85.33 ..... Body Mass Index 33.0–33.9, adult ................................................................................................ N 23 467 V85.34 ..... Body Mass Index 34.0–34.9, adult ................................................................................................ N 23 467 V85.35 ..... Body Mass Index 35.0–35.9, adult ................................................................................................ N 23 467 V85.36 ..... Body Mass Index 36.0–36.9, adult ................................................................................................ N 23 467 V85.37 ..... Body Mass Index 37.0–37.9, adult ................................................................................................ N 23 467 V85.38 ..... Body Mass Index 38.0–38.9, adult ................................................................................................ N 23 467 V85.39 ..... Body Mass Index 39.0–39.9, 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00360 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47637 TABLE 6B.—NEW PROCEDURE CODES—Continued Procedure Description OR MDC DRG 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 Diagnosis Description CC MDC DRG 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00361 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47638 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6D.—INVALID PROCEDURE CODES Procedure Description OR MDC DRG 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 * 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. 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 Diagnosis Description CC MDC DRG 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00362 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47639 TABLE 6E.—REVISED DIAGNOSIS CODE TITLES—Continued Diagnosis Description CC MDC DRG 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 were not finalized in time to include with the proposed rule. TABLE 6F.—REVISED PROCEDURE CODE TITLES Procedure Description OR MDC DRG 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. * 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00363 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47640 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00364 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47641 TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00365 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47642 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00366 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47643 TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] *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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00367 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47644 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] *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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00368 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47645 TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00369 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47646 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00370 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47647 TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00371 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47648 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00372 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47649 TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00373 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47650 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00374 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47651 TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00375 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47652 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00376 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47653 TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST—Continued 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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00377 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47654 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6G.—ADDITIONS TO THE CC TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued [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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00378 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47655 TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued [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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00379 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47656 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued [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.] *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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00380 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47657 TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC TABLE 6H.—DELETIONS FROM THE CC EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued EXCLUSIONS LIST—Continued [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.] 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00381 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47658 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00382 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47659 TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00383 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47660 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00384 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47661 TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00385 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47662 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00386 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47663 TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued [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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00387 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47664 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued [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 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 [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00388 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47665 TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00389 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47666 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00390 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47667 TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00391 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47668 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00392 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47669 TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00393 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47670 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00394 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47671 TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00395 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47672 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS-OF-STAY—Continued [FY 2004 MedPAR Update March 2005 GROUPER V23.0] Number Arithmetic 10th 25th 50th 75th 90th DRG discharges Mean LOS percentile percentile percentile percentile percentile 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00396 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47673 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00397 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47674 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00398 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47675 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00399 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47676 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00400 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47677 TABLE 9B.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS BY INDIVIDUAL HOSPITAL UNDER SECTION 508 OF PUB. L. 108–173—FY 2006—Continued Wage index Geographic CBSA Sec. Own wage Provider No. Note CBSA 508 reclassi- 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00401 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47678 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 9B.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS BY INDIVIDUAL HOSPITAL UNDER SECTION 508 OF PUB. L. 108–173—FY 2006—Continued Wage index Geographic CBSA Sec. Own wage Provider No. Note CBSA 508 reclassi- 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00402 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47679 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00403 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47680 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00404 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47681 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 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00405 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47682 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00406 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47683 TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00407 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47684 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00408 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47685 TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00409 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47686 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00410 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47687 TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00411 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47688 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00412 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47689 TABLE 11.—FY 2006 LTC-DRGS, RELATIVE WEIGHTS, GEOMETRIC AVERAGE LENGTH OF STAY, AND 5/6THS OF THE GEOMETRIC AVERAGE LENGTH OF STAY—Continued 5/6th of the Geometric geometric Relative average LTC-DRG Description average weight length of length of 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. 2 Relative weights for these LTC-DRGs were determined by assigning these cases to low-volume quintile 2. 3 Relative weights for these LTC-DRGs were determined by assigning these cases to low-volume quintile 3. 4 Relative weights for these LTC-DRGs were determined by assigning these cases to low-volume quintile 4. 5 Relative weights for these LTC-DRGs were determined by assigning these cases to low-volume quintile 5. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00413 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47690 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00414 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47691 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00415 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47692 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00416 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47693 ER12AU05.005 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00417 Fmt 4701 Sfmt 4725 E:\FR\FM\12AUR2.SGM 12AUR2 47694 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations ER12AU05.006 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00418 Fmt 4701 Sfmt 4725 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47695 ER12AU05.007 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00419 Fmt 4701 Sfmt 4725 E:\FR\FM\12AUR2.SGM 12AUR2 47696 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations ER12AU05.008 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00420 Fmt 4701 Sfmt 4725 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47697 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00421 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47698 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00422 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47699 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. VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00423 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47700 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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: VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00424 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47701 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00425 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47702 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00426 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47703 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00427 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47704 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00428 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47705 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00429 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 47706 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00430 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2 Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules and Regulations 47707 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 VerDate jul<14>2003 19:11 Aug 11, 2005 Jkt 205001 PO 00000 Frm 00431 Fmt 4701 Sfmt 4700 E:\FR\FM\12AUR2.SGM 12AUR2