Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians, 23528-23938 [08-1135]

Download as PDF 23528 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 411, 412, 413, 422, and 489 [CMS–1390–P] RIN 0938–AP15 Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians Centers for Medicare and Medicaid Services (CMS), HHS. ACTION: Proposed rule. jlentini on PROD1PC65 with PROPOSALS2 AGENCY: SUMMARY: We are proposing to revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs to implement changes arising from our continuing experience with these systems, and to implement certain provisions made by the Deficit Reduction Act of 2005, the Medicare Improvements and Extension Act, Division B, Title I of the Tax Relief and Health Care Act of 2006, and the TMA, Abstinence Education, and QI Programs Extension Act of 2007. In addition, in the Addendum to this proposed rule, we describe the proposed changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. These proposed changes would be applicable to discharges occurring on or after October 1, 2008. We also are setting forth the proposed update to the rate-ofincrease limits for certain hospitals and hospital units excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The proposed updated rate-of-increase limits would be effective for cost reporting periods beginning on or after October 1, 2008. Among the other policy decisions and changes that we are proposing to make are changes related to: Limited proposed revisions of the classification of cases to Medicare severity diagnosis-related groups (MS–DRGs), proposals to address charge compression issues in the calculation of MS–DRG relative weights, the proposed revisions to the classifications and relative weights for the Medicare severity long-term care diagnosis-related groups (MS–LTC– VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 DRGs); applications for new medical services and technologies add-on payments; wage index reform changes and the wage data, including the occupational mix data, used to compute the proposed FY 2009 wage indices; submission of hospital quality data; proposed changes to the postacute care transfer policy relating to transfers to home for the furnishing of home health services; and proposed policy changes relating to the requirements for furnishing hospital emergency services under the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). In addition, we are proposing policy changes relating to disclosure to patients of physician ownership or investment interests in hospitals and soliciting public comments on a proposed collection of information regarding financial relationships between hospitals and physicians. We are also proposing changes or soliciting comments on issues relating to policies on physician self-referrals. DATES: To be assured consideration, comments must be received at one of the addresses provide below, no later than 5 p.m. E.S.T. on June 13, 2008. ADDRESSES: When commenting on issues presented in this proposed rule, please refer to filecode CMS–1390–P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only one of the ways listed): 1. Electronically. You may submit electronic comments on this regulation to https://www.regulations.gov. Follow the instructions for ‘‘Comment or Submission’’ and enter the file code CMS–1390–P to submit comments on this proposed rule. 2. By regular mail. You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–1390– P, P.O. Box 8011, Baltimore, MD 21244– 1850. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. By express or overnight mail. You may send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–1390–P, Mail Stop C4–26–05, 7500 Security Boulevard, Baltimore, MD 21244–1850. 4. By hand or courier. If you prefer, you may deliver (by hand or courier) PO 00000 Frm 00002 Fmt 4701 Sfmt 4702 your written comments (one original and two copies) before the close of the comment period to either of the following addresses: a. Room 445–G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201. (Because access to the interior of the HHH Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) b. 7500 Security Boulevard, Baltimore, MD 21244–1850. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 7867195 in advance to schedule your arrival with one of our staff members. Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. Submission of comments on paperwork requirements. You may submit comments on this document’s paperwork requirements by following the instructions at the end of the ‘‘Collection of Information Requirements’’ section in this document. For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. FOR FURTHER INFORMATION, CONTACT: Michele Hudson, (410) 786–4487, Operating Prospective Payment, MS– DRGs, Wage Index, New Medical Service and Technology Add-On Payments, Hospital Geographic Reclassifications, and Postacute Care Transfer Issues. Tzvi Hefter, (410) 786–4487, Capital Prospective Payment, Excluded Hospitals, Direct and Indirect Graduate Medical Education, MS–LTC–DRGs, EMTALA, Hospital Emergency Services, and Hospital-within-Hospital Issues. Siddhartha Mazumdar, (410) 786– 6673, Rural Community Hospital Demonstration Program Issues. Sheila Blackstock, (410) 786–3502, Quality Data for Annual Payment Update Issues. Thomas Valuck, (410) 786–7479, Hospital Value-Based Purchasing and Readmissions to Hospital Issues. Anne Hornsby, (410) 786–1181, Collection of Managed Care Encounter Data Issues. Jacqueline Proctor, (410) 786–8852, Disclosure of Physician Ownership in E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Hospitals and Financial Relationships between Hospitals and Physicians Issues. Lisa Ohrin, (410) 786–4565, and Don Romano, (410) 786–1404, Physician Self-Referral Issues. SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: https:// www.regulations.gov. Follow the search instructions on that Web site to view public comments. Comments received timely will also be available for public inspection, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1–800– 743–3951. Electronic Access jlentini on PROD1PC65 with PROPOSALS2 This Federal Register document is also available from the Federal Register online database through GPO Access, a service of the U.S. Government Printing Office. Free public access is available on a Wide Area Information Server (WAIS) through the Internet and via asynchronous dial-in. Internet users can access the database by using the World Wide Web (the Superintendent of Documents’ home page address is https://www.gpoaccess.gov/), by using local WAIS client software, or by telnet to swais.access.gpo.gov, then login as guest (no password required). Dial-in users should use communications software and modem to call (202) 512– 1661; type swais, then login as guest (no password required). Acronyms AARP American Association of Retired Persons AAHKS American Association of Hip and Knee Surgeons AAMC Association of American Medical Colleges ACGME Accreditation Council for Graduate Medical Education AF Artrial fibrillation AHA American Hospital Association AICD Automatic implantable cardioverter defibrillator AHIMA American Health Information Management Association VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 AHIC American Health Information Community AHRQ Agency for Healthcare Research and Quality AMA American Medical Association AMGA American Medical Group Association AMI Acute myocardial infarction AOA American Osteopathic Association APR DRG All Patient Refined Diagnosis Related Group System ASC Ambulatory surgical center ASITN American Society of Interventional and Therapeutic Neuroradiology BBA Balanced Budget Act of 1997, Pub. L. 105–33 BBRA Medicare, Medicaid, and SCHIP [State Children’s Health Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 106–113 BIPA Medicare, Medicaid, and SCHIP [State Children’s Health Insurance Program] Benefits Improvement and Protection Act of 2000, Pub. L. 106–554 BLS Bureau of Labor Statistics CAH Critical access hospital CARE [Medicare] Continuity Assessment Record & Evaluation [Instrument] CART CMS Abstraction & Reporting Tool CBSAs Core-based statistical areas CC Complication or comorbidity CCR Cost-to-charge ratio CDAC [Medicare] Clinical Data Abstraction Center CDAD Clostridium difficile-associated disease CIPI Capital input price index CMI Case-mix index CMS Centers for Medicare & Medicaid Services CMSA Consolidated Metropolitan Statistical Area COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99–272 CoP [Hospital] condition of participation CPI Consumer price index CY Calendar year DFRR Disclosure of financial relationship report DRA Deficit Reduction Act of 2005, Pub. L. 109–171 DRG Diagnosis-related group DSH Disproportionate share hospital DVT Deep vein thrombosis ECI Employment cost index EMR Electronic medical record EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 99–272 FAH Federation of Hospitals FDA Food and Drug Administration FHA Federal Health Architecture FIPS Federal information processing standards FQHC Federally qualified health center FTE Full-time equivalent FY Fiscal year GAAP Generally Accepted Accounting Principles GAF Geographic Adjustment Factor GME Graduate medical education HACs Hospital-acquired conditions HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems HCFA Health Care Financing Administration HCRIS Hospital Cost Report Information System PO 00000 Frm 00003 Fmt 4701 Sfmt 4702 23529 HHA Home health agency HHS Department of Health and Human Services HIC Health insurance card HIPAA Health Insurance Portability and Accountability Act of 1996, Pub. L. 104– 191 HIPC Health Information Policy Council HIS Health information system HIT Health information technology HMO Health maintenance organization HPMP Hospital Payment Monitoring Program HSA Health savings account HSCRC [Maryland] Health Services Cost Review Commission HSRV Hospital-specific relative value HSRVcc Hospital-specific relative value cost center HQA Hospital Quality Alliance HQI Hospital Quality Initiative HWH Hospital-within-a hospital ICD–9–CM International Classification of Diseases, Ninth Revision, Clinical Modification ICD–10–PCS International Classification of Diseases, Tenth Edition, Procedure Coding System ICR Information collection requirement IHS Indian Health Service IME Indirect medical education IOM Institute of Medicine IPF Inpatient psychiatric facility IPPS [Acute care hospital] inpatient prospective payment system IRF Inpatient rehabilitation facility LAMCs Large area metropolitan counties LTC–DRG Long-term care diagnosis-related group LTCH Long-term care hospital MA Medicare Advantage MAC Medicare Administrative Contractor MCC Major complication or comorbidity MCE Medicare Code Editor MCO Managed care organization MCV Major cardiovascular condition MDC Major diagnostic category MDH Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider Analysis and Review File MEI Medicare Economic Index MGCRB Medicare Geographic Classification Review Board MIEA–TRHCA Medicare Improvements and Extension Act, Division B of the Tax Relief and Health Care Act of 2006, Pub. L. 109– 432 MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108–173 MPN Medicare provider number MRHFP Medicare Rural Hospital Flexibility Program MRSA Methicillin-resistant Staphylococcus aureus MSA Metropolitan Statistical Area MS–DRG Medicare severity diagnosisrelated group MS–LTC–DRG Medicare severity long-term care diagnosis-related group NAICS North American Industrial Classification System NCD National coverage determination E:\FR\FM\30APP2.SGM 30APP2 23530 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 NCHS National Center for Health Statistics NCQA National Committee for Quality Assurance NCVHS National Committee on Vital and Health Statistics NECMA New England County Metropolitan Areas NQF National Quality Forum NTIS National Technical Information Service NVHRI National Voluntary Hospital Reporting Initiative OES Occupational employment statistics OIG Office of the Inspector General OMB Executive Office of Management and Budget O.R. Operating room OSCAR Online Survey Certification and Reporting [System] PE Pulmonary embolism PMSAs Primary metropolitan statistical areas POA Present on admission PPI Producer price index PPS Prospective payment system PRM Provider Reimbursement Manual ProPAC Prospective Payment Assessment Commission PRRB Provider Reimbursement Review Board PSF Provider-Specific File PS&R Provider Statistical and Reimbursement (System) QIG Quality Improvement Group, CMS QIO Quality Improvement Organization RCE Reasonable compensation equivalent RHC Rural health clinic RHQDAPU Reporting hospital quality data for annual payment update RNHCI Religious nonmedical health care institution RRC Rural referral center RUCAs Rural-urban commuting area codes RY Rate year SAF Standard Analytic File SCH Sole community hospital SFY State fiscal year SIC Standard Industrial Classification SNF Skilled nursing facility SOCs Standard occupational classifications SOM State Operations Manual TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248 TMA TMA [Transitional Medical Assistance], Abstinence Education, and QI [Qualifying Individuals] Programs Extension Act of 2007, Pub. L. 110–09 TJA Total joint arthroplasty UHDDS Uniform hospital discharge data set VAP Ventilator-associated pneumonia VBP Value-based purchasing Table of Contents I. Background A. Summary 1. Acute Care Hospital Inpatient Prospective Payment System (IPPS) 2. Hospitals and Hospital Units Excluded From the IPPS a. Inpatient Rehabilitation Facilities (IRFs) b. Long-Term Care Hospitals (LTCHs) c. Inpatient Psychiatric Facilities (IPFs) 3. Critical Access Hospitals (CAHs) 4. Payments for Graduate Medical Education (GME) B. Provisions of the Deficit Reduction Act of 2005 (DRA) VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 C. Provisions of the Medicare Improvements and Extension Act under Division B, Title I of the Tax Relief and Health Care Act of 2006 (MIEA–TRHCA) D. Provision of the TMA, Abstinence Education, and QI Programs Extension Act of 2007 E. Major Contents of this Proposed Rule 1. Proposed Changes to MS–DRG Classifications and Recalibrations of Relative Weights 2. Proposed Changes to the Hospital Wage Index 3. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs 4. Proposed Changes to the IPPS for Capital-Related Costs 5. Proposed Changes to the Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages 6. Proposed Changes Relating to Disclosure of Physician Ownership in Hospitals 7. Proposed Changes and Solicitation of Comments on Physician Self-Referral Provisions 8. Proposed Collection of Information Regarding Financial Relationships between Hospitals and Physicians 9. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits 10. Impact Analysis 11. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services 12. Disclosure of Financial Relationships Report (DFRR) Form 13. Discussion of Medicare Payment Advisory Commission Recommendations F. Public Comments Received on Issues in Related Rules 1. Comments on Phase-Out of the Capital Teaching Adjustment under the IPPS Included in the FY 2008 IPPS Final Rule with Comment Period 2. Policy Revisions Related to Medicare GME Group Affiliations for Hospitals in Certain Declared Emergency Areas II. Proposed Changes to Medicare Severity DRG (MS–DRG) Classifications and Relative Weights A. Background B. MS–DRG Reclassifications 1. General 2. Yearly Review for Making MS–DRG Changes C. Adoption of the MS–DRGs in FY 2008 D. MS–DRG Documentation and Coding Adjustment, Including the Applicability to the Hospital-Specific Rates and the Puerto Rico-Specific Standardized Amount 1. MS–DRG Documentation and Coding Adjustment 2. Application of the Documentation and Coding Adjustment to the HospitalSpecific Rates 3. Application of the Documentation and Coding Adjustment to Puerto RicoSpecific Standardized Amount 4. Potential Additional Payment Adjustments in FYs 2010 through 2012 E. Refinement of the MS–DRG Relative Weight Calculation 1. Background PO 00000 Frm 00004 Fmt 4701 Sfmt 4702 2. Refining the Medicare Cost Report 3. Timeline for Revising the Medicare Cost Report 4. Revenue Codes used in the MedPAR File F. Preventable Hospital-Acquired Conditions (HACs), Including Infections 1. General 2. Statutory Authority 3. Public Input 4. Collaborative Process 5. Selection Criteria for HACs 6. HACs Selected in FY 2008 and Proposed Changes to Certain Codes a. Foreign Object Retained After Surgery: Proposed Inclusion of ICD–9–CM Code 998.7 (CC) b. Pressure Ulcers: Proposed Changes in Code Assignments 7. HACs Under Consideration as Additional Candidates a. Surgical Site Infections Following Elective Surgeries b. Legionnaires’ Disease c. Glycemic Control d. Iatrogenic Pneumothorax e. Delirium f. Ventilator-Associated Pneumonia (VAP) g. Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE) h. Staphylococcus aureus Septicemia i. Clostridium Difficile-Associated Disease (CDAD) j. Methicillin-Resistant Staphylococcus aureus (MRSA) 8. Present on Admission (POA) Indicator Reporting 9. Enhancement and Future Issues a. Risk Adjustment b. Rates of HACs c. Use of POA Information d. Transition to ICD–10–PCS e. Application of Nonpayment for HACs to Other Settings f. Relationship to NQF’s Serious Reportable Adverse Events G. Proposed Changes to Specific MS–DRG Classifications 1. Pre-MDCs: Artificial Heart Devices 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Transferred Stroke Patients Receiving Tissue Plasminogen Activator (tPA) b. Intractable Epilepsy with Video Electroencephalogram (EEG) 3. MDC 5 (Diseases and Disorders of the Circulatory System) a. Automatic Implantable CardioverterDefibrillators (AICD) Lead and Generator Procedures b. Left Atrial Appendage Device 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue): Hip and Knee Replacements and Revisions a. Brief History of Development of Hip and Knee Replacement Codes b. Prior Recommendations of the AAHKS c. Adoption of MS–DRGs for Hip and Knee Replacements for FY 2008 and AAHKS’ Recommendations d. AAHKS’ Recommendations for FY 2009 e. CMS’ Response to AAHKS’ Recommendations f. Conclusion 5. MDC 18 (Infections and Parasitic Diseases Systemic or Unspecified Sites): Severe Sepsis E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs): Traumatic Compartment Syndrome 7. Medicare Code Editor (MCE) Changes a. List of Unacceptable Principal Diagnoses in MCE b. Diagnoses Allowed for Male Only Edit c. Limited Coverage Edit 8. Surgical Hierarchies 9. CC Exclusions List a. Background b. CC Exclusions List for FY 2009 10. Review of Procedure Codes in MS– DRGs 981, 982, and 983; 984, 985, and 986; and 987, 988, and 989 a. Moving Procedure Codes from MS–DRG 981 through 983 or MS–DRG 987 through 989 to MDCs b. Reassignment of Procedures among MS– DRGs 981 through 983, 984 through 986, and 987 through 989 c. Adding Diagnosis or Procedure Codes to MDCs 11. Changes to the ICD–9–CM Coding System H. Recalibration of MS–DRG Weights I. Proposed Medicare Severity Long-Term Care Diagnosis-Related Group (MS–LTC– DRG) Reclassifications and Relative Weights for LTCHs for FY 2009 1. Background 2. Proposed Changes in the MS–LTC–DRG Classifications a. Background b. Patient Classifications into MS–LTC– DRGs 3. Development of the Proposed FY 2009 MS–LTC–DRG Relative Weights a. General Overview of Development of the MS–LTC–DRG Relative Weights b. Data c. Hospital-Specific Relative Value (HSRV) Methodology d. Treatment of Severity Levels in Developing Proposed Relative Weights e. Proposed Low-Volume MS–LTC–DRGs 4. Steps for Determining the Proposed FY 2009 MS–LTC–DRG Relative Weights J. Proposed Add-On Payments for New Services and Technologies 1. Background 2. Public Input Before Publication of a Notice of Proposed Rulemaking on Add– On Payments 3. FY 2009 Status of Technologies Approved for FY 2008 Add-On Payments 4. FY 2009 Applications for New Technology Add-On Payments a. CardioWestTM Temporary Total Artificial Heart System (CardioWestTM TAH–t) b. Emphasys Medical Zephyr Endobronchial Valve (Zephyr EBV) c. Oxiplex d. TherOx Downstream System 5. Proposed Regulatory Change III. Proposed Changes to the Hospital Wage Index A. Background B. Requirements of Section 106 of the MIEA–TRHCA 1. Wage Index Study Required Under the MIEA–TRHCA 2. CMS Proposals in Response to Requirements Under Section 106(b) of the MIEA–TRHCA VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 a. Proposed Revision of the Reclassification Average Hourly Wage Comparison Criteria b. Within-State Budget Neutrality Adjustment for the Rural and Imputed Floors c. Within-State Budget Neutrality Adjustment for Geographic Reclassification C. Core-Based Statistical Areas for the Hospital Wage Index D. Proposed Occupational Mix Adjustment to the Proposed FY 2009 Wage Index 1. Development of Data for the Proposed FY 2009 Occupational Mix Adjustment 2. Calculation of the Proposed Occupational Mix Adjustment for FY 2009 3. 2007–2008 Occupational Mix Survey for the FY 2010 Wage Index E. Worksheet S–3 Wage Data for the Proposed FY 2009 Wage Index 1. Included Categories of Costs 2. Excluded Categories of Costs 3. Use of Wage Index Data by Providers Other Than Acute Care Hospitals Under the IPPS F. Verification of Worksheet S–3 Wage Data 1. Wage Data for Multicampus Hospitals 2. New Orleans’ Post-Katrina Wage Index G. Method for Computing the Proposed FY 2009 Unadjusted Wage Index H. Analysis and Implementation of the Proposed Occupational Mix Adjustment and the Proposed FY 2009 Occupational Mix Adjustment Wage Index I. Proposed Revisions to the Wage Index Based on Hospital Redesignations 1. General 2. Effects of Reclassification/Redesignation 3. FY 2009 MGCRB Reclassifications 4. FY 2008 Policy Clarifications and Revisions 5. Redesignations of Hospitals under Section 1886(d)(8)(B) of the Act 6. Reclassifications under Section 1886(d)(8)(B) of the Act J. Proposed FY 2009 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees K. Process for Requests for Wage Index Data Corrections L. Labor-Related Share for the Proposed Wage Index for FY 2009 IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs A. Proposed Changes to the Postacute Care Transfer Policy 1. Background 2. Proposed Policy Change Relating to Transfers to Home with a Written Plan for the Provision of Home Health Services 3. Evaluation of MS–DRGs under Postacute Care Transfer Policy for FY 2009 B. Reporting of Hospital Quality Data for Annual Hospital Payment Update 1. Background a. Overview b. Voluntary Hospital Quality Data Reporting c. Hospital Quality Data Reporting under Section 501(b) of Pub. L. 108–173 d. Hospital Quality Data Reporting under Section 5001(a) of Pub. L. 109–171 PO 00000 Frm 00005 Fmt 4701 Sfmt 4702 23531 2. Proposed Quality Measures for FY 2010 and Subsequent Years a. Proposed Quality Measures for FY 2010 b. Possible New Quality Measures, Measure Sets, and Program Requirements for FY 2011 and Subsequent Years c. Considerations in Expanding and Updating Quality Measures Under the RHQDAPU Program 3. Form and Manner and Timing of Quality Data Submission 4. Current and Proposed RHQDAPU Program Procedures a. RHQDAPU Program Procedures for FY 2009 b. Proposed RHQDAPU Program Procedures for FY 2010 5. Current and Proposed HCAHPS Requirements a. FY 2009 HCAHPS Requirements b. Proposed FY 2010 HCAHPS Requirements 6. Current and Proposed Chart Validation Requirements a. Chart Validation Requirements for FY 2009 b. Proposed Chart Validation Requirements for FY 2010 c. Chart Validation Methods and Requirements Under Consideration for FY 2011 and Subsequent Years 7. Data Attestation Requirements a. Proposed Change to Requirements for FY 2009 b. Proposed Requirements for FY 2010 8. Public Display Requirements 9. Proposed Reconsideration and Appeal Procedures 10. Proposed RHQDAPU Program Withdrawal Deadline for FYs 2009 and 2010 11. Requirements for New Hospitals 12. Electronic Medical Records C. Medicare Hospital Value-Based Purchasing (VBP) 1. Medicare Hospital VBP Plan Report to Congress 2. Testing and Further Development of the Medicare Hospital VBP Plan D. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small Rural Hospitals (MDHs): Volume Decrease Adjustment 1. Background 2. Volume Decrease Adjustment for SCHs and MDHs: Data Sources for Determining Core Staff Values a. Occupational Mix Survey b. AHA Annual Survey E. Rural Referral Centers (RRCs) 1. Case-Mix Index 2. Discharges F. Indirect Medical Education (IME) Adjustment 1. Background 2. IME Adjustment Factor for FY 2009 G. Medicare GME Affiliation Provisions for Teaching Hospitals in Certain Emergency Situations; Technical Correction 1. Background 2. Technical Correction H. Payments to Medicare Advantage Organizations: Collection of Risk Adjustment Data I. Hospital Emergency Services under EMTALA E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23532 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 1. Background 2. EMTALA Technical Advisory Group (TAG): Recommendations 3. Proposed Changes Relating to Applicability of EMTALA Requirements to Hospital Inpatients 4. Proposed Changes to the EMTALA Physician On-Call Requirements a. Relocation of Regulatory Provisions b. Shared/Community Call 5. Proposed Technical Change to Regulations J. Application of Incentives To Reduce Avoidable Readmissions to Hospitals 1. Introduction 2. Measurement 3. Accountability 4. Interventions 5. Financial Incentive: Direct Payment Adjustment 6. Financial Incentive: Performance-Based Payment Adjustment 7. Nonfinancial Incentive: Public Reporting 8. Conclusion K. Rural Community Hospital Demonstration Program V. Proposed Changes to the IPPS for CapitalRelated Costs A. Background 1. Exception Payments 2. New Hospitals 3. Hospitals Located in Puerto Rico B. Revisions to the Capital IPPS Based on Data on Hospitals Medicare Capital Margins 1. Elimination of the Large Add-On Payment Adjustment 2. Changes to the Capital IME Adjustment a. Background and Changes Made for FY 2008 b. Public Comments Received on Phase Out of Capital IPPS Teaching Adjustment Provisions Included in the FY 2008 Final Rule With Comment Period and Further Solicitation of Public Comments VI. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS A. Proposed Payments to Excluded Hospitals and Hospital Units B. IRF PPS C. LTCH PPS D. IPF PPS E. Determining Proposed LTCH Cost-toCharge Ratios (CCRs) under the LTCH PPS F. Proposed Change to the Regulations Governing Hospitals-Within-Hospitals VII. Disclosure Required of Certain Hospitals and Critical Access Hospitals Regarding Physician Ownership VIII. Physician Self-Referrals Provisions A. Stand in the Shoes Provisions 1. Physician ‘‘Stand in the Shoes’’ Provisions a. Background b. Proposals 2. DHS Entity ‘‘Stand in the Shoes’’ Provisions 3. Application of the Physician ‘‘Stand in the Shoes’’ and the Entity ‘‘Stand in the Shoes’’ Provisions 4. Definitions: ‘‘Physician’’ and ‘‘Physician Organization’’ B. Period of Disallowance C. Gainsharing Arrangements VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 1. Background 2. Statutory Impediments to Gainsharing Arrangements 3. Office of Inspector General (OIG) Approach Towards Gainsharing Arrangements 4. MedPAC Recommendation 5. Demonstration Programs 6. Solicitation of Comments D. Physician-Owned Implant and Other Medical Device Companies 1. Background 2. Solicitation of Comments IX. Financial Relationships between Hospitals and Physicians A. Background B. Section 5006 of the Deficit Reduction Act (DRA) of 2005 C. Disclosure of Financial Relationships Report (DFRR) D. Civil Monetary Penalties E. Uses of Information Captured by the DFRR F. Solicitation of Comments X. MedPAC Recommendations XI. Other Required Information A. Requests for Data from the Public B. Collection of Information Requirements 1. Legislative Requirement for Solicitation of Comments 2. Solicitation of Comments on Proposed Requirements in Regulatory Text a. ICRs Regarding Physician Reporting Requirements b. ICRs Regarding Risk Adjustment Data c. ICRs Regarding Basic Commitments of Providers 3. Associated Information Collections Not Specified in Regulatory Text a. Present on Admission (POA) Indicator Reporting b. Proposed Add-On Payments for New Services and Technologies c. Reporting of Hospital Quality Data for Annual Hospital Payment Update d. Occupational Mix Adjustment to the FY 2009 Index (Hospital Wage Index Occupational Mix Survey) 4. Addresses for Submittal of Comments on Information Collection Requirements C. Response to Public Comments Regulation Text Addendum—Proposed Schedule of Standardized Amounts, Update Factors, and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2008 I. Summary and Background II. Proposed Changes to the Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2009 A. Calculation of the Adjusted Standardized Amount B. Proposed Adjustments for Area Wage Levels and Cost-of-Living C. Proposed MS–DRG Relative Weights D. Calculation of the Proposed Prospective Payment Rates III. Proposed Changes of Payment Rates for Acute Care Hospital Inpatient CapitalRelated Costs for FY 2009 A. Determination of Proposed Federal Hospital Inpatient Capital-Related Prospective Payment Rate Update PO 00000 Frm 00006 Fmt 4701 Sfmt 4702 B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2009 C. Capital Input Price Index IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages V. Tables Table 1A.—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1) Table 1B.—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal to 1) Table 1C.—Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D.—Capital Standard Federal Payment Rate Table 2.—Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2007; Hospital Wage Indexes for Federal Fiscal Year 2009; Hospital Average Hourly Wages for Federal Fiscal Years 2007 (2003 Wage Data), 2008 (2004 Wage Data), and 2009 (2005 Wage Data); and 3-Year Average of Hospital Average Hourly Wages Table 3A.—FY 2009 and 3-Year Average Hourly Wage for Urban Areas by CBSA Table 3B.—FY 2009 and 3-Year Average Hourly Wage for Rural Areas by CBSA Table 4A.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA and by State—FY 2009 Table 4B.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA and by State—FY 2009 Table 4C.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA and by State—FY 2009 Table 4D–1.—Rural Floor Budget Neutrality Factors—FY 2009 Table 4D–2.—Urban Areas with Hospitals Receiving the Statewide Rural Floor or Imputed Floor Wage Index—FY 2009 Table 4E.—Urban CBSAs and Constituent Counties—FY 2009 Table 4F.—Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA—FY 2009 Table 4J.—Out-Migration Wage Adjustment—FY 2009 Table 5.—List of Medicare Severity Diagnosis-Related Groups (MS–DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay Table 6A.—New Diagnosis Codes Table 6B.—New Procedure Codes Table 6C.—Invalid Diagnosis Codes Table 6D.—Invalid Procedure Codes Table 6E.—Revised Diagnosis Code Titles Table 6F.—Revised Procedure Code Titles Table 6G.—Additions to the CC Exclusions List (Available through the Internet on the CMS Web site at: https:// www.cms.hhs.gov/AcuteInpatientPPS/) Table 6H.—Deletions From the CC Exclusions List (Available Through the E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 Internet on the CMS Web site at: https://www.cms.hhs.gov/ AcuteInpatientPPS/) Table 6I.—Complete List of Complication and Comorbidity (CC) Exclusions (Available Only Through the Internet on the CMS Web site at: http:/ www.cms.hhs.gov/AcuteInpatientPPS/) Table 6J.—Major Complication and Comorbidity (MCC) List (Available Through the Internet on the CMS Web Site at: https://www.cms.hhs.gov/ AcuteInpatientPPS/) Table 6K.—Complication and Comorbidity (CC) List (Available Through the Internet on the CMS Web site at: https:// www.cms.hhs.gov/AcuteInpatientPPS/) Table 7A.—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2007 MedPAR Update— December 2007 GROUPER V25.0 MS– DRGs Table 7B.—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2007 MedPAR Update— December 2007 GROUPER V26.0 MS– DRGs Table 8A.—Proposed Statewide Average Operating Cost-to-Charge Ratios—March 2008 Table 8B.—Proposed Statewide Average Capital Cost-to-Charge Ratios—March 2008 Table 8C.—Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs— March 2008 Table 9A.—Hospital Reclassifications and Redesignations—FY 2009 Table 9B.—Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act—FY 2009 Table 10.—Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Medicare Severity Diagnosis-Related Groups (MS–DRGs)—March 2008 Table 11.—Proposed FY 2009 MS–LTC– DRGs, Proposed Relative Weights, Proposed Geometric Average Length of Stay, and Proposed Short-Stay Outlier Threshold Appendix A—Regulatory Impact Analysis I. Overall Impact II. Objectives III. Limitations on Our Analysis IV. Hospitals Included in and Excluded From the IPPS V. Effects on Excluded Hospitals and Hospital Units VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS for Operating Costs A. Basis and Methodology of Estimates B. Analysis of Table I C. Effects of the Proposed Changes to the MS–DRG Reclassifications and Relative Cost-Based Weights (Column 2) D. Effects of Proposed Wage Index Changes (Column 3) E. Combined Effects of Proposed MS–DRG and Wage Index Changes (Column 4) F. Effects of MGCRB Reclassifications (Column 5) VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 G. Effects of the Proposed Rural Floor and Imputed Rural Floor, Including the Proposed Application of Budget Neutrality at the State Level (Column 6) H. Effects of the Proposed Wage Index Adjustment for Out-Migration (Column 7) I. Effects of All Proposed Changes with CMI Adjustment Prior to Estimated Growth (Column 8) J. Effects of All Proposed Changes with CMI Adjustment and Estimated Growth (Column 9) K. Effects of Policy on Payment Adjustment for Low-Volume Hospitals L. Impact Analysis of Table II VII. Effects of Other Proposed Policy Changes A. Effects of Proposed Policy on HACs, Including Infections B. Effects of Proposed MS–LTC–DRG Reclassifications and Relative Weights for LTCHs C. Effects of Proposed Policy Change Relating to New Medical Service and Technology Add-On Payments D. Effects of Proposed Policy Change Regarding Postacute Care Transfers to Home Health Services E. Effects of Proposed Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update F. Effects of Proposed Policy Change to Methodology for Computing Core Staffing Factors for Volume Decrease Adjustment for SCHs and MDHs G. Effects of Proposed Clarification of Policy for Collection of Risk Adjustment Data From MA Organizations H. Effects of Proposed Policy Changes Relating to Hospital Emergency Services under EMTALA I. Effects of Implementation of Rural Community Hospital Demonstration Program J. Effects of Proposed Policy Changes Relating to Payments to HospitalsWithin-Hospitals K. Effects of Proposed Policy Changes Relating to Requirements for Disclosure of Physician Ownership in Hospitals L. Effects of Proposed Changes Relating to Physician Self-Referral Provisions M. Effects of Proposed Changes Relating to Reporting of Financial Relationships Between Hospitals and Physicians VIII. Effects of Proposed Changes in the Capital IPPS A. General Considerations B. Results IX. Alternatives Considered X. Overall Conclusion XI. Accounting Statement XII. Executive Order 12866 Appendix B—Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services I. Background II. Inpatient Hospital Update for FY 2009 III. Secretary’s Recommendation IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare PO 00000 Frm 00007 Fmt 4701 Sfmt 4702 23533 Appendix C—Disclosure of Financial Relationships Report (DFRR) Form I. Background A. Summary 1. Acute Care Hospital Inpatient Prospective Payment System (IPPS) Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of hospital inpatient stays under a prospective payment system (PPS). Under these PPSs, Medicare payment for hospital inpatient operating and capital-related costs is made at predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs). The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The laborrelated share is adjusted by the wage index applicable to the area where the hospital is located. If the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-living adjustment factor. This base payment rate is multiplied by the DRG relative weight. If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients. For qualifying hospitals, the amount of this adjustment may vary based on the outcome of the statutory calculations. If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid under the IPPS, known as the indirect medical education (IME) adjustment. This percentage varies, depending on the ratio of residents to beds. Additional payments may be made for cases that involve new technologies or medical services that have been approved for special add-on payments. To qualify, a new technology or medical service must demonstrate that it is a substantial clinical improvement over technologies or services otherwise available, and that, absent an add-on E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23534 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules payment, it would be inadequately paid under the regular DRG payment. The costs incurred by the hospital for a case are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. Any outlier payment due is added to the DRG-adjusted base payment rate, plus any DSH, IME, and new technology or medical service add-on adjustments. Although payments to most hospitals under the IPPS are made on the basis of the standardized amounts, some categories of hospitals are paid in whole or in part based on their hospitalspecific rate based on their costs in a base year. For example, sole community hospitals (SCHs) receive the higher of a hospital-specific rate based on their costs in a base year (the higher of FY 1982, FY 1987, or FY 1996) or the IPPS rate based on the standardized amount. Until FY 2007, a Medicare-dependent, small rural hospital (MDH) has received the IPPS rate plus 50 percent of the difference between the IPPS rate and its hospital-specific rate if the hospitalspecific rate based on their costs in a base year (the higher of FY 1982, FY 1987, or FY 2002) is higher than the IPPS rate. As discussed below, for discharges occurring on or after October 1, 2007, but before October 1, 2011, an MDH will receive the IPPS rate plus 75 percent of the difference between the IPPS rate and its hospital-specific rate, if the hospital-specific rate is higher than the IPPS rate. SCHs are the sole source of care in their areas, and MDHs are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries. Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services ‘‘in accordance with a prospective payment system established by the Secretary.’’ The basic methodology for determining capital prospective payments is set forth in our regulations at 42 CFR 412.308 and 412.312. Under the capital IPPS, payments are adjusted by the same DRG for the case as they are under the operating IPPS. Capital IPPS payments are also adjusted for IME and DSH, similar to the adjustments made under the operating IPPS. However, as discussed in section V.B.2. of this preamble, we are phasing out the IME adjustment beginning with FY 2008. In addition, hospitals may receive outlier payments for those cases that have unusually high costs. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 The existing regulations governing payments to hospitals under the IPPS are located in 42 CFR Part 412, Subparts A through M. 2. Hospitals and Hospital Units Excluded From the IPPS Under section 1886(d)(1)(B) of the Act, as amended, certain specialty hospitals and hospital units are excluded from the IPPS. These hospitals and units are: Rehabilitation hospitals and units; long-term care hospitals (LTCHs); psychiatric hospitals and units; children’s hospitals; and cancer hospitals. Religious nonmedical health care institutions (RNHCIs) are also excluded from the IPPS. Various sections of the Balanced Budget Act of 1997 (Pub. L. 105–33), the Medicare, Medicaid and SCHIP [State Children’s Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106–113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Pub. L. 106–554) provide for the implementation of PPSs for rehabilitation hospitals and units (referred to as inpatient rehabilitation facilities (IRFs)), LTCHs, and psychiatric hospitals and units (referred to as inpatient psychiatric facilities (IPFs)), as discussed below. Children’s hospitals, cancer hospitals, and RNHCIs continue to be paid solely under a reasonable cost-based system. The existing regulations governing payments to excluded hospitals and hospital units are located in 42 CFR Parts 412 and 413. a. Inpatient Rehabilitation Facilities (IRFs) Under section 1886(j) of the Act, as amended, rehabilitation hospitals and units (IRFs) have been transitioned from payment based on a blend of reasonable cost reimbursement subject to a hospital-specific annual limit under section 1886(b) of the Act and the adjusted facility Federal prospective payment rate for cost reporting periods beginning on or after January 1, 2002 through September 30, 2002, to payment at 100 percent of the Federal rate effective for cost reporting periods beginning on or after October 1, 2002. IRFs subject to the blend were also permitted to elect payment based on 100 percent of the Federal rate. The existing regulations governing payments under the IRF PPS are located in 42 CFR Part 412, Subpart P. b. Long-Term Care Hospitals (LTCHs) Under the authority of sections 123(a) and (c) of Pub. L. 106–113 and section 307(b)(1) of Pub. L. 106–554, the LTCH PPS was effective for a LTCH’s first cost PO 00000 Frm 00008 Fmt 4701 Sfmt 4702 reporting period beginning on or after October 1, 2002. LTCHs that do not meet the definition of ‘‘new’’ under § 412.23(e)(4) are paid, during a 5-year transition period, a LTCH prospective payment that is comprised of an increasing proportion of the LTCH Federal rate and a decreasing proportion based on reasonable cost principles. Those LTCHs that did not meet the definition of ‘‘new’’ under § 412.23(e)(4) could elect to be paid based on 100 percent of the Federal prospective payment rate instead of a blended payment in any year during the 5-year transition. For cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the Federal rate. The existing regulations governing payment under the LTCH PPS are located in 42 CFR Part 412, Subpart O. c. Inpatient Psychiatric Facilities (IPFs) Under the authority of sections 124(a) and (c) of Pub. L. 106–113, inpatient psychiatric facilities (IPFs) (formerly psychiatric hospitals and psychiatric units of acute care hospitals) are paid under the IPF PPS. For cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the Federal per diem payment amount established under the IPF PPS. (For cost reporting periods beginning on or after January 1, 2005, and ending on or before December 31, 2007, some IPFs received transitioned payments for inpatient hospital services based on a blend of reasonable cost-based payment and a Federal per diem payment rate.) The existing regulations governing payment under the IPF PPS are located in 42 CFR part 412, Subpart N. 3. Critical Access Hospitals (CAHs) Under sections 1814, 1820, and 1834(g) of the Act, payments are made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services are based on 101 percent of reasonable cost. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under 42 CFR Parts 413 and 415. 4. Payments for Graduate Medical Education (GME) Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act. The amount of payment for direct GME costs E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules for a cost reporting period is based on the hospital’s number of residents in that period and the hospital’s costs per resident in a base year. The existing regulations governing payments to the various types of hospitals are located in 42 CFR Part 413. B. Provisions of the Deficit Reduction Act of 2005 (DRA) Section 5001(b) of the Deficit Reduction Act of 2005 (DRA), Pub. L. 109–171, requires the Secretary to develop a plan to implement, beginning with FY 2009, a value-based purchasing plan for section 1886(d) hospitals defined in the Act. In section IV.C. of the preamble of this proposed rule, we discuss the report to Congress on the Medicare value-based purchasing plan and the current testing of the plan. jlentini on PROD1PC65 with PROPOSALS2 C. Provisions of the Medicare Improvements and Extension Act Under Division B, Title I of the Tax Relief and Health Care Act of 2006 (MIEA–TRHCA) Section 106(b)(2) of the MIEA– TRHCA instructs the Secretary of Health and Human Services to include in the FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS. The Secretary was also instructed to consider MedPAC’s recommendations on the Medicare wage index classification system in developing these proposals. In section III. of the preamble of this proposed rule, we discuss MedPAC’s recommendations in a report to Congress and present our proposed changes to the FY 2009 wage index in response to those recommendations. D. Provision of the TMA, Abstinence Education, and QI Programs Extension Act of 2007 Section 7 of the TMA [Transitional Medical Assistance], Abstinence Education, and QI [Qualifying Individuals] Programs Extension Act of 2007 (Pub. L. 110–90) provides for a 0.9 percent prospective documentation and coding adjustment in the determination of standardized amounts under the IPPS (except for MDHs and SCHs) for discharges occurring during FY 2009. The prospective documentation and coding adjustment was established in FY 2008 in response to the implementation of an MS–DRG system under the IPPS that resulted in changes in coding and classification that did not reflect real changes in case-mix under section 1886(d) of the Act. We discuss our proposed implementation of this provision in section II.D. of the preamble of this proposed rule and in VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 the Addendum and in Appendix A to this proposed rule. E. Major Contents of This Proposed Rule In this proposed rule, we are setting forth proposed changes to the Medicare IPPS for operating costs and for capitalrelated costs in FY 2009. We also are setting forth proposed changes relating to payments for IME costs and payments to certain hospitals and units that continue to be excluded from the IPPS and paid on a reasonable cost basis. In addition, we are presenting proposed changes relating to disclosure to patients of physician ownership and investment interests in hospitals, proposed changes to our physician selfreferral regulations, and a solicitation of public comments on a proposed collection of information regarding financial relationships between hospitals and physicians. The following is a summary of the major changes that we are proposing to make: 1. Proposed Changes to MS–DRG Classifications and Recalibrations of Relative Weights In section II. of the preamble to this proposed rule, we are including— • Proposed changes to MS–DRG reclassifications based on our yearly review. • Proposed application of the documentation and coding adjustment to hospital-specific rates resulting from implementation of the MS–DRG system. • Proposed changes to address the RTI reporting recommendations on charge compression. • Proposed recalibrations of the MS– DRG relative weights. We also are proposing to refine the hospital cost reports so that charges for relatively inexpensive medical supplies are reported separately from the costs and charges for more expensive medical devices. This proposal would be applied to the determination of both the IPPS and the OPPS relative weights as well as the calculation of the ambulatory surgical center payment rates. We are presenting a listing and discussion of additional hospitalacquired conditions (HACs), including infections, that are being proposed to be subject to the statutorily required quality adjustment in MS–DRG payments for FY 2009. We are presenting our evaluation and analysis of the FY 2009 applicants for add-on payments for high-cost new medical services and technologies (including public input, as directed by Pub. L. 108–173, obtained in a town hall meeting). PO 00000 Frm 00009 Fmt 4701 Sfmt 4702 23535 We are proposing the annual update of the MS–LTC–DRG classifications and relative weights for use under the LTCH PPS for FY 2009. 2. Proposed Changes to the Hospital Wage Index In section III. of the preamble to this proposed rule, we are proposing revisions to the wage index and the annual update of the wage data. Specific issues addressed include the following: • Proposed wage index reform changes in response to recommendations made to Congress as a result of the wage index study required under Pub. L. 109–432. We discuss changes related to reclassifications criteria, application of budget neutrality in reclassifications, and the rural floor and imputed floor budget neutrality at the State level. • Changes to the CBSA designations. • The methodology for computing the proposed FY 2009 wage index. • The proposed FY 2009 wage index update, using wage data from cost reporting periods that began during FY 2006. • Analysis and implementation of the proposed FY 2009 occupational mix adjustment to the wage index. • Proposed revisions to the wage index based on hospital redesignations and reclassifications. • The proposed adjustment to the wage index for FY 2009 based on commuting patterns of hospital employees who reside in a county and work in a different area with a higher wage index. • The timetable for reviewing and verifying the wage data used to compute the proposed FY 2009 wage index. • The proposed labor-related share for the FY 2009 wage index, including the labor-related share for Puerto Rico. 3. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs In section IV. of the preamble to this proposed rule, we discuss a number of the provisions of the regulations in 42 CFR Parts 412, 413, and 489, including the following: • Proposed changes to the postacute care transfer policy as it relates to transfers to home with the provision of home health services. • The reporting of hospital quality data as a condition for receiving the full annual payment update increase. • Proposed changes in the collection of Medicare Advantage (MA) encounter data that are used for computing the risk payment adjustment made to MA organizations. • Discussion of the report to Congress on the Medicare value-based purchasing E:\FR\FM\30APP2.SGM 30APP2 23536 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules plan and current testing and further development of the plan. • Proposed changes to the methodology for determining core staff values for the volume decrease payment adjustment for SCHs and MDHs. • The proposed updated national and regional case-mix values and discharges for purposes of determining RRC status. • The statutorily-required IME adjustment factor for FY 2009 and technical changes to the GME payment policies. • Proposed changes to policies on hospital emergency services under EMTALA to address EMTALA Technical Advisory Group (TAG) recommendations. • Solicitation of public comments on Medicare policies relating to incentives for avoidable readmissions to hospitals. • Discussion of the fifth year of implementation of the Rural Community Hospital Demonstration Program. 4. Proposed Changes to the IPPS for Capital-Related Costs In section V. of the preamble to this proposed rule, we discuss the payment policy requirements for capital-related costs and capital payments to hospitals. We acknowledge the public comments that we received on the phase-out of the capital teaching adjustment included in the FY 2008 IPPS final rule with comment period, and again are soliciting public comments on this phase-out in this proposed rule. 5. Proposed Changes to the Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages In section VI. of the preamble to this proposed rule, we discuss proposed changes to payments to excluded hospitals and hospital units, proposed changes for determining LTCH CCRs under the LTCH PPS, including a discussion regarding changing the annual payment rate update schedule for the LTCH PPS, and proposed changes to the regulations on hospitalswithin-hospitals. jlentini on PROD1PC65 with PROPOSALS2 6. Proposed Changes Relating to Disclosure of Physician Ownership in Hospitals In section VII. of the preamble of this proposed rule, we present proposed changes to the regulations relating to the disclosure to patients of physician ownership or investment interests in hospitals. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 7. Proposed Changes and Solicitation of Comments on Physician Self-Referrals Provisions In section VIII. of the preamble of this proposed rule, we present proposed changes to the policies on physician self-referrals relating to the ‘‘Stand in Shoes’’ provision, In addition, we solicit public comments regarding physicianowned implant companies and gainsharing arrangements. 8. Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians In section IX. of the preamble of this proposed rule, we solicit public comments on our proposed collection of information regarding financial relationships between hospitals and physicians. 9. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits In the Addendum to this proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 2009 prospective payment rates for operating costs and capital-related costs. We also establish the proposed threshold amounts for outlier cases. In addition, we address the proposed update factors for determining the rateof-increase limits for cost reporting periods beginning in FY 2009 for hospitals and hospital units excluded from the PPS. 10. Impact Analysis In Appendix A of this proposed rule, we set forth an analysis of the impact that the proposed changes would have on affected hospitals. 11. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services In Appendix B of this proposed rule, as required by sections 1886(e)(4) and (e)(5) of the Act, we provided our recommendations of the appropriate percentage changes for FY 2009 for the following: • A single average standardized amount for all areas for hospital inpatient services paid under the IPPS for operating costs (and hospital-specific rates applicable to SCHs and MDHs). • Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the IPPS. 12. Disclosure of Financial Relationships Report (DFRR) Form In Appendix C of this proposed rule, we present the reporting form that we PO 00000 Frm 00010 Fmt 4701 Sfmt 4702 are proposing to use for the proposed collection of information on financial relationships between hospitals and physicians discussed in section IX, of the preamble of this proposed rule. 13. Discussion of Medicare Payment Advisory Commission Recommendations Under section 1805(b) of the Act, MedPAC is required to submit a report to Congress, no later than March 1 of each year, in which MedPAC reviews and makes recommendations on Medicare payment policies. MedPAC’s March 2008 recommendations concerning hospital inpatient payment policies address the update factor for inpatient hospital operating costs and capital-related costs under the IPPS and for hospitals and distinct part hospital units excluded from the IPPS. We address these recommendations in Appendix B of this proposed rule. For further information relating specifically to the MedPAC March 2008 reports or to obtain a copy of the reports, contact MedPAC at (202) 220–3700 or visit MedPAC’s Web site at: www.medpac.gov. F. Public Comments Received on Issues in Related Rules 1. Comments on Phase-Out of the Capital Teaching Adjustment Under the IPPS Included in the FY 2008 IPPS Final Rule With Comment Period In the FY 2008 IPPS final rule with comment period, we solicited public comments on our policy changes related to phase-out of the capital teaching adjustment to the capital payment update under the IPPS (72 FR 47401). We received approximately 90 timely pieces of correspondence in response to our solicitation. (These public comments may be viewed on the following Web site: https:// www.cms.hhs.gov/eRulemaking/ ECCMSR/list.asp under file code CMS– 1533–FC.) In section V. of the preamble of this proposed rule, we acknowledge receipt of these public comments and again solicit public comments on the phase-out in this proposed rule. We will respond to the public comments received in response to both the FY 2008 IPPS final rule with comment period and this proposed rule in the FY 2009 IPPS final rule, which is scheduled to be published in August 2008. 2. Policy Revisions Related to Medicare GME Group Affiliations for Hospitals in Certain Declared Emergency Areas We have issued two interim final rules with comment periods in the Federal Register that modified the GME E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules regulations as they apply to Medicare GME affiliated groups to provide for greater flexibility in training residents in approved residency programs during times of disasters: on April 12, 2006 (71 FR 18654) and on November 27, 2007 (72 FR 66892). We received a number of timely pieces of correspondence in response to these interim final rules with comment period. (The public comments that we received may be viewed on the Web site at: https:// www.cms.hhs.gov/eRulemaking/ ECCMSR/list.asp under the file codes CMS–1531–IFC1 and CMS–1531–IFC2, respectively.) We will summarize and address these public comments in the FY 2009 IPPS final rule, which is scheduled to be published in August 2008. II. Proposed Changes to Medicare Severity DRG (MS–DRG) Classifications and Relative Weights A. Background Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, under the IPPS, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary’s stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital’s payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs. Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. jlentini on PROD1PC65 with PROPOSALS2 B. MS–DRG Reclassifications 1. General As discussed in the preamble to the FY 2008 IPPS final rule with comment period (72 FR 47138), we focused our efforts in FY 2008 on making significant reforms to the IPPS consistent with the recommendations made by MedPAC in its ‘‘Report to the Congress, Physician- VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Owned Specialty Hospitals’’ in March 2005. MedPAC recommended that the Secretary refine the entire DRG system by taking into account severity of illness and applying hospital-specific relative value (HSRV) weights to DRGs.1 We began this reform process by adopting cost-based weights over a 3-year transition period beginning in FY 2007 and making interim changes to the DRG system for FY 2007 by creating 20 new CMS DRGs and modifying 32 others across 13 different clinical areas involving nearly 1.7 million cases. As described below in more detail, these refinements were intermediate steps towards comprehensive reform of both the relative weights and the DRG system that is occurring as we undertook further study. For FY 2008, we adopted 745 new Medicare Severity DRGs (MS– DRGs) to replace the CMS DRGs. We refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a full detailed discussion of how the MS–DRG system was established based on severity levels of illness (72 FR 47141). Currently, cases are classified into MS–DRGs for payment under the IPPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay. In a small number of MS–DRGs, classification is also based on the age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9– CM). The process of forming the MS–DRGs was begun by dividing all possible principal diagnoses into mutually exclusive principal diagnosis areas, referred to as Major Diagnostic Categories (MDCs). The MDCs were formed by physician panels to ensure that the DRGs would be clinically coherent. The diagnoses in each MDC correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. Thus, in order to maintain the requirement of clinical coherence, no final MS–DRG could contain patients in different MDCs. Most MDCs are based on a particular organ system of the body. For example, MDC 6 is Diseases and Disorders of the Digestive System. This approach is used because clinical care is generally organized in accordance with the organ system affected. However, some MDCs are not 1 Medicare Payment Advisory Commission: Report to the Congress, Physician-Owned Specialty Hospitals, March 25, page viii. PO 00000 Frm 00011 Fmt 4701 Sfmt 4702 23537 constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)). For FY 2008, cases are assigned to one of 745 MS– DRGs in 25 MDCs. The table below lists the 25 MDCs. MAJOR DIAGNOSTIC CATEGORIES (MDCS) 1 ............. 2 ............. 3 ............. 4 ............. 5 ............. 6 ............. 7 ............. 8 ............. 9 ............. 10 ........... 11 ........... 12 ........... 13 ........... 14 ........... 15 ........... 16 ........... 17 ........... 18 ........... 19 ........... 20 ........... 21 ........... 22 ........... 23 ........... 24 ........... 25 ........... Diseases and Disorders of the Nervous System. Diseases and Disorders of the Eye. Diseases and Disorders of the Ear, Nose, Mouth, and Throat. Diseases and Disorders of the Respiratory System. Diseases and Disorders of the Circulatory System. Diseases and Disorders of the Digestive System. Diseases and Disorders of the Hepatobiliary System and Pancreas. Diseases and Disorders of the Musculoskeletal System and Connective Tissue. Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast. Endocrine, Nutritional and Metabolic Diseases and Disorders. Diseases and Disorders of the Kidney and Urinary Tract. Diseases and Disorders of the Male Reproductive System. Diseases and Disorders of the Female Reproductive System. Pregnancy, Childbirth, and the Puerperium. Newborns and Other Neonates with Conditions Originating in the Perinatal Period. Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders. Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms. Infectious and Parasitic Diseases (Systemic or Unspecified Sites). Mental Diseases and Disorders. Alcohol/Drug Use and Alcohol/ Drug Induced Organic Mental Disorders. Injuries, Poisonings, and Toxic Effects of Drugs. Burns. Factors Influencing Health Status and Other Contacts with Health Services. Multiple Significant Trauma. Human Immunodeficiency Virus Infections. In general, cases are assigned to an MDC based on the patient’s principal diagnosis before assignment to an MS– DRG. However, under the most recent version of the Medicare GROUPER (Version 26.0), there are 9 MS–DRGs to E:\FR\FM\30APP2.SGM 30APP2 23538 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules which cases are directly assigned on the basis of ICD–9–CM procedure codes. These MS–DRGs are for heart transplant or implant of heart assist systems, liver and/or intestinal transplants, bone marrow transplants, lung transplants, simultaneous pancreas/kidney transplants, pancreas transplants, and for tracheostomies. Cases are assigned to these MS–DRGs before they are classified to an MDC. The table below lists the nine current pre-MDCs. PRE-MAJOR DIAGNOSTIC CATEGORIES (PRE-MDCS) MS–DRG 103 MS–DRG 480 MS–DRG 481 MS–DRG 482 MS–DRG 495 MS–DRG 512 MS–DRG 513 MS–DRG 541 jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 542 Heart Transplant or Implant of Heart Assist System. Liver Transplant and/or Intestinal Transplant. Bone Marrow Transplant. Tracheostomy for Face, Mouth, and Neck Diagnoses. Lung Transplant. Simultaneous Pancreas/Kidney Transplant. Pancreas Transplant. ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis with Major O.R. Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis without Major O.R. Once the MDCs were defined, each MDC was evaluated to identify those additional patient characteristics that would have a consistent effect on the consumption of hospital resources. Because the presence of a surgical procedure that required the use of the operating room would have a significant effect on the type of hospital resources used by a patient, most MDCs were initially divided into surgical DRGs and medical DRGs. Surgical DRGs are based on a hierarchy that orders operating room (O.R.) procedures or groups of O.R. procedures by resource intensity. Medical DRGs generally are differentiated on the basis of diagnosis and age (0 to 17 years of age or greater than 17 years of age). Some surgical and medical DRGs are further differentiated based on the presence or absence of a complication or comorbidity (CC) or a major complication or comorbidity (MCC). Generally, nonsurgical procedures and minor surgical procedures that are not usually performed in an operating room are not treated as O.R. procedures. However, there are a few non-O.R. procedures that do affect MS–DRG VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 assignment for certain principal diagnoses. An example is extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones. Lithotripsy procedures are not routinely performed in an operating room. Therefore, lithotripsy codes are not classified as O.R. procedures. However, our clinical advisors believe that patients with urinary stones who undergo extracorporeal shock wave lithotripsy should be considered similar to other patients who undergo O.R. procedures. Therefore, we treat this group of patients similar to patients undergoing O.R. procedures. Once the medical and surgical classes for an MDC were formed, each diagnosis class was evaluated to determine if complications or comorbidities would consistently affect the consumption of hospital resources. Each diagnosis was categorized into one of three severity levels. These three levels include a major complication or comorbidity (MCC), a complication or comorbidity (CC), or a non-CC. Physician panels classified each diagnosis code based on a highly iterative process involving a combination of statistical results from test data as well as clinical judgment. As stated earlier, we refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a full detailed discussion of how the MS–DRG system was established based on severity levels of illness (72 FR 47141). A patient’s diagnosis, procedure, discharge status, and demographic information is entered into the Medicare claims processing systems and subjected to a series of automated screens called the Medicare Code Editor (MCE). The MCE screens are designed to identify cases that require further review before classification into an MS–DRG. After patient information is screened through the MCE and any further development of the claim is conducted, the cases are classified into the appropriate MS–DRG by the Medicare GROUPER software program. The GROUPER program was developed as a means of classifying each case into an MS–DRG on the basis of the diagnosis and procedure codes and, for a limited number of MS–DRGs, demographic information (that is, sex, age, and discharge status). After cases are screened through the MCE and assigned to an MS–DRG by the GROUPER, the PRICER software calculates a base MS–DRG payment. The PRICER calculates the payment for each case covered by the IPPS based on the MS–DRG relative weight and additional factors associated with each hospital, such as IME and DSH payment adjustments. These additional factors PO 00000 Frm 00012 Fmt 4701 Sfmt 4702 increase the payment amount to hospitals above the base MS–DRG payment. The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and Review (MedPAR) file. The data in this file are used to evaluate possible MS– DRG classification changes and to recalibrate the MS–DRG weights. However, in the FY 2000 IPPS final rule (64 FR 41500), we discussed a process for considering non-MedPAR data in the recalibration process. In order for us to consider using particular non-MedPAR data, we must have sufficient time to evaluate and test the data. The time necessary to do so depends upon the nature and quality of the non-MedPAR data submitted. Generally, however, a significant sample of the non-MedPAR data should be submitted by midOctober for consideration in conjunction with the next year’s proposed rule. This date allows us time to test the data and make a preliminary assessment as to the feasibility of using the data. Subsequently, a complete database should be submitted by early December for consideration in conjunction with the next year’s proposed rule. As we indicated above, for FY 2008, we made significant improvement in the DRG system to recognize severity of illness and resource usage by adopting MS–DRGs. The changes we adopted were reflected in the FY 2008 GROUPER, Version 25.0, and were effective for discharges occurring on or after October 1, 2007. Our DRG analysis for the FY 2008 final rule with comment period was based on data from the March 2007 update of the FY 2006 MedPAR file, which contained hospital bills received through March 31, 2007, for discharges occurring through September 30, 2006. For this proposed rule, for FY 2009, our DRG analysis is based on data from the September 2007 update of the FY 2007 MedPAR file, which contains hospital bills received through September 30, 2007, for discharges through September 30, 2007. 2. Yearly Review for Making MS–DRG Changes Many of the changes to the MS–DRG classifications we make annually are the result of specific issues brought to our attention by interested parties. We encourage individuals with concerns about MS–DRG classifications to bring those concerns to our attention in a timely manner so they can be carefully considered for possible inclusion in the annual proposed rule and, if included, may be subjected to public review and comment. Therefore, similar to the E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 timetable for interested parties to submit non-MedPAR data for consideration in the MS–DRG recalibration process, concerns about MS–DRG classification issues should be brought to our attention no later than early December in order to be considered and possibly included in the next annual proposed rule updating the IPPS. The actual process of forming the MS–DRGs was, and will likely continue to be, highly iterative, involving a combination of statistical results from test data combined with clinical judgment. In the FY 2008 IPPS final rule (72 FR 47140 through 47189), we described in detail the process we used to develop the MS–DRGs that we adopted for FY 2008. In addition, in deciding whether to make further modification to the MS–DRGs for particular circumstances brought to our attention, we considered whether the resource consumption and clinical characteristics of the patients with a given set of conditions are significantly different than the remaining patients in the MS–DRG. We evaluated patient care costs using average charges and lengths of stay as proxies for costs and relied on the judgment of our medical advisors to decide whether patients are clinically distinct or similar to other patients in the MS–DRG. In evaluating resource costs, we considered both the absolute and percentage differences in average charges between the cases we selected for review and the remainder of cases in the MS–DRG. We also considered variation in charges within these groups; that is, whether observed average differences were consistent across patients or attributable to cases that were extreme in terms of charges or length of stay, or both. Further, we considered the number of patients who will have a given set of characteristics and generally preferred not to create a new MS–DRG unless it would include a substantial number of cases. C. Adoption of the MS–DRGs in FY 2008 In the FY 2006, FY 2007, and FY 2008 IPPS final rules, we discussed a number of recommendations made by MedPAC regarding revisions to the DRG system used under the IPPS (70 FR 47473 through 47482; 71 FR 47881 through 47939; and 72 FR 47140 through 47189). As we noted in the FY 2006 IPPS final rule, we had insufficient time to complete a thorough evaluation of these recommendations for full implementation in FY 2006. However, we did adopt severity-weighted cardiac DRGs in FY 2006 to address public comments on this issue and the specific concerns of MedPAC regarding cardiac surgery DRGs. We also indicated that we VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 planned to further consider all of MedPAC’s recommendations and thoroughly analyze options and their impacts on the various types of hospitals in the FY 2007 IPPS proposed rule. For FY 2007, we began this process. In the FY 2007 IPPS proposed rule, we proposed to adopt Consolidated Severity DRGs (CS DRGs) for FY 2008 (if not earlier). However, based on public comments received on the FY 2007 IPPS proposed rule, we decided not to adopt the CS DRGs. Rather, we decided to make interim changes to the existing DRGs for FY 2007 by creating 20 new DRGs involving 13 different clinical areas that would significantly improve the CMS DRG system’s recognition of severity of illness. We also modified 32 DRGs to better capture differences in severity. The new and revised DRGs were selected from 40 existing CMS DRGs that contained 1,666,476 cases and represent a number of body systems. In creating these 20 new DRGs, we deleted 8 and modified 32 existing DRGs. We indicated that these interim steps for FY 2007 were being taken as a prelude to more comprehensive changes to better account for severity in the DRG system by FY 2008. In the FY 2007 IPPS final rule, we indicated our intent to pursue further DRG reform through two initiatives. First, we announced that we were in the process of engaging a contractor to assist us with evaluating alternative DRG systems that were raised as potential alternatives to the CMS DRGs in the public comments. Second, we indicated our intent to review over 13,000 ICD–9– CM diagnosis codes as part of making further refinements to the current CMS DRGs to better recognize severity of illness based on the work that CMS (then HCFA) did in the mid-1990’s in connection with adopting severity DRGs. We describe below the progress we have made on these two initiatives, our actions for FY 2008, and our proposals for FY 2009 based on our continued analysis of reform of the DRG system. We note that the adoption of the MS–DRGs to better recognize severity of illness has implications for the outlier threshold, the application of the postacute care transfer policy, the measurement of real case-mix versus apparent case-mix, and the IME and DSH payment adjustments. We discuss these implications for FY 2009 in other sections of this preamble and in the Addendum to this proposed rule. In the FY 2007 IPPS proposed rule, we discussed MedPAC’s recommendations to move to a costbased HSRV weighting methodology using HSRVs beginning with the FY PO 00000 Frm 00013 Fmt 4701 Sfmt 4702 23539 2007 IPPS proposed rule for determining the DRG relative weights. Although we proposed to adopt the HSRV weighting methodology for FY 2007, we decided not to adopt the proposed methodology in the final rule after considering the public comments we received on the proposal. Instead, in the FY 2007 IPPS final rule, we adopted a cost-based weighting methodology without the HSRV portion of the proposed methodology. The cost-based weights are being adopted over a 3-year transition period in 1⁄3 increments between FY 2007 and FY 2009. In addition, in the FY 2007 IPPS final rule, we indicated our intent to further study the HSRV-based methodology as well as other issues brought to our attention related to the cost-based weighting methodology adopted in the FY 2007 final rule. There was significant concern in the public comments that our costbased weighting methodology does not adequately account for charge compression—the practice of applying a higher percentage charge markup over costs to lower cost items and services and a lower percentage charge markup over costs to higher cost items and services. Further, public commenters expressed concern about potential inconsistencies between how costs and charges are reported on the Medicare cost reports and charges on the Medicare claims. In the FY 2007 IPPS final rule, we used costs and charges from the cost report to determine departmental level cost-to-charge ratios (CCRs) which we then applied to charges on the Medicare claims to determine the cost-based weights. The commenters were concerned about potential distortions to the cost-based weights that would result from inconsistent reporting between the cost reports and the Medicare claims. After publication of the FY 2007 IPPS final rule, we entered into a contract with RTI International (RTI) to study both charge compression and to what extent our methodology for calculating DRG relative weights is affected by inconsistencies between how hospitals report costs and charges on the cost reports and how hospitals report charges on individual claims. Further, as part of its study of alternative DRG systems, the RAND Corporation analyzed the HSRV cost-weighting methodology. We refer readers to section II.E. of the preamble of this proposed rule for our proposals for addressing the issue of charge compression and the HSRV costweighting methodology for FY 2009. We believe that revisions to the DRG system to better recognize severity of E:\FR\FM\30APP2.SGM 30APP2 23540 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules illness and changes to the relative weights based on costs rather than charges are improving the accuracy of the payment rates in the IPPS. We agree with MedPAC that these refinements should be pursued. Although we continue to caution that any prospective payment system based on grouping cases will always present some opportunities for providers to specialize in cases they believe have higher margins, we believe that the changes we have adopted and the continuing reforms we are proposing in this proposed rule for FY 2009 will improve payment accuracy and reduce financial incentives to create specialty hospitals. We refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a full discussion of how the MS–DRG system was established based on severity levels of illness (72 FR 47141). D. MS–DRG Documentation and Coding Adjustment, Including the Applicability to the Hospital-Specific Rates and the Puerto Rico-Specific Standardized Amount jlentini on PROD1PC65 with PROPOSALS2 1. MS–DRG Documentation and Coding Adjustment As stated above, we adopted the new MS–DRG patient classification system for the IPPS, effective October 1, 2007, to better recognize severity of illness in Medicare payment rates. Adoption of the MS–DRGs resulted in the expansion of the number of DRGs from 538 in FY 2007 to 745 in FY 2008. By increasing the number of DRGs and more fully taking into account severity of illness in Medicare payment rates, the MS–DRGs encourage hospitals to improve their documentation and coding of patient diagnoses. In the FY 2008 IPPS final rule with comment period (72 FR 47175 through 47186), which appeared in the Federal Register on August 22, 2007, we indicated that we believe the adoption of the MS–DRGs had the potential to lead to increases in aggregate payments without a corresponding increase in actual patient severity of illness due to the incentives for improved documentation and coding. In that final rule with comment period, using the Secretary’s authority under section 1886(d)(3)(A)(vi) of the Act to maintain budget neutrality by adjusting the standardized amount to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix, we established prospective documentation and coding adjustments of ¥1.2 percent for FY 2008, ¥1.8 percent for FY 2009, and ¥1.8 percent for FY 2010. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 On September 29, 2007, the TMA, Abstinence Education, and QI Programs Extension Act of 2007, Pub. L. 110–90, was enacted. Section 7 of Pub. L. 110– 90 included a provision that reduces the documentation and coding adjustment for the MS–DRG system that we adopted in the FY 2008 IPPS final rule with comment period to ¥0.6 percent for FY 2008 and ¥0.9 percent for FY 2009. To comply with the provision of section 7 of Pub. L. 110–90, in a final rule that appeared in the Federal Register on November 27, 2007 (72 FR 66886), we changed the IPPS documentation and coding adjustment for FY 2008 to ¥0.6 percent, and revised the FY 2008 payment rates, factors, and thresholds accordingly, with these revisions effective October 1, 2007. For FY 2009, Pub. L. 110–90 requires a documentation and coding adjustment of ¥0.9 percent instead of the ¥1.8 percent adjustment specified in the FY 2008 IPPS final rule with comment period. As required by statute, we are applying a documentation and coding adjustment of ¥0.9 percent to the FY 2009 IPPS national standardized amounts. The documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. As a result, the ¥0.9 percent documentation and coding adjustment in FY 2009 is in addition to the ¥0.6 percent adjustment in FY 2008, yielding a combined effect of ¥1.5 percent. 2. Application of the Documentation and Coding Adjustment to the HospitalSpecific Rates Under section 1886(d)(5)(D)(i) of the Act, SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: The Federal national rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge. Under section 1886(d)(5)(G) of the Act, MDHs are paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent of the difference between the Federal national rate and the updated hospital-specific rate based on the greater of either the FY 1982, 1987, or 2002 costs per discharge. In the FY 2008 IPPS final rule with comment period, we established a policy of applying the documentation and coding adjustment to the hospital-specific rates. In that rule, we indicated that because SCHs and MDHs use the same DRG system as all other hospitals, we believe they should be equally subject to the budget neutrality adjustment that we are PO 00000 Frm 00014 Fmt 4701 Sfmt 4702 applying for adoption of the MS–DRGs to all other hospitals. In establishing this policy, we cited our authority under section 1886(d)(3)(A)(vi) of the Act, which provides the authority to adjust ‘‘the standardized amount’’ to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix. However, in a final rule that appeared in the Federal Register on November 27, 2007 (72 FR 66886), we rescinded the application of the documentation and coding adjustment to the hospital-specific rates retroactive to October 1, 2007. In that final rule, we indicated that, while we still believe it would be appropriate to apply the documentation and coding adjustment to the hospital-specific rates, upon further review we decided that application of the documentation and coding adjustment to the hospitalspecific rates is not consistent with the plain meaning of section 1886(d)(3)(A)(vi) of the Act, which only mentions adjusting ‘‘the standardized amount’’ and does not mention adjusting the hospital-specific rates. We continue to have concerns about this issue. Because hospitals paid based on the hospital-specific rate use the same MS–DRG system as other hospitals, we believe they have the potential to realize increased payments from coding improvements that do not reflect real increases in patients’ severity of illness. In section 1886(d)(3)(A)(vi) of the Act, Congress stipulated that hospitals paid based on the standardized amount should not receive additional payments based on the effect of documentation and coding changes that do not reflect real changes in case-mix. Similarly, we believe that hospitals paid based on the hospitalspecific rate should not have the potential to realize increased payments due to documentation and coding improvements that do not reflect real increases in patients’ severity of illness. While we continue to believe that section 1886(d)(3)(A)(vi) of the Act does not provide explicit authority for application of the documentation and coding adjustment to the hospitalspecific rates, we believe that we have the authority to apply the documentation and coding adjustment to the hospital-specific rates using our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of the Act. The special exceptions and adjustment authority authorizes us to provide ‘‘for such other exceptions and adjustments to [IPPS] payment amounts * * * as the Secretary deems appropriate.’’ In light of this authority, for the FY 2010 rulemaking, we plan to E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 examine our FY 2008 claims data for hospitals paid based on the hospitalspecific rate. If we find evidence of significant increases in case-mix for patients treated in these hospitals, we would consider proposing application of the documentation and coding adjustments to the FY 2010 hospitalspecific rates under our authority in section 1886(d)(5)(I)(i) of the Act. As noted previously, the documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. For example, the ¥0.9 percent documentation and coding adjustment to the national standardized amount in FY 2009 is in addition to the ¥0.6 percent adjustment made in FY 2008, yielding a combined effect of ¥1.5 percent in FY 2009. Given the cumulative nature of the documentation and coding adjustments, if we were to propose to apply the documentation and coding adjustment to the FY 2010 hospital-specific rates, it may involve applying the FY 2008 and FY 2009 documentation and coding adjustments (¥1.5 percent combined) plus the FY 2010 documentation and coding adjustment, discussed in the FY 2008 IPPS final rule with comment period, to the FY 2010 hospital-specific rates. 3. Application of the Documentation and Coding Adjustment to the Puerto Rico-Specific Standardized Amount Puerto Rico hospitals are paid based on 75 percent of the national standardized amount and 25 percent of the Puerto Rico-specific standardized amount. As noted previously, the documentation and coding adjustment we adopted in the FY 2008 IPPS final rule with comment period relied upon our authority under section 1886(d)(3)(A)(vi) of the Act, which provides the authority to adjust ‘‘the standardized amounts computed under this paragraph’’ to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix. Section 1886(d)(3)(A)(vi) of the Act applies to the national standardized amounts computed under section 1886(d)(3) of the Act, but does not apply to the Puerto Rico-specific standardized amount computed under section 1886(d)(9)(C) of the Act. In calculating the FY 2008 payment rates, we made an inadvertent error and applied the FY 2008 ¥0.6 percent documentation and coding adjustment to the Puerto Ricospecific standardized amount, relying on our authority under section 1886(d)(3)(A)(vi) of the Act. We are currently in the process of developing a Federal Register notice to correct that error in the Puerto Rico-specific VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 standardized amount for FY 2008 retroactive to October 1, 2007. While section 1886(d)(3)(A)(vi) of the Act is not applicable to the Puerto Ricospecific standardized amount, we believe that we have the authority to apply the documentation and coding adjustment to the Puerto Rico-specific standardized amount using our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of the Act. Similar to SCHs and MDHs that are paid based on the hospital-specific rate, discussed in section II.D.2. of this preamble, we believe that Puerto Rico hospitals that are paid based on the Puerto Rico-specific standardized amount should not have the potential to realize increased payments due to documentation and coding improvements that do not reflect real increases in patients’ severity of illness. Consistent with the approach described for SCHs and MDHs in section II.D.2. of the preamble of this proposed rule, for the FY 2010 rulemaking, we plan to examine our FY 2008 claims data for hospitals in Puerto Rico. If we find evidence of significant increases in casemix for patients treated in these hospitals, we would consider proposing application of the documentation and coding adjustments to the FY 2010 Puerto Rico-specific standardized amount under our authority in section 1886(d)(5)(I)(i) of the Act. As noted previously, the documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. Given the cumulative nature of the documentation and coding adjustments, if we were to propose to apply the documentation and coding adjustment to the FY 2010 Puerto Rico-specific standardized amount, it may involve applying the FY 2008 and FY 2009 documentation and coding adjustments (¥1.5 percent combined) plus the FY 2010 documentation and coding adjustment, discussed in the FY 2008 IPPS final rule with comment period, to the FY 2010 Puerto Rico-specific standardized amount. 4. Potential Additional Payment Adjustments in FYs 2010 Through 2012 Section 7 of Pub. L.110–90 also provides for payment adjustments in FYs 2010 through 2012 based upon a retrospective evaluation of claims data from the implementation of the MS– DRG system. If, based on this retrospective evaluation, the Secretary finds that in FY 2008 and FY 2009, the actual amount of change in case-mix that does not reflect real change in underlying patient severity differs from the statutorily mandated documentation PO 00000 Frm 00015 Fmt 4701 Sfmt 4702 23541 and coding adjustments implemented in those years, the law requires the Secretary to adjust payments for discharges occurring in FYs 2010 through 2012 to offset the estimated amount of increase or decrease in aggregate payments that occurred in FY 2008 and FY 2009 as a result of that difference, in addition to making an appropriate adjustment to the standardized amount under section 1886(d)(3)(A)(vi) of the Act. In order to implement these requirements of section 7 of Pub. L. 110–90, we are planning a thorough retrospective evaluation of our claims data. Results of this evaluation would be used by our actuaries to determine any necessary payment adjustments in FYs 2010 through 2012 to ensure the budget neutrality of the MS–DRG implementation for FY 2008 and FY 2009, as required by law. We are currently developing our analysis plans for this effort. We intend to measure and corroborate the extent of the overall national average changes in case-mix for FY 2008 and FY 2009. We expect part of this overall national average change would be attributable to underlying changes in actual patient severity and part would be attributable to documentation and coding improvements under the MS– DRG system. In order to separate the two effects, we plan to isolate the effect of shifts in cases among base DRGs from the effect of shifts in the types of cases within base DRGs. The shifts among base DRGs are the result of changes in principal diagnoses while the shifts within base DRGs are the result of changes in secondary diagnoses. Because we expect most of the documentation and coding improvements under the MS–DRG system will occur in the secondary diagnoses, the shifts among base DRGs are less likely to be the result of the MS– DRG system and the shifts within base DRGs are more likely to be the result of the MS–DRG system. We also anticipate evaluating data to identify the specific MS–DRGs and diagnoses that contributed significantly to the improved documentation and coding payment effect and to quantify their impact. This step would entail analysis of the secondary diagnoses driving the shifts in severity within specific base DRGs. While we believe that the data analysis plan described previously will produce an appropriate estimate of the extent of case-mix changes resulting from documentation and coding improvements, we may also decide, if feasible, to use historical data from our Hospital Payment Monitoring Program E:\FR\FM\30APP2.SGM 30APP2 23542 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules (HPMP) to corroborate the within base DRG shift analysis. The HPMP is supported by the Medicare Clinical Data Abstraction Center (CDAC). From 1999 to 2007, the CDAC obtained medical records for a sample of discharges as part of our hospital monitoring activities. These data were collected on a random sample of between 30,000 to 50,000 hospital discharges per year. The historical CDAC data could be used to develop an upper bound estimate of the trend in real case-mix growth (that is, real change in underlying patient severity) prior to implementation of the MS–DRGs. We welcome public comments on our analysis plans, as well as suggestions on other possible approaches for conducting a retrospective analysis to identify the amount of case-mix changes that occurred in FY 2008 and FY 2009 that did not reflect real increases in patients’ severity of illness. Our analysis, findings, and any resulting proposals to adjust payments for discharges occurring in FYs 2010 through 2012 to offset the estimated amount of increase or decrease in aggregate payments that occurred in FY 2008 and FY 2009 will be discussed in future years’ rulemakings. jlentini on PROD1PC65 with PROPOSALS2 E. Refinement of the MS–DRG Relative Weight Calculation 1. Background In the FY 2008 IPPS final rule with comment period (72 FR 47188), we continued to implement significant revisions to Medicare’s inpatient hospital rates by basing relative weights on hospitals’ estimated costs rather than on charges. We continued our 3-year transition from charge-based relative weights to cost-based relative weights. Beginning in FY 2007, we implemented relative weights based on cost report data instead of based on charge information. We had initially proposed to develop cost-based relative weights using the hospital-specific relative value cost center (HSRVcc) methodology as recommended by MedPAC. However, after considering concerns raised in the public comments, we modified MedPAC’s methodology to exclude the hospital-specific relative weight feature. Instead, we developed national CCRs based on distinct hospital departments and engaged a contractor to evaluate the HSRVcc methodology for future consideration. To mitigate payment instability due to the adoption of costbased relative weights, we decided to transition cost-based weights over 3 years by blending them with chargebased weights beginning in FY 2007. In FY 2008, we continued our transition by VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 blending the relative weights with onethird charge-based weights and twothirds cost-based weights. Also, in FY 2008, we adopted severity-based MS–DRGs, which increased the number of DRGs from 538 to 745. Many commenters raised concerns as to how the transition from charge-based weights to cost-based weights would continue with the introduction of new MS–DRGs. We decided to implement a 2-year transition for the MS–DRGs to coincide with the remainder of the transition to cost-based relative weights. In FY 2008, 50 percent of the relative weight for each DRG was based on the CMS DRG relative weight and 50 percent was based on the MS–DRG relative weight. We refer readers to the FY 2007 IPPS final rule (71 FR 47882) for more detail on our final policy for calculating the cost-based DRG relative weights and to the FY 2008 IPPS final rule with comment period (72 FR 47199) for information on how we blended relative weights based on the CMS DRGs and MS–DRGs. As we transitioned to cost-based relative weights, some commenters raised concerns about potential bias in the weights due to ‘‘charge compression,’’ which is the practice of applying a higher percentage charge markup over costs to lower cost items and services, and a lower percentage charge markup over costs to higher cost items and services. As a result, the costbased weights would undervalue high cost items and overvalue low cost items if a single CCR is applied to items of widely varying costs in the same cost center. To address this concern, in August 2006, we awarded a contract to RTI to study the effects of charge compression in calculating the relative weights and to consider methods to reduce the variation in the CCRs across services within cost centers. RTI issued an interim draft report in March 2007 which was posted on the CMS Web site with its findings on charge compression. In that report, RTI found that a number of factors contribute to charge compression and affect the accuracy of the relative weights. RTI found inconsistent matching of charges in the Medicare cost report and their corresponding charges in the MedPAR claims for certain cost centers. In addition, there was inconsistent reporting of costs and charges among hospitals. For example, some hospitals would report costs and charges for devices and medical supplies in the Medical Supplies Charged to Patients cost center, while other hospitals would report those costs and charges in their related ancillary departments such as PO 00000 Frm 00016 Fmt 4701 Sfmt 4702 Operating Room or Radiology. RTI also found evidence that certain revenue codes within the same cost center had significantly different markup rates. For example, within the Medicare Supplies Charged to Patients cost center, revenue codes for devices, implantables, and prosthetics had different markup rates than the other medical supplies in that cost center. RTI’s findings demonstrated that charge compression exists in several CCRs, most notably in the Medical Supplies and Equipment CCR. RTI offered short-term, medium-term, and long-term recommendations to mitigate the effects of charge compression. RTI’s short-term recommendations included expanding the distinct hospital CCRs to 19 by disaggregating the ‘‘Emergency Room’’ and ‘‘Blood and Blood Products’’ from the Other Services cost center and by estimating regression-based CCRs to disaggregate Medical Supplies, Drugs, and Radiology cost centers. RTI recommended, for the medium-term, to expand the MedPAR file to include separate fields that disaggregate several existing charge departments. In addition, RTI recommended improving hospital cost reporting instructions so that hospitals can properly report costs in the appropriate cost centers. RTI’s long-term recommendations included adding new cost centers to the Medicare cost report, such as adding a ‘‘Devices, Implants and Prosthetics’’ line under ‘‘Medical Supplies Charged to Patients’’ and a ‘‘CT Scanning and MRI’’ subscripted line under ‘‘RadiologyDiagnostics’’. Among RTI’s short-term recommendations, for FY 2008, we expanded the number of distinct hospital department CCRs from 13 to 15 by disaggregating ‘‘Emergency Room’’ and ‘‘Blood and Blood Products’’ from the Other Services cost center as these lines already exist on the hospital cost report. Furthermore, in an effort to improve consistency between costs and their corresponding charges in the MedPAR file, we moved the costs for cases involving electroencephalography (EEG) from the Cardiology cost center to the Laboratory cost center group which corresponds with the EEG MedPAR claims categorized under the Laboratory charges. We also agreed with RTI’s recommendations to revise the Medicare cost report and the MedPAR file as a long-term solution for charge compression. We stated that, in the upcoming year, we would consider additional lines to the cost report and additional revenue codes for the MedPAR file. We did not adopt RTI’s short-term recommendation to create four E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules additional regression-based CCRs for several reasons, even though we had received comments in support of the regression-based CCRs as a means to immediately resolve the problem of charge compression, particularly within the Medical Supplies and Equipment CCR. We were concerned that RTI’s analysis was limited to charges on hospital inpatient claims while typically hospital cost report CCRs combine both inpatient and outpatient services. Further, because both the IPPS and OPPS rely on cost-based weights, we preferred to introduce any methodological adjustments to both payment systems at the same time. We have since expanded RTI’s analysis of charge compression to incorporate outpatient services. RTI has been evaluating the cost estimation process for the OPPS cost-based weights, including a reassessment of the regression-based CCR models using both outpatient and inpatient charge data. The RTI report was finalized at the conclusion of our proposed rule development process and is expected to be posted on the CMS Web site in the near future. We welcome comments on this report. A second reason that we did not implement regression-based CCRs at the time of the FY 2008 IPPS final rule with comment period was our inability to investigate how regression-based CCRs would interact with the implementation of MS–DRGs. We stated that we would consider the results of the second phase of the RAND study as we prepared for the FY 2009 IPPS rulemaking process. The purpose of the RAND study was to analyze how the relative weights would change if we were to adopt regressionbased CCRs to address charge compression while simultaneously adopting an HSRV methodology using fully phased-in MS–DRGs. We had intended to include a detailed discussion of RAND’s study in this FY 2009 IPPS proposed rule. However, due to some delays in releasing identifiable data to the contractor under revised data security rules, the report on this second stage of RAND’s analysis was not completed in time for the development of this proposed rule. Therefore, we continue to have the same concerns with respect to uncertainty about how regression-based CCRs would interact with the MS–DRGs or an HSRV methodology. Therefore, we are not proposing to adopt the regression-based CCRs or an HSRV methodology in this FY 2009 IPPS proposed rule. Nevertheless, we welcome public comments on our proposals not to adopt regression-based CCRs or an HSRV VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 methodology at this time or in the future. The RAND report on regressionbased CCRs and the HSRV methodology was finalized at the conclusion of our proposed rule development process and is expected to be posted on the CMS Web site in the near future. Although we are unable to include a discussion of the results of the RAND study in this proposed rule, we welcome public comment on the report. Finally, we received public comments on the FY 2008 IPPS proposed rule raising concerns on the accuracy of using regression-based CCR estimates to determine the relative weights rather than the Medicare cost report. Commenters noted that regression-based CCRs would not fix the underlying mismatch of hospital reporting of costs and charges. Instead, the commenters suggested that the impact of charge compression might be mitigated through an educational initiative that would encourage hospitals to improve their cost reporting. Commenters recommended that hospitals be educated to report costs and charges in a way that is consistent with how charges are grouped in the MedPAR file. In an effort to achieve this goal, hospital associations have launched an educational campaign to encourage consistent reporting, which would result in consistent groupings of the cost centers used to establish the cost-based relative weights. The commenters requested that CMS communicate to the fiscal intermediaries/MACs that such action is appropriate. In the FY 2008 IPPS final rule with comment period, we stated that we were supportive of the educational initiative of the industry, and we encouraged hospitals to report costs and charges consistently with how the data are used to determine relative weights (72 FR 47196). We would also like to affirm that the longstanding Medicare principles of cost apportionment at 42 CFR 413.53 convey that, under the departmental method of apportionment, the cost of each ancillary department is to be apportioned separately rather than being combined with another ancillary department (for example, combining the cost of Medical Supplies Charged to Patients with the costs of Operating Room or any other ancillary cost center. (We note that, effective for cost reporting periods starting on or after January 1, 1979, the departmental method of apportionment replaced the combination method of apportionment where all the ancillary departments were apportioned in the aggregate (Section 2200.3 of the Provider Reimbursement Manual (PRM), Part I).) PO 00000 Frm 00017 Fmt 4701 Sfmt 4702 23543 Furthermore, longstanding Medicare cost reporting policy has been that hospitals must include the cost and charges of separately ‘‘chargeable medical supplies’’ in the Medical Supplies Charged to Patients cost center (line 55 of Worksheet A), rather than in the Operating Room, Emergency Room, or other ancillary cost centers. Routine services, which can include ‘‘minor medical and surgical supplies’’ (Section 2202.6 of the PRM, Part 1), and items for which a separate charge is not customarily made, may be directly assigned through the hospital’s accounting system to the department in which they were used, or they may be included in the Central Services and Supply cost center (line 15 of Worksheet A). Conversely, the separately chargeable medical supplies should be assigned to the Medical Supplies Charged to Patients cost center on line 55. We note that not only is accurate cost reporting important for IPPS hospitals to ensure that accurate relative weights are computed, but hospitals that are still paid on the basis of cost, such as CAHs and cancer hospitals, and SCHs and MDHs must adhere to Medicare cost reporting principles as well. The CY 2008 OPPS/ASC final rule with comment period (72 FR 66601) also discussed the issue of charge compression and regression-based CCRs, and noted that RTI is currently evaluating the cost estimation process underpinning the OPPS cost-based weights, including a reassessment of the regression models using both outpatient and inpatient charges, rather than inpatient charges only. In responding to comments in the CY 2008 OPPS/ASC final rule with comment period, we emphasized that we ‘‘fully support’’ the educational initiatives of the industry and that we would ‘‘examine whether the educational activities being undertaken by the hospital community to improve cost reporting accuracy under the IPPS would help to mitigate charge compression under the OPPS, either as an adjunct to the application of regression-based CCRs or in lieu of such an adjustment’’ (72 FR 66601). However, as we stated in the FY 2008 IPPS final rule with comment period that we would consider the results of the RAND study before considering whether to adopt regression-based CCRs, in the CY 2008 OPPS/ASC final rule with comment period, we stated that we would determine whether refinements should be proposed, after reviewing the results of the RTI study. On February 29, 2008, we issued Transmittal 321, Change Request 5928, to inform the fiscal intermediaries/ E:\FR\FM\30APP2.SGM 30APP2 23544 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 MACs of the hospital associations’ initiative to encourage hospitals to modify their cost reporting practices with respect to costs and charges in a manner that is consistent with how charges are grouped in the MedPAR file. We noted that the hospital cost reports submitted for FY 2008 may have costs and charges grouped differently than in prior years, which is allowable as long as the costs and charges are properly matched and the Medicare cost reporting instructions are followed. Furthermore, we recommended that fiscal intermediaries/MACs remain vigilant to ensure that the costs of items and services are not moved from one cost center to another without moving their corresponding charges. Due to a time lag in submittal of cost reporting data, the impact of changes in providers’ cost reporting practices occurring during FY 2008 would be reflected in the FY 2011 IPPS relative weights. 2. Refining the Medicare Cost Report In developing this FY 2009 proposed rule, we considered whether there were concrete steps we could take to mitigate the bias introduced by charge compression in both the IPPS and OPPS relative weights in a way that balance hospitals’ desire to focus on improving the cost reporting process through educational initiatives with device industry interest in adopting regressionadjusted CCRs. Although RTI recommended adopting regressionbased CCRs, particularly for medical supplies and devices, as a short-term solution to address charge compression, RTI also recommended refinements to the cost report as a long-term solution. RTI’s draft interim March 2007 report discussed a number of options that could improve the accuracy and precision of the CCRs currently being derived from the Medicare cost report and also reduce the need for statistically-based adjustments. As mentioned in the FY 2008 IPPS final rule with comment period (72 FR 47193), we believe that RTI and many of the public commenters on the FY 2008 IPPS proposed rule concluded that, ultimately, improved and more precise cost reporting is the best way to minimize charge compression and improve the accuracy of cost weights. Therefore, in this proposed rule, we are proposing to begin making cost report changes geared to improving the accuracy of the IPPS and OPPS relative weights. However, we also received comments last year asking that we proceed cautiously with changing the Medicare cost report to avoid unintended consequences for hospitals that are paid on a cost basis (such as VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 CAHs and, to some extent, SCHs and MDHs), and to consider the administrative burden associated with adapting to new cost reporting forms and instructions. Accordingly, we are proposing to focus at this time on the CCR for Medical Supplies and Equipment because RTI found that the largest impact on the relative weights could result from correcting charge compression for devices and implants. When examining markup differences within the Medical Supplies Charged to Patients cost center, RTI found that its ‘‘regression results provide solid evidence that if there were distinct cost centers for items, cost ratios for devices and implants would average about 17 points higher than the ratios for other medical supplies’’ (January 2007 RTI report, page 59). This suggests that much of the charge compression within the Medical Supplies CCR results from inclusion of medical devices that have significantly different markups than the other supplies in that CCR. Furthermore, in the FY 2007 final rule and FY 2008 IPPS final rule with comment period, the Medical Supplies and Equipment CCR received significant attention by the public commenters. Although we are proposing to make improvements to lessen the effects of charge compression only on the Medical Supplies and Equipment CCR as a first step, we are inviting public comments as to whether to make other changes to the Medicare cost report to refine other CCRs. In addition, we are open to making further refinements to other CCRs in the future. Therefore, we are proposing at this time to add only one cost center to the cost report, such that, in general, the costs and charges for relatively inexpensive medical supplies would be reported separately from the costs and charges of more expensive devices (such as pacemakers and other implantable devices). We will consider public comments submitted on this proposed rule for purposes of both the IPPS and the OPPS relative weights and, by extension, the calculation of the ambulatory surgical center (ASC) payment rates. Under the IPPS for FY 2007 and FY 2008, the aggregate CCR for supplies and equipment was computed based on line 55 for Medical Supplies Charged to Patients and lines 66 and 67 for DME Rented and DME Sold, respectively. To compute the 15 national CCRs used in developing the cost-based weights under the IPPS (explained in more detail under section II.H. of the preamble of this proposed rule), we take the costs and charges for the 15 cost groups from Worksheet C, Part I of the Medicare cost report for all hospital PO 00000 Frm 00018 Fmt 4701 Sfmt 4702 patients and multiply each of these 15 CCRs by the Medicare charges on Worksheet D–4 for those same cost centers to impute the Medicare cost for each of the 15 cost groups. Under this proposal, the goal would be to split the current CCR for Medical Supplies and Equipment into one CCR for medical supplies, and another CCR for devices and DME Rented and DME Sold. In considering how to instruct hospitals on what to report in the cost center for supplies and the cost center for devices, we looked at the existing criteria for what type of device qualifies for payment as a transitional passthrough device category in the OPPS. (There are no such existing criteria for devices under the IPPS.) The provisions of the regulations under § 419.66(b) state that for a medical device to be eligible for pass-through payment under the OPPS, the medical device must meet the following criteria: a. If required by the FDA, the device must have received FDA approval or clearance (except for a device that has received an FDA investigational device exemption (IDE) and has been classified as a Category B device by the FDA in accordance with §§ 405.203 through 405.207 and 405.211 through 405.215 of the regulations) or another appropriate FDA exemption. b. The device is determined to be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part (as required by section 1862(a)(1)(A) of the Act). c. The device is an integral and subordinate part of the service furnished, is used for one patient only, comes in contact with human tissues, and is surgically implanted or inserted whether or not it remains with the patient when the patient is released from the hospital. d. The device is not any of the following: • Equipment, an instrument, apparatus, implement, or item of this type for which depreciation and financing expenses are recovered as depreciable assets as defined in Chapter 1 of the Medicare Provider Reimbursement Manual (CMS Pub. 15– 1). • A material or supply furnished incident to a service (for example, a suture, customized surgical kit, or clip, other than a radiological site marker). • Material that may be used to replace human skin (for example, a biological or synthetic material). These requirements are the OPPS criteria used to define a device for passthrough payment purposes and do not include additional criteria that are used E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules under the OPPS to determine if a candidate device is new and represents a substantial clinical improvement, two other requirements for qualifying for pass-through payment. For purposes of applying the eligibility criteria, we interpret ‘‘surgical insertion or implantation’’ to include devices that are surgically inserted or implanted via a natural or surgically created orifice as well as those devices that are inserted or implanted via a surgically created incision (70 FR 68630). In proposing to modify the cost report to have one cost center for medical supplies and one cost center for devices, we are proposing that hospitals would determine what should be reported in the Medical Supplies cost center and what should be reported in the Medical Devices cost center using criteria consistent with those listed above that are included under § 419.66(b), with some modification. Specifically, for purposes of the cost reporting instructions, we are proposing that an item would be reported in the device cost center if it meets the following criteria: a. If required by the FDA, the device must have received FDA approval or clearance (except for a device that has received an FDA investigational device exemption (IDE) and has been classified as a Category B device by the FDA in accordance with §§ 405.203 through 405.207 and 405.211 through 405.215 of the regulations) or another appropriate FDA exemption. b. The device is reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part (as required by section 1862(a)(1)(A) of the Act). c. The device is an integral and subordinate part of the service furnished, is used for one patient only, comes in contact with human tissue, is surgically implanted or inserted through a natural or surgically created orifice or surgical incision in the body, and remains in the patient when the patient is discharged from the hospital. d. The device is not any of the following: • Equipment, an instrument, apparatus, implement, or item of this type for which depreciation and financing expenses are recovered as depreciable assets as defined in Chapter 1 of the Medicare Provider Reimbursement Manual (CMS Pub. 15– 1). • A material or supply furnished incident to a service (for example, a surgical staple, a suture, customized VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 surgical kit, or clip, other than a radiological site marker). • Material that may be used to replace human skin (for example, a biological or synthetic material). • A medical device that is used during a procedure or service and does not remain in the patient when the patient is released from the hospital. We are proposing to select the existing criteria for what type of device qualifies for payment as a transitional pass-through device under the OPPS as a basis for instructing hospitals on what to report in the cost center for Medical Supplies Charged to Patients or the cost center for Medical Devices Charged to Patients because these criteria are concrete and already familiar to the hospital community. However, the key difference between the existing criteria for devices that are eligible for passthrough payment under the OPPS at § 419.66(b) and our proposed criteria stated above to be used for cost reporting purposes is that the device that is implanted remains in the patient when the patient is discharged from the hospital. Essentially, we are proposing to instruct hospitals to report only implantable devices that remain in the patient at discharge in the cost center for devices. All other devices and nonroutine supplies which are separately chargeable would be reported in the medical supplies cost center. We believe that defining a device for cost reporting purposes based on criteria that specify implantation and adding that the device must remain in the patient upon discharge would have the benefit of capturing virtually all costly implantable devices (for example, implantable cardioverter defibrillators (ICDs), pacemakers, and cochlear implants) for which charge compression is a significant concern. However, we acknowledge that a definition of device based on whether an item is implantable and remains in the patient could, in some cases, include items that are relatively inexpensive (for example, urinary catheters, fiducial markers, vascular catheters, and drainage tubes), and which many would consider to be supplies. Thus, some modest amount of charge compression could still be present in the cost center for devices if the hospital does not have a uniform markup policy. In addition, requiring as a cost reporting criterion that the device is to remain in the patient at discharge could exclude certain technologies that are moderately expensive (for example, cryoablation probes, angioplasty catheters, and cardiac echocardiography catheters, which do not remain in the patient upon discharge). Therefore, PO 00000 Frm 00019 Fmt 4701 Sfmt 4702 23545 some charge compression could continue for these technologies. We believe this limited presence of charge compression is acceptable, given that the proposed definition of device for cost reporting purposes would isolate virtually all of the expensive items, allowing them to be separately reported from most inexpensive supplies. The criteria we are proposing above for instructing hospitals as to what to report in the device cost center specify that a device is not a material or supply furnished incident to a service (for example, a surgical staple, a suture, customized surgical kit, or clip, other than a radiological site marker) (emphasis added). We understand that hospitals may sometimes receive surgical kits from device manufacturers that consist of a high-cost primary implantable device, external supplies required for operation of the device, and other disposable surgical supplies required for successful device implantation. Often the device and the attending supplies are included on a single invoice from the manufacturer, making it difficult for the hospital to determine the cost of each item in the kit. In addition, manufacturers sometimes include with the primary device other free or ‘‘bonus’’ items or supplies that are not an integral and necessary part of the device (that is, not actually required for the safe surgical implantation and subsequent operation of that device). (We note that arrangements involving free or bonus items or supplies may implicate the Federal anti-kickback statue, depending on the circumstances.) One option is for the hospital to split the total combined charge on the invoice in a manner that the hospital believes best identifies the cost of the device alone. However, because it may be difficult for hospitals to determine the respective costs of the actual device and the attending supplies (whether they are required for the safe surgical implantation and subsequent operation of that device or not), we are soliciting comments with respect to how supplies, disposable or otherwise, that are part of surgical kits should be reported. We are distinguishing between such supplies that are an integral and necessary part of the primary device (that is, required for the safe surgical implantation and subsequent operation of that device) from other supplies that are not directly related to the implantation of that device, but may be included by the device manufacturer with or without charge as ‘‘perks’’ along with the kit. If it is difficult to break out the costs and charges of these lower cost items that are an integral and necessary E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23546 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules part of the primary device, we would consider allowing hospitals to report the costs and charges of these lower cost supplies along with the costs and charges of the more expensive primary device in the cost report cost center for implantable devices. However, to the extent that device manufacturers could be encouraged to refine their invoicing practices to break out the charges and costs for the lower cost supplies and the higher cost primary device separately, so that hospitals need not ‘‘guesstimate’’ the cost of the device, this would facilitate more accurate cost reporting and, therefore, the calculation of more accurate cost-based weights. Under either scenario, even for an aggregated invoice that contains an expensive device, we believe that RTI’s findings of significant differences in supply CCRs for hospitals with a greater percentage of charges in device revenue codes demonstrate that breaking the Medical Supplies Charged to Patients cost center into two cost centers and using appropriate revenue codes for devices, and walking those costs to the new Implantable Devices Charged to Patients cost center, will result in an increase in estimated device costs. In summary, we are proposing to modify the cost report to have one cost center for Medical Supplies Charged to Patients and one cost center for Implantable Devices Charged to Patients. We are proposing to instruct hospitals to report only devices that meet the four criteria listed above (specifically including that the device is implantable and remains in the patient at discharge) in the cost center for Implantable Devices Charged to Patients. All other devices and nonchargeable supplies would be reported in the Medical Supplies cost center. This would allow for two distinct CCRs, one for medical supplies and one for implantable devices and DME rented and DME sold. However, we are also soliciting comments on alternative approaches that could be used in conjunction with or in lieu of the four proposed criteria for distinguishing between what should be reported in the cost center for Implantable Devices and Medical Supplies, respectively. Another option we are considering would distinguish between high-cost and low-cost items based on a cost threshold. Under this methodology, we would also have one cost center for Medical Supplies and one cost center for Devices, but we would instruct hospitals to report items that are not movable equipment or a capital expense but are above a certain cost threshold in the cost center for Devices. Items costing below that VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 threshold would be reported in the cost center for Medical Supplies. Establishing a cost threshold for cost reporting purposes would directly address the problem of charge compression and would enable hospitals to easily determine whether an item should be reported in the supply or the device cost center. A cost threshold would also potentially allow a broader variety of expensive, single use devices that do not remain in the patient at discharge to be reported in the device cost center (such as specialized catheters or ablation probes). While we have a number of concerns with the cost threshold approach, we are nevertheless soliciting public comments on whether such an approach would be worthwhile to pursue. Specifically, we are concerned that establishing a single cost threshold for pricing devices could possibly be inaccurate across hospitals. Establishing a threshold would require identifying a cost at which hospitals would begin applying reduced markup policies. Currently, we do not have data from which to derive a threshold. We have anecdotal reports that hospitals change their markup thresholds between $15,000 and $20,000 in acquisition costs. Recent research on this issue indicated that hospitals with average inpatient discharges in DRGs with supply charges greater than $15,000, $20,000, and $30,000 have higher supply CCRs (Advamed March 2006). Furthermore, although a cost threshold directly addresses charge compression, it may not eliminate all charge compression from the device cost center because a fixed cost threshold may not accurately capture differential markup policies for an individual hospital. At the same time, we are also concerned that establishing a cost threshold may interfere with the pricing practices of device manufacturers in that the prices for certain devices or surgical kits could be inflated to ensure that the devices met the cost threshold. We believe our proposed approach of identifying a group of items that are relatively expensive based on the existing criteria for OPPS device passthrough payment status, rather than adopting a cost threshold, would not influence pricing by the device industry. In addition, if a cost threshold were adopted for distinguishing between high-cost devices and low-cost supplies on the cost report, we would need to periodically reassess the threshold for changes in markup policies and price inflation over time. Another option for distinguishing between high-cost and low-cost items for purposes of the cost report would be PO 00000 Frm 00020 Fmt 4701 Sfmt 4702 to divide the Medical Supplies cost center based on markup policies by placing items with lower than average markups in a separate cost center. This approach would center on documentation requirements for differential charging practices that would lead hospitals to distinguish between the reporting of supplies and devices on different cost report lines. That is, because charge compression results from the different markup policies that hospitals apply to the supplies and devices they use based on the estimated costs of those supplies and devices, isolating supplies and devices with different markup policies mitigates aggregation in markup policies that cause charge compression and is specific to a hospital’s internal accounting and pricing practices. If requested by the fiscal intermediaries/ MACs at audit, hospitals could be required to submit documentation of their markup policies to justify the way they have reported relatively inexpensive supplies on one line and more expensive devices on the other line. We believe that it should not be too difficult for hospitals to document their markup practices because, as was pointed out by many commenters since the implementation of cost-based weights, the source of charge compression is varying markup practices. Greater knowledge of the specifics of hospital markup practices may allow ultimately for development of standard cost reporting instructions that instruct hospitals to report an item as a device or a supply based on the type of markup applied to that item. This option related to markup practices, the proposal to define devices based on four specific criteria, and the third alternative that would establish a cost threshold for purposes of distinguishing between high-cost and low-cost items, could be utilized separately or in some combination for purposes of cost report modification. Again, we are soliciting comments on these alternative approaches. We are also interested in other recommendations for appropriate cost reporting improvements that address charge compression. 3. Timeline for Revising the Medicare Cost Report As mentioned in the FY 2008 IPPS final rule with comment period (72 FR 47198), we have begun a comprehensive review of the Medicare hospital cost report, and the proposed splitting of the current cost center for Medical Supplies Charged to Patients into one line for Medical Supplies Charged to Patients and another line for Implantable Devices Charged to Patients, is part of E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 our initiative to update and revise the hospital cost report. Under an effort initiated by CMS to update the Medicare hospital cost report to eliminate outdated requirements in conjunction with the Paperwork Reduction Act, we plan to propose the actual changes to the cost reporting form, the attending cost reporting software, and the cost report instructions in Chapter 36 of the Medicare Provider Reimbursement Manual (PRM), Part II. We expect the proposed revision to the Medicare hospital cost report to be issued after publication of this IPPS proposed rule. If we were to adopt as final our proposal to create one cost center for Medical Supplies Charged to Patients and one cost center for Implantable Devices Charged to Patients in the FY 2009 IPPS final rule, the cost report forms and instructions would reflect those changes. We expect the revised cost report would be available for hospitals to use when submitting cost reports during FY 2009 (that is, for cost reporting periods beginning on or after October 1, 2008). Because there is approximately a 3-year lag between the availability of cost report data for IPPS and OPPS ratesetting purposes and a given fiscal year, we may be able to derive two distinct CCRs, one for medical supplies and one for devices, for use in calculating the FY 2012 IPPS relative weights and the CY 2012 OPPS relative weights. 4. Revenue Codes Used in the MedPAR File An important first step in RTI’s study (as explained in its draft interim March 2007 report) was determining how well the cost report charges used to compute CCRs matched to the charges in the MedPAR file. This match (or lack thereof) directly affects the accuracy of the DRG cost estimates because MedPAR charges are multiplied by CCRs to estimate cost. RTI found inconsistent reporting between the cost reports and the claims data for charges in several ancillary departments (Medical Supplies, Operating Room, Cardiology, and Radiology). For example, the data suggested that some hospitals often include costs and charges for devices and other medical supplies within the Medicare cost report cost centers for Operating Room, Radiology, or Cardiology, while other hospitals include them in the Medical Supplies Charged to Patients cost center. While the educational initiative undertaken by the national hospital associations is encouraging hospitals to consistently report costs and charges for devices and other medical supplies only in the Medical Supplies Charged to VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Patients cost center, equal attention must be paid to the way in which charges are grouped by hospitals in the MedPAR file. Several commenters on the FY 2008 IPPS proposed rule supported RTI’s recommendation of including additional fields in the MedPAR file to disaggregate certain cost centers. One commenter stated that the assignment of revenue codes and charges to revenue centers in the MedPAR file should be reviewed and changed to better reflect hospital accounting practices as reflected on the cost report (72 FR 47198). In an effort to improve the match between the costs and charges included on the cost report and the charges in the MedPAR file, we are recommending that certain revenue codes be used for items reported in the proposed Medical Supplies Charged to Patients cost center and the proposed Implantable Devices Charged to Patients cost center, respectively. Specifically, under the proposal to create a cost center for implantable devices that remain in the patient upon discharge, revenue codes 0275 (Pacemaker), 0276 (Intraocular Lens), and 0278 (Other Implants) would correspond to implantable devices reported in the proposed Implantable Devices Charged to Patients cost center. Items for which a hospital may have previously used revenue code 0270 (General Classification), but actually meet the proposed definition of an implantable device that remains in the patient upon discharge should instead be billed with the 0278 revenue code. Conversely, relatively inexpensive items and supplies that are not implantable and do not remain in the patient at discharge would be reported in the proposed Medical Supplies Charged to Patients cost center on the cost report, and should be billed with revenue codes 0271 (nonsterile supply), 0272 (sterile supply), and 0273 (take-home supplies), as appropriate. Revenue code 0274 (Prosthetic/Orthotic devices) and revenue code 0277 (Oxygen—Take Home) should be associated with the costs reported on lines 66 and 67 for DME—Rented and DME—Sold on the cost report. Charges associated with supplies used incident to radiology or to other diagnostic services (revenue codes 0621 and 0622 respectively) should match those items used incident to those services on the Medical Supplies Charged to Patients cost center of the cost report, because, under this proposal, supplies furnished incident to a service would be reported in the Medical Supplies Charged to Patients cost center (see item b. listed above, in the proposed definition of a device). A PO 00000 Frm 00021 Fmt 4701 Sfmt 4702 23547 revenue code of 0623 for surgical dressings would similarly be associated with the costs and charges of items reported in the proposed Medical Supplies Charged to Patients cost center, while a revenue code of 0624 for FDA investigational device, if that device does not remain in the patient upon discharge, could be associated with items reported on the Medical Supplies Charged to Patients cost center as well. In general, if an item is reported as an implantable device on the cost report, the associated charges should be recorded in the MedPAR file with either revenue codes 0275 (Pacemaker), 0276 (Intraocular Lens), or 0278 (Other Implants). Likewise, items reported as Medical Supplies should receive an appropriate revenue code indicative of supplies. We understand that many of these revenue codes have been in existence for many years and have been added for purposes unrelated to the goal of refining the calculation of cost-based weights. Accordingly, we acknowledge that additional instructions relating to the appropriate use of these revenue codes may need to be issued. In addition, CMS or the hospital associations may need to request new revenue codes from the National Uniform Billing Committee (NUBC). In either case, we do not believe either should delay use of the new Medical Supplies and Implantable Devices CCRs in setting payment rates. However, in light of our proposal to create two separate cost centers for Medical Supplies Charged to Patients and Implantable Devices Charged to Patients, respectively, we are soliciting comments on how the existing revenue codes or additional revenue codes could best be used in conjunction with the revised cost centers on the cost report. F. Preventable Hospital-Acquired Conditions (HACs), Including Infections 1. General In its landmark 1999 report ‘‘To Err is Human: Building a Safer Health System,’’ the Institute of Medicine found that medical errors, particularly hospital-acquired conditions (HACs) caused by medical errors, are a leading cause of morbidity and mortality in the United States. The report noted that the number of Americans who die each year as a result of medical errors that occur in hospitals may be as high as 98,000. The cost burden of HACs is also high. Total national costs of these errors due to lost productivity, disability, and health care costs were estimated at $17 E:\FR\FM\30APP2.SGM 30APP2 23548 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules billion to $29 billion.2 In 2000, the CDC estimated that hospital-acquired infections added nearly $5 billion to U.S. health care costs every year.3 A 2007 study found that, in 2002, 1.7 million hospital-acquired infections were associated with 99,000 deaths4 Research has also shown that hospitals are not following recommended guidelines to avoid preventable hospital-acquired infections. A 2007 Leapfrog Group survey of 1,256 hospitals found that 87 percent of those hospitals do not follow recommendations to prevent many of the most common hospital-acquired infections.5 As one approach to combating HACs, including infections, in 2005 Congress authorized CMS to adjust for Medicare IPPS hospital payments to encourage the prevention of these conditions. The preventable HAC provision at section 1886(d)(4)(D) of the Act is part of an array of Medicare value-based purchasing (VBP) tools that CMS is using to promote increased quality and efficiency of care. Those tools include measuring performance, using payment incentives, publicly reporting performance results, applying national and local coverage policy decisions, enforcing conditions of participation, and providing direct support for providers through Quality Improvement Organization (QIO) activities. CMS’ application of VBP tools through various initiatives, such as this HAC provision, is transforming Medicare from a passive payer to an active purchaser of higher value health care services. We are applying these strategies for inpatient hospital care and across the continuum of care for Medicare beneficiaries. The President’s FY 2009 Budget outlines another approach for addressing serious preventable adverse events (‘‘never events’’), including HACs. The President’s Budget proposal would: (1) Prohibit hospitals from billing the Medicare program for ‘‘never events’’ and prohibit Medicare payment for these events; and (2) require hospitals to report occurrence of these events or receive a reduced annual payment update. Medicare’s IPPS encourages hospitals to treat patients efficiently. Hospitals receive the same DRG payment for stays that vary in length and in the services provided, which gives hospitals an incentive to avoid unnecessary costs in the delivery of care. In many cases, complications acquired in the hospital do not generate higher payments than the hospital would otherwise receive for uncomplicated cases paid under the same DRG. To this extent, the IPPS encourages hospitals to avoid complications. However, complications, such as infections, acquired in the hospital can generate higher Medicare payments in two ways. First, the treatment of complications can increase the cost of a hospital stay enough to generate an outlier payment. However, the outlier payment methodology requires that a hospital experience a large loss on an outlier case, which serves as an incentive for hospitals to prevent outliers. Second, under the MS– DRGs that took effect in FY 2008, there are currently 258 sets of MS–DRGs that are split into 2 or 3 subgroups based on the presence or absence of a CC or an MCC. If a condition acquired during a hospital stay is one of the conditions on the CC or MCC list, the hospital currently receives a higher payment under the MS–DRGs (prior to the October 1, 2008 effective date of the HAC payment provision). (We refer readers to section II.D. of the FY 2008 IPPS final rule with comment period for a discussion of DRG reforms (72 FR 47141).) The following is an example of how an MS–DRG may be paid. Present on admission (status of secondary diagnosis) Service: MS–DRG Assignment* (Examples below with CC/MCC indicate a single secondary diagnosis only) Principal Diagnosis .................................................................................................................................................. • Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCC—MS–DRG 066. Principal Diagnosis .................................................................................................................................................. • Intracranial hemorrhage or cerebral infarction (stroke) with CC—MS–DRG 065. Example Secondary Diagnosis • Dislocation of patella-open due to a fall (code 836.4 (CC)). Principal Diagnosis .................................................................................................................................................. • Intracranial hemorrhage or cerebral infarction (stroke) with CC—MS–DRG 065. Example Secondary Diagnosis • Dislocation of patella-open due to a fall (code 836.4 (CC)). Principal Diagnosis .................................................................................................................................................. • Intracranial hemorrhage or cerebral infarction (stroke) with MCC—MS–DRG 064. Example Secondary Diagnosis • Stage III pressure ulcer (code 707.23 (MCC)). Principal Diagnosis .................................................................................................................................................. • Intracranial hemorrhage or cerebral infarction (stroke) with MCC—MS–DRG 064. Example Secondary Diagnosis • Stage III pressure ulcer (code 707.23 (MCC)). * Operating jlentini on PROD1PC65 with PROPOSALS2 ........................ $5,347.98 Y 6,177.43 N 5,347.98 Y 8,030.28 N 5,347.98 amounts for a hospital whose wage index is equal to the national average. 2. Statutory Authority Section 1886(d)(4)(D) of the Act required the Secretary to select at least two conditions by October 1, 2007, that 2 Institute of Medicine: To Err Is Human: Building a Safer Health System, November 1999. Available at: https://www.iom.edu/Object.File/Master/4/117/ ToErr–8pager.pdf. VerDate Aug<31>2005 Average payment (based on 50th percentile) 19:42 Apr 29, 2008 Jkt 214001 are: (a) High cost, high volume, or both; (b) assigned to a higher paying DRG when present as a secondary diagnosis; and (c) could reasonably have been prevented through the application of evidence-based guidelines. Beginning October 1, 2008, Medicare can no longer assign an inpatient hospital discharge to 3 Centers for Disease Control and Prevention: Press Release, March 2000. Available at: https:// www.cdc.gov/od/oc/media/pressrel/r2k0306b.htm. 4 Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March–April 2007. Volume 122. 5 2007 Leapfrog Group Hospital Survey. The Leapfrog Group 2007. Available at: https:// www.leapfroggroup.org/media/file/Leapfrog_ hospital_acquired_infections_release.pdf PO 00000 Frm 00022 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules initially apply, and noted that we would be seeking comments on additional HAC candidates in this proposed rule. 3. Public Input 5. Selection Criteria for HACs In the FY 2007 IPPS proposed rule (71 FR 24100), we sought public input regarding conditions with evidencebased prevention guidelines that should be selected in implementing section 1886(d)(4)(D) of the Act. The public comments we received were summarized in the FY 2007 IPPS final rule (71 FR 48051 through 48053). In the FY 2008 IPPS proposed rule (72 FR 24716), we again sought formal public comment on conditions that we proposed to select. In the FY 2008 IPPS final rule with comment period (72 FR 47200 through 47218), we summarized the public comments we received on the FY 2008 IPPS proposed rule, presented our responses, selected eight conditions to which the HAC provision will jlentini on PROD1PC65 with PROPOSALS2 a higher paying MS–DRG if a selected HAC was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. (Medicare will continue to assign a discharge to a higher paying MS–DRG if the selected condition was present on admission.) Section 1886(d)(4)(D) of the Act provides that the list of conditions can be revised from time to time, as long as the list contains at least two conditions. Beginning October 1, 2007, we required hospitals to begin submitting information on Medicare claims specifying whether diagnoses were present on admission (POA). The POA indicator reporting requirement and the HACs payment provision apply to IPPS hospitals only. At this time, non-IPPS hospitals such as CAHs, LTCHs, IRFs, and hospitals in Maryland operating under waivers, among others, are exempt from POA reporting and the HAC payment provision. Throughout this section, ‘‘hospital’’ refers to IPPS hospitals. CMS and CDC staff evaluated each candidate condition against the criteria established by section 1886(d)(4)(D)(iv) of the Act. • Cost or Volume—Medicare data 6 must support that the selected conditions are high cost, high volume, or both. At this point, there are no Medicare claims data indicating which secondary diagnoses were POA because POA indicator reporting began only recently; therefore, the currently available data for candidate conditions includes all secondary diagnoses. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 4. Collaborative Process CMS experts worked with public health and infectious disease professionals from the CDC to identify the candidate preventable HACs. CMS and CDC staff also collaborated on the process for hospitals to submit a POA indicator for each diagnosis listed on IPPS hospital Medicare claims. On December 17, 2007, CMS and CDC hosted a jointly sponsored HAC and POA Listening Session to receive input from interested organizations and individuals. The agenda, presentations, audio file, and written transcript of the listening session are available on the Web site at: https://www.cms.hhs.gov/ HospitalAcqCond/ 07_EducationalResources.asp. CMS and CDC also received informal comments during the listening session and subsequently received numerous written comments. 6 For this FY 2009 IPPS proposed rule, the DRG analysis is based on data from the September 2007 update of the FY 2007 MedPAR file, which contains hospital bills received through September 30, 2007, for discharges through September 30, 2007. PO 00000 Frm 00023 Fmt 4701 Sfmt 4702 23549 • Complicating Condition (CC) or Major Complicating Condition (MCC)— Selected conditions must be represented by ICD–9-CM diagnosis codes that clearly identify the condition, are designated as a CC or an MCC, and result in the assignment of the case to an MS-DRG that has a higher payment when the code is reported as a secondary diagnosis. That is, selected conditions must be a CC or an MCC that would, in the absence of this provision, result in assignment to a higher paying MS-DRG. • Evidence-Based Guidelines— Selected conditions must be reasonably preventable through the application of evidence-based guidelines. By reviewing guidelines from professional organizations, academic institutions, and entities such as the Healthcare Infection Control Practices Advisory Committee (HICPAC), we evaluated whether guidelines are available that hospitals should follow to prevent the condition from occurring in the hospital. • Reasonably Preventable—Selected conditions must be reasonably preventable through the application of evidence-based guidelines. 6. HACs Selected in FY 2008 and Proposed Changes to Certain Codes The HACs that were selected for the HAC payment provision through the FY 2008 IPPS final rule with comment period are listed below. The payment provision for these selected HACs will take effect on October 1, 2008. We refer readers to section II.F.6. of the FY 2008 IPPS final rule with comment period (72 FR 47202 through 47218) for a detailed analysis supporting the selection of each of these HACs. BILLING CODE 4120–01–P E:\FR\FM\30APP2.SGM 30APP2 VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00024 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.000</GPH> jlentini on PROD1PC65 with PROPOSALS2 23550 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23551 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00025 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.001</GPH> jlentini on PROD1PC65 with PROPOSALS2 BILLING CODE 4120–01–C 23552 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules We are seeking public comments on the following refinements to two of the previously selected HACs: a. Foreign Object Retained After Surgery: Proposed Inclusion of ICD–9– CM Code 998.7 (CC) In the FY 2008 IPPS final rule with comment period (72 FR 47206), we indicated that a foreign body accidentally left in the patient during a procedure (ICD–9–CM code 998.4) was one of the conditions selected. It has come to our attention that ICD–9–CM diagnosis code 998.7 (Acute reaction to foreign substance accidentally left during a procedure) should also be included. ICD–9–CM code 998.7 describes instances in which a patient developed an acute reaction due to a retained foreign substance. Therefore, we are proposing to make this code subject to the HAC payment provision. b. Pressure Ulcers: Proposed Changes in Code Assignments jlentini on PROD1PC65 with PROPOSALS2 As discussed in the FY 2008 IPPS final rule with comment period (72 FR 47205–47206), we referred the need for more detailed ICD–9–CM pressure ulcer codes to the CDC. The topic of expanding pressure ulcer codes to capture the stage of the ulcer was addressed at the September 27–28, 2007, meeting of the ICD–9–CM Coordination and Maintenance Committee. A summary report of this meeting is available on the Web site at: https://www.cdc.gov/nchs/about/ otheract/icd9/maint/maint.htm. Numerous wound care professionals supported modifying the pressure ulcer codes to capture staging information. The stage of the pressure ulcer is a powerful predictor of severity and VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 resource utilization. At its September 27–28, 2007 meeting, the ICD–9–CM Coordination and Maintenance Committee discussed the creation of pressure ulcer codes to capture this information. The new codes, along with their proposed CC/MCC classifications, are shown in Table 6A of the Addendum to this proposed rule. The new codes are as follows: • 707.20 (Pressure ulcer, unspecified stage). • 707.21 (Pressure ulcer stage I). • 707.22 (Pressure ulcer stage II). • 707.23 (Pressure ulcer stage III). • 707.24 (Pressure ulcer stage IV). While the code titles are final, we are soliciting comment on the proposed MS–DRG classifications of these codes, as indicated in Table 6A of the Addendum to this proposed rule. We are proposing to remove the CC/MCC classifications from the current pressure ulcer codes that show the site of the ulcer (ICD–9–CM codes 707.00 through 707.09). Therefore, the following codes would no longer be a CC: • 707.00 (Decubitus ulcer, unspecified site). • 707.01 (Decubitus ulcer, elbow). • 707.09 (Decubitus ulcer, other site). The following codes would no longer be an MCC: • 707.02 (Decubitus ulcer, upper back). • 707.03 (Decubitus ulcer, lower back). • 707.04 (Decubitus ulcer, hip). • 707.05 (Decubitus ulcer, buttock). • 707.06 (Decubitus ulcer, ankle). • 707.07 (Decubitus ulcer, heel). We are proposing to instead assign the CC/MCC classifications to the stage of the pressure ulcer as shown in Table 6A of the Addendum to this proposed rule. We are proposing to classify ICD–9–CM PO 00000 Frm 00026 Fmt 4701 Sfmt 4702 codes 707.23 and 707.24 as MCCs. We are proposing to classify codes 707.20, 707.21, and 707.22 as non-CCs. Therefore, we are proposing that, beginning October 1, 2008, the codes used to make MS–DRG adjustments for pressure ulcers under the HAC provision would include the proposed MCC codes 707.23 and 707.24. 7. HACs Under Consideration as Additional Candidates CMS and CDC have diligently worked together and with other stakeholders to identify additional HACs that might appropriately be subject to the HAC payment provision. If the additional candidate HACs are selected in the FY 2009 IPPS final rule, the payment provision will take effect for these candidate HACS on October 1, 2008. The statutory criteria for each HAC candidate are presented in tabular format. Each table contains the following: • HAC Candidate—We are seeking public comment on all HAC candidates. • Medicare Data—We are seeking public comment on the statutory criterion of high cost, high volume, or both as it applies to the HAC candidate. • CC/MCC—We are seeking public comment on the statutory criterion that an ICD–9–CM diagnosis code(s) clearly identifies the HAC candidate. • Selected Evidence-Based Guidelines—We are seeking public comment on the degree to which the HAC candidate is reasonably preventable through the application of the identified evidence-based guidelines. a. Surgical Site Infections Following Elective Surgeries E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 of the statutory criteria to surgical site infections following elective procedures, we are particularly interested in receiving comments on the degree of preventability of surgical site infections following elective procedures generally, as well as specifically for those listed above. We also are seeking public comments on additional elective surgical procedures that would qualify for the HAC provision by meeting all of the statutory criteria. Based on the public comments we receive, we may select some combination of the four procedures presented here along with additional conditions that qualify and are supported by the comments. comment period (72 FR 47216). Legionnaires’ Disease is a type of pneumonia caused by the bacterium Legionella pneumophila. It is contracted PO 00000 Frm 00027 Fmt 4701 Sfmt 4702 b. Legionnaires’ Disease E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.003</GPH> We discussed Legionnaires’ Disease in the FY 2008 IPPS final rule with • Total Knee Replacement (81.54): ICD–9–CM codes 996.66 (CC) and 998.59 (CC) • Laparoscopic Gastric Bypass (44.38) and Laparoscopic Gastroenterostomy (44.39): ICD–9–CM code 998.59 (CC) • Ligation and Stripping of Varicose Veins (38.50 through 38.53, 38.55, 38.57, and 38.59): ICD–9–CM code 998.59 (CC) Evidence-based guidelines for preventing surgical site infections emphasize the importance of appropriately using prophylactic antibiotics, using clippers rather than razors for hair removal and tightly controlling postoperative glucose. While we are seeking public comments on the applicability of each EP30AP08.002</GPH> jlentini on PROD1PC65 with PROPOSALS2 In the FY 2008 IPPS final rule with comment period (72 FR 47213), surgical site infections were identified as a broad category for consideration, and we selected mediastinitis after coronary artery bypass graft (CABG) as one of the initial eight HACs for implementation. We are now considering the addition of other surgical site infections, particularly those following elective procedures. In most cases, patients selected as candidates for elective surgeries should have a relatively lowrisk profile for surgical site infections. The following elective surgical procedures are under consideration: 23553 23554 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules these water systems. While we are seeking public comments regarding the applicability of each of the statutory criteria to Legionnaires’ Disease, we are particularly interested in receiving comments on the degree of preventability of Legionnaires’ Disease through the application of hospital water system maintenance guidelines. Legionnaires’ Disease is typically acquired outside of the hospital setting and may be difficult to diagnose as present on admission. We are seeking comments on the degree to which hospital-acquired Legionnaires’ Disease can be distinguished from communityacquired cases. We also are seeking public comments on additional water-borne pathogens that would qualify for the HAC provision by meeting the statutory criteria. Based on the public comments we receive, we may finalize some combination of Legionnaires’ Disease and additional conditions that qualify and are supported by the public comments. During the December 17, 2007 HAC and POA Listening Session, one of the commenters suggested that we explore hyperglycemia and hypoglycemia as HACs for selection. NQF’s list of Serious Reportable Adverse Events includes death or serious disability associated with hypoglycemia that occurs during hospitalization. Hyperglycemia and hypoglycemia are extremely common laboratory findings in hospitalized patients and can be complicating features of underlying diseases and some therapies. However, we believe that extreme forms of poor glycemic control should not occur while under medical care in the hospital setting. Thus, we are considering whether the following forms of extreme glucose derangement should be subject to the HAC payment provision: • Diabetic Ketoacidosis: ICD–9–CM codes 250.10–250.13 (CC) • Nonketotic Hyperosmolar Coma: ICD–9–CM code 251.0 (CC) • Diabetic Coma: ICD–9–CM codes 250.30–250.33 (CC) • Hypoglycemic Coma: ICD–9–CM codes 250.30–251.0 (CC) While we are seeking public comments regarding the applicability of each of the statutory criteria to these extreme aberrations in glycemic control, we are particularly interested in receiving comments on the degree to which these extreme aberrations in glycemic control are reasonably preventable, in the hospital setting, through the application of evidencebased guidelines. Based on the public comments we receive, we may select some combination of these glycemic control-related conditions as HACs. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00028 Fmt 4701 Sfmt 4702 c. Glycemic Control d. Iatrogenic Pneumothorax E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.004</GPH> jlentini on PROD1PC65 with PROPOSALS2 by inhaling contaminated water vapor or droplets. It is not spread person to person. Individuals at risk include those who are elderly, immunocompromised, smokers, or persons with underlying lung disease. The bacterium thrives in warm aquatic environments and infections have been linked to large industrial water systems, including hospital water systems such as air conditioning cooling towers and potable water plumbing systems. Prevention depends primarily on regular monitoring and decontamination of Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23555 lung, thoracentesis, central venous catheter placement, pleural biopsy, tracheostomy, and liver biopsy. Iatrogenic pneumothorax can occur secondary to positive pressure mechanical ventilation when an air sac in the lung ruptures allowing air into the pleural space. While we are seeking public comments on the applicability of each of the statutory criteria to iatrogenic pneumothorax, we are particularly interested in receiving comments on the degree to which iatrogenic pneumothorax is reasonably preventable through the application of evidencebased guidelines. Based on the public comments we receive, we may select iatrogenic pneumothorax as an HAC. Delirium is a relatively abrupt deterioration in a patient’s ability to sustain attention, learn, or reason. Delirium is strongly associated with aging and treatment of illnesses that are associated with hospitalizations. Delirium affects nearly half of hospital patient days for individuals age 65 and older, and approximately three-quarters of elderly individuals in intensive care units have delirium. About 14 to 24 percent of hospitalized elderly individuals have delirium at the time of admission. Having delirium is a very serious risk factor, with 1-year mortality of 35 to 40 percent, a rate as high as those associated with heart attacks and sepsis. The adverse effects of delirium routinely last for months. Delirium is a clinical diagnosis, commonly assisted by screening tests such as the Confusion Assessment Method. Well-established practices, such as reducing certain medications, reorienting the patient, assuring sensory input and sleep, and avoiding malnutrition and dehydration, prevent 30 to 40 percent of the possible cases. While we are seeking public comments on the applicability of each of the statutory criteria to delirium, we are particularly interested in receiving comments on the degree to which delirium is reasonably preventable through the application of evidencebased guidelines. Based upon the public comments we receive, we may select delirium as an HAC. e. Delirium EP30AP08.006</GPH> f. Ventilator-Associated Pneumonia (VAP) VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00029 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.005</GPH> jlentini on PROD1PC65 with PROPOSALS2 Iatrogenic pneumothorax refers to the accidental introduction of air into the pleural space, which is the space between the lung and the chest wall. When air is introduced into this space it partially or completely collapses the lung. Iatrogenic pneumothorax can occur during any procedure where there is the possibility of air entering pleural space, including needle biopsy of the Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules We discussed ventilator-associated pneumonia (VAP) in the FY 2008 IPPS final rule with comment period (72 FR 47209–47210). VAP is a serious hospital-acquired infection associated with high mortality, significantly increased hospital length of stay, and high cost. It is typically caused by the aspiration of contaminated gastric and/ or oropharyngeal secretions. The presence of an endotracheal tube facilitates both the contamination of secretions as well as aspiration. During the past year, the ICD–9–CM Coordination and Maintenance Committee discussed the creation of a new ICD–9–CM code 997.31 to identify VAP. This new code is shown in Table 6A of the Addendum to this proposed rule. The lack of a specific code was one of the barriers to including VAP as an HAC that we discussed in the FY 2008 IPPS final rule with comment period. We also discussed the degree to which VAP may be reasonably preventable through the application of evidencebased guidelines. Specifically, the FY 2008 IPPS final rule with comment period referenced the American Association for Respiratory Care’s VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Clinical Practice Guidelines at the Web site: https://www.rcjournal.com/cpgs/ 09.03.0869.html. To further investigate the extent to which VAP is reasonably preventable, we reviewed published clinical research. The literature, including recommendations by CDC and the HICPAC, from 2003 shows numerous prevention guidelines that can significantly reduce the incidence of VAP in the hospital setting. These guidelines include interventions such as educating staff, hand washing, using gowns and gloves, properly positioning the patient, elevating the head of the bed, changing ventilator tubing, sterilizing reusable equipment, applying chlorhexadine solution for oral decontamination, monitoring sedation daily, administering stress ulcer prophylaxis, and administering pneumococcal vaccinations. Further review of the literature, specifically regarding the proportion of VAP cases that might be preventable, revealed two large-scale analyses that were completed recently. One study concluded that an estimated 40 percent of VAP cases are preventable. A second study concluded PO 00000 Frm 00030 Fmt 4701 Sfmt 4702 that at least 20 percent of nosocomial infections in general (not just VAP) are preventable.7 During the December 17, 2007 HAC and POA Listing Session, we also received comments on evidence-based guidelines for preventing VAP. Commenters referenced two articles 8 9 that both state there is a high degree of risk associated with endotracheal tube insertions, suggesting that VAP may not always be preventable. While we are seeking public comments on the applicability of each of the statutory criteria to VAP, we are particularly interested in receiving comment on the degree to which VAP 7 American Association for Respiratory Care Clinical Practice: Guideline: Care of the Ventilator Circuit and Its Relation to Ventilator Associated Pneumonia. Available at the Web site: https:// www.rcjournal.com/cpgs/09.03.0869.html. 8 Ramirez et al.: Prevention Measures for Ventilator-Associated Pneumonia: A New Focus on the Endotracheal Tube. Current Opinion in Infectious Disease, April 2007, Vol.20 (2), pp. 190– 197. 9 Safdar et al.: The Pathogenesis of VentilatorAssociated Pneumonia: Its Relevance to Developing Effective Strategies for Prevention. Respiratory Care, June 2005, Vol. 50, No. 6, pp.725–741. E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.007</GPH> jlentini on PROD1PC65 with PROPOSALS2 23556 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23557 comments we receive, we may select VAP as an HAC. g. Deep Vein Thrombosis (DVT)/ Pulmonary Embolism (PE) We discussed deep vein thrombosis (DVT) and pulmonary embolism (PE) in the FY 2008 IPPS final rule with comment period (72 FR 47215). DVT and PE are common events. DVT occurs when a blood clot forms in the deep veins of the leg and causes local swelling and inflammation. PE occurs when a clot or a piece of a clot migrates from its original site into the lungs, causing the death of lung tissue, which can be fatal. Risk factors for DVTs and PEs include inactivity, smoking, use of oral contraceptives, prolonged bed rest, prolonged sitting with bent knees, certain types of cancer and other disease states, certain blood clotting disorders, and certain types of orthopedic and other surgical procedures. DVT is not always clinically apparent because the manifestations of pain, redness, and swelling may develop some time after the venous clot forms. As we discussed in the FY 2008 IPPS final rule with comment period, DVTs and PEs may be preventable in certain circumstances, but it is possible that a patient may have a DVT that is difficult to detect on admission. We also received comments during the December 17, 2007 HAC and POA Listening Session reiterating that not all cases of DVTs and PEs are preventable. For example, common patient characteristics such as immobility, obesity, severe vessel trauma, and venous stasis put certain trauma and joint replacement surgery patients at high risk for these conditions. In our review of the literature, we found that there are definite pharmacologic and nonpharmacologic interventions that may reduce the likelihood of developing DVTs and PEs, including exercise, compression stockings, intermittent pneumatic boots, aspirin, enoxaparin, dalteparin, heparin, coumadin, clopidogrel, and fondaparinux. However, the evidenceπbased guidelines indicate that some patients may still develop clots despite these therapies. While we are seeking public comments on the applicability of each of the statutory criteria to DVTs and PEs, we are particularly interested in receiving comments on the degree of preventability of DVTs and PEs. We are also interested in comments on determining the presence of DVT and PE at admission. Based on the public comments we receive, we may select DVTs and PEs as HACs. EP30AP08.009</GPH> h. Staphylococcus aureus Septicemia VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00031 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.008</GPH> jlentini on PROD1PC65 with PROPOSALS2 is reasonably preventable through the application of evidence-based guidelines. Based on the public 23558 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules history of an invasive medical procedure. CDC has developed evidence-based guidelines for the prevention of the Staphylococcus aureus Septicemia. Most preventable cases of septicemia are primarily related to the presence of a central venous or vascular catheter. During the December 17, 2007 HAC and POA Listening Session, commenters noted that intravascular catheterassociated infections are only one cause of septicemia. Therefore, catheteroriented evidence-based guidelines would not cover all cases of Staphylococcus aureus Septicemia.10 We identified evidence-based guidelines that suggest Staphylococcus aureus Septicemia is reasonably preventable. These guidelines emphasize the importance of effective and fastidious hand washing by both staff and visitors, using gloves and gowns where appropriate, applying proper decontamination techniques, and exercising contact isolation where clinically indicated. While we are seeking public comments on the applicability of each of the statutory criteria to Staphylococcus aureus infections generally, we are particularly interested in receiving comments on the degree of preventability of Staphylococcus aureus infections generally, and specifically Staphylococcus aureus Septicemia. Based on the public comments we receive, we may select Staphylococcus aureus Septicemia as an HAC. We discussed Clostridium difficileassociated disease (CDAD) in the FY 2008 IPPS final rule with comment period. Clostridium difficile is a bacterium that colonizes the gastrointestinal (GI) tract of a certain number of healthy people. Under conditions where the normal flora of the gastrointestinal tract is altered, Clostridium difficile can flourish and release large enough amounts of a toxin to cause severe diarrhea or even life threatening colitis. Risk factors for CDAD include prolonged use of broad spectrum antibiotics, gastrointestinal surgery, prolonged nasogastric tube insertion, and repeated enemas. CDAD can be acquired in the hospital or in the community. Its spores can live outside of the body for months and thus can be spread to other patients in the absence of meticulous hand washing by care providers and others who contact the infected patient. We continue to receive strong support in favor of selecting CDAD as an HAC. During the December 17, 2007 HAC and POA Listening Session, representatives of consumers and purchasers advocated to include CDAD as an HAC. The evidence-based guidelines for CDAD prevention emphasize that hand washing by staff and visitors and effective decontamination of environmental surfaces prevent the spread of Clostridium difficile. While we are seeking public comments on the applicability of each of the statutory criteria to CDADs, we are particularly interested in receiving comments on the degree of preventability of CDAD. Based on the public comments we receive, we may select CDAD as an HAC. i. Clostridium Difficile-Associated Disease (CDAD) j. Methicillin-Resistant Staphylococcus aureus (MRSA) 10 Jensen, A.G. Importance of Focus Identification in the Treatment of Staphylococcus aureus Bacteremia. 2002. Vol. 52, pp. 29–36. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00032 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.010</GPH> jlentini on PROD1PC65 with PROPOSALS2 We discuss Staphylococcus aureus Septicemia in the FY 2008 IPPS final rule with comment period (72 FR 47208). Staphylococcus aureus is a bacterium that lives in the nose and on the skin of a large percentage of the population. It usually does not cause physical illness, but it can cause infections ranging from superficial boils to cellulitis to pneumonia to life threatening bloodstream infections (septicemia). It usually enters the body through traumatized tissue, such as cuts or abrasions, or at the time of invasive procedures. Staphylococcus aureus Septicemia can also be a late effect of an injury or a surgical procedure. Risk factors for developing Staphylococcus aureus Septicemia include advanced age, debilitated state, immunocompromised status, and a We discussed the special case of methicillin-resistant Staphylococcus aureus (MRSA) in the FY 2008 IPPS final rule with comment period (72 FR 47212). In October 2007, the CDC published in the Journal of the American Medical Association an article citing high mortality rates from MRSA, an antibiotic-resistant ‘‘superbug.’’ The article estimates 19,000 people died from MRSA infections in the United States in 2005. The majority of invasive MRSA cases are health care-related—contracted in hospitals or nursing homes—though community-acquired MRSA also poses a significant public health concern. Hospitals have been focused for years on controlling MRSA through the application of CDC’s evidence-based guidelines outlining best practices for combating the bacterium in that setting. MRSA is currently addressed by the HAC payment provision. For every infectious condition selected, MRSA could be the etiology of that infection. For example, if MRSA were the cause of a vascular catheter-associated infection (one of the eight conditions selected in the FY 2008 IPPS final rule with comment period), the HAC payment provision would apply to that MRSA infection. As we noted in the FY 2008 IPPS final rule with comment period, colonization by MRSA is not a reasonably preventable HAC according to the current evidence-based guidelines; therefore, MRSA does not meet the reasonably preventable statutory criterion for an HAC. An estimated 32.4 percent of Americans are colonized with MRSA, which may reside in the nose or on the skin of asymptomatic carriers.11 In addition, in last year’s final rule with comment period, we noted that there is no CC/MCC code available for MRSA, and therefore it also does not meet the codeable CC/MCC statutory criterion for an HAC. Only when MRSA causes an infection does a codeable condition occur. However, we referenced the possibility that new codes for MRSA were being considered by the ICD–9– CM Coordination and Maintenance Committee. The creation of unique codes to capture MRSA was discussed during the March 19–20, 2008 Committee meeting. While these codes will enhance the data available and our understanding of MRSA, the availability and use of these codes will not change the fact that the mere presence of MRSA as a colonizing bacterium does not constitute an HAC. Because MRSA as a bacterium does not meet two of our statutory criteria, codeable CC/MCC and reasonably preventable through evidence-based guidelines, we are not proposing MRSA as an HAC. However, we recognize the significant public health concerns that were raised by representatives of consumers and purchasers at the HAC and POA Listening Session, and we are committed to reducing the spread of multi-drug resistant organisms, such as MRSA. In addition, we are pursuing collaborative efforts with other HHS agencies to combat MRSA. The Agency for Healthcare Research and Quality (AHRQ) has launched a new initiative in collaboration with CDC and CMS to identify and suppress the spread of MRSA and related infections. In support of this work, Congress has appropriated $5 million to fund research, 11 Kuehnert, M.J., et al.: Prevalence of Staphylococcusa aureus Nasal Colonization in the United States, 2001-2002. The Journal of Infectious Disease, January 15, 2006; Vol. 193. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00033 Fmt 4701 Sfmt 4702 23559 implementation, management, and evaluation practices that mitigate such infections. CDC has carried out extensive research on the epidemiology of MRSA and effective techniques that could be used to treat the infection and reduce its spread. The following Web sites contain information that reflect CDC’s commitment: (1) https://www.cdc.gov/ ncidod/dhqp/ar_mrsa.html (health careassociated MRSA); (2) https:// www.cdc.gov/ncidod/dhqp/ ar_mrsa_ca_public.html (communityacquired MRSA); (3) https:// www.cdc.gov/mmwr/preview/ mmwrhtml/mm4908a1.htm; and (4) https://www.cdc.gov/handhygiene/. AHRQ has made previous investments in systems research to help monitor MRSA and related infections in hospital settings, as reflected in material on the Web site at: https:// www.guideline.gov/browse/ guideline_index.aspx and https:// www.ahrq.gov/clinic/ptsafety/pdf/ ptsafety.pdf. 8. Present on Admission (POA) Indicator Reporting POA indicator information is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision and for broader public health uses of Medicare data. Through Change Request No. 5679 (released June 20, 2007), CMS issued instructions requiring IPPS hospitals to submit the POA indicator data for all diagnosis codes on Medicare claims. Specific instructions on how to select the correct POA indicator for each diagnosis code are included in the ICD– 9–CM Official Guidelines for Coding and Reporting, available at the Web site: https://www.cdc.gov/nchs/datawh/ ftpserv/ftpicd9/icdguide07.pdf (POA E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.011</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23560 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules reporting guidelines begin on page 92). Additional instructions, including information regarding CMS’s phased implementation of POA indicator reporting and application of the POA reporting options, are available at the Web site: https://www.cms.hhs.gov/ HospitalAcqCond. There are five POA indicator reporting options: ‘‘Y,’’ ‘‘N,’’ ‘‘W,’’ ‘‘U,’’ and ‘‘1.’’ Under the HAC payment provision, we are proposing to pay the CC/MCC MS–DRGs only for those HACs coded as ‘‘Y’’ and ‘‘W’’ indicators. The ‘‘Y’’ option indicates that the condition was present on admission. The ‘‘W’’ indicator affirms that the provider has determined, based on data and clinical judgment, that it is not possible to document when the onset of the condition occurred. We expect that this approach will encourage better documentation and promote the public health goals of POA reporting by providing more accurate data about the occurrence of HACs in the Medicare population. We anticipate that true clinical uncertainty will occur in only a very small number of cases. We plan to analyze how frequently the ‘‘W’’ indicator is used, and we leave open the possibility of proposing in future IPPS rulemaking not paying the CC/MCC MS–DRGs for HACs coded with the ‘‘W’’ indicator. In addition, we plan to analyze whether both the ‘‘Y’’ and ‘‘W’’ indicators are being used appropriately. Medicare program integrity initiatives closely monitor for inaccurate coding and coding that is inconsistent with medical record documentation. We are seeking public comments regarding the proposed treatment of the ‘‘Y’’ and ‘‘W’’ POA reporting options under the HAC payment provision. We are proposing to not pay the CC/ MMC MS–DRGs for HACs coded with the ‘‘N’’ indicator. The ‘‘N’’ option indicates that the condition was not present on admission. We are also proposing to not pay the CC/MCC MS– DRGs for HACs coded with the ‘‘U’’ indicator. The ‘‘U’’ option indicates that the medical record documentation is insufficient to determine whether the condition was present at the time of admission. Not paying for the CC/MCC MS–DRGs for HACs that are coded with the ‘‘U’’ indicator is expected to foster better medical record documentation. Although we are proposing not paying the CC/MCC MS–DRG for HACs coded with the ‘‘U’’ indicator, we do recognize there may be some exceptional circumstances under which payment might be made. Death, elopement (leaving against medical advice), and transfers out of a hospital may preclude making an informed determination of whether an HAC was present on admission. We are seeking public comments on the potential use of the following current patient discharge status codes to identify the exceptional circumstances: PATIENT DISCHARGE STATUS CODES Form locator code Code descriptor Exception for Patient Death 20 ............................... Expired. Exception for Patient Elopement (Leaving Against Medical Device) 7 ................................. Left against medical advice or discontinued care. Exception for Transfer jlentini on PROD1PC65 with PROPOSALS2 02 03 04 05 06 43 50 51 61 62 63 64 65 66 70 ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... ............................... Discharged/transferred to a short-term general hospital for inpatient care. Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care. Discharged/transferred to an intermediate care facility (ICF). Discharged/transferred to a designated cancer center or children’s hospital. Discharged/transferred to home under care of organized home health service organization. Discharged/transferred to a Federal health care facility. Hospice-home. Hospice-medical facility (certified) providing hospice level of care. Discharged/transferred to a hospital-based Medicare approved swing bed. Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital. Discharged/transferred to a Medicare certified long term care hospital (LTCH). Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare. Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital. Discharged/transferred to a critical access hospital (CAH). Discharged/transferred to another type of health care institution not otherwise defined in this code list. We plan to analyze whether both the ‘‘N’’ and ‘‘U’’ POA reporting options are being used appropriately. The American Health Information Management Association (AHIMA) has promulgated Standards of Ethical Coding that require accurate coding regardless of the payment implications of the diagnoses. That is, diagnoses must be reported accurately regardless of their effect on payment. Medicare program integrity initiatives closely monitor for inaccurate coding and coding inconsistent with medical record documentation. We are VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 seeking public comments regarding the proposal to not pay the CC/MCC MS– DRGs for HACs coded with ‘‘N’’ and ‘‘U’’ indicators. 9. Enhancement and Future Issues The preventable HAC payment provision is one of CMS’ VBP initiatives, as noted earlier in this section. VBP ties payment to performance through the use of incentives based on quality measures and cost of care. The implementation of VBP is rapidly transforming CMS from PO 00000 Frm 00034 Fmt 4701 Sfmt 4702 being a passive payer of claims to an active purchaser of higher quality, more efficient health care for Medicare beneficiaries. Other VBP initiatives include hospital pay for reporting (the RHQDAPU program discussed in section IV.B. of the preamble of this proposed rule), physician pay for reporting (the Physician Quality Reporting Initiative), home health pay for reporting, the Hospital VBP Plan Report to Congress (discussed in section IV.C. of the preamble of this proposed rule), and various VBP demonstration E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 programs across payment settings, including the Premier Hospital Quality Incentive Demonstration and the Physician Group Practice Demonstration. The success of CMS’ VBP initiatives depends in large part on the validity of the performance measures and on the effectiveness of incentives in driving desired changes in behavior that will result in greater quality and efficiency. We are committed to enhancing the Medicare VBP programs, in close collaboration with stakeholders, to fulfill VBP’s potential to promise of promoting higher value health care for Medicare beneficiaries. It is in this spirit that we seek public comment on enhancements to the preventable HACs payment policy and to concomitant POA indicator reporting. We welcome all public comments presenting ideas and models for combating preventable HACs through the application of VBP principles. To stimulate reflection and creativity, we present several options: • Risk adjustment could be applied to make the HAC payment provision more precise. • Rates of HACs could be collected to obtain a more robust longitudinal measure of a hospital’s incidence of these conditions. • POA information could be used in various ways to decrease the incidence of preventable HACs. • The adoption of ICD–10–PCS could facilitate more precise identification of HACs. • The principle behind the HAC payment provision (Medicare not paying more for preventable HACs) could be applied to Medicare payments in settings of care other than the IPPS. • CMS is using authority other than the HAC payment provision to address other events on the NQF’s list of Serious Reportable Adverse Events. We note that we are not proposing new Medicare policy in this Enhancements and Future Issues discussion, as some of these approaches may require new statutory authority. a. Risk Adjustment To make the HAC payment provision more precise, the adjustments to payment made when one of the selected HACs occurs during the hospitalization could be further adjusted to account for patient-specific risk factors. The expected occurrence of an HAC may be greater or lesser depending on the health status of the patient, as reflected by severity of illness, presence of comorbidities, or other factors. Rather than not paying any additional amount for the complication, the additional VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 payment for the complication could range from zero for the lowest risk patient to the full amount for the highest risk patient. An option may be individualized adjustment for every hospitalization based on the patient’s unique characteristics, but state-of-theart risk adjustment currently precludes such individualized adjustment. b. Rates of HACs Given our limited capability at present for precise patient-level risk adjustment, adding a consideration of risk to the criteria for selecting HACs could be an alternative. If primarily high-risk patients are acquiring a certain condition during hospitalization, that condition could be considered a less-fit candidate for selection. Other alternatives to precise individualized risk adjustment could be adjustment for overall facility case mix or facility casemix by condition. At the highest level, national Medicare program data could be used to make adjustments to the payment implications for the selected HACs based on expected rates of complications. Another option could be to designate certain patient risk factors as exemptions that would prohibit or mitigate the application of the HAC payment policy to the claims of patients with those risk factors. The Medicare Hospital VBP Plan was submitted in a Report to Congress on November 21, 2007. The plan includes a performance assessment model that scores a hospital’s attainment or improvement on various measures. The scores for each measure would be summed within each domain, such as the clinical process of care domain or the patient experience domain, and then the domains would be weighted and summed to yield a total performance score. The total performance score would then be translated into an incentive payment, proposed to be a certain percentage of each MS–DRG payment, using an exchange function. The plan also calls for public reporting of hospitals’ performance scores by domain and in total. (Section IV.C. of this preamble included a related discussion of the Hospital VBP Plan Report to Congress.) In accordance with this hospital VBP model, a hospital’s rates of HACs could be included as a domain within each hospital’s total performance score. The measurement of rates over time could be a more meaningful, actionable, and fair way to adjust a hospital’s MS–DRG payments for the incidence of HACs. The consequence of a higher incidence of measured conditions would be a lower VBP incentive payment. Public reporting of the measured rates of HACs PO 00000 Frm 00035 Fmt 4701 Sfmt 4702 23561 would give hospitals an additional, nonfinancial incentive to prevent occurrence of the conditions to avoid lower public ratings. c. Use of POA Information Information obtained from hospitals’ reporting of POA data could be used in various ways to better understand and prevent the occurrence of HACs. The POA information could be provided to health services researchers to analyze factors that lead to HACs and disseminate the best practices for prevention of HACs. At least two states, New York and California, already collect POA data from their hospitals. Comparison of the State POA data with the Medicare data could fill in gaps in the databases and yield valuable insights about POA data validity. POA data could also be used to calculate the incidence of HACs by hospital. This application of the POA data would be particularly powerful if the Medicare POA data were combined with state or private sector payer POA data. The Medicare-only or combined quality of care information could be initially shared with hospitals and thereafter publicly reported to support better healthcare decision making by Medicare beneficiaries, other health care consumers, professionals, and caregivers. d. Transition to ICD–10–PCS Accurate identification of HACs requires unambiguous and precise diagnosis codes. The current ICD–9–CM diagnosis coding system is three decades old. It is outdated and contains numerous instances of broad and vague codes. Attempts to add necessary detail to the ICD–9–CM system are inhibited by lack of expansion capacity. These factors negatively affect CMS’ attempts to identify HAC cases. ICD–10–PCS codes are more precise and capture information using more current medical terminology. For example, ICD–9–CM codes for pressure ulcers do not provide information about the size, depth, or exact location of the ulcer, while ICD–10–PCS has 60 codes to capture this information. ICD–10– PCS would also provide codes, beyond the current ICD–9–CM codes, that would enable the selection of additional surgical complications and adverse drug events. e. Application of Nonpayment for HACs to Other Settings The broad principle of Medicare not paying for preventable health careassociated conditions could potentially be applied to Medicare payment settings other than IPPS hospitals. Other E:\FR\FM\30APP2.SGM 30APP2 23562 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 possible settings of care might include hospital outpatient departments, SNFs, HHAs, end-stage renal disease facilities, and physician practices. The implications would be different for each setting, as each payment system is different and the reasonable preventability through the application of evidence-based guidelines would vary for candidate conditions over the different settings. However, alignment of incentives across settings of care is an important goal for all of CMS’ VBP initiatives, including the HAC provision. A related application of the broad principle behind the HAC payment could be accomplished through modification to the Medicare secondary payer policy which would allow us to directly recoup from the provider that failed to prevent the occurrence of a preventable condition in one setting to pay for all or part of the necessary followup care in a second setting. This would help shield the Medicare program from inappropriately paying for the downstream effects of a preventable condition acquired in the first setting but treated in the second setting. f. Relationship to NQF’s Serious Reportable Adverse Events CMS is applying its authority to address the events on the NQF’s list of Serious Reportable Adverse Events (also known as ‘‘never events’’). In May 2006 testimony before the Senate Finance Committee, the CMS Administrator noted that paying hospitals for serious preventable events is contrary to the promise that hospital payments should support higher quality and efficiency. There is growing consensus that health care purchasers should not be paying for these events when they occur during a hospitalization. In January 2005, HealthPartners, a Minnesota-based notfor-profit HMO, announced that it would no longer reimburse hospitals for services associated with events enumerated in the Minnesota Adverse Health Care Events Reporting Act (essentially the NQF’s list of Serious Reportable Adverse Events). Further, HealthPartners’ contracts preclude hospitals from seeking reimbursement from the patient for these costs. During 2007, several State hospital associations adopted policies stating that their members will not bill payers or patients when these events occur in their hospitals. In the FY 2008 IPPS final rule with comment period, we adopted several items from the NQF’s list of events as HACs, including retained foreign object after surgery, air embolism, blood incompatibility, stage III and IV VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 pressure ulcers, falls, electric shock, and burns. In this proposed rule, we are seeking public comments regarding adding hypoglycemic coma, which is closely related to NQF’s listing of death or serious disability associated with hypoglycemia. However, as we discussed in the FY 2008 IPPS final rule with comment period, the HAC payment provision is not ideally suited to address every condition on the NQF’s list of Serious Reportable Adverse Events. To address the events on the NQF’s list beyond the effect of the HAC policy, CMS is exploring the application of Medicare authority, including other payment provisions, coverage policy, conditions of participation, and Quality Improvement Organization (QIO) retrospective review. We note that we are not proposing new Medicare policy in this discussion of the HAC payment provision for IPPS hospitals, as some of these approaches may require new statutory authority. We are seeking public comments on these and other options for enhancing the preventable HACs payment provision and maximizing the use of POA indicator reporting data. We look forward to working with stakeholders in the fight against HACs. G. Proposed Changes to Specific MS– DRG Classifications 1. Pre-MDCs: Artificial Heart Devices Heart failure affects more than 5 million patients in the United States with 550,000 new cases each year, and causes more than 55,000 deaths annually. It is a progressive disease that is medically managed at all stages, but over time leads to continued deterioration of the heart’s ability to pump sufficient amounts of adequately oxygenated blood throughout the body. When medical management becomes inadequate to continue to support the patient, the patient’s heart failure would be considered to be the end stage of the disease. At this point, the only remaining treatment options are a heart transplant or mechanical circulatory support. A device termed an artificial heart has been used only for severe failure of both the right and left ventricles, also known as biventricular failure. Relatively small numbers of patients suffer from biventricular failure, but the exact numbers are unknown. There are about 4,000 patients approved and waiting to receive heart transplants in the United States at any given time, but only about 2,000 hearts per year are transplanted due to a scarcity of donated organs. There are a number of mechanical devices that may be used to support the PO 00000 Frm 00036 Fmt 4701 Sfmt 4702 ventricles of a failing heart on either a temporary or permanent basis. When it is apparent that a patient will require long-term support, a ventricular support device is generally implanted and may be considered either as a bridge to recovery or a bridge to transplantation. Sometimes a patient’s prognosis is uncertain, and with device support the native heart may recover its function. However when recovery is not likely, the patient may qualify as a transplant candidate and require mechanical circulatory support until a donor heart becomes available. This type of support is commonly supplied by ventricular assist devices, (VADs), which are surgically attached to the native ventricles but do not replace them. Devices commonly called artificial hearts are biventricular heart replacement systems that differ from VADs in that a substantial part of the native heart, including both ventricles, is removed. When the heart remains intact, it remains possible for the native heart to recover its function after being assisted by a VAD. However, because the artificial heart device requires the resection of the ventricles, the native heart is no longer intact and such recovery is not possible. The designation ‘‘artificial heart’’ is somewhat of a misnomer because some portion of the native heart remains and there is no current mechanical device that fully replaces all four chambers of the heart. Over time, better descriptive language for these devices may be adopted. In 1986, CMS made a determination that the use of artificial hearts was not covered under the Medicare program. To conform to that decision, we placed ICD–9–CM procedure code 37.52 (Implantation of total replacement heart system) on the GROUPER program’s MCE in the noncovered procedure list. On August 1, 2007, CMS began a national coverage determination process for artificial hearts. SynCardia Systems, Inc. submitted a request for reconsideration of the longstanding noncoverage policy when its device, the CardioWest Temporary Total Artificial Heart (TAH–t) System, is used for ‘‘bridge to transplantation’’ in accordance with the FDA-labeled indication for the device. ‘‘Bridge to transplantation’’ is a phrase meaning that a patient in end-stage heart failure may qualify as a heart transplant candidate, but will require mechanical circulatory support until a donor heart becomes available. The CardioWest TAH–t System is indicated for use as a bridge to transplantation in cardiac transplant-eligible candidates at risk of imminent death from biventricular E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules failure. The system is intended for use inside the hospital as the patient awaits a donor heart. The ultimate desired outcome for insertion of the TAH–t is a successful heart transplant, along with the potential that offers for cure from heart failure. CMS determined that a broader analysis of artificial heart coverage was deemed appropriate, as another manufacturer, Abiomed, Inc. has developed an artificial heart device, AbioCor Implantable Replacement Heart Device, with different indications. SynCardia Systems, Inc has received approval of its device from the FDA for humanitarian use as destination therapy for patients in end-stage biventricular failure who cannot qualify as transplant candidates. The AbioCor Implantable Replacement Heart Device is indicated for use in severe biventricular end-stage heart disease patients who are not cardiac transplant candidates and who are less than 75 years old, who require multiple inotropic support, who are not treatable by VAD destination therapy, and who cannot be weaned from biventricular support if they are on such support. The desired outcome for this device is prolongation of life and discharge to home. On February 1, 2008, CMS published a proposed coverage decision memorandum for artificial hearts which stated, in part, that while the evidence is inadequate to conclude that the use of an artificial heart is reasonable and necessary for Medicare beneficiaries, the evidence is promising for the uses of artificial heart devices as described above. CMS supports additional research for these devices, and therefore proposed that the artificial heart will be covered by Medicare when performed under the auspices of a clinical study. The study must meet all of the criteria listed in the proposed decision memorandum. This proposed coverage decision memorandum may be found on the CMS Web site at: https:// www.cms.hhs.gov/mcd/ viewdraftdecisionmemo.asp?id=211. Following consideration of the public comments received, CMS expects to make a final decision on or about May 1, 2008. The topic of coding of artificial heart devices was discussed at the September 27–28, 2007 ICD–9–CM Coordination and Maintenance Committee meeting held at CMS in Baltimore, MD. We note that this topic was placed on the Committee’s agenda because any proposed changes to the ICD–9–CM coding system must be discussed at a Committee meeting, with opportunity for comment from the public. At the September 2007 Committee meeting, the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Committee accepted oral comments from participants and encouraged attendees or anyone with an interest in the topic to comment on proposed changes to the code, inclusion terms, or exclusion terms. We accepted written comments until October 12, 2007. As a result of discussion and comment from the Committee meeting, the Committee revised the title of procedure code 37.52 for artificial hearts to read ‘‘Implantation of internal biventricular heart replacement system.’’ In addition, the Committee created new code 37.55 (Removal of internal biventricular heart replacement system) to identify explantation of the artificial heart prior to heart transplantation. To make conforming changes to the IPPS system with regard to the proposed revision to the coverage decision for artificial hearts, in this proposed rule, we are proposing to remove procedure code 37.52 from MS–DRG 215 (Other Heart Assist System Implant) and assign it to MS–DRG 001 (Heart Transplant or Implant of Heart Assist System with Major Comorbidity or Complication (MCC)) and MS–DRG 002 (Heart Transplant or Implant of Heart Assist System without Major Comorbidity or Complication (MCC)). In addition, we are proposing to remove procedure code 37.52 from the MCE ‘‘Non-Covered Procedure’’ edit and assign it to the ‘‘Limited Coverage’’ edit. We are proposing to include in this proposed edit the requirement that ICD–9–CM diagnosis code V70.7 (Examination of participant in clinical trial) also be present on the claim. We are proposing that claims submitted without both procedure code 37.52 and diagnosis code V70.7 would be denied because they would not be in compliance with the proposed coverage policy. During FY 2008, we are making midyear changes to portions of the GROUPER program that do not affect MS–DRG assignment or ICD–9–CM coding. However, as the proposed coverage decision memorandum for artificial hearts was published after the CMS contractor’s testing and release of the mid-year product, the above proposed changes to the MCE will not be included in that revision of the GROUPER Version 25.0. GROUPER Version 26.0, which will be in use for FY 2009, will contain the proposed changes if they are approved. If the proposed revisions to the MCE are accepted, the edits in the MCE Version 25.0 will be effective retroactive to May 1, 2008. (To reduce confusion, we note that the version number of the MCE is one digit lower than the current GROUPER version number; that is, PO 00000 Frm 00037 Fmt 4701 Sfmt 4702 23563 Version 26.0 of the GROUPER uses Version 25.0 of the MCE.) 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Transferred Stroke Patients Receiving Tissue Plasminogen Activator (tPA) In 1996, the FDA approved the use of tissue plasminogen activator (tPA), one type of thrombolytic agent that dissolves blood clots. In 1998, the ICD–9–CM Coordination and Maintenance Committee created code 99.10 (Injection or infusion of thrombolytic agent) in order to be able to uniquely identify the administration of these agents. Studies have shown that tPA can be effective in reducing the amount of damage the brain sustains during an ischemic stroke, which is caused by blood clots that block blood flow to the brain. tPA is approved for patients who have blood clots in the brain, but not for patients who have a bleeding or hemorrhagic stroke. Thrombolytic therapy has been shown to be most effective when used within the first 3 hours after the onset of an embolic stroke, but it is contraindicated in hemorrhagic strokes. For FY 2006, we modified the structure of CMS DRGs 14 (Intracranial Hemorrhage or Cerebral Infarction) and 15 (Nonspecific CVA and Precerebral Occlusion without Infarction) by removing the diagnostic ischemic (embolic) stroke codes. We created a new CMS DRG 559 (Acute Ischemic Stroke with Use of Thrombolytic Agent) which increased reimbursement for patients who sustained an ischemic or embolic stroke and who also had administration of tPA. The intent of this DRG was not to award higher payment for a specific drug but to recognize the need for better overall care for this group of patients. Even though tPA is indicated only for a small proportion of stroke patients, that is, those patients experiencing ischemic strokes treated within 3 hours of the onset of symptoms, our data suggested that there was a sufficient quantity of patients to support the DRG change. While our goal is to make payment relate more closely to resource use, we also note that use of tPA in a carefully selected patient population may lead to better outcomes and overall care and may lessen the need for postacute care. For FY 2008, with the adoption of MS–DRGs, CMS DRG 559 became MS– DRGs 061 (Acute Ischemic Stroke with Use of Thrombolytic Agent with MCC), 062 (Acute Ischemic Stroke with Use of Thrombolytic Agent with CC), and 063 (Acute Ischemic Stroke with Use of Thrombolytic Agent without CC/MCC). Stroke cases in which no thrombolytic E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23564 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules agent was administered were grouped to MS–DRGs 064 (Intracranial Hemorrhage or Cerebral Infarction with MCC), 065 (Intracranial Hemorrhage or Cerebral Infarction with CC), or 066 (Intracranial Hemorrhage or Cerebral Infarction without CC/MCC). The MS–DRGs that reflect use of a thrombolytic agent, that is, MS–DRGs 061, 062, and 063, have higher relative weights than the hemorrhagic or cerebral infarction MS– DRGs 064, 065, and 066. The American Society of Interventional and Therapeutic Neuroradiology (ASITN) has made us aware of a treatment issue that is of concern to the stroke provider’s community. In some instances, patients suffering an embolytic or thrombolytic stroke are evaluated and given tPA in a community hospital’s emergency department, and then are transferred to a larger facility’s stroke center that is able to provide the level of services required by the increased severity of these cases. The facility providing the administration of tPA in its emergency department does not realize increased reimbursement, as the patient is often transferred as soon a possible to a stroke center. The facility to which the patient is transferred does not realize increased reimbursement, as the tPA was not administered there. The ASITN has requested that CMS give permission to code the administration of tPA as if it had been given in the receiving facility. This would result in the receiving facility being paid the higher weighted MS–DRGs 061, 062, or 063 instead of MS–DRGs 064, 065, or 066. The ASITN’s rationale is that the patients who received tPA in another facility (even though administration of tPA may have alleviated some of the worst consequences of their strokes) are still extremely compromised and require increased health care services that are much more resource consumptive than patients with less severe types of stroke. We have advised the ASITN that hospitals may not report services that were not performed in their facility. We recognize that the ASITN’s concerns potentially have merit but the quantification of the increased resource consumption of these patients is not currently possible in the existing ICD– 9–CM coding system. Without specific length of stay and average charges data, we are unable to determine an appropriate MS–DRG for these cases. Therefore, we have advised the ASITN to present a request at the diagnostic portion of the ICD–9–CM Coordination and Maintenance Committee meeting on March 20, 2008, for a code that would VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 recognize the fact that the patient had received a thrombolytic agent for treatment of the current stroke. If this request is presented at the March 20, 2008 meeting, it will not be approved in time to be published as a final code in this proposed rule. However, if a diagnosis code is created by the National Centers for Health Statistics as a result of that meeting, it can be added to the list of codes published in the FY 2009 IPPS final rule that will go into effect on October 1, 2008. With such information appearing on subsequent claims, we will have a better idea of how to classify these cases within the MS–DRGs. Therefore, because we lack the data to identify these patients, we are not proposing an MS–DRG modification for the stroke patients receiving tPA in one facility prior to being transferred to another facility. b. Intractable Epilepsy With Video Electroencephalogram (EEG) As we did for FY 2008, we received a request from an individual representing the National Association of Epilepsy Centers to consider further refinements to the MS–DRGs describing seizures. Specifically, the representative recommended that a new MS–DRG be established for patients with intractable epilepsy who receive an electroencephalogram with video monitoring (vEEG) during their hospital stay. Similar to the initial recommendation, the representative stated that patients who suffer from uncontrolled seizures or intractable epilepsy are admitted to an epilepsy center for a comprehensive evaluation to identify the epilepsy seizure type, the cause of the seizure, and the location of the seizure. These patients are admitted to the hospital for 4 to 6 days with 24hour monitoring that includes the use of EEG video monitoring along with cognitive testing and brain imaging procedures. Effective October 1, 2007, MS–DRG 100 (Seizures with MCC) and MS–DRG 101 (Seizures without MCC) were implemented as a result of refinements to the DRG system to better recognize severity of illness and resource utilization. Once again, the representative applauded CMS for making changes in the DRG structure to better recognize differences in patient severity. However, the representative stated that a subset of patients in MS– DRG 101 who have a primary diagnosis of intractable epilepsy and are treated with vEEG are substantially more costly to treat than other patients in this MS– DRG and represent the majority of PO 00000 Frm 00038 Fmt 4701 Sfmt 4702 patients being evaluated by specialized epilepsy centers. Alternatively, the representative stated that he was not requesting any change in the structure of MS–DRG 100. According to the representative, the number of cases that would fall into this category is not significant. The representative further noted that this is a change from last year’s request. Epilepsy is currently identified by ICD–9–CM diagnosis codes 345.0x through 345.9x. There are two fifth digits that may be assigned to a subset of the epilepsy codes depending on the physician documentation: • ‘‘0’’ for without mention of intractable epilepsy. • ‘‘1’’ for with intractable epilepsy. With the assistance of an outside reviewer, the representative analyzed cost data for MS–DRGs 100 and 101, which focused on three subsets of patients identified with a primary diagnosis of epilepsy or convulsions who also received vEEG (procedure code 89.19): • Patients with a primary diagnosis of epilepsy with intractability specified (codes 345.01 through 345.91). • Patients with a primary diagnosis of epilepsy without intractability specified (codes 345.00 through 345.90). • Patients with a primary diagnosis of convulsions (codes 780.39). The representative acknowledged that the association did not include any secondary diagnoses in its analyses. Based on its results, the representative recommended that CMS further refine MS–DRG 101 by subdividing cases with a primary diagnosis of intractable epilepsy (codes 345.01 through 345.91) when vEEG (code 89.19) is also performed into a separate MS–DRG that would be defined as ‘‘MS–DRG XXX’’ (Epilepsy Evaluation without MCC). According to the representative, these cases are substantially more costly than the other cases within MS–DRG 101 and are consistent with the criteria for dividing MS–DRGs on the basis of CCs and MCCs. In addition, the representative stated that the request would have a minimal impact on most hospitals but would substantially improve the accuracy of payment to hospitals specializing in epilepsy care. We performed an analysis using FY 2007 MedPAR data. As shown in the table below, we found a total of 54,060 cases in MS–DRG 101 with average charges of $14,508 and an average length of stay of 3.69 days. There were 879 cases with intractable epilepsy and vEEG with average charges of $19,227 and an average length of stay of 5 days. E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Number of cases MS–DRG MS–DRG 100—All Cases ......................................................................................................... MS–DRG 100—Cases with Intractable Epilepsy with vEEG (Codes 345.01, 345.11, 345.41, 345.51, 345.61, 345.71, 345.81, 345.91) .............................................................................. MS–DRG 100—Cases with Intractable Epilepsy without vEEG ............................................... MS–DRG 101—All cases .......................................................................................................... MS–DRG 101—Cases with Intractable Epilepsy with vEEG (Codes 345.01, 345.11, 345.41, 345.51, 345.61, 345.71, 345.81, 345.91) .............................................................................. MS–DRG 101—Cased with Intractable Epilepsy without vEEG ............................................... In applying the criteria to establish subgroups, the data do not support the creation of a new subdivision for MS– DRG 101 for cases with intractable epilepsy and vEEG nor does the data support moving the 879 cases from MS– DRG 101 to MS–DRG 100. Moving the 879 cases to MS–DRG 100 would mean moving cases with average charges of approximately $19,000 into an MS–DRG with average charges of $28,000. Therefore, we are not proposing to refine MS–DRG 101 by subdividing cases with a primary diagnosis of intractable epilepsy (codes 345.01 through 345.91) when vEEG (code 89.19) is also performed into a separate MS–DRG. jlentini on PROD1PC65 with PROPOSALS2 3. MDC 5 (Diseases and Disorders of the Circulatory System) a. Automatic Implantable CardioverterDefibrillators (AICD) Lead and Generator Procedures In the FY 2008 IPPS final rule with comment period (72 FR 47257), we created a separate, stand alone DRG for automatic implantable cardioverterdefibrillator (AICD) generator replacements and defibrillator lead replacements. The new MS–DRG 245 (AICD lead and generator procedures) contains the following codes: • 00.52, Implantation or replacement of transvenous lead [electrode] into left ventricular coronary venous system. • 00.54, Implantation or replacement of cardiac resynchronization defibrillator pulse generator device only [CRT–D]. • 37.95, Implantation of automatic cardioverter/defibrillator leads(s) only. • 37.96, Implantation of automatic cardioverter/defibrillator pulse generator only. • 37.97, Replacement of automatic cardioverter/defibrillator leads(s) only. • 37.98, Replacement of automatic cardioverter/defibrillator pulse generator only. Commenters on the FY 2008 IPPS proposed rule supported this new MS– DRG, which recognizes the distinct differences in resource utilization between pacemaker and defibrillator generators and leads, but suggested that VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 CMS should consider additional refinements for the defibrillator generator and leads. In reviewing the standardized charges for the AICD leads, the commenter believed that the leads may be more appropriately assigned to another DRG such as MS–DRG 243 (Permanent Cardiac Pacemaker Implant with CC) or MS–DRG 258 (Cardiac Pacemaker Device Replacement with MCC). The commenter recommended that CMS consider moving the defibrillator leads back into a pacemaker DRG, either MS–DRG 243 or MS–DRG 258. In response to the commenters, we indicated that the data supported separate DRGs for these very different devices (72 FR 47257). We indicated that moving the defibrillator leads back into a pacemaker MS–DRG defeated the purpose of creating separate MS–DRGs for defibrillators and pacemakers. Therefore, we finalized MS–DRG 245 as proposed with the leads and generator codes listed above. After publication of the FY 2008 IPPS final rule with comment period, we received a request from a manufacturer that recommended a subdivision for MS–DRG 245 (AICD Lead and Generator Procedures). The requestor suggested creating a new MS–DRG to separate the implantation or replacement of the AICD leads from the implantation or replacement of the AICD pulse generators to better recognize the differences in resource utilization for these distinct procedures. The requestor applauded CMS’ decision to create separate MS–DRGs for the pacemaker device procedures from the AICD procedures in the FY 2008 IPPS final rule (72 FR 47257). The requestor further acknowledged its support of the clinically distinct MS– DRGs for pacemaker devices. Currently, MS–DRGs 258 and 259 (Cardiac Pacemaker Device Replacement with MCC and without MCC, respectively) describe the implantation or replacement of pacemaker generators while MS–DRGs 260, 261, and 262 (Cardiac Pacemaker Revision Except Device Replacement with MCC, with CC, without CC/MCC, respectively) PO 00000 Frm 00039 Fmt 4701 Sfmt 4702 Average length of stay 23565 Average charges 16,142 6.34 $27,623 69 328 54,060 6.6 7.81 3.69 26,990 32,539 14,508 879 1,351 5.0 4.25 19,227 14,913 describe the insertion or replacement of pacemaker leads. The requestor believed that the IPPS ‘‘needs to continue to evolve to accurately reflect clinical differences and costs of services.’’ As such, the requestor recommended that CMS follow the same structure as it did with the pacemaker MS–DRGs for MS–DRG 245 to separately identify the implantation or replacement of the defibrillator leads (codes 37.95, 37.97, and 00.52) from the implantation or replacement of the pulse generators (codes 37.96, 37.98, 00.54). In our analysis of the FY 2007 MedPAR data, we found a total of 5,546 cases in MS–DRG 245 with average charges of $62,631 and an average length of stay of 3.3 days. We found 1,894 cases with implantation or replacement of the defibrillator leads (codes 37.95, 37.97, and 00.52) with average charges of $42, 896 and an average length of stay of 3.4 days. We also found a total of 3,652 cases with implantation or replacement of the pulse generator (codes 37.96, 37.98, 00.54) with average charges of $72, 866 and an average length of stay of 3.2 days. We agree with the requestor that the IPPS should accurately recognize differences in resource utilization for clinically distinct procedures. As the data demonstrate, average charges for the implantation or replacement of the AICD pulse generators are significantly higher than for the implantation or replacement of the AICD leads. Therefore, we are proposing to create a new MS–DRG 265 to separately identify these distinct procedures. The proposed new MS–DRG 265 would be titled ‘‘AICD Lead Procedures’’ and would include procedure codes that identify the AICD leads (codes 37.95, 37.97 and 00.52). The title for MS–DRG 245 would be revised to ‘‘AICD Generator Procedures’’ and include procedure codes 37.96, 37.98, 00.54. We believe these changes would better reflect the clinical differences and resources utilized for these distinct procedures. E:\FR\FM\30APP2.SGM 30APP2 23566 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules b. Left Atrial Appendage Device jlentini on PROD1PC65 with PROPOSALS2 Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic or embolytic stroke. Most ischemic strokes associated with AF are possibly due to an embolism or thrombus that has formed in the left atrial appendage. Evidence from studies such as transesophageal echocardiography shows left atrial thrombi to be more frequent in AF patients with ischemic stroke as compared to AF patients without stroke. While anticoagulation medication can be efficient in ischemic stroke prevention, there can be problems of safety and tolerability in many patients, especially those older than 75 years. Chronic warfarin therapy has been proven to reduce the risk of embolism but there can be difficulties concerning its administration. Frequent blood tests to monitor warfarin INR are required at some cost and patient inconvenience. In addition, because warfarin INR is affected by a large number of drug and dietary interactions, it can be unpredictable in some patients and difficult to manage. The efficacy of aspirin for stroke prevention in AF patients is less clear and remains controversial. With the known disutility of warfarin and the questionable effectiveness of aspirin, a device-based solution may provide added protection against thromboembolism in certain patients with AF. At the April 1, 2004 ICD–9–CM Coordination and Maintenance Committee meeting, a proposal was presented for the creation of a unique procedure code describing insertion of the left atrial appendage filter system. Subsequently, ICD–9–CM code 37.90 (Insertion of left atrial appendage device) was created for use beginning October 1, 2004. This code was designated as a non-operating room (non-O.R.) procedure, and had an effect only on cases in MDC 5, CMS DRG 518 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent or Acute Myocardial Infarction). With the adoption of MS–DRGs in FY 2008, CMS DRG 518 was divided into MS–DRGs 250 and 251 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent or AMI with MCC, and without MCC, respectively). We have reviewed the data concerning this procedure code annually. Using FY 2005 MedPAR data for the FY 2007 IPPS final rule, 24 cases were reported, and the average charges ($27,620) closely mimicked the average charges of the other 22,479 cases in CMS DRG 518 ($28,444). As the charges were comparable, we made no recommendations to change the CMS DRG assignment for FY 2007. Using FY 2006 MedPAR data for the FY 2008 final rule with comment period, we divided CMS DRG 518 into the cases that would be reflected in the MS–DRG configuration; that is, we divided the cases based on the presence or absence of an MCC. There were 35 cases without an MCC with average charges of $24,436, again mimicking the 38,002 cases with average charges of $32,546. There were 3 cases with MCC with average charges of $62,337, compared to the 5,458 cases also with an MCC with average charges of $53,864. Again it was deemed that cases with code 37.90 were comparable to the rest of the cases in CMS DRG 518, and the decision was made not to make any changes in the DRG assignment for this procedure code. As noted above, CMS DRG 518 became MS–DRGs 250 and 251 in FY 2008. We have received a request regarding code 37.90, and its placement within the MS–DRG system for FY 2009. The requestor asked for either the reassignment of code 37.90 to an MS– DRG that would adequately cover the costs associated with the complete procedure or the creation of a new MS– DRG that would reimburse hospitals adequately for the cost of the device. The requestor, a manufacturer’s representative, reported that the device’s IDE clinical trial is nearing completion, with the conclusion of study enrollment in May 2008. The requestor will continue to enroll patients in a Continued Use Registry following completion of the trial. The requestor reported that it did not charge hospitals for the atrial appendage device, estimated to cost $6,000, during the trial period, but it will begin to charge hospitals upon the completion of the trial in May. The requestor provided us with its data showing what it believed to be a differential of $107 more per case than the payment average for MS–DRG 250, and a shortfall of $3,808 per case than the payment average for MS–DRG 251. The requestor pointed out that code 37.90 is assigned to both MS–DRGs 250 and 251, but stated that the final MS– DRG assignment would be MS–DRG 251 when the patient has a principal diagnosis of atrial fibrillation (code 427.31) because AF is not presently listed as a CC or an MCC. We would take this opportunity to note that the principal diagnosis is used to determine assignment of a case to the correct MDC. Secondary or additional diagnosis codes are the only codes that can be used to determine the presence of a CC or an MCC. With regard to the request to create a specific DRG for the insertion of this device entitled ‘‘Percutaneous Cardiovascular Procedures with Implantation of a Left Atrial Appendage Device without CC/MCC’’, we would point out that the payments under a prospective payment system are predicated on averages. The device is already assigned to MS–DRGs containing other percutaneous cardiovascular devices; to create a new MS–DRG specific to this device would be to remove all other percutaneously inserted devices and base the MS–DRG assignment solely on the presence of code 37.90. This approach negates our longstanding method of grouping like procedures, and removes the concept of averaging. Further, to ignore the structure of the MS–DRG system solely for the purpose of increasing payment for one device would set an unwelcome precedent for defining all of the other MS–DRGs in the system. We would also point out that the final rule establishing the MS–DRGs set forth five criteria, all five of which are required to be met, in order to warrant creation of a CC or an MCC subgroup within a base MS–DRG. The criteria can be found in the FY 2008 IPPS final rule with comment period (72 FR 47169). One of the criteria specifies that there will be at least 500 cases in the CC or MCC subgroup. To date, there are not enough cases of code 37.90 reported within the MedPAR data. Using FY 2007 MedPAR data, for this FY 2009 IPPS proposed rule, we reviewed MS–DRGs 250 and 251 for the presence of the left atrial appendage device. The following table displays our results: Number of cases MS–DRG 250—All Cases ............................................................................................................................ 250—Cases with code 37.90 ...................................................................................................... 250—Cases without code 37.90 ................................................................................................. 251—All Cases ............................................................................................................................ VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00040 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 6,424 4 6,420 39,456 30APP2 Average length of stay 7.72 6.50 7.72 2.84 Average charges $60,597.58 65,829.51 60,594.32 35,719.81 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Number of cases MS–DRG 251—Cases with code 37.90 ...................................................................................................... 251—Cases without code 37.90 ................................................................................................. There were a total of 105 cases with code 37.90 reported for Medicare beneficiaries in the 2007 MedPAR data. There are 4 cases with an atrial appendage device in MS–DRG 250 that have higher average charges than the other 6,420 cases in the MS–DRG, and that have slightly shorter lengths of stay by 1.25 days. However, the more telling data are located in MS–DRG 251, which shows that the 101 cases in which an atrial appendage device was implanted have much lower average charges ($20,846.09) than the other 39,355 cases in the MS–DRG, with average charges of $35,758.98. The difference in the average charges is approximately $14,912, so even when the manufacturer begins charging the hospitals the estimated $6,000 for the device, there is still a difference of approximately $8,912 in average charges based on the comparison within the total MS–DRG 251. Interestingly, the 101 cases also have an average length of stay of less than half of the average length of stay compared to the other cases assigned to that MS–DRG. Because the data do not support either the creation of a unique MS–DRG or the assignment of procedure code 37.90 to another higher-weighted MS–DRG, we are not proposing any change to MS– DRGs 250 and 251, or to code 37.90 for FY 2009. We believe, based on the past 3 year’s comparisons, that this code is appropriately located within the MS– DRG structure. jlentini on PROD1PC65 with PROPOSALS2 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue): Hip and Knee Replacements and Revisions For FY 2009, we again received a request from the American Association of Hip and Knee Surgeons (AAHKS), a specialty group within the American Academy of Orthopedic Surgeons (AAOS), concerning modifications of the lower joint procedure MS–DRGs. The request is similar, in some respects, to the AAHKS’s request in FY 2008, particularly as it relates to separating routine and complex procedures. For the benefit of the reader, we are republishing a history of the development of DRGs for hip and knee replacements and a summary of the AAHKS FY 2008 request that were included in the FY 2008 IPPS final rule with comment period (72 FR 47222 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 through 47224) before we discuss the AAHKS’s more recent request. a. Brief History of Development of Hip and Knee Replacement Codes In the FY 2006 IPPS final rule (70 FR 47303), we deleted CMS DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) and created two new CMS DRGs: 544 (Major Joint Replacement or Reattachment of Lower Extremity) and 545 (Revision of Hip or Knee Replacement). The two new CMS DRGs were created because revisions of joint replacement procedures are significantly more resource intensive than original hip and knee replacements procedures. CMS DRG 544 included the following procedure code assignments: • 81.51, Total hip replacement. • 81.52, Partial hip replacement. • 81.54, Total knee replacement. • 81.56, Total ankle replacement. • 84.26, Foot reattachment. • 84.27, Lower leg or ankle reattachment. • 84.28, Thigh reattachment. CMS DRG 545 included the following procedure code assignments: • 00.70, Revision of hip replacement, both acetabular and femoral components. • 00.71, Revision of hip replacement, acetabular component. • 00.72, Revision of hip replacement, femoral component. • 00.73, Revision of hip replacement, acetabular liner and/or femoral head only. • 00.80, Revision of knee replacement, total (all components). • 00.81, Revision of knee replacement, tibial component. • 00.82, Revision of knee replacement, femoral component. • 00.83, Revision of knee replacement, patellar component. • 00.84, Revision of knee replacement, tibial insert (liner). • 81.53, Revision of hip replacement, not otherwise specified • 81.55, Revision of knee replacement, not otherwise specified Further, we created a number of new ICD–9–CM procedure codes effective October 1, 2005, that better distinguish the many different types of joint replacement procedures that are being performed. In the FY 2006 IPPS final rule (70 FR 47305), we indicated a commenter had requested that, once we PO 00000 Frm 00041 Fmt 4701 Sfmt 4702 101 39,335 Average length of stay 1.30 2.85 23567 Average charges 20,846.09 35,757.98 receive claims data using the new procedure codes, we closely examine data from the use of the codes under the two new CMS DRGs to determine if future additional DRG modifications are needed. b. Prior Recommendations of the AAHKS Prior to this year, the AAHKS had recommended that we make further refinements to the CMS DRGs for knee and hip arthroplasty procedures. The AAHKS previously presented data to CMS on the important differences in clinical characteristics and resource utilization between primary and revision total joint arthroplasty procedures. The AAHKS stated that CMS’s decision to create a separate DRG for revision of total joint arthroplasty (TJA) in October 2005 resulted in more equitable reimbursement for hospitals that perform a disproportionate share of complex revision of TJA procedures, recognizing the higher resource utilization associated with these cases. The AAHKS stated that this important payment policy change led to increased access to care for patients with failed total joint arthroplasties, and ensured that high volume TJA centers could continue to provide a high standard of care for these challenging patients. The AAHKS further stated that the addition of new, more descriptive ICD– 9–CM diagnosis and procedure codes for TJA in October 2005 gave it the opportunity to further analyze differences in clinical characteristics and resource intensity among TJA patients and procedures. Inclusive of the preparatory work to submit its recommendations, the AAHKS compiled, analyzed, and reviewed detailed clinical and resource utilization data from over 6,000 primary and revision TJA procedure codes from 4 high volume joint arthroplasty centers located within different geographic regions of the United States: University of California, San Francisco, CA; Mayo Clinic, Rochester, MN; Massachusetts General Hospital, Boston, MA; and the Hospital for Special Surgery, New York, NY. Based on its analysis, the AAHKS recommended that CMS examine Medicare claims data and consider the creation of separate DRGs for total hip and total knee arthroplasty procedures. The AAHKS stated that based on the differences between patient E:\FR\FM\30APP2.SGM 30APP2 23568 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules characteristics, procedure characteristics, resource utilization, and procedure code payment rates between total hip and total knee replacements, separate DRGs were warranted. Furthermore, the AAHKS recommended that CMS create separate base DRGs for routine versus complex joint revision or replacement procedures as shown below. Routine Hip Replacements • 00.73, Revision of hip replacement, acetabular liner and/or femoral head only. • 00.85, Resurfacing hip, total, acetabulum and femoral head. • 00.86, Resurfacing hip, partial, femoral head. • 00.87, Resurfacing hip, partial, acetabulum. • 81.51, Total hip replacement. • 81.52, Partial hip replacement. • 81.53, Revision of hip replacement, not otherwise specified. Complex Hip Replacements • 00.70, Revision of hip replacement, both acetabular and femoral components. • 00.71, Revision of hip replacement, acetabular component. • 00.72, Revision of hip replacement, femoral component. Routine Knee Replacements and Ankle Procedures • 00.83, Revision of knee replacement, patellar component. • 00.84, Revision of knee replacement, tibial insert (liner). • 81.54, Revision of knee replacement, not otherwise specified. • 81.55, Revision of knee replacement, not otherwise specified. • 81.56, Total ankle replacement. jlentini on PROD1PC65 with PROPOSALS2 Complex Knee Replacements and Other Reattachments • 00.80, Revision of knee replacement, total (all components). • 00.81, Revision of knee replacement, tibial component. • 00.82, Revision of knee replacement, femoral component. • 84.26, Foot reattachment. • 84.27, Lower leg or ankle reattachment. • 84.28, Thigh reattachment. The AAHKS also recommended the continuation of CMS DRG 471 (Bilateral or Multiple Major Joint Procedures of Lower Extremity) without modifications. CMS DRG 471 included any combination of two or more of the following procedure codes: • 00.70, Revision of hip replacement, both acetabular and femoral components. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 • 00.80, Revision of knee replacement, total (all components). • 00.85, Resurfacing hip, total, acetabulum and femoral head. • 00.86, Resurfacing hip, partial, femoral head. • 00.87, Resurfacing hip, partial, acetabulum. • 81.51, Total hip replacement. • 81.52, Partial hip replacement. • 81.54, Total knee replacement. • 81.56, Total ankle replacement. c. Adoption of MS–DRGs for Hip and Knee Replacements for FY 2008 and AAHKS’s Recommendations In the FY 2008 IPPS final rule with comment period (72 FR 47222 through 47226), we adopted MS–DRGs to better recognize severity of illness for FY 2008. The MS–DRGs include two new severity of illness levels under the then current base DRG 544. We also added three new severity of illness levels to the base DRG for Revision of Hip or Knee Replacement. The new MS–DRGs are as follows: • MS–DRG 466 (Revision of Hip or Knee Replacement with MCC) • MS–DRG 467 (Revision of Hip or Knee Replacement with CC) • MS–DRG 468 (Revision of Hip or Knee Replacement without CC/MCC) • MS–DRG 469 (Major Joint Replacement or Reattachment of Lower Extremity with MCC) • MS–DRG 470 (Major Joint Replacement or Reattachment of Lower Extremity without MCC) We found that the MS–DRGs greatly improved our ability to identify joint procedures with higher resource costs. In the final rule, we presented data indicating the average charges for each new MS–DRG for the joint procedures. In the FY 2008 IPPS final rule with comment period, we acknowledged the valuable assistance the AAHKS had provided to CMS in creating the new joint replacement procedure codes and modifying the joint replacement DRGs beginning in FY 2006. These efforts greatly improved our ability to categorize significantly different groups of patients according to severity of illness. Commenters on the FY 2008 proposed rule had encouraged CMS to continue working with the orthopedic community, including the AAHKS, to monitor the need for additional new DRGs. The commenters stated that MS– DRGs 466 through 470 are a good first step. However, they stated that CMS should continue to evaluate the data for these procedures and consider additional refinements to the MS–DRGs, including the need for additional severity levels. AAHKS stated that its data suggest that all three base DRGs PO 00000 Frm 00042 Fmt 4701 Sfmt 4702 (primary replacement, revision of major joint replacement, and bilateral joint replacement) should be separated into three severity levels (that is, MCC, CC, and non-CC). (We had proposed three severity levels for revision of hip and knee replacement (MS–DRGs 466, 467, and 468), and AAHKS agreed with this 3-level subdivision.) The AAHKS recommended that the base DRG for the proposed two severity subdivision MS–DRGs for major joint replacement or reattachment of lower extremity with and without CC/MCC (MS–DRGs 483 and 484) be subdivided into three severity levels, as was the case for the revision of hip and knee replacement MS–DRGs. AAHKS also recommended that the two severity subdivision MS–DRGs for bilateral or multiple major joint procedures of lower extremity with and without MCC (MS– DRGs 461 and 462) be subdivided three ways for this base DRG. AAHKS acknowledged that the three way split would not meet all five of the criteria for establishing a subgroup, and stated that these criteria were too restrictive, lack face validity, and create perverse admission selection incentives for hospitals by significantly overpaying for cases without a CC and underpaying for cases with a CC. It recommended that the existing five criteria be modified for low volume subgroups to assure materiality. For higher volume MS–DRG subgroups, the AAHKS recommended that two other criteria be considered, particularly for nonemergency, elective admissions: • Is the per-case underpayment amount significant enough to affect admission vs. referral decisions on a case-by-case basis? • Is the total level of underpayments sufficient to encourage systematic admission vs. referral policies, procedures, and marketing strategies? The AAHKS also recommended refining the five existing criteria for MCC/CC/without subgroups as follows: • Create subgroups if they meet the five existing criteria, with cost difference between subgroups ($1,350) substituted for charge difference between subgroups ($4,000); • If a proposed subgroup meets criteria number 2 and 3 (at least 5 percent and at least 500 cases) but fails one of the others, then create the subgroup if either of the following criteria are met: b At least $1,000 cost difference per case between subgroups; or b At least $1 million overall cost should be shifted to cases with a CC (or MCC) within the base DRG for payment weight calculations. E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules In response, we indicated that we did not believe it was appropriate to modify our five criteria for creating severity subgroups. Our data did not support creating additional subdivisions based on the criteria. At that time, we believed the criteria we established to create subdivisions within a base DRG were reasonable and establish the appropriate balance between better recognition of severity of illness, sufficient differences between the groups, and a reasonable number of cases in each subgroup. However, we indicated that we may consider further modifications to the criteria at a later date once we have had some experience with MS–DRGs created using the proposed criteria. The AAHKS indicated in its response to the FY 2008 proposed rule that it continued to support the separation of routine and complex joint procedures. It believed that certain joint replacement procedures have significantly lower average charges than do other joint replacements. The AAKHS’s data suggest that more routine joint replacements are associated with substantially less resource utilization than other more complex revision procedures. The AAHKS stated that leaving these procedures in the revision MS–DRGs results in substantial overpayment for these relatively simple, less costly revision procedures, which in turn results in a relative underpayment for the more complex revision procedures. In response, we examined data on this issue and identified two procedure codes for partial knee revisions that had significantly lower average charges than did other joint revisions. The two codes are as follows: • 00.83 Revision of knee replacement, patellar component • 00.84 Revision of total knee replacement, tibial insert (liner) The data suggest that these less complex partial knee revisions are less resource intensive than other cases assigned to MS–DRGs 466, 467, or 468. We examined other orthopedic DRGs to which these two codes could be assigned. We found that these cases have very similar average charges to those in MS–DRG 485 (Knee Procedures with Principal Diagnosis of Infection with MCC), MS–DRG 486 (Knee Procedures with Principal Diagnosis of Infection with CC), MS–DRG 487 (Knee Procedures with Principal Diagnosis of Infection without CC), MS–DRG 488 (Knee Procedures without Principal Diagnosis of Infection with CC or MCC), and MS–DRG 489 (Knee Procedures without Principal Diagnosis of Infection without CC). VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Given the very similar resource requirements of MS–DRG 485 and the fact that these DRGs also contain knee procedures, we moved codes 00.83 and 00.84 out of MS–DRGs 466, 467, and 468 and into MS–DRGs 485, 486, 487, 488, and 489. We also indicated that we would continue to monitor the revision DRGs to determine if additional modifications are needed. d. AAHKS’ Recommendations for FY 2009 The AAHKS’ current request involves the following recommendations: • That CMS consolidate and reassign certain joint procedures that have a diagnosis of an infection or malignancy into MS–DRGs that are similar in terms of clinical characteristics and resource utilization. The AAKHS further identifies groups called Stage 1 and 2 procedures that it believes require significant differences in resource utilization. • That CMS reclassify certain specific joint procedures, which AAHKS refers to as ‘‘routine,’’ out of their current MS– DRG assignments. The three joint procedures that AAHKS classifies as ‘‘routine’’ are codes 00.73 (Revision of hip replacement, acetabular liner and/or femoral head only), 00.83 (Revision of knee replacement, patellar component), and 00.84 (Revision of total knee replacement, tibial insert (liner)). The AAHKS advocated removing these three ‘‘routine’’ procedures from the following DRGs: MS–DRGs 466, 467, and 468, MS–DRGs 485, 486, and 487, and MS– DRGs 488 and 489. The AAHKS refers to MS–DRGs 466, 467, and 468 as ‘‘complex’’ revision DRGs, and recommended that the three ‘‘routine’’ procedures be moved out of MS–DRGs 466, 467, and 468 and MS–DRGs 485, 486, and 489 and into MS–DRGs 469 and 470 (Major Joint Replacement or Reattachment of Lower Extremity with and without MCC, respectively). The AAHKS contended that the three ‘‘routine’’ procedures have similar clinical characteristics and resource utilization to those in MS–DRGs 469. The recommendations suggested by AAHKS are quite complex and involve a number of specific code lists and MS– DRG assignment changes. We discuss each of these requests in detail below. (1) AAHKS Recommendation 1: Consolidate and reassign patients with hip and knee prosthesis related infections or malignancies. The AAHKS pointed out that deep infection is one of the most devastating complications associated with hip and knee replacements. These infections have been reported to occur in approximately 0.5 percent to 3 percent PO 00000 Frm 00043 Fmt 4701 Sfmt 4702 23569 of primary and 4 percent to 6 percent of revision total joint replacement procedures. These infections often result in the need for multiple reoperations, prolonged use of intravenous and oral antibiotics, extended inpatient and outpatient rehabilitation, and frequent followup visits. Furthermore, clinical outcomes following single- and two-stage revision total joint arthroplasty procedures have been less favorable than revision for other causes of failure not associated with infection. In addition to the clinical impact, the AAHKS stated that infected total joint replacement procedures also have substantial economic implications for patients, payers, hospitals, physicians, and society in terms of direct medical costs, resource utilization, and the indirect costs associated with lost wages and productivity. The AAHKS stated that the considerable resources required to care for these patients has resulted in a strong financial disincentive for physicians and hospitals to provide care for patients with infected total joint replacements, an increased economic burden on the high volume tertiary care referral centers where patients with infected hip replacement procedures are frequently referred for definitive management. The AAHKS further stated that, in some cases, there are compromised patient outcomes due to treatment delays as patients with infected joint replacements seek providers who are willing to care for them. Once a deep infection of a total joint prosthesis is identified, the first stage of treatment involves a hospital admission for removal of the infected prosthesis and debridement of the involved bone and surrounding tissue. During the same procedure, an antibiotic-impregnated cement spacer is typically inserted to maintain alignment of the limb during the course of antibiotic therapy. The patient is then discharged to a rehabilitation facility/nursing home (or to home if intravenous therapy can be safely arranged for the patient) for a 6week course of IV antibiotic treatment until the infection has cleared. After the completion of antibiotic therapy, the hip or knee may be reaspirated to look for evidence of persistent infection or eradication of infection. A second stage procedure is then undertaken, where the patient is readmitted, the hip or knee is reexplored, and the cement spacer removed. If there are no signs of persistent infection, a hip or knee prosthesis is reimplanted, often using bone graft and costly revision implants in order to address extensive bone loss E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23570 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules and distorted anatomy. Thus, the entire course of treatment for patients with infected joint replacements is 4 to 6 months, with an additional 6 to 12 months of rehabilitation. Furthermore, clinical outcomes following revision for infection are poor relative to outcomes following revision for other, aseptic causes. The AAHKS noted that patients with bone malignancy have a similar treatment focus—surgery to remove diseased tissue, chemotherapy to treat the malignancy, and implantation of the new prosthesis. They also have similar resource use. For simplicity, the AAHKS’ discussion focused on infected joint prostheses, but it suggested that the issues it raises would apply to patients with a malignancy as well. The AAHKS stated that these patients are currently grouped in multiple MS– DRGs, and the cases are often ‘‘outliers’’ in each one. AAHKS proposed to consolidate these patients with similar clinical characteristics and treatment into MS–DRGs reflective of their resource utilization. The AAHKS states that these more severe patients are currently classified into the following MS–DRGs: • MS–DRGs 463, 463, and 465 (Wound Debridement and Skin Graft Excluding Hand, for MusculoskeletalConnective Tissue Disease with MCC, with CC, without CC/MCC, respectively). • MS–DRGs 480, 481, and 482 (Hip and Femur Procedures Except Major Joint with MCC, with CC, without CC/ MCC, respectively). • MS–DRGs 485, 486, and 487 (Knee Procedures with Principal Diagnosis of Infection and with MCC, with CC, and without CC/MCC, respectively). • MS–DRGs 488 and 489 (Knee Procedures without Principal Diagnosis of Infection and with CC/MCC and without CC/MCC, respectively). • MS–DRGs 495, 496, and 497 (Local Excision and Removal of Internal Fixation Devices Except Hip and Femur with MCC, with CC, and without CC/ MCC, respectively). • Other MS–DRGs (The AAHKS did not specify what these other MS–DRGs were.). The AAHKS indicated that cases with the severe diagnoses of infections, neoplasms, and structural defects have similarities. These similarities are due to an overlap of a severe diagnosis (including a principal diagnosis of code 996.66 (Infected joint prosthesis) and the resulting need for more extensive surgical procedures. The AAHKS stated that currently these patients are grouped into MS–DRGs by major procedure alone. AAHKS recommended that these VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 cases be grouped into what it refers to as Stages 1 and 2 as follows: • Stage 1 would include the removal of an infected prosthesis and includes cases in MS–DRGs 463, 464, and 465, 480, 481, and 482, 485 through 489, and 495, 496, and 497. Stage 1 joint procedure codes would include codes 80.05 (Arthrotomy for removal of prosthesis, hip), 80.06 (Arthrotomy for removal of prosthesis, knee), 00.73 (Revision of hip replacement, acetabular liner and/or femoral head only), and 00.84 (Revision of knee replacement, tibial insert (liner)). • Stage 2 would include the implant of a new prosthesis and includes cases in MS–DRGs 461 and 462, 463, 464, and 465, 466, 467, and 468, and 469 and 470. Stage 2 joint procedure codes would include codes 00.70 (Revision of hip replacement, both acetabular and femoral components), 00.71 (Revision of hip replacement, acetabular component), 00.72 (Revision of hip replacement, femoral component), 00.80 (Revision of knee replacement, total (all components)), 00.81 (Revision of knee replacement, tibial component), 00.82 (Revision of knee replacement, femoral component), 00.85 (Resurfacing hip, total, acetabulum and femoral head), 00.86 (Resurfacing hip, partial, femoral head), 00.87 (Resurfacing hip, partial, acetabulum), 81.51 (Total hip replacement), 81.52 (Partial hip replacement), 81.53 (Revise hip replacement), 81.54 (Total knee replacement), 81.55 (Revise knee replacement), and 81.56 (Total ankle replacement). As stated earlier, the AAHKS recommended patients with certain more severe diagnoses be grouped into a higher severity level. While most of AAHKS’ comments focused on joint replacement patients with infections, the AAHKS also believed that patients with certain neoplasms require greater resources. To this group of infections and neoplasms, the AAHKS recommended the addition of four codes that capture acquired deformities. The AAHKS believed that these codes would capture admissions for the second stage of the treatment for an infected joint. The AAHKS stated that the significance of these diagnoses when they are reported as the principal code position was significant in predicting resource utilization. However, the impact was not as significant when the diagnosis was reported as a secondary diagnosis. The AAHKS recommended that patients with one of the following infection/ neoplasm/defect principal diagnosis codes be segregated into a higher severity level. PO 00000 Frm 00044 Fmt 4701 Sfmt 4702 Stage 1 Infection/Neoplasm/Defect Principal Diagnosis Codes • 170.7 (Malignant neoplasm of long bones of lower limb). • 171.3 (Malignant neoplasm of soft tissue, lower limb, including hip). • 711.05 (Pyogenic arthritis, pelvic region and thigh). • 711.06 (Pyogenic arthritis, lower leg). • 730.05 (Acute osteomyelitis, pelvic region and thigh). • 730.06 (Acute osteomyelitis, lower leg). • 730.15 (Chronic osteomyelitis, pelvic region and thigh). • 730.16 (Chronic osteomyelitis, lower leg). • 730.25 (Unspecified osteomyelitis, pelvic region and thigh). • 730.26 (Unspecified osteomyelitis, lower leg). • 996.66 (Infection and inflammatory reaction due to internal joint prosthesis). • 996.67 (Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft). Stage 2 Infection/Neoplasm/Defect Principal Diagnosis Codes (an Asterisk * Shows the Diagnoses Included in Stage 2 That Were Not Listed in Stage 1) • 170.7 (Malignant neoplasm of long bones of lower limb). • 171.3 (Malignant neoplasm of soft tissue, lower limb, including hip). • 198.5 (Secondary malignant neoplasm of bone and bone marrow) .* • 711.05 (Pyogenic arthritis, pelvic region and thigh). • 711.06 (Pyogenic arthritis, lower leg). • 730.05 (Acute osteomyelitis, pelvic region and thigh). • 730.06 (Acute osteomyelitis, lower leg). • 730.15 (Chronic osteomyelitis, pelvic region and thigh). • 730.16 (Chronic osteomyelitis, lower leg). • 730.25 (Unspecified osteomyelitis, pelvic region and thigh). • 730.26 (Unspecified osteomyelitis, lower leg). • 736.30 (Acquired deformities of hip, unspecified deformity). • 736.39 (Other acquired deformities of hip) .* • 736.6 (Other acquired deformities of knee) .* • 736.89 (Other acquired deformities of other parts of limbs). * • 996.66 (Infection and inflammatory reaction due to internal joint prosthesis). * • 996.67 (Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft). * E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules For the Stage 2 procedures, AAHKS also suggested the use of the following secondary diagnosis codes to assign the cases to a higher severity level. These conditions would not be the reason the patient was admitted to the hospital. They would instead represent secondary conditions that were also present on admission or conditions that were diagnosed after admission. Stage 2 Infection/Neoplasm/Defect Secondary Diagnosis Codes • 170.7 (Malignant neoplasm of long bones of lower limb). • 171.3 (Malignant neoplasm of soft tissue, lower limb, including hip). • 711.05 (Pyogenic arthritis, pelvic region and thigh). • 711.06 (Pyogenic arthritis, lower leg). • 730.05 (Acute osteomyelitis, pelvic region and thigh). • 730.06 (Acute osteomyelitis, lower leg). • 730.15 (Chronic osteomyelitis, pelvic region and thigh). • 730.16 (Chronic osteomyelitis, lower leg). • 730.25 (Unspecified osteomyelitis, pelvic region and thigh). • 730.26 (Unspecified osteomyelitis, lower leg). • 996.66 (Infection and inflammatory reaction due to internal joint prosthesis). • 996.67 (Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft). (2) AAHKS Recommendation 2: Reclassify certain specific joint procedures. The AAHKS suggested that cases with the infection/neoplasm/defect diagnoses listed above be segregated according to the Stage 1 and 2 groups listed above. The AAHKS made one final recommendation concerning joint procedure cases with infections. It identified a subset of patients who had a principal diagnosis of 996.66 (Infection and inflammatory reaction due to internal joint prosthesis) and who also had a secondary diagnosis of sepsis or septicemia. The AAHKS believed that these patients are for the most part admitted with both the joint infection and sepsis/septicemia present at the time of admission. The codes for sepsis/septicemia are classified as MCCs under MS–DRGs. The AAHKS believed it is inappropriate to count the secondary diagnosis of sepsis/ septicemia as a MCC when it is reported with code 996.66. The AAHKS believed that counting sepsis and septicemia as a MCC results in double counting the infections. It believed that the joint infection and septicemia are the same infection. The AAHKS recommended that the following sepsis and septicemia codes not count as a MCC when reported with code 996.66: • 038.0 (Streptococcal septicemia). • 038.10 (Staphylococcal septicemia, unspecified). • 038.11 (Staphylococcal aureus septicemia). • 038.19 (Other staphylococcal septicemia). • 038.2 (Pneumococcal septicemia [streptococcus pneumonia septicemia]). • 038.3 (Septicemia due anaerobes). • 038.40 (Septicemia due to gramnegative organisms). • 038.41 (Hemophilus influenzae [H. Influenzae]). • 038.42 (Escherichia coli [E. Coli]). • 038.43 (Pseudomonas). • 038.44 (Serratia). • 038.49 (Other septicemia due to gram-negative organisms). • 038.8 (Other specified septicemias). • 038.9 (Unspecified septicemia). • 995.91 (Sepsis). • 995.92 (Severe sepsis). jlentini on PROD1PC65 with PROPOSALS2 485—All Cases ............................................................................................................................ 485—Cases with Code 00.83 or 00.84 ....................................................................................... 485—Cases without Code 00.83 or 00.84 .................................................................................. 486—All Cases ............................................................................................................................ 486—Cases with Code 00.83 or 00.84 ....................................................................................... 486—Cases without Code 00.83 or 00.84 .................................................................................. 487—All Cases ............................................................................................................................ 487—Cases with Code 00.83 or 00.84 ....................................................................................... 487—Cases without Code 00.83 or 00.84 .................................................................................. 488—All Cases ............................................................................................................................ 488—Cases with code 00.83 or 00.84 ........................................................................................ 488—Cases without code 00.83 or 00.84 ................................................................................... 489—All Cases ............................................................................................................................ 489—Cases with code 00.83 or 00,.84 ....................................................................................... 489—Cases without code 00.83 or 00.84 ................................................................................... 469—All cases ............................................................................................................................. 470—All Cases ............................................................................................................................ 466—All Cases ............................................................................................................................ 466—Cases with Code 00.73 ...................................................................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 e. CMS’ Response to AAHKS’ Recommendations The MS–DRG modifications proposed by the AAHKS are quite complex and have many separate parts. We made changes to the MS-DRGs in FY 2008 as a result of a request by the AAHKS as discussed above, to recognize two types of partial knee replacements as less complex procedures. We have no data on how effective the new MS–DRGs for joint procedures are in differentiating patients with varying degrees of severity. Therefore, we analyzed data reported prior to the adoption of MS– DRGs to analyze each of the recommendations made. We begin our analysis by focusing first on the more simple aspects of the recommendations made by the AAHKS. (1) Changing the MS–DRG Assignment for Codes 00.73, 00.83, and 00.84 As discussed previously, in FY 2008, the AAHKS recommended that CMS classify certain joint procedures as either routine or complex. We examined the data for these cases and found that the following two codes had significantly lower charges than the other joint revisions: 00.83 (Revision of knee replacement, patellar component) and 00.84 (Revision of knee replacement, tibial insert (liner)). Therefore, we moved these two codes to MS–DRGs 485, 486, and 487, and MS– DRGs 488 and 489. As a result of AAHKS’ most recent recommendations, we once again examined claims data for these two knee procedures (codes 00.83 and 00.84) as well as its request that we move code 00.73 (Revision of hip replacement, acetabular liner and/or femoral head only). Code 00.73 is assigned to MS– DRGs 466, 467, and 468. The following tables show our findings. Number of cases MS–DRG Frm 00045 Fmt 4701 Sfmt 4702 23571 1,122 179 943 2,061 464 1,597 1,236 284 952 2,374 754 1,620 5,493 2,154 3,339 29,030 385,123 3,888 273 E:\FR\FM\30APP2.SGM 30APP2 Average length of stay 12.20 11.83 12.27 8.03 7.34 8.23 5.67 5.61 5.68 5.17 4.09 5.67 3.04 3.07 3.03 8.17 3.93 9.18 10.02 Average charges $64,672.47 64,446.68 64,715.33 40,758.55 39,864.39 41,018.34 29,180.88 31,231.79 28,569.06 30,180.80 28,432.06 30,994.73 21,385.67 23,122.18 20,265.44 56,681.64 36,126.23 76,015.66 71,293.33 23572 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Number of cases MS–DRG 466—Cases without Code 00.73 ................................................................................................. 467—All Cases ............................................................................................................................ 467—Cases with Code 00.73 ...................................................................................................... 467—Cases without Code 00.73 ................................................................................................. 468—All Cases ............................................................................................................................ 468—Cases with Code 00.73 ...................................................................................................... 468—Cases without Code 00.73 ................................................................................................. 469—All Cases ............................................................................................................................ 470—All Cases ............................................................................................................................ The tables show that codes 00.73, 00.83, and 00.84 are appropriately assigned to their current MS–DRGs. The data do not support moving these three codes to MS–DRGs 469 and 470. Therefore, we are not proposing a change of MS–DRG assignment for codes 00.73, 00.83, and 00.84. (2) Excluding Sepsis and Septicemia From Being a MCC With Code 996.66 There are cases where a patient may be admitted with an infection of a joint prosthesis (code 996.66) and also have sepsis. In these cases, it may be possible to perform joint procedures as suggested by AAHKS. However, in other cases, a patient may be admitted with an infection of a joint prosthesis and then develop sepsis during the stay. Because our current data do not indicate whether a condition is present on admission, we could not determine whether or not the sepsis occurred after admission. Our data have consistently shown that cases of sepsis and septicemia require significant resources. Therefore, we classified the sepsis and septicemia codes as MCCs. Our clinical advisors do not believe it is appropriate to exclude all cases of sepsis and septicemia that are reported as a secondary diagnosis with code 996.66 from being classified as a MCC. We discuss septicemia as part of hospital acquired conditions provision under section II.F. of the preamble of this proposed rule. For the purposes of classifying sepsis and septicemia as non-CCs when reported with code 996.66, we do not support this recommendation. Therefore, we are not proposing that the sepsis and septicemia codes be added to the CC exclusion list for code 996.66. (3) Differences Between Stage 1 and 2 Cases With Severe Diagnoses We next examined data on AAHKS’ suggestion that there are significantly differences in resource utilization for Average length of stay 3,616 13,551 1,078 12,484 19,917 1,688 18,232 29,030 385,123 9.12 5.50 5.94 5.47 3.94 3.93 3.94 8.17 3.93 Average charges 76,372.06 53,431.63 43,635.63 54,284.13 44,055.62 33,449.22 45,037.09 56,681.64 36,126.23 cases they refer to as Stage 1 and 2. AAHKS stated that this is particularly true for those with infections, neoplasms, or structural defects. We used the list of procedure codes listed above that AAHKS describes as Stage 1 and 2 procedures. We also used AAHKS’ designated lists of Stage 1 and 2 principal diagnosis codes to examine this proposal. This proposal entails moving cases with a Stage 1 or 2 principal diagnosis and procedure out of their current MS–DRG assignment in the following 19 MS–DRGs and into a newly consolidated set of MS–DRGs: MS–DRGs 463, 464, and 465, 480, 481, and 482, 485 through 489, and 495, 496, and 497. As can be seen from the information below, there was not a significant difference in average charges between these Stage 1 and Stage 2 cases that have an MCC. STAGE 1.—CASES WITH INFECTION, NEOPLASM, OR STRUCTURAL DEFECT Stage 1 Total cases With MCC .................................................................................................................................... Without MCC ............................................................................................................................... Average length of stay 1,306 4,115 14.1 7.6 Average charges $79,232 44,716 STAGE 2.—CASES WITH INFECTION, NEOPLASM, OR STRUCTURAL DEFECT Stage 2 Total cases jlentini on PROD1PC65 with PROPOSALS2 With MCC .................................................................................................................................... Without MCC ............................................................................................................................... Average charges for Stage 1 cases with an MCC was $79,232 compared to $80,781 for Stage 2. Stage 1 cases without an MCC had average charges of $44,716 compared to $57,355. These data do not support reconfiguring the current MS–DRGs based on this new subdivision. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 (4) Moving Joint Procedure Cases to New MS–DRGs Based on Secondary Diagnoses of Infection We examined AAHKS’ recommendation that Stage 2 joint cases with specific secondary diagnoses of infection or neoplasm be moved out of their current MS–DRG assignments and into a newly constructed MS–DRG. We are reluctant to make this type of significant DRG change to the joint MS– DRGs based on the presence of a PO 00000 Frm 00046 Fmt 4701 Sfmt 4702 1,072 5,413 Average length of stay 10.9 6.0 Average charges $80,781 57,355 secondary diagnosis. This results in the movement of cases out of MS–DRGs which were configured based on the reason for the admission (for example, principal diagnosis) and surgery. The cases would instead be assigned based on conditions that are reported as secondary diagnoses. In some cases, the infection may have developed or be diagnosed during the admission. This would be a significant logic change to the MS–DRGs for joint procedures. We have not had an opportunity to examine E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules claims data based on hospital discharges under the MS–DRGs which began October 1, 2008. Our clinical advisors believe it would be more appropriate to wait for data under the new MS–DRG system to determine how well the new severity levels are addressing accurate payment for these cases before considering this approach to assigning cases to a MS–DRG. (5) Moving Cases With Infection, Neoplasms, or Structural Defects Out of 19 MS–DRGs and Into Two Newly Developed MS–DRGs The last recommended by AAHKS that we considered was moving cases with a principal diagnosis of infection, neoplasm, or structural defect from their list of Stage 1 and 2 diagnoses and consolidated them into newly constructed and modified MS–DRGs. AAHKS could not identify an existing set of MS–DRGs with similar resource utilizations into which the Stage 1 cases could be assigned. Therefore, the AAHKS recommended that CMS create three new MS–DRGs for Stage 1 cases with infections, neoplasms and structural defects which would be titled ‘‘Arthrotomy/Removal/Component exchange of Infected Hip or Knee Prosthesis with MCC, with CC, and without CC/MCC’’, respectively. The AAHKS recommended moving Stage 2 cases out of MS–DRGs 466, 467, and 468, and 469 and 470 and into MS– DRGs 461 and 462. AAHKS recommended that MS–DRGs 461 and 462 be renamed ‘‘Major Joint Procedures of Lower Extremity—Bilateral/Multiple/ Infection/Malignancy’’. In reviewing these proposed changes, we had a number of concerns. The first concern was that these proposed changes would result in the removal of jlentini on PROD1PC65 with PROPOSALS2 463—All Cases ............................................................................................................................ 463—Cases with PDX of Infection/Malignancy/React ................................................................ 464—All Cases ............................................................................................................................ 464—Cases with PDX of Infection/Malignancy/React ................................................................ 465—All Cases ............................................................................................................................ 465—Cases with PDX of Infection/Malignancy/React ................................................................ 466—All Cases ............................................................................................................................ 466—Cases with PDX of Infection/Malignancy/React ................................................................ 467—All Cases ............................................................................................................................ 467—Cases with PDX of Infection/Malignancy/React ................................................................ 468—All Cases ............................................................................................................................ 468—Cases with PDX of Infection/Malignancy/React ................................................................ 469—All Cases ............................................................................................................................ 469—Cases with PDX of Infection/Malignancy/React ................................................................ 470—All Cases ............................................................................................................................ 470—Cases with PDX of Infection/Malignancy/React ................................................................ 480—All Cases ............................................................................................................................ 480—Cases with PDX of Infection/Malignancy/React ................................................................ 481—All Cases ............................................................................................................................ 481—Cases with PDX of Infection/Malignancy/React ................................................................ 482—All Cases ............................................................................................................................ 482—Cases with PDX of Infection/Malignancy/React ................................................................ 485—All Cases ............................................................................................................................ 485—Cases with PDX of Infection/Malignancy/React ................................................................ 486—All Cases ............................................................................................................................ 486—Cases with PDX of Infection/Malignancy/React ................................................................ 487—All Cases ............................................................................................................................ 487—Cases with PDX of Infection/Malignancy/React ................................................................ 488—All Cases ............................................................................................................................ 488—Cases with PDX of Infection/Malignancy/React ................................................................ 489—All Cases ............................................................................................................................ 489—Cases with PDX of Infection/Malignancy/React ................................................................ 495—All Cases ............................................................................................................................ 495—Cases with PDX of Infection/Malignancy/React ................................................................ 496—All Cases ............................................................................................................................ 496—Cases with PDX of Infection/Malignancy/React ................................................................ 497—All Cases ............................................................................................................................ 497—Cases with PDX of Infection/Malignancy/React ................................................................ Given the wide variety of charges and the small number of cases where there are differences in charges, we do not VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 believe the data support the AAHKS’ recommendations. The data do not support removing these cases from the PO 00000 cases with varying average charges from 19 current MS–DRGs and consolidating them into two separate sets of MS– DRGs. As the data below indicate, the average charges vary from as low as $29,181 in MS–DRG 487 to $81,089 in MS–DRG 463. Furthermore, the average charges for these infection/neoplasm/ structural defect cases are very similar to other cases in their respective MS– DRG assignments for many of these MS– DRGs. There are cases where the average charges are higher. In MS–DRG 469 and 470, the infection/neoplasm/structural defect cases are significantly higher. However, there are only 136 cases in MS–DRG 469 out of a total of 29,030 cases with these diagnoses. There are only 673 cases in MS–DRG 470 out of a total of 385,123 cases with one of these diagnoses. The table below clearly demonstrates the wide variety of charges for cases with these diagnoses. Number of cases MS–DRGs Frm 00047 Fmt 4701 Sfmt 4702 23573 4,747 1,009 5,499 1,420 2,271 557 3,888 890 13,551 2,401 19,917 1,994 29,030 136 385,123 673 25,391 880 68,655 878 45,832 577 1,122 1,122 2,061 2,061 1,236 1,236 2,374 31 5,493 36 1,860 1,025 5,203 2,759 6,259 1,500 Average length of stay 16.25 17.79 10.21 10.59 5.95 10.59 9.18 10.67 5.50 6.71 3.94 4.76 8.17 11.74 3.93 6.44 9.32 14.53 5.94 8.78 4.86 6.19 12.20 12.20 8.03 8.03 5.67 5.67 5.17 7.13 3.04 3.72 10.94 11.74 5.95 6.98 3.01 5.18 Average charges $73,405.46 81,089.07 44,387.73 46,800.60 26,631.57 29,816.40 76,015.66 79,334.69 53,431.63 58,506.86 44,055.62 54,322.03 56,681.64 85,256.07 36,126.23 59,676.31 52,281.65 76,355.15 32,963.64 48,655.30 27,266.20 37,572.38 64,672.47 64,672.47 40,758.55 40,758.55 29,180.88 29,180.88 30,180.80 50,155.42 21,385.67 35,313.84 55,103.91 59,453.69 32,177.29 36,940.99 21,445.60 29,966.98 19 MS–DRGs above and consolidating them into a new set of MS–DRGs, either newly created, or by adding them to E:\FR\FM\30APP2.SGM 30APP2 23574 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules MS–DRG 461 or 462, which have average charges of $80,718 and $57,355, respectively. A second major concern involves redefining MS–DRGs 461 and 462 is that these MS–DRG currently captures bilateral and multiple joint procedures. These MS–DRGs were specifically created to capture a unique set of patients who undergo procedures on more than one lower joint. Redefining these MS–DRGs to include both single and multiple joints undermines the clinical coherence of this MS–DRG. It would create a widely diverse group of patients based on either a list of specific diagnoses or the fact that the patient had multiple lower joint procedures. jlentini on PROD1PC65 with PROPOSALS2 f. Conclusion The AAHKS recommended a number of complicated, interrelated MS–DRG changes to the joint procedure MS– DRGs. We have not yet had the opportunity to review data for these cases under the new MS–DRGs. We did analyze the impact of these recommendations using cases prior to the implementation of MS–DRGs. The recommendations were difficult to analyze because there were so many separate logic changes that impacted a number of MS–DRGs. We did examine each major suggestion separately, and found that our data and clinical analysis did not support making these changes. Therefore, we are not proposing any revisions to the joint procedure MS– DRGs for FY 2009. We look forward to examining these issues once we receive data under the MS–DRG system. We also welcome additional recommendations from the AAHKS and others on a more incremental approach to resolving its concerns about the ability of the current MS–DRGs to adequately capture differences in severity levels for joint procedure patients. 5. MDC 18 (Infections and Parasitic Diseases (Systemic or Unspecified Sites)): Severe Sepsis We received a request from a manufacturer to modify the titles for three MS–DRGs with the most significant concentration of severe sepsis patients. The manufacturer stated that modification of the titles will assist in quality improvement efforts and provide a better reflection on the types of patients included in these MS–DRGs. Specifically, the manufacturer urged CMS to incorporate the term ‘‘severe sepsis’’ into the titles of the following MS–DRGs that became effective October 1, 2007 (FY 2008) • MS–DRG 870 (Septicemia with Mechanical Ventilation 96+ Hours). VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 • MS–DRG 871 (Septicemia without Mechanical Ventilation 96+ Hours with MCC). • MS–DRG 872 (Septicemia without Mechanical Ventilation 96+ Hours without MCC). These MS–DRGs were created to better recognize severity of illness among patients diagnosed with conditions including septicemia, severe sepsis, septic shock, and systemic inflammatory response syndrome (SIRS) who are also treated with mechanical ventilation for a specified duration of time. According to the manufacturer, ‘‘severe sepsis is a common, deadly and costly disease, yet the number of patients impacted and the outcomes associated with their care remain largely hidden within the administrative data set.’’ The manufacturer further noted that, although improvements have been made in the ICD–9–CM coding of severe sepsis (diagnosis code 995.92) and septic shock (diagnosis code 785.52), results of an analysis demonstrated an unacceptably high mortality rate for patients reported to have those conditions. The manufacturer believed that revising the titles to incorporate ‘‘severe sepsis’’ will provide various clinicians and researchers the opportunity to improve outcomes for these patients. Therefore, the manufacturer recommended revising the current MS–DRG titles as follows: • Proposed Revised MS–DRG 870 (Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours). • Proposed Revised MS–DRG 871 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with MCC). • Proposed Revised MS–DRG 872 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC). We agree with the manufacturer that revising the current MS–DRG titles to include the term ‘‘severe sepsis’’ would better assist in the recognition and identification of this disease, which could lead to better clinical outcomes and quality improvement efforts. In addition, both severe sepsis (diagnosis code 995.92) and septic shock (diagnosis code 785.52) are currently already assigned to these three MS– DRGs. Therefore, we are proposing to revise the titles of MS–DRGs 870, 871, and 872 to reflect severe sepsis in the titles as suggested by the manufacturer and listed above for FY 2009. PO 00000 Frm 00048 Fmt 4701 Sfmt 4702 6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs): Traumatic Compartment Syndrome Traumatic compartment syndrome is a condition in which increased pressure within a confined anatomical space that contains blood vessels, muscles, nerves, and bones causes a decrease in blood flow and may lead to tissue necrosis. There are five ICD–9–CM diagnosis codes that were created effective October 1, 2006, to identify traumatic compartment syndrome of various sites. • 958.90 (Compartment syndrome, unspecified). • 958.91 (Traumatic compartment syndrome of upper extremity). • 958.92 (Traumatic compartment syndrome of lower extremity). • 958.93 (Traumatic compartment syndrome of abdomen). • 958.99 (Traumatic compartment syndrome of other sites) . Cases with one of the diagnosis codes listed above reported as the principal diagnosis and no operating room procedure are assigned to either MS– DRG 922 (Other Injury, Poisoning and Toxic Effect Diagnosis with MCC) or MS–DRG 923 (Other Injury, Poisoning and Toxic Effect Diagnosis without MCC) in MDC 21. In the FY 2008 IPPS final rule with comment period when we adopted the MS–DRGs, we inadvertently omitted the addition of these traumatic compartment syndrome codes 958.90 through 958.99 to the multiple trauma MS–DRGs 963 (Other Multiple Significant Trauma with MCC), MS– DRG 964 (Other Multiple Significant Trauma with CC), and MS–DRG 965 (Other Multiple Significant Trauma without CC/MCC) in MDC 24 (Multiple Significant Trauma). Cases are assigned to MDC 24 based on the principal diagnosis of trauma and at least two significant trauma diagnosis codes (either as principal or secondary diagnoses) from different body site categories. There are eight different body site categories as follows: • Significant head trauma. • Significant chest trauma. • Significant abdominal trauma. • Significant kidney trauma. • Significant trauma of the urinary system. • Significant trauma of the pelvis or spine. • Significant trauma of the upper limb. • Significant trauma of the lower limb. Therefore, we are proposing to add traumatic compartment syndrome codes 958.90 through 958.99 to MS–DRGs 963 and MS–DRG 965 in MDC 24. Under E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules this proposal, codes 958.90 through 958.99 would be added to the list of principal diagnosis of significant trauma. In addition, code 958.91 would be added to the list of significant trauma of upper limb, code 958.92 would be added to the list of significant trauma of lower limb, and code 958.93 would be added to the list of significant abdominal trauma. 7. Medicare Code Editor (MCE) Changes As explained under section II.B.1. of the preamble of this proposed rule, the Medicare Code Editor (MCE) is a software program that detects and reports errors in the coding of Medicare claims data. Patient diagnoses, procedure(s), and demographic information are entered into the Medicare claims processing systems and are subjected to a series of automated screens. The MCE screens are designed to identify cases that require further review before classification into a DRG. For FY 2009, we are proposing to make the following changes to the MCE edits: jlentini on PROD1PC65 with PROPOSALS2 a. List of Unacceptable Principal Diagnoses in MCE Diagnosis code V62.84 (Suicidal ideation) was created for use beginning October 1, 2005. At the time the diagnosis code was created, it was not clear that the creation of this code was requested in order to describe the principal reason for admission to a facility or the principal reason for treatment. The NCHS Official ICD–9– CM Coding Guidelines therefore categorized the group of codes in V62.X for use only as additional or secondary diagnoses. It has been brought to the government’s attention that the use of this code is hampered by its designation as an additional-only diagnosis. NCHS has therefore modified the Official Coding Guidelines for FY 2009 by making this code acceptable as a principal diagnosis as well as an additional diagnosis. In order to conform to this change by NCHS, we are proposing to remove code V62.84 from the MCE list of ‘‘Unacceptable Principal Diagnoses’’ for FY 2009. b. Diagnoses Allowed for Males Only Edit There are four diagnosis codes that were inadvertently left off of the MCE edit titled ‘‘Diagnoses Allowed for Males Only.’’ These codes are located in the chapter of the ICD–9–CM diagnosis codes entitled ‘‘Diseases of Male Genital Organs.’’ We are proposing to add the following four codes to this MCE edit: 603.0 (Encysted hydrocele), 603.1 (Infected hydrocele), 603.8 (Other specified types of hydrocele), and 603.9 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 (Hydrocele, unspecified). We have had no reported problems or confusion with the omission of these codes from this section of the MCE, but in order to have an accurate product, we are proposing that these codes be added for FY 2009. c. Limited Coverage Edit As explained in section II.G.1. of the preamble of this proposed rule, we are proposing to remove procedure code 37.52 (Implantation of internal biventricular heart replacement system) from the MCE ‘‘Non-Covered Procedure’’ edit and to assign it to the ‘‘Limited Coverage’’ edit. We are proposing to include in this proposed edit the requirement that ICD–9–CM diagnosis code V70.7 (Examination of participant in clinical trial) also be present on the claim. We are proposing that claims submitted without both procedure code 37.52 and diagnosis code V70.7 would be denied because they would not be in compliance with the proposed coverage policy explained in section II.G.1. of this preamble. 8. Surgical Hierarchies Some inpatient stays entail multiple surgical procedures, each one of which, occurring by itself, could result in assignment of the case to a different MS–DRG within the MDC to which the principal diagnosis is assigned. Therefore, it is necessary to have a decision rule within the GROUPER by which these cases are assigned to a single MS–DRG. The surgical hierarchy, an ordering of surgical classes from most resource-intensive to least resource-intensive, performs that function. Application of this hierarchy ensures that cases involving multiple surgical procedures are assigned to the MS–DRG associated with the most resource-intensive surgical class. Because the relative resource intensity of surgical classes can shift as a function of MS–DRG reclassification and recalibrations, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications and recalibrations, to determine if the ordering of classes coincides with the intensity of resource utilization. A surgical class can be composed of one or more MS–DRGs. For example, in MDC 11, the surgical class ‘‘kidney transplant’’ consists of a single MS–DRG (MS–DRG 652) and the class ‘‘kidney, ureter and major bladder procedures’’ consists of three MS–DRGs (MS–DRGs 653, 654, and 655). Consequently, in many cases, the surgical hierarchy has an impact on more than one MS–DRG. The methodology for determining the most resource-intensive surgical class involves weighting the average PO 00000 Frm 00049 Fmt 4701 Sfmt 4702 23575 resources for each MS–DRG by frequency to determine the weighted average resources for each surgical class. For example, assume surgical class A includes MS–DRGs 1 and 2 and surgical class B includes MS–DRGs 3, 4, and 5. Assume also that the average charge of MS–DRG 1 is higher than that of MS– DRG 3, but the average charges of MS– DRGs 4 and 5 are higher than the average charge of MS–DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each MS–DRG in the class by frequency (that is, by the number of cases in the MS– DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of ‘‘other O.R. procedures’’ as discussed below. This methodology may occasionally result in assignment of a case involving multiple procedures to the lowerweighted MS–DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER search for the procedure in the most resource-intensive surgical class, in cases involving multiple procedures, this result is sometimes unavoidable. We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average charge is ordered above a surgical class with a higher average charge. For example, the ‘‘other O.R. procedures’’ surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the average charge for the MS–DRG or MS–DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The ‘‘other O.R. procedures’’ class is a group of procedures that are only infrequently related to the diagnoses in the MDC, but are still occasionally performed on patients in the MDC with these diagnoses. Therefore, assignment to these surgical classes should only occur if no other surgical class more closely related to the diagnoses in the MDC is appropriate. A second example occurs when the difference between the average charges for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy because, as a result of reassigning cases on the basis of the hierarchy change, the average charges are likely to shift such that the higherordered surgical class has a lower E:\FR\FM\30APP2.SGM 30APP2 23576 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules average charge than the class ordered below it. For FY 2009, we are proposing a revision of the surgical hierarchy for MDC 5 (Diseases and Disorders of the Circulatory System) by placing MS–DRG 245 (AICD Generator Procedures) above proposed new MS–DRG 265 (AICD Lead Procedures). 9. CC Exclusions List a. Background As indicated earlier in the preamble of this proposed rule, under the IPPS DRG classification system, we have developed a standard list of diagnoses that are considered CCs. Historically, we developed this list using physician panels that classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial complication or comorbidity. A substantial complication or comorbidity was defined as a condition that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least 1 day in at least 75 percent of the patients. We refer readers to section II.D.2. and 3. of the preamble of the FY 2008 IPPS final rule with comment period for a discussion of the refinement of CCs in relation to the MS–DRGs we adopted for FY–2008 (72 FR 47152 through 47121). b. CC Exclusions List for FY 2009 In the September 1, 1987 final notice (52–FR–33143) concerning changes to the DRG classification system, we modified the GROUPER logic so that certain diagnoses included on the standard list of CCs would not be considered valid CCs in combination with a particular principal diagnosis. We created the CC Exclusions List for the following reasons: (1) To preclude coding of CCs for closely related conditions; (2) to preclude duplicative or inconsistent coding from being treated as CCs; and (3) to ensure that cases are appropriately classified between the complicated and uncomplicated DRGs in a pair. As we indicated above, we developed a list of diagnoses, using physician panels, to include those diagnoses that, when present as a secondary condition, would be considered a substantial complication or comorbidity. In previous years, we have made changes to the list of CCs, either by adding new CCs or deleting CCs already on the list. In the May 19, 1987 proposed notice (52 FR 18877) and the September 1, 1987 final notice (52 FR 33154), we explained that the excluded secondary diagnoses were established using the following five principles: • Chronic and acute manifestations of the same condition should not be considered CCs for one another. • Specific and nonspecific (that is, not otherwise specified (NOS)) diagnosis codes for the same condition should not be considered CCs for one another. • Codes for the same condition that cannot coexist, such as partial/total, unilateral/bilateral, obstructed/ unobstructed, and benign/malignant, should not be considered CCs for one another. • Codes for the same condition in anatomically proximal sites should not be considered CCs for one another. • Closely related conditions should not be considered CCs for one another. The creation of the CC Exclusions List was a major project involving hundreds of codes. We have continued to review the remaining CCs to identify additional exclusions and to remove diagnoses from the master list that have been shown not to meet the definition of a CC.12 For FY 2009, we are proposing to make limited revisions to the CC Exclusions List to take into account the changes that will be made in the ICD– 9–CM diagnosis coding system effective October 1, 2008. (See section II.G.11. of the preamble of this proposed rule with comment period for a discussion of ICD–9–CM changes.) We are proposing to make these changes in accordance with the principles established when we created the CC Exclusions List in 1987. In addition, as discussed in section II.D.3. of the preamble of this proposed rule, we are indicating on the CC exclusion list some updates to reflect the exclusion of a few codes from being an MCC under the MS–DRG system that we adopted for FY 2008. Tables 6G and 6H, Additions to and Deletions from the CC Exclusion List, respectively, which will be effective for discharges occurring on or after October 1, 2008, are not being published in this proposed rule because of the length of the two tables. Instead, we are making them available through the Internet on the CMS Web site at: https:// www.cms.hhs.gov/AcuteInpatientPPS. Each of these principal diagnoses for which there is a CC exclusion is shown in Tables 6G and 6H with an asterisk, and the conditions that will not count as a CC, are provided in an indented column immediately following the affected principal diagnosis. A complete updated MCC, CC, and Non-CC Exclusions List is also available through the Internet on the CMS Web site at: http:/www.cms.hhs.gov/ AcuteInpatientPPS. Beginning with discharges on or after October 1, 2008, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis. To assist readers in the review of changes to the MCC and CC lists that occurred as a result of updates to the ICD–9–CM codes, as described in Tables 6A, 6C, and 6E, we are providing the following summaries of those MCC and CC changes. SUMMARY OF ADDITIONS TO THE MS–DRG MCC LIST.—TABLE 6I.1 Code Description jlentini on PROD1PC65 with PROPOSALS2 249.10 ........................ 249.11 ........................ 249.20 ........................ Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with ketoacidosis, uncontrolled. Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified. 12 See the FY 1989 final rule (53 FR 38485, September 30, 1988), for the revision made for the discharges occurring in FY 1989; the FY 1990 final rule (54 FR 36552, September 1, 1989), for the FY 1990 revision; the FY 1991 final rule (55 FR 36126, September 4, 1990), for the FY 1991 revision; the FY 1992 final rule (56 FR 43209, August 30, 1991) for the FY 1992 revision; the FY 1993 final rule (57 FR 39753, September 1, 1992), for the FY 1993 revision; the FY 1994 final rule (58 FR 46278, September 1, 1993), for the FY 1994 revisions; the FY 1995 final rule (59 FR 45334, September 1, VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 1994), for the FY 1995 revisions; the FY 1996 final rule (60 FR 45782, September 1, 1995), for the FY 1996 revisions; the FY 1997 final rule (61 FR 46171, August 30, 1996), for the FY 1997 revisions; the FY 1998 final rule (62 FR 45966, August 29, 1997) for the FY 1998 revisions; the FY 1999 final rule (63 FR 40954, July 31, 1998), for the FY 1999 revisions; the FY 2001 final rule (65 FR 47064, August 1, 2000), for the FY 2001 revisions; the FY 2002 final rule (66 FR 39851, August 1, 2001), for the FY 2002 revisions; the FY 2003 final rule (67 FR 49998, August 1, 2002), for the FY 2003 revisions; the FY PO 00000 Frm 00050 Fmt 4701 Sfmt 4702 2004 final rule (68 FR 45364, August 1, 2003), for the FY 2004 revisions; the FY 2005 final rule (69 FR 49848, August 11, 2004), for the FY 2005 revisions; the FY 2006 final rule (70 FR 47640, August 12, 2005), for the FY 2006 revisions; the FY 2007 final rule (71 FR 47870) for the FY 2007 revisions; and the FY 2008 final rule (72 FR 47130) for the FY 2008 revisions. In the FY 2000 final rule (64 FR 41490, July 30, 1999, we did not modify the CC Exclusions List because we did not make any changes to the ICD–9–CM codes for FY 2000. E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules SUMMARY OF ADDITIONS TO THE MS–DRG MCC LIST.—TABLE 6I.1—Continued Code 249.21 249.30 249.31 707.23 707.24 777.50 777.51 777.52 777.53 780.72 Description ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ Secondary diabetes mellitus with hyperosmolarity, uncontrolled. Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with other coma, uncontrolled. Pressure ulcer, stage III. Pressure ulcer, stage IV. Necrotizing enterocolitis in newborn, unspecified. Stage I necrotizing enterocolitis in newborn. Stage II necrotizing enterocolitis in newborn. Stage III necrotizing enterocolitis in newborn. Functional quadriplegia. SUMMARY OF DELETIONS FROM THE MS–DRG MCC LIST.—TABLE 6I.2 Code Description 136.2 .......................... 511.8 .......................... 707.02 ........................ 707.03 ........................ 707.04 ........................ 707.05 ........................ 707.06 ........................ 707.07 ........................ 777.5 .......................... Specific infections by free-living amebae. Other specified forms of pleural effusion, except tuberculous. Pressure ulcer, upper back. Pressure ulcer, lower back. Pressure ulcer, hip. Pressure ulcer, buttock. Pressure ulcer, ankle. Pressure ulcer, heel. Necrotizing enterocolitis in fetus or newborn. SUMMARY OF ADDITIONS TO THE MS–DRG CC LIST.—TABLE 6J.1 jlentini on PROD1PC65 with PROPOSALS2 Code Description 046.11 ........................ 046.19 ........................ 046.71 ........................ 046.72 ........................ 046.79 ........................ 059.01 ........................ 059.21 ........................ 136.29 ........................ 199.2 .......................... 203.02 ........................ 203.12 ........................ 203.82 ........................ 204.02 ........................ 204.12 ........................ 204.22 ........................ 204.82 ........................ 204.92 ........................ 205.02 ........................ 205.12 ........................ 205.22 ........................ 205.32 ........................ 205.82 ........................ 205.92 ........................ 206.02 ........................ 206.12 ........................ 206.22 ........................ 206.82 ........................ 206.92 ........................ 207.02 ........................ 207.12 ........................ 207.22 ........................ 207.82 ........................ 208.02 ........................ 208.12 ........................ 208.22 ........................ 208.82 ........................ 208.92 ........................ 209.00 ........................ 209.01 ........................ 209.02 ........................ 209.03 ........................ VerDate Aug<31>2005 Variant Creutzfeldt-Jakob disease. Other and unspecified Creutzfeldt-Jakob disease. ¨ Gerstmann-Straussler-Scheinker syndrome. Fatal familial insomnia. Other and unspecified prion disease of central nervous system. Monkeypox. Tanapox. Other specific infections by free-living amebae. Malignant neoplasm associated with transplant organ. Multiple myeloma, in relapse. Plasma cell leukemia, in relapse. Other immunoproliferative neoplasms, in relapse. Acute lymphoid leukemia, in relapse. Chronic lymphoid leukemia, in relapse. Subacute lymphoid leukemia, in relapse. Other lymphoid leukemia, in relapse. Unspecified lymphoid leukemia, in relapse. Acute myeloid leukemia, in relapse. Chronic myeloid leukemia, in relapse. Subacute myeloid leukemia, in relapse. Myeloid sarcoma, in relapse. Other myeloid leukemia, in relapse. Unspecified myeloid leukemia, in relapse. Acute monocytic leukemia, in relapse. Chronic monocytic leukemia, in relapse. Subacute monocytic leukemia, in relapse. Other monocytic leukemia, in relapse. Unspecified monocytic leukemia, in relapse. Acute erythremia and erythroleukemia, in relapse. Chronic erythremia, in relapse. Megakaryocytic leukemia, in relapse. Other specified leukemia, in relapse. Acute leukemia of unspecified cell type, in relapse. Chronic leukemia of unspecified cell type, in relapse. Subacute leukemia of unspecified cell type, in relapse. Other leukemia of unspecified cell type, in relapse. Unspecified leukemia, in relapse. Malignant carcinoid tumor of the small intestine, unspecified portion. Malignant carcinoid tumor of the duodenum. Malignant carcinoid tumor of the jejunum. Malignant carcinoid tumor of the ileum. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00051 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23577 23578 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules SUMMARY OF ADDITIONS TO THE MS–DRG CC LIST.—TABLE 6J.1—Continued Code 209.10 209.11 209.12 209.13 209.14 209.15 209.16 209.17 209.20 209.21 209.22 209.23 209.24 209.25 209.26 209.27 209.29 209.30 238.77 279.50 279.51 279.52 279.53 346.60 Description ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ 346.61 ........................ 346.62 346.63 511.81 511.89 649.70 649.71 649.73 695.12 695.13 695.14 695.15 695.53 695.54 695.55 695.56 695.57 695.58 695.59 997.31 997.39 998.30 998.33 999.81 999.82 ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ ........................ Malignant carcinoid tumor of the large intestine, unspecified portion. Malignant carcinoid tumor of the appendix. Malignant carcinoid tumor of the cecum. Malignant carcinoid tumor of the ascending colon. Malignant carcinoid tumor of the transverse colon. Malignant carcinoid tumor of the descending colon. Malignant carcinoid tumor of the sigmoid colon. Malignant carcinoid tumor of the rectum. Malignant carcinoid tumor of unknown primary site. Malignant carcinoid tumor of the bronchus and lung. Malignant carcinoid tumor of the thymus. Malignant carcinoid tumor of the stomach. Malignant carcinoid tumor of the kidney. Malignant carcinoid tumor of foregut, not otherwise specified. Malignant carcinoid tumor of midgut, not otherwise specified. Malignant carcinoid tumor of hindgut, not otherwise specified. Malignant carcinoid tumor of other sites. Malignant poorly differentiated neuroendocrine carcinoma, any site. Post-transplant lymphoproliferative disorder (PTLD). Graft-versus-host disease, unspecified. Acute graft-versus-host disease. Chronic graft-versus-host disease. Acute on chronic graft-versus-host disease. Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status migrainosus. Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus. Persistent migraine aura with cerebral infarction, without mention of intractable migraine with status migrainosus. Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with status migrainosus. Malignant pleural effusion. Other specified forms of effusion, except tuberculous. Cervical shortening, unspecified as to episode of care or not applicable. Cervical shortening, delivered, with or without mention of antepartum condition. Cervical shortening, antepartum condition or complication. Erythema multiforme major. Stevens-Johnson syndrome. Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome. Toxic epidermal necrolysis. Exfoliation due to erythematous condition involving 30–39 percent of body surface. Exfoliation due to erythematous condition involving 40–49 percent of body surface. Exfoliation due to erythematous condition involving 50–59 percent of body surface. Exfoliation due to erythematous condition involving 60–69 percent of body surface. Exfoliation due to erythematous condition involving 70–79 percent of body surface. Exfoliation due to erythematous condition involving 80–89 percent of body surface. Exfoliation due to erythematous condition involving 90 percent or more of body surface. Ventilator associated pneumonia. Other respiratory complications. Disruption of wound, unspecified. Disruption of traumatic wound repair. Extravasation of vesicant chemotherapy. Extravasation of other vesicant agent. SUMMARY OF DELETIONS TO THE MS– DRG CC LIST.—TABLE 6J.2 Description 046.1 ...... 337.0 ...... jlentini on PROD1PC65 with PROPOSALS2 Code Jakob-Creutzfeldt disease. Idiopathic peripheral autonomic neuropathy. Erythema multiforme. Pressure ulcer, unspecified site. Pressure ulcer, elbow. Pressure ulcer, other site. Respiratory complications. Other transfusion reaction. 695.1 ...... 707.00 .... 707.01 .... 707.09 .... 997.3 ...... 999.8 ...... Alternatively, the complete documentation of the GROUPER logic, including the current CC Exclusions VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 List, is available from 3M/Health Information Systems (HIS), which, under contract with CMS, is responsible for updating and maintaining the GROUPER program. The current DRG Definitions Manual, Version 25.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 26.0 of this manual, which will include the final FY 2009 DRG changes, will be available in hard copy for $250.00. Version 26.0 of the manual is also available on a CD for $200.00; a combination hard copy and CD is available for $400.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road, PO 00000 Frm 00052 Fmt 4701 Sfmt 4702 Wallingford, CT 06492; or by calling (203) 949–0303. Please specify the revision or revisions requested. 10. Review of Procedure Codes in MS DRGs 981, 982, and 983; 984, 985, and 986; and 987, 988, and 989 Each year, we review cases assigned to former CMS DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis), CMS DRG 476 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis), and CMS DRG 477 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis) to determine whether it would be appropriate to change the procedures assigned among E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules these CMS DRGs. Under the MS–DRGs that we adopted for FY 2008, CMS DRG 468 was split three ways and became MS–DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC). CMS DRG 476 became MS–DRGs 984, 985, and 986 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC). CMS DRG 477 became MS–DRGs 987, 988, and 989 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC). MS–DRGs 981 through 983, 984 through 986, and 987 through 989 (formerly CMS DRGs 468, 476, and 477, respectively) are reserved for those cases in which none of the O.R. procedures performed are related to the principal diagnosis. These DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. MS–DRGs 984 through 986 (previously CMS DRG 476) are assigned to those discharges in which one or more of the following prostatic procedures are performed and are unrelated to the principal diagnosis: • 60.0, Incision of prostate. • 60.12, Open biopsy of prostate. • 60.15, Biopsy of periprostatic tissue. • 60.18, Other diagnostic procedures on prostate and periprostatic tissue. • 60.21, Transurethral prostatectomy. • 60.29, Other transurethral prostatectomy. • 60.61, Local excision of lesion of prostate. • 60.69, Prostatectomy, not elsewhere classified. • 60.81, Incision of periprostatic tissue. • 60.82, Excision of periprostatic tissue. • 60.93, Repair of prostate. • 60.94, Control of (postoperative) hemorrhage of prostate. • 60.95, Transurethral balloon dilation of the prostatic urethra. • 60.96, Transurethral destruction of prostate tissue by microwave thermotherapy. • 60.97, Other transurethral destruction of prostate tissue by other thermotherapy. • 60.99, Other operations on prostate. All remaining O.R. procedures are assigned to MS–DRGs 981 through 983 and 987 through 989, with MS–DRGs 987 through 989 assigned to those discharges in which the only procedures performed are nonextensive procedures VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 that are unrelated to the principal diagnosis.13 For FY 2009, we are not proposing to change the procedures assigned among these DRGs. a. Moving Procedure Codes From MS– DRGs 981 Through 983 or MS–DRGs 987 Through 989 to MDCs We annually conduct a review of procedures producing assignment to MS–DRGs 981 through 983 (formerly CMS DRG 468) or MS–DRGs 987 through 989 (formerly CMS DRG 477) on the basis of volume, by procedure, to see if it would be appropriate to move procedure codes out of these DRGs into one of the surgical DRGs for the MDC into which the principal diagnosis falls. The data are arrayed in two ways for comparison purposes. We look at a frequency count of each major operative procedure code. We also compare procedures across MDCs by volume of procedure codes within each MDC. We identify those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. For FY 2009, we are not proposing to remove any procedures from MS–DRGs 981 through 983 or MS–DRGs 987 through 989. b. Reassignment of Procedures Among MS–DRGs 981 Through 983, 984 Through 986, and 987 Through 989) We also annually review the list of ICD–9–CM procedures that, when in combination with their principal 13 The original list of the ICD–9–CM procedure codes for the procedures we consider nonextensive procedures, if performed with an unrelated principal diagnosis, was published in Table 6C in section IV. of the Addendum to the FY 1989 final rule (53 FR 38591). As part of the FY 1991 final rule (55 FR 36135), the FY 1992 final rule (56 FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final rule (58 FR 46279), the FY 1995 final rule (59 FR 45336), the FY 1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173), and the FY 1998 final rule (62 FR 45981), we moved several other procedures from DRG 468 to DRG 477, and some procedures from DRG 477 to DRG 468. No procedures were moved in FY 1999, as noted in the final rule (63 FR 40962); in FY 2000 (64 FR 41496); in FY 2001 (65 FR 47064); or in FY 2002 (66 FR 39852). In the FY 2003 final rule (67 FR 49999) we did not move any procedures from DRG 477. However, we did move procedure codes from DRG 468 and placed them in more clinically coherent DRGs. In the FY 2004 final rule (68 FR 45365), we moved several procedures from DRG 468 to DRGs 476 and 477 because the procedures are nonextensive. In the FY 2005 final rule (69 FR 48950), we moved one procedure from DRG 468 to 477. In addition, we added several existing procedures to DRGs 476 and 477. In the FY 2006 (70 FR 47317), we moved one procedure from DRG 468 and assigned it to DRG 477. In FY 2007, we moved one procedure from DRG 468 and assigned it to DRGs 479, 553, and 554. In FY 2008, no procedures were moved, as noted in the final rule with comment period (72 FR 46241). PO 00000 Frm 00053 Fmt 4701 Sfmt 4702 23579 diagnosis code, result in assignment to MS–DRGs 981 through 983, 984 through 986, and 987 through 989 (formerly, CMS DRGs 468, 476, and 477, respectively), to ascertain whether any of those procedures should be reassigned from one of these three DRGs to another of the three DRGs based on average charges and the length of stay. We look at the data for trends such as shifts in treatment practice or reporting practice that would make the resulting DRG assignment illogical. If we find these shifts, we would propose to move cases to keep the DRGs clinically similar or to provide payment for the cases in a similar manner. Generally, we move only those procedures for which we have an adequate number of discharges to analyze the data. For FY 2009, we are not proposing to move any procedure codes among these DRGs. c. Adding Diagnosis or Procedure Codes to MDCs Based on our review this year, we are not proposing to add any diagnosis codes to MDCs for FY 2009. 11. Changes to the ICD–9–CM Coding System As described in section II.B.1. of the preamble of this proposed rule, the ICD– 9–CM is a coding system used for the reporting of diagnoses and procedures performed on a patient. In September 1985, the ICD–9–CM Coordination and Maintenance Committee was formed. This is a Federal interdepartmental committee, co-chaired by the National Center for Health Statistics (NCHS), the Centers for Disease Control and Prevention, and CMS, charged with maintaining and updating the ICD–9– CM system. The Committee is jointly responsible for approving coding changes, and developing errata, addenda, and other modifications to the ICD–9–CM to reflect newly developed procedures and technologies and newly identified diseases. The Committee is also responsible for promoting the use of Federal and non-Federal educational programs and other communication techniques with a view toward standardizing coding applications and upgrading the quality of the classification system. The Official Version of the ICD–9–CM contains the list of valid diagnosis and procedure codes. (The Official Version of the ICD–9–CM is available from the Government Printing Office on CD– ROM for $27.00 by calling (202) 512– 1800.) Complete information on ordering the CD–ROM is also available at: https://www.cdc.gov/nchs/products/ prods/subject/icd96ed.htm. The Official E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23580 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Version of the ICD–9–CM is no longer available in printed manual form from the Federal Government; it is only available on CD–ROM. Users who need a paper version are referred to one of the many products available from publishing houses. The NCHS has lead responsibility for the ICD–9–CM diagnosis codes included in the Tabular List and Alphabetic Index for Diseases, while CMS has lead responsibility for the ICD–9–CM procedure codes included in the Tabular List and Alphabetic Index for Procedures. The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and various physician specialty groups, as well as individual physicians, health information management professionals, and other members of the public, to contribute ideas on coding matters. After considering the opinions expressed at the public meetings and in writing, the Committee formulates recommendations, which then must be approved by the agencies. The Committee presented proposals for coding changes for implementation in FY 2009 at a public meeting held on September 27–28, 2007 and finalized the coding changes after consideration of comments received at the meetings and in writing by December 3, 2007. Those coding changes are announced in Tables 6A through 6F in the Addendum to this proposed rule. The Committee held its 2008 meeting on March 19–20, 2008. Proposed new codes for which there was a consensus of public support and for which complete tabular and indexing changes can be made by May 2008 will be included in the October 1, 2008 update to ICD–9–CM. Code revisions that were discussed at the March 19–20, 2008 Committee meeting but that could not be finalized in time to include them in the Addendum to this proposed rule are not included in Tables 6A through 6F. These additional codes will be included in Tables 6A through 6F of the final rule with comment period and are marked with an asterisk (*). Copies of the minutes of the procedure codes discussions at the Committee’s September 27–28, 2007 meeting can be obtained from the CMS Web site at: https://cms.hhs.gov/ VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 ICD9ProviderDiagnosticCodes/ 03_meetings.asp. The minutes of the diagnosis codes discussions at the September 27–28, 2007 meeting are found at: https://www.cdc.gov/nchs/ icd9.htm. Paper copies of these minutes are no longer available and the mailing list has been discontinued. These Web sites also provide detailed information about the Committee, including information on requesting a new code, attending a Committee meeting, and timeline requirements and meeting dates. We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, CoChairperson, ICD–9–CM Coordination and Maintenance Committee, NCHS, Room 2402, 3311 Toledo Road, Hyattsville, MD 20782. Comments may be sent by E-mail to: dfp4@cdc.gov. Questions and comments concerning the procedure codes should be addressed to: Patricia E. Brooks, CoChairperson, ICD–9–CM Coordination and Maintenance Committee, CMS, Center for Medicare Management, Hospital and Ambulatory Policy Group, Division of Acute Care, C4–08–06, 7500 Security Boulevard, Baltimore, MD 21244–1850. Comments may be sent by E-mail to: patricia.brooks2@cms.hhs.gov. The ICD–9–CM code changes that have been approved will become effective October 1, 2008. The new ICD– 9–CM codes are listed, along with their DRG classifications, in Tables 6A and 6B (New Diagnosis Codes and New Procedure Codes, respectively) in the Addendum to this proposed rule. As we stated above, the code numbers and their titles were presented for public comment at the ICD–9–CM Coordination and Maintenance Committee meetings. Both oral and written comments were considered before the codes were approved. In this proposed rule, we are only soliciting comments on the proposed classification of these new codes. For codes that have been replaced by new or expanded codes, and the corresponding new or expanded diagnosis codes are included in Table 6A. New procedure codes are shown in Table 6B. Diagnosis codes that have been replaced by expanded codes or other codes or have been deleted are in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2008. Table 6D contains invalid procedure codes. These invalid procedure codes will not be recognized by the GROUPER beginning with discharges occurring on or after PO 00000 Frm 00054 Fmt 4701 Sfmt 4702 October 1, 2008. Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also includes the MS–DRG assignments for these revised codes. Table 6F includes revised procedure code titles for FY 2009. In the September 7, 2001 final rule implementing the IPPS new technology add-on payments (66 FR 46906), we indicated we would attempt to include proposals for procedure codes that would describe new technology discussed and approved at the Spring meeting as part of the code revisions effective the following October. As stated previously, ICD–9–CM codes discussed at the March 19–20, 2008 Committee meeting that received consensus and that are finalized by May 2008, will be included in Tables 6A through 6F of the Addendum to the final rule. Section 503(a) of Pub. L. 108–173 included a requirement for updating ICD–9–CM codes twice a year instead of a single update on October 1 of each year. This requirement was included as part of the amendments to the Act relating to recognition of new technology under the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by adding a clause (vii) which states that the ‘‘Secretary shall provide for the addition of new diagnosis and procedure codes on April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * * until the fiscal year that begins after such date.’’ This requirement improves the recognition of new technologies under the IPPS system by providing information on these new technologies at an earlier date. Data will be available 6 months earlier than would be possible with updates occurring only once a year on October 1. While section 1886(d)(5)(K)(vii) of the Act states that the addition of new diagnosis and procedure codes on April 1 of each year shall not require the Secretary to adjust the payment, or DRG classification, under section 1886(d) of the Act until the fiscal year that begins after such date, we have to update the DRG software and other systems in order to recognize and accept the new codes. We also publicize the code changes and the need for a mid-year systems update by providers to identify the new codes. Hospitals also have to obtain the new code books and encoder updates, and make other system changes in order to identify and report the new codes. The ICD–9–CM Coordination and Maintenance Committee holds its E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules meetings in the spring and fall in order to update the codes and the applicable payment and reporting systems by October 1 of each year. Items are placed on the agenda for the ICD–9–CM Coordination and Maintenance Committee meeting if the request is received at least 2 months prior to the meeting. This requirement allows time for staff to review and research the coding issues and prepare material for discussion at the meeting. It also allows time for the topic to be publicized in meeting announcements in the Federal Register as well as on the CMS Web site. The public decides whether or not to attend the meeting based on the topics listed on the agenda. Final decisions on code title revisions are currently made by March 1 so that these titles can be included in the IPPS proposed rule. A complete addendum describing details of all changes to ICD–9–CM, both tabular and index, is published on the CMS and NCHS Web sites in May of each year. Publishers of coding books and software use this information to modify their products that are used by health care providers. This 5-month time period has proved to be necessary for hospitals and other providers to update their systems. A discussion of this timeline and the need for changes are included in the December 4–5, 2005 ICD–9–CM Coordination and Maintenance Committee minutes. The public agreed that there was a need to hold the fall meetings earlier, in September or October, in order to meet the new implementation dates. The public provided comment that additional time would be needed to update hospital systems and obtain new code books and coding software. There was considerable concern expressed about the impact this new April update would have on providers. In the FY 2005 IPPS final rule, we implemented section 1886(d)(5)(K)(vii) of the Act, as added by section 503(a) of Pub. L. 108–173, by developing a mechanism for approving, in time for the April update, diagnosis and procedure code revisions needed to describe new technologies and medical services for purposes of the new technology add-on payment process. We also established the following process for making these determinations. Topics considered during the Fall ICD–9–CM Coordination and Maintenance Committee meeting are considered for an April 1 update if a strong and convincing case is made by the requester at the Committee’s public meeting. The request must identify the reason why a new code is needed in April for purposes of the new VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 technology process. The participants at the meeting and those reviewing the Committee meeting summary report are provided the opportunity to comment on this expedited request. All other topics are considered for the October 1 update. Participants at the Committee meeting are encouraged to comment on all such requests. There were no requests approved for an expedited April l, 2008 implementation of an ICD– 9–CM code at the September 27–28, 2007 Committee meeting. Therefore, there were no new ICD–9–CM codes implemented on April 1, 2008. We believe that this process captures the intent of section 1886(d)(5)(K)(vii) of the Act. This requirement was included in the provision revising the standards and process for recognizing new technology under the IPPS. In addition, the need for approval of new codes outside the existing cycle (October 1) arises most frequently and most acutely where the new codes will identify new technologies that are (or will be) under consideration for new technology addon payments. Thus, we believe this provision was intended to expedite data collection through the assignment of new ICD–9–CM codes for new technologies seeking higher payments. Current addendum and code title information is published on the CMS Web site at: www.cms.hhs.gov/ icd9ProviderDiagnosticCodes/ 01_overview.asp#TopofPage. Information on ICD–9–CM diagnosis codes, along with the Official ICD–9– CM Coding Guidelines, can be found on the Web site at: www.cdc.gov/nchs/ icd9.htm. Information on new, revised, and deleted ICD–9–CM codes is also provided to the AHA for publication in the Coding Clinic for ICD–9–CM. AHA also distributes information to publishers and software vendors. CMS also sends copies of all ICD–9– CM coding changes to its contractors for use in updating their systems and providing education to providers. These same means of disseminating information on new, revised, and deleted ICD–9–CM codes will be used to notify providers, publishers, software vendors, contractors, and others of any changes to the ICD–9–CM codes that are implemented in April. The code titles are adopted as part of the ICD–9–CM Coordination and Maintenance Committee process. Thus, although we publish the code titles in the IPPS proposed and final rules, they are not subject to comment in the proposed or final rules. We will continue to publish the October code updates in this manner within the IPPS proposed and final rules. For codes that are implemented in April, we will assign the new procedure PO 00000 Frm 00055 Fmt 4701 Sfmt 4702 23581 code to the same DRG in which its predecessor code was assigned so there will be no DRG impact as far as DRG assignment. Any midyear coding updates will be available through the Web sites indicated above and through the Coding Clinic for ICD–9–CM. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software systems. We will strive to have the April 1 updates available through these Web sites 5 months prior to implementation (that is, early November of the previous year), as is the case for the October 1 updates. H. Recalibration of MS–DRG Weights In section II.E. of the preamble of this proposed rule, we state that we are proposing to fully implement the costbased DRG relative weights for FY 2009, which is the third year in the 3-year transition period to calculate the relative weights at 100 percent based on costs. In the FY 2008 IPPS final rule with comment period (72 FR 47267), as recommended by RTI, for FY 2008, we added two new CCRs for a total of 15 CCRs: one for ‘‘Emergency Room’’ and one for ‘‘Blood and Blood Products,’’ both of which can be derived directly from the Medicare cost report. In developing the FY 2009 proposed system of weights, we used two data sources: claims data and cost report data. As in previous years, the claims data source is the MedPAR file. This file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. The FY 2007 MedPAR data used in this proposed rule include discharges occurring on October 1, 2006, through September 30, 2007, based on bills received by CMS through December 2007, from all hospitals subject to the IPPS and short-term, acute care hospitals in Maryland (which are under a waiver from the IPPS under section 1814(b)(3) of the Act). The FY 2007 MedPAR file used in calculating the relative weights includes data for approximately 11,433,806 Medicare discharges from IPPS providers. Discharges for Medicare beneficiaries enrolled in a Medicare Advantage managed care plan are excluded from this analysis. The data exclude CAHs, including hospitals that subsequently became CAHs after the period from which the data were taken. The second data source used in the cost-based relative weighting methodology is the FY 2006 Medicare cost report data files from HCRIS (that is, cost reports beginning on or after October 1, 2005, and before October 1, 2006), which represents the most recent full set of cost report data available. We used the E:\FR\FM\30APP2.SGM 30APP2 23582 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 December 31, 2007 update of the HCRIS cost report files for FY 2006 in setting the relative cost-based weights. The methodology we used to calculate the DRG cost-based relative weights from the FY 2007 MedPAR claims data and FY 2006 Medicare cost report data is as follows: • To the extent possible, all the claims were regrouped using the proposed FY 2009 MS–DRG classifications discussed in sections II.B. and G. of the preamble of this proposed rule. • The transplant cases that were used to establish the relative weights for heart and heart-lung, liver and/or intestinal, and lung transplants (MS–DRGs 001, 002, 005, 006, and 007, respectively) were limited to those Medicareapproved transplant centers that have cases in the FY 2007 MedPAR file. (Medicare coverage for heart, heart-lung, liver and/or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.) • Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 from the prospective payment rate, it is necessary to subtract the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average cost for each DRG and before eliminating statistical outliers. • Claims with total charges or total length of stay less than or equal to zero were deleted. Claims that had an amount in the total charge field that differed by more than $10.00 from the sum of the routine day charges, intensive care charges, pharmacy charges, special equipment charges, therapy services charges, operating room charges, cardiology charges, laboratory charges, radiology charges, other service charges, labor and delivery charges, inhalation therapy charges, emergency room charges, blood charges, and anesthesia charges were also deleted. • At least 96.1 percent of the providers in the MedPAR file had charges for 10 of the 15 cost centers. Claims for providers that did not have charges greater than zero for at least 10 of the 15 cost centers were deleted. • Statistical outliers were eliminated by removing all cases that were beyond 3.0 standard deviations from the mean of the log distribution of both the total PO 00000 Frm 00056 Fmt 4701 Sfmt 4702 charges per case and the total charges per day for each DRG. Once the MedPAR data were trimmed and the statistical outliers were removed, the charges for each of the 15 cost groups for each claim were standardized to remove the effects of differences in area wage levels, IME and DSH payments, and for hospitals in Alaska and Hawaii, the applicable costof-living adjustment. Because hospital charges include charges for both operating and capital costs, we standardized total charges to remove the effects of differences in geographic adjustment factors, cost-of-living adjustments, DSH payments, and IME adjustments under the capital IPPS as well. Charges were then summed by DRG for each of the 15 cost groups so that each DRG had 15 standardized charge totals. These charges were then adjusted to cost by applying the national average CCRs developed from the FY 2006 cost report data. The 15 cost centers that we used in the relative weight calculation are shown in the following table. The table shows the lines on the cost report and the corresponding revenue codes that we used to create the 15 national cost center CCRs. BILLING CODE 4120–01–P E:\FR\FM\30APP2.SGM 30APP2 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00057 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23583 EP30AP08.012</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00058 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.013</GPH> jlentini on PROD1PC65 with PROPOSALS2 23584 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00059 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23585 EP30AP08.014</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00060 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.015</GPH> jlentini on PROD1PC65 with PROPOSALS2 23586 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00061 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23587 EP30AP08.016</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 BILLING CODE 4120–01–C We developed the national average CCRs as follows: Taking the FY 2006 cost report data, we removed CAHs, Indian Health Service hospitals, all-inclusive rate hospitals, and cost reports that represented time periods of less than 1 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 year (365 days). We included hospitals located in Maryland as we are including their charges in our claims database. We then created CCRs for each provider for each cost center (see prior table for line items used in the calculations) and removed any CCRs that were greater PO 00000 Frm 00062 Fmt 4701 Sfmt 4702 than 10 or less than 0.01. We normalized the departmental CCRs by dividing the CCR for each department by the total CCR for the hospital for the purpose of trimming the data. We then took the logs of the normalized cost center CCRs and removed any cost E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.017</GPH> 23588 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules center CCRs where the log of the cost center CCR was greater or less than the mean log plus/minus 3 times the standard deviation for the log of that cost center CCR. Once the cost report data were trimmed, we calculated a Medicare-specific CCR. The Medicarespecific CCR was determined by taking the Medicare charges for each line item from Worksheet D–4 and deriving the Medicare-specific costs by applying the hospital-specific departmental CCRs to the Medicare-specific charges for each line item from Worksheet D–4. Once each hospital’s Medicare-specific costs were established, we summed the total Medicare-specific costs and divided by the sum of the total Medicare-specific charges to produce national average, charge-weighted CCRs. After we multiplied the total charges for each DRG in each of the 15 cost centers by the corresponding national average CCR, we summed the 15 ‘‘costs’’ across each DRG to produce a total standardized cost for the DRG. The average standardized cost for each DRG was then computed as the total standardized cost for the DRG divided by the transfer-adjusted case count for the DRG. The average cost for each DRG was then divided by the national average standardized cost per case to determine the relative weight. The new cost-based relative weights were then normalized by an adjustment factor of 1.50612 so that the average case weight after recalibration was equal to the average case weight before recalibration. The normalization adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS, as required by section 1886(d)(4)(C)(iii) of the Act. The 15 proposed national average CCRs for FY 2009 are as follows: contain fewer than 10 cases. Under the MS–DRGs, we have fewer low-volume Routine Days .................................. 0.527 DRGs than under the CMS DRGs Intensive Days ................................ 0.476 because we no longer have separate Drugs .............................................. 0.205 DRGs for patients age 0 to 17 years. Supplies & Equipment .................... 0.341 Therapy Services ............................ 0.419 With the exception of newborns, we Laboratory ....................................... 0.166 previously separated some DRGs based Operating Room ............................. 0.293 on whether the patient was age 0 to 17 Cardiology ....................................... 0.186 years or age 17 years and older. Other Radiology ........................................ 0.171 than the age split, cases grouping to Emergency Room ........................... 0.291 these DRGs are identical. The DRGs for Blood and Blood Products .............. 0.449 Other Services ................................ 0.419 patients age 0 to 17 years generally have Labor & Delivery ............................. 0.482 very low volumes because children are Inhalation Therapy .......................... 0.198 typically ineligible for Medicare. In the Anesthesia ...................................... 0.150 past, we have found that the low volume of cases for the pediatric DRGs As we explained in section II.E. of the could lead to significant year-to-year preamble of this proposed rule, we are instability in their relative weights. proposing to complete our 2-year Although we have always encouraged transition to the MS–DRGs. For FY non-Medicare payers to develop weights 2008, the first year of the transition, 50 applicable to their own patient percent of the relative weight for an populations, we have heard frequent MS–DRG was based on the two-thirds complaints from providers about the use cost-based weight/one-third chargeof the Medicare relative weights in the based weight calculated using FY 2006 pediatric population. We believe that MedPAR data grouped to the Version eliminating this age split in the MS– 24.0 (FY 2007) DRGs. The remaining 50 DRGs will provide more stable payment percent of the FY 2008 relative weight for pediatric cases by determining their for an MS–DRG was based on the twopayment using adult cases that are thirds cost-based weight/one-third much higher in total volume. All of the charge-based weight calculated using low-volume MS–DRGs listed below are FY 2006 MedPAR grouped to the Version 25.0 (FY 2008) MS–DRGs. In FY for newborns. Newborns are unique and require separate DRGs that are not 2009, we are proposing that the relative mirrored in the adult population. weights will be based on 100 percent Therefore, it remains necessary to retain cost weights computed using the separate DRGs for newborns. In FY Version 26.0 (FY 2009) MS–DRGs. 2009, because we do not have sufficient When we recalibrated the DRG MedPAR data to set accurate and stable weights for previous years, we set a cost weights for these low-volume MS– threshold of 10 cases as the minimum DRGs, we are proposing to compute number of cases required to compute a weights for the low-volume MS–DRGs reasonable weight. We are proposing to by adjusting their FY 2008 weights by use that same case threshold in the percentage change in the average recalibrating the MS–DRG weights for FY 2009. Using the FY 2007 MedPAR weight of the cases in other MS–DRGs. data set, there are 8 MS–DRGs that The crosswalk table is shown below: Group CCR Low-volume MS–DRG MS-DRG title 768 ................ Vaginal Delivery with O.R. Procedure Except Sterilization and/ or D&C. Neonates, Died or Transferred to Another Acute Care Facility 789 ................ Crosswalk to MS–DRG 791 ................ Extreme Immaturity or Respiratory Distress Syndrome, Neonate. Prematurity with Major Problems ................................................ 792 ................ Prematurity without Major Problems ........................................... 793 ................ Full-Term Neonate with Major Problems .................................... 794 ................ jlentini on PROD1PC65 with PROPOSALS2 790 ................ Neonate with Other Significant Problems ................................... 795 ................ Normal Newborn ......................................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 23589 PO 00000 Frm 00063 Fmt 4701 Sfmt 4702 FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). FY 2008 FR weight (adjusted by percent weight of the cases in other MS–DRGs). E:\FR\FM\30APP2.SGM 30APP2 change in average change in average change in average change in average change in average change in average change in average change in average 23590 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 I. Proposed Medicare Severity LongTerm Care (MS–LTC–DRG) Reclassifications and Relative Weights for LTCHs for FY 2009 1. Background Section 123 of the BBRA requires that the Secretary implement a PPS for LTCHs (that is, a per discharge system with a diagnosis-related group (DRG)based patient classification system reflecting the differences in patient resources and costs). Section 307(b)(1) of the BIPA modified the requirements of section 123 of the BBRA by requiring that the Secretary examine ‘‘the feasibility and the impact of basing payment under such a system [the longterm care hospital (LTCH) PPS] on the use of existing (or refined) hospital DRGs that have been modified to account for different resource use of LTCH patients, as well as the use of the most recently available hospital discharge data.’’ When the LTCH PPS was implemented for cost reporting periods beginning on or after October 1, 2002, we adopted the same DRG patient classification system (that is, the CMS DRGs) that was utilized at that time under the IPPS. As a component of the LTCH PPS, we refer to the patient classification system as the ‘‘long-term care diagnosis-related groups (LTC– DRGs).’’ As discussed in greater detail below, although the patient classification system used under both the LTCH PPS and the IPPS are the same, the relative weights are different. The established relative weight methodology and data used under the LTCH PPS result in LTC–DRG relative weights that reflect ‘‘the differences in patient resource use * * *’’ of LTCH patients (section 123(a)(1) of the BBRA (Pub. L. 106–113). As part of our efforts to better recognize severity of illness among patients, in the FY 2008 IPPS final rule with comment period (72 FR 47130), the MS–DRGs and the Medicare severity long-term care diagnosis related groups (MS–LTC–DRGs) were adopted for the IPPS and the LTCH PPS, respectively, effective October 1, 2007 (FY 2008). For a full description of the development and implementation of the MS–DRGs and MS–LTC–DRGs, we refer readers to the FY 2008 IPPS final rule with comment period (72 FR 47141 through 47175 and 47277 through 47299). (We note that, in that same final rule, we revised the regulations at § 412.503 to specify that for LTCH discharges occurring on or after October 1, 2007, when applying the provisions of 42 CFR Part 412, Subpart O applicable to LTCHs for policy descriptions and payment calculations, VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 all references to LTC–DRGs would be considered a reference to MS–LTC– DRGs. For the remainder of this section, we present the discussion in terms of the current MS–LTC–DRG patient classification unless specifically referring to the previous LTC–DRG patient classification system (that was in effect before October 1, 2007).) We believe the MS–DRGs (and by extension, the MS–LTC–DRGs) represent a substantial improvement over the previous CMS DRGs in their ability to differentiate cases based on severity of illness and resource consumption. The MS–DRGs represent an increase in the number of DRGs by 207 (that is, from 538 to 745) (72 FR 47171). In addition to improving the DRG system’s recognition of severity of illness, we believe the MS–DRGs are responsive to the public comments that were made on the FY 2007 IPPS proposed rule with respect to how we should undertake further DRG reform. The MS–DRGs use the CMS DRGs as the starting point for revising the DRG system to better recognize resource complexity and severity of illness. We have generally retained all of the refinements and improvements that have been made to the base DRGs over the years that recognize the significant advancements in medical technology and changes to medical practice. Consistent with section 123 of the BBRA as amended by section 307(b)(1) of the BIPA and § 412.515, we use information derived from LTCH PPS patient records to classify LTCH discharges into distinct MS–LTC–DRGs based on clinical characteristics and estimated resource needs. We then assign an appropriate weight to the MS– LTC–DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple medical problems characteristic of LTCHs. Generally, under the LTCH PPS, a Medicare payment is made at a predetermined specific rate for each discharge; and that payment varies by the MS–LTC–DRG to which a beneficiary’s stay is assigned. Cases are classified into MS–LTC–DRGs for payment based on the following six data elements: • Principal diagnosis. • Up to eight additional diagnoses. • Up to six procedures performed. • Age. • Sex. • Discharge status of the patient. Upon the discharge of the patient from a LTCH, the LTCH must assign appropriate diagnosis and procedure codes from the most current version of the International Classification of PO 00000 Frm 00064 Fmt 4701 Sfmt 4702 Diseases, Ninth Revision, Clinical Modification (ICD–9–CM). HIPAA Transactions and Code Sets Standards regulations at 45 CFR Parts 160 and 162 require that no later than October 16, 2003, all covered entities must comply with the applicable requirements of Subparts A and I through R of Part 162. Among other requirements, those provisions direct covered entities to use the ASC X12N 837 Health Care Claim: Institutional, Volumes 1 and 2, Version 4010, and the applicable standard medical data code sets for the institutional health care claim or equivalent encounter information transaction (see 45 CFR 162.1002 and 45 CFR 162.1102). For additional information on the ICD–9–CM Coding System, we refer readers to the FY 2008 IPPS final rule with comment period (72 FR 47241 through 47243 and 47277 through 47281). We also refer readers to the detailed discussion on correct coding practices in the August 30, 2002 LTCH PPS final rule (67 FR 55981 through 55983). Additional coding instructions and examples are published in the Coding Clinic for ICD–9–CM, a product of the American Hospital Association. Medicare contractors (that is, fiscal intermediaries or MACs) enter the clinical and demographic information into their claims processing systems and subject this information to a series of automated screening processes called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before assignment into a MS–LTC–DRG can be made. During this process, the following types of cases are selected for further development: • Cases that are improperly coded. (For example, diagnoses are shown that are inappropriate, given the sex of the patient. Code 68.69 (Other and unspecified radical abdominal hysterectomy) would be an inappropriate code for a male.) • Cases including surgical procedures not covered under Medicare. (For example, organ transplant in a nonapproved transplant center.) • Cases requiring more information. (For example, ICD–9–CM codes are required to be entered at their highest level of specificity. There are valid 3digit, 4-digit, and 5-digit codes. That is, code 262 (Other severe protein-calorie malnutrition) contains all appropriate digits, but if it is reported with either fewer or more than 3 digits, the claim will be rejected by the MCE as invalid.) After screening through the MCE, each claim is classified into the appropriate MS–LTC–DRG by the Medicare LTCH GROUPER software. E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules The Medicare GROUPER software, which is used under the LTCH PPS, is specialized computer software, and is the same GROUPER software program used under the IPPS. The GROUPER software was developed as a means of classifying each case into a MS–LTC– DRG on the basis of diagnosis and procedure codes and other demographic information (age, sex, and discharge status). Following the MS–LTC–DRG assignment, the Medicare contractor determines the prospective payment amount by using the Medicare PRICER program, which accounts for hospitalspecific adjustments. Under the LTCH PPS, we provide an opportunity for the LTCH to review the MS–LTC–DRG assignments made by the Medicare contractor and to submit additional information within a specified timeframe as specified in § 412.513(c). The GROUPER software is used both to classify past cases to measure relative hospital resource consumption to establish the DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the MedPAR file. The data in this file are used to evaluate possible MS–DRG classification changes and to recalibrate the MS–DRG and MS–LTC–DRG relative weights during our annual update under both the IPPS (§ 412.60(e)) and the LTCH PPS (§ 412.517), respectively. In the June 6, 2003 LTCH PPS final rule (68 FR 34122), we changed the LTCH PPS annual payment rate update cycle to be effective July 1 through June 30 instead of October 1 through September 30. In addition, because the patient classification system utilized under the LTCH PPS uses the same DRGs as those used under the IPPS for acute care hospitals, in that same final rule, we explained that the annual update of the LTC–DRG classifications and relative weights will continue to remain linked to the annual reclassification and recalibration of the DRGs used under the IPPS. Therefore, we specified that we will continue to update the LTC–DRG classifications and relative weights to be effective for discharges occurring on or after October 1 through September 30 each year. We further stated that we will publish the annual proposed and final update of the LTC–DRGs in same notice as the proposed and final update for the IPPS (69 FR 34125). In the RY 2009 LTCH PPS proposed rule (73 FR 5351–5352), due to administrative considerations as well as in response to numerous comments urging CMS to establish one rulemaking cycle that would encompass the update VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 of the LTCH PPS payment rates (currently updated on a rate year basis, effective July 1) as well as the development of the LTC–DRG weights (currently updated on a fiscal year basis, effective October 1), we proposed to amend the regulations at § 412.535 in order to consolidate the rate year and fiscal year rulemaking cycles. Specifically, we proposed that the annual update of the LTCH PPS payment rates (and description of the methodology and data used to calculate these payment rates) and the annual update of the MS–LTC–DRG classifications and associated weighting factors for LTCHs would be effective on October 1 each Federal fiscal year. In order to revise the payment rate update (currently on a rate year cycle of July 1 through June 30) to an October 1 through September 30 cycle, we proposed to extend the 2009 rate period to September 30, 2009, so that RY 2009 would be 15 months. This proposed 15month rate period would extend from July 1, 2008, through September 30, 2009. We believe that extending RY 2009 by 3 months (July, August, and September) would provide for a smooth transition to a consolidated annual update for both the LTCH PPS payment rates and the LTCH PPS MS–LTC–DRG classifications and weighting factors. (We believe that proposing to shorten the 2009 rate year period to an October 1 through September 30 period so that RY 2009 would only be 3 months (that is, July 1, 2008 through September 30, 2008) would exacerbate the current time-consuming, biannual update process by resulting in two payment rate changes within a very short period of time.) Consequently, under the proposal to extend RY 2009 to a 15-month rate period, after September 30, 2009, when the RY 2009 cycle ends, the LTCH PPS payment rates and other policy changes would subsequently be updated on an October 1 through September 30 cycle in conjunction with the annual update to the MS–LTC–DRG classifications and relative weights. Accordingly, the next update to the LTCH PPS payment rates, after the proposed 15-month RY 2009, would begin October 1, 2009, coinciding with the 2010 Federal fiscal year. In the past, the annual update to the DRGs used under the IPPS has been based on the annual revisions to the ICD–9–CM codes and was effective each October 1. As discussed in the RY 2009 LTCH PPS proposed rule (73 FR 5348– 5349), with the implementation of section 503(a) of Pub. L. 108–173, there is the possibility that one feature of the GROUPER software program may be updated twice during a Federal fiscal PO 00000 Frm 00065 Fmt 4701 Sfmt 4702 23591 year (October 1 and April 1) as required by the statute for the IPPS. Section 503(a) of Pub. L. 108–173 amended section 1886(d)(5)(K) of the Act by adding a new clause (vii) which states that ‘‘the Secretary shall provide for the addition of new diagnosis and procedure codes in [sic] April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * * until the fiscal year that begins after such date.’’ This requirement improves the recognition of new technologies under the IPPS by accounting for those ICD–9–CM codes in the MedPAR claims data earlier than the agency had accounted for new technology in the past. In implementing the statutory change, the agency has provided that ICD–9–CM diagnosis and procedure codes for new medical technology may be created and assigned to existing DRGs in the middle of the Federal fiscal year, on April 1. However, this policy change will not impact the DRG relative weights in effect for that year, which will continue to be updated only once a year (October 1). The use of the ICD–9–CM code set is also compliant with the current requirements of the Transactions and Code Sets Standards regulations at 45 CFR Parts 160 and 162, promulgated in accordance with HIPAA. As noted above, the patient classification system used under the LTCH PPS is the same patient classification system that is used under the IPPS. Therefore, the ICD–9–CM codes currently used under both the IPPS and the LTCH PPS have the potential of being updated twice a year. This requirement is included as part of the amendments to the Act relating to recognition of new medical technology under the IPPS. Because we do not publish a midyear IPPS rule, any April 1 ICD–9–CM coding update will not be published in the Federal Register. Rather, we will assign any new diagnosis or procedure codes to the same DRG in which its predecessor code was assigned, so that there will be no impact on the DRG assignments (as also discussed in section II.G.11. of the preamble of this proposed rule). Any coding updates will be available through the Web sites provided in section II.G.11. of the preamble of this proposed rule and through the Coding Clinic for ICD–9– CM. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software system. If new codes are implemented on April 1, revised code books and software systems, including the GROUPER E:\FR\FM\30APP2.SGM 30APP2 23592 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 software program, will be necessary because the most current ICD–9–CM codes must be reported. Therefore, for purposes of the LTCH PPS, because each ICD–9–CM code must be included in the GROUPER algorithm to classify each case under the correct LTCH PPS, the GROUPER software program used under the LTCH PPS would need to be revised to accommodate any new codes. In implementing section 503(a) of Pub. L. 108–173, there will only be an April 1 update if new technology diagnosis and procedure code revisions are requested and approved. We note that any new codes created for April 1 implementation will be limited to those primarily needed to describe new technologies and medical services. However, we reiterate that the process of discussing updates to the ICD–9–CM is an open process through the ICD–9– CM Coordination and Maintenance Committee. Requestors will be given the opportunity to present the merits for a new code and to make a clear and convincing case for the need to update ICD–9–CM codes for purposes of the IPPS new technology add-on payment process through an April 1 update (as also discussed in section II.G.11. of the preamble of this proposed rule). At the September 27, 2007 ICD–9–CM Coordination and Maintenance Committee meeting, there were no requests for an April 1, 2008 implementation of ICD–9–CM codes. Therefore, the next update to the ICD– 9–CM coding system will occur on October 1, 2008 (FY 2009). Because there were no coding changes suggested for an April 1, 2008 update, the ICD–9– CM coding set implemented on October 1, 2008, will continue through September 30, 2009 (FY 2009). The update to the ICD–9–CM coding system for FY 2009 is discussed in section II.G.11. of the preamble of this proposed rule. Accordingly, in this proposed rule, as discussed in greater detail below, we are proposing to modify and revise the MS–LTC–DRG classifications and relative weights to be effective October 1, 2008 through September 30, 2009 (FY 2009). As discussed in greater detail below, the MS–LTC–DRGs for FY 2009 in this proposed rule are the same as the MS–DRGs proposed for the IPPS for FY 2009 (GROUPER Version 26.0) discussed in section II.B. of the preamble to this proposed rule. 2. Proposed Changes in the MS–LTC– DRG Classifications a. Background As discussed earlier, section 123 of Pub. L. 106–113 specifically requires that the agency implement a PPS for VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 LTCHs that is a per discharge system with a DRG-based patient classification system reflecting the differences in patient resources and costs in LTCHs. Section 307(b)(1) of Pub. L. 106–554 modified the requirements of section 123 of Pub. L. 106–113 by specifically requiring that the Secretary examine ‘‘the feasibility and the impact of basing payment under such a system [the LTCH PPS] on the use of existing (or refined) hospital diagnosis-related groups (DRGs) that have been modified to account for different resource use of long-term care hospital patients as well as the use of the most recently available hospital discharge data.’’ Consistent with section 123 of Pub. L. 106–113 as amended by section 307(b)(1) of Pub. L. 106–554 and § 412.515 of our existing regulations, the LTCH PPS uses information from LTCH patient records to classify patient cases into distinct LTC–DRGs based on clinical characteristics and expected resource needs. As described in section II.D. of the preamble of this proposed rule, for FY 2008, we adopted MS–DRGs under the IPPS because we believe that this system results in a significant improvement in the DRG system’s recognition of severity of illness and resource usage. We stated that we believe these improvements in the DRG system are equally applicable to the LTCH PPS. The changes we are proposing to make for the FY 2009 IPPS are reflected in the proposed FY 2009 GROUPER, Version 26.0, that would be effective for discharges occurring on or after October 1, 2008 through September 30, 2009. Consistent with our historical practice of having LTC–DRGs correspond to the DRGs applicable under the IPPS, under the broad authority of section 123(a) of Pub. L. 106–113, as modified by section 307(b) of Pub. L. 106–554, under the LTCH PPS for FY 2008, we adopted the use of MS–LTC–DRGs, which correspond to the MS–DRGs we adopted under the IPPS. In addition, as stated above, we are proposing to use the FY 2009 GROUPER Version 26.0 to classify cases effective for LTCH discharges occurring on or after October 1, 2008, through September 30, 2009. The changes to the MS–DRG classification system that we are proposing to use under the IPPS for FY 2009 (GROUPER Version 26.0) are discussed in section II.B. of the preamble to this proposed rule. Under the LTCH PPS, as described in greater detail below, we determine relative weights for each of the MS– LTC–DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple PO 00000 Frm 00066 Fmt 4701 Sfmt 4702 medical problems characteristic of LTCH patients. (Unless otherwise noted in this proposed rule, our MS–LTC– DRG analysis is based on LTCH data from the December 2007 update of the FY 2007 MedPAR file, which contains hospital bills received through December 31, 2007, for discharges occurring in FY 2007.) LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. Therefore, as we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55985), which implemented the LTCH PPS, and the FY 2008 IPPS final rule with comment period (72 FR 47283), we use low-volume quintiles in determining the DRG relative weights for DRGs with less than 25 LTCH cases (low-volume MS–LTC–DRGs). Specifically, we group those lowvolume DRGs into 5 quintiles based on average charges per discharge. (A listing of the composition of low-volume quintiles for the FY 2008 MS–LTC– DRGs (based on FY 2006 MedPAR data) appears in section II.I.3. of the FY 2008 IPPS final rule with comment period (72 FR 47281 through 47288).) We also adjust for cases in which the stay at the LTCH is less than or equal to five-sixths of the geometric average length of stay; that is, short-stay outlier cases, as discussed below in section II.I.4. of the preamble of this proposed rule. b. Patient Classifications Into MS–LTC– DRGs Generally, under the LTCH PPS, Medicare payment is made at a predetermined specific rate for each discharge; that is, payment varies by the DRG to which a beneficiary’s stay is assigned. Just as cases have been classified into the MS–DRGs for acute care hospitals under the IPPS (section II.B. of the preamble of this proposed rule), cases have been classified into MS–LTC–DRGs for payment under the LTCH PPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as demographic information about the patient. The diagnosis and procedure information is reported by the hospital using the ICD–9–CM coding system. Under the MS–DRGs for the IPPS and the MS–LTC–DRGs for the LTCH PPS, these factors will not change. Section II.B. of the preamble of this proposed rule discusses the organization of the existing MS–DRGs, which we are maintaining under the MS–LTC–DRG system. As noted above, the patient classification system for the LTCH PPS is derived from the IPPS DRGs and is similarly organized into 25 major diagnostic categories (MDCs). E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Most of these MDCs are based on a particular organ system of the body and the remainder involves multiple organ systems (such as MDC 22, Burns). Accordingly, the principal diagnosis determines MDC assignment. Within most MDCs, cases are then divided into surgical DRGs and medical DRGs. Under the MS–DRGs, some surgical and medical DRGs are further defined for severity purposes based on the presence or absence of MCCs or CCs. The existing MS–LTC–DRGs are similarly categorized. (We refer readers to section II.B. of the preamble of this proposed rule for further discussion of surgical DRGs and medical DRGs.) Therefore, consistent with the MS– DRGs, a base MS–LTC–DRG may be subdivided according to three alternatives. The first alternative includes division of the DRG into one, two, or three severity levels. The most severe level has cases with at least one code that is a major CC, referred to as ‘‘with MCC’’. The next lower severity level contains cases with at least one CC, referred to as ‘‘with CC’’. Those DRGs without an MCC or a CC are referred to as ‘‘without CC/MCC’’. When data do not support the creation of three severity levels, the base DRG is divided into either two levels or the base is not subdivided. The two-level subdivisions consist of one of the following subdivisions: ‘‘with CC/MCC’’ or ‘‘without CC/MCC.’’ In this type of subdivision, cases with at least one code that is on the CC or MCC list are assigned to the ‘‘ CC/MCC’’ DRG. Cases without a CC or an MCC are assigned to the ‘‘without CC/MCC’’ DRG. The other type of two-level subdivision is as follows: ‘‘with MCC’’ and ‘‘without MCC.’’ In this type of subdivision, cases with at least one code that is on the MCC list are assigned to the ‘‘with MCC’’ DRG. Cases that do not have an MCC are assigned to the ‘‘without MCC’’ DRG. This type of subdivision could include cases with a CC code, but no MCC. and access to adequate care for those Medicare patients whose care is more costly. To accomplish these goals, we have annually adjusted the LTCH PPS standard Federal prospective payment system rate by the applicable relative weight in determining payment to LTCHs for each case. (As we have noted above, in last year’s final rule, we adopted the MS–LTC–DRGs for the LTCH PPS beginning in FY 2008. However, this change in the patient classification system does not affect the basic principles of the development of relative weights under a DRG-based prospective payment system. Although the adoption of the MS– LTC–DRGs resulted in some modifications of existing procedures for assigning weights in cases of zero volume and/or nonmonotonicity, as discussed in the FY 2008 IPPS final rule with comment period (72 FR 47289 through 47295) and discussed in detail in the following sections, the basic methodology for developing the proposed FY 2009 MS–LTC–DRG relative weights in this proposed rule continue to be determined in accordance with the general methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). Under the LTCH PPS, relative weights for each MS–LTC– DRG are a primary element used to account for the variations in cost per discharge and resource utilization among the payment groups (§ 412.515). To ensure that Medicare patients classified to each MS–LTC–DRG have access to an appropriate level of services and to encourage efficiency, we calculate a relative weight for each MS– LTC–DRG that represents the resources needed by an average inpatient LTCH case in that MS–LTC–DRG. For example, cases in an MS–LTC–DRG with a relative weight of 2 will, on average, cost twice as much to treat as cases in an MS–LTC–DRG with a weight of 1. 3. Development of the Proposed FY 2009 MS–LTC–DRG Relative Weights To calculate the proposed MS–LTC– DRG relative weights for FY 2009, we obtained total Medicare allowable charges from FY 2007 Medicare LTCH bill data from the December 2007 update of the MedPAR file, which are the best available data at this time, and we used the proposed Version 26.0 of the CMS GROUPER that is also proposed for use under the IPPS to classify cases for FY 2009. We also are proposing that if more recent data are available, we will use those data and the finalized Version 26.0 of the CMS GROUPER in establishing the FY 2009 jlentini on PROD1PC65 with PROPOSALS2 a. General Overview of Development of the MS–LTC–DRG Relative Weights As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55981), one of the primary goals for the implementation of the LTCH PPS is to pay each LTCH an appropriate amount for the efficient delivery of medical care to Medicare patients. The system must be able to account adequately for each LTCH’s case-mix in order to ensure both fair distribution of Medicare payments VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 b. Data PO 00000 Frm 00067 Fmt 4701 Sfmt 4702 23593 MS–LTC–DRG relative weights in the final rule. Consistent with our historical methodology, we have excluded the data from LTCHs that are all-inclusive rate providers and LTCHs that are reimbursed in accordance with demonstration projects authorized under section 402(a) of Pub. L. 90–248 or section 222(a) of Pub. L. 92–603 (We refer readers to the FY 2008 IPPS final rule with comment period (72 FR 47282)). Therefore, in the development of the proposed FY 2009 MS–LTC–DRG relative weights in this proposed rule, we have excluded the data of the 17 allinclusive rate providers and the 2 LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2007 MedPAR file. c. Hospital-Specific Relative Value (HSRV) Methodology By nature, LTCHs often specialize in certain areas, such as ventilatordependent patients and rehabilitation and wound care. Some case types (DRGs) may be treated, to a large extent, in hospitals that have, from a perspective of charges, relatively high (or low) charges. This nonarbitrary distribution of cases with relatively high (or low) charges in specific MS–LTC– DRGs has the potential to inappropriately distort the measure of average charges. To account for the fact that cases may not be randomly distributed across LTCHs, we are proposing to use a hospital-specific relative value (HSRV) methodology to calculate the MS–LTC–DRG relative weights instead of the methodology used to determine the MS–DRG relative weights under the IPPS described in section II.H. of the preamble of this proposed rule. We believe this method will remove this hospital-specific source of bias in measuring LTCH average charges. Specifically, we are proposing to reduce the impact of the variation in charges across providers on any particular MS–LTC–DRG relative weight by converting each LTCH’s charge for a case to a relative value based on that LTCH’s average charge. Under the HSRV methodology, we standardize charges for each LTCH by converting its charges for each case to hospital-specific relative charge values and then adjusting those values for the LTCH’s case-mix. The adjustment for case-mix is needed to rescale the hospital-specific relative charge values (which, by definition, average 1.0 for each LTCH). The average relative weight for a LTCH is its case-mix, so it is reasonable to scale each LTCH’s average relative charge value by its case-mix. In this way, each LTCH’s relative charge E:\FR\FM\30APP2.SGM 30APP2 23594 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 value is adjusted by its case-mix to an average that reflects the complexity of the cases it treats relative to the complexity of the cases treated by all other LTCHs (the average case-mix of all LTCHs). In accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991), we continue to standardize charges for each case by first dividing the adjusted charge for the case (adjusted for short-stay outliers under § 412.529 as described in section II.I.4. (step 3) of the preamble of this proposed rule) by the average adjusted charge for all cases at the LTCH in which the case was treated. Short-stay outliers are cases with a length of stay that is less than or equal to five-sixths the average length of stay of the MS– LTC–DRG (§ 412.529 and § 412.503). The average adjusted charge reflects the average intensity of the health care services delivered by a particular LTCH and the average cost level of that LTCH. The resulting ratio is multiplied by that LTCH’s case-mix index to determine the standardized charge for the case. Multiplying by the LTCH’s case-mix index accounts for the fact that the same relative charges are given greater weight at a LTCH with higher average costs than they would at a LTCH with low average costs, which is needed to adjust each LTCH’s relative charge value to reflect its case-mix relative to the average case-mix for all LTCHs. Because we standardize charges in this manner, we count charges for a Medicare patient at a LTCH with high average charges as less resource intensive than they would be at a LTCH with low average charges. For example, a $10,000 charge for a case at a LTCH with an average adjusted charge of $17,500 reflects a higher level of relative resource use than a $10,000 charge for a case at a LTCH with the same case-mix, but an average adjusted charge of $35,000. We believe that the adjusted charge of an individual case more accurately reflects actual resource use for an individual LTCH because the variation in charges due to systematic differences in the markup of charges among LTCHs is taken into account. d. Treatment of Severity Levels in Developing Proposed Relative Weights Under the proposed MS–LTC–DRGs, for purposes of the proposed setting of the relative weights, there would be three different categories of DRGs based on volume of cases within specific MS– LTC–DRGs. MS–LTC–DRGs with at least 25 cases are each assigned a unique relative weight; low-volume MS–LTC– DRGs (that is, MS–LTC–DRGs that contain between one and 24 cases VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 annually) are grouped into quintiles (described below) and assigned the weight of the quintile. No-volume MS– LTC–DRGs (that is, no cases in the database were assigned to those MS– LTC–DRGs) are crosswalked to other MS–LTC–DRGs based on the clinical similarities and assigned the relative weight of the crosswalked MS–LTC– DRG. (We provide in-depth discussions of our proposed policy regarding weight setting for low-volume MS–LTC–DRGs in section II.I.3.e. of the preamble of this proposed rule and for no-volume MS– LTC–DRGs, under Step 5 in section II.I.4. of the preamble of this proposed rule.) As described above, in response to the need to account for severity and pay appropriately for cases, we developed a severity-adjusted patient classification system which we adopted for both the IPPS and the LTCH PPS in FY 2008. As described in greater detail above, the MS–LTC–DRG system can accommodate three severity levels: ‘‘with MCC’’ (most severe); ‘‘with CC,’’ and ‘‘without CC/ MCC’’ (the least severe) with each level assigned an individual MS–LTC–DRG number. In cases with two subdivisions, the levels are either ‘‘with CC/MCC’’ and ‘‘without CC/MCC’’ or ‘‘with MCC’’ and ‘‘without MCC’’. For example, under the MS–LTC–DRG system, multiple sclerosis and cerebellar ataxia with MCC is MS–LTC–DRG 58; multiple sclerosis and cerebellar ataxia with CC is MS–LTC–DRG 59; and multiple sclerosis and cerebellar ataxia without CC/MCC is MS–LTC–DRG 60. For purposes of discussion in this section, the term ‘‘base DRG’’ is used to refer to the DRG category that encompasses all levels of severity for that DRG. For example, when referring to the entire DRG category for multiple sclerosis and cerebellar ataxia, which includes the above three severity levels, we would use the term ‘‘base-DRG.’’ As noted above, while the LTCH PPS and the IPPS use the same patient classification system, the methodology that is used to set the DRG weights for use in each payment system differs because the overall volume of cases in the LTCH PPS is much less than in the IPPS. As a general rule, consistent with the methodology we used when we adopted the MS–LTC–DRGs in the FY 2008 IPPS final rule with comment period (72 FR 47278 through 47281), we are proposing to determine the FY 2009 relative weights for the MS–LTC–DRGs using the following steps: (1) if an MS– LTC–DRG has at least 25 cases, it is assigned its own relative weight; (2) if an MS–LTC–DRG has between 1 and 24 cases, it is assigned to a quintile for which we will compute a relative PO 00000 Frm 00068 Fmt 4701 Sfmt 4702 weight; and (3) if an MS–LTC–DRG has no cases, it is crosswalked to another MS–LTC–DRG based upon clinical similarities to assign an appropriate relative weight (as described below in detail in Step 5 of the Steps for Determining the proposed FY 2009 MS– LTC–DRG Relative Weights). Furthermore, in determining the proposed FY 2009 MS–LTC–DRG relative weights, when necessary, we are proposing to make adjustments to account for nonmonotonicity, as explained below. Theoretically, cases under the MS– LTC–DRG system that are more severe require greater expenditure of medical care resources and will result in higher average charges. Therefore, in the three severity levels, weights should increase with severity, from lowest to highest. If the weights do not increase (that is, if based on the relative weight methodology outlined above, the MS– LTC–DRG with MCC would have a lower relative weight than one with CC, or the MS–LTC–DRG without CC/MCC would have a higher relative weight than either of the others), there is a problem with monotonicity. Since the start of the LTCH PPS for FY 2003 (67 FR 55990), we have adjusted the setting of the LTC–DRG relative weights in order to maintain monotonicity by grouping both sets of cases together and establishing a new relative weight for both LTC–DRGs. We continue to believe that utilizing nonmonotonic relative weights to adjust Medicare payments would result in inappropriate payments because, in a nonmonotonic system, cases that are more severe and require greater expenditure of medical care resources would be paid based on a lower relative weight than cases that are less severe and require lower resource use. The procedure for dealing with nonmonotonicity under the MS–LTC– DRG classification system is discussed in greater detail below in section II.I.4. (Step 6) of the preamble of this proposed rule. e. Proposed Low-Volume MS–LTC– DRGs In order to account for MS–LTC– DRGs with low volume (that is, with fewer than 25 LTCH cases), consistent with the methodology we established when we implemented the LTCH PPS (August 30, 2002; 67 FR 55984 through 55995), we group those ‘‘low-volume MS–LTC–DRGs’’ (that is, MS–LTC– DRGs that contained between 1 and 24 cases annually) into one of five categories (quintiles) based on average charges, for the purposes of determining relative weights (72 FR 47283 through 47288). In determining the proposed FY E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 2009 MS–LTC–DRG relative weights in this proposed rule, we are proposing to continue to employ this quintile methodology for proposed low-volume MS–LTC–DRGs. In addition, in cases where the initial assignment of a lowvolume MS–LTC–DRG to quintiles results in nonmonotonicity within a base DRG, in order to ensure appropriate Medicare payments, consistent with our historical methodology, we are proposing to make adjustments to the treatment of lowvolume MS–LTC–DRGs to preserve monotonicity, as discussed in detail below in section II.I.4 (Step 6 of the methodology for determining the proposed FY 2009 MS–LTC–DRG relative weights). In this proposed rule, using LTCH cases from the December 2007 update of the FY 2007 MedPAR file, we identified 290 MS–LTC–DRGs that contained between 1 and 24 cases. This list of proposed MS–LTC–DRGs was then divided into one of the proposed 5 low-volume quintiles, each containing 58 MS–LTC–DRGs (290/5 = 58). We are proposing to make the assignment of a low-volume MS–LTC– DRG to a specific low-volume quintile by sorting the proposed low-volume MS–LTC–DRGs in ascending order by average charge in accordance with our established methodology. Specifically, for this proposed rule, the 290 proposed low-volume MS–LTC–DRGs are sorted by ascending order by average charge and assigned to a specific proposed lowvolume quintile (as described below). After sorting the 290 proposed lowvolume MS–LTC–DRGs by average charge in ascending order, we are proposing to group the first fifth (1st through 58th) of proposed low-volume MS–LTC–DRGs (with the lowest average charge) into Quintile 1. This process is repeated through the remaining proposed low-volume MS–LTC–DRGs so that each of the 5 proposed lowvolume quintiles contains 58 proposed MS–LTC–DRGs. The highest average charge cases would be grouped into Quintile 5. (We note that, consistent with our historical methodology, if the number of proposed low-volume MS– LTC–DRGs had not been evenly divisible by 5, we would have used the average charge of the proposed lowvolume MS–LTC–DRG to determine which proposed low-volume quintile would have received the additional proposed low-volume MS–LTC–DRG.) Accordingly, in order to determine the proposed relative weights for the proposed MS–LTC–DRGs with lowvolume for FY 2009, we are proposing to use the five low-volume quintiles described above. The composition of each of the proposed five low-volume quintiles shown in the chart below was used in determining the proposed MS– LTC–DRG relative weights for FY 2009 (Table 11 of the Addendum of this proposed rule). We would determine a proposed relative weight and (geometric) average length of stay for each of the proposed five low-volume quintiles using the methodology that we are proposing to apply to the regular MS–LTC–DRGs (25 or more cases), as described in section II.I.4. of the preamble of this proposed rule. We are proposing to assign the same relative weight and average length of stay to each of the proposed low-volume MS– LTC–DRGs that make up an individual low-volume quintile. We note that, as this system is dynamic, it is possible that the number and specific type of MS–LTC–DRGs with a low volume of LTCH cases will vary in the future. We use the best available claims data in the MedPAR file to identify low-volume MS–LTC–DRGs and to calculate the relative weights based on our methodology. PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009 Proposed MS–LTC–DRG (version 26.0) Proposed MS–LTC–DRG description (version 26.0) jlentini on PROD1PC65 with PROPOSALS2 PROPOSED QUINTILE 1 66 ......................................... 67 ......................................... 68 ......................................... 69 ......................................... 72 ......................................... 79 ......................................... 87 ......................................... 89 ......................................... 125 ....................................... 135 ....................................... 136 ....................................... 148 ....................................... 149 ....................................... 159 ....................................... 183 ....................................... 184 ....................................... 185 ....................................... 201 ....................................... 257 ....................................... 261 ....................................... 263 ....................................... 304 ....................................... 305 ....................................... 311 ....................................... 313 ....................................... 382 ....................................... 387 ....................................... 437 ....................................... 443 ....................................... 468 ....................................... 510 ....................................... 537 ....................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Intracranial hemorrhage or cerebral infarction w/o CC/MCC. Nonspecific cva & precerebral occlusion w/o infarct w MCC. Nonspecific cva & precerebral occlusion w/o infarct w/o MCC. Transient ischemia. Nonspecific cerebrovascular disorders w/o CC/MCC. Hypertensive encephalopathy w/o CC/MCC. Traumatic stupor & coma, coma <1 hr w/o CC/MCC. Concussion w CC. Other disorders of the eye w/o MCC. Sinus & mastoid procedures w CC/MCC. Sinus & mastoid procedures w/o CC/MCC.** Ear, nose, mouth & throat malignancy w/o CC/MCC. Dysequilibrium. Dental & Oral Diseases w/o CC/MCC. Major chest trauma w MCC. Major chest trauma w CC. Major chest trauma w/o CC/MCC. Pneumothorax w/o CC/MCC. Upper limb & toe amputation for circ system disorders w/o CC/MCC. Cardiac pacemaker revision except device replacement w CC.*** Vein ligation & stripping. Hypertension w MCC. Hypertension w/o MCC. Angina pectoris. Chest pain. Complicated peptic ulcer w/o CC/MCC. Inflammatory bowel disease w/o CC/MCC. Malignancy of hepatobiliary system or pancreas w/o CC/MCC. Disorders of liver except malig, cirr, alc hepa w/o CC/MCC. Revision of hip or knee replacement w/o CC/MCC. Shoulder, elbow or forearm proc, exc major joint proc w MCC.*** Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC. Jkt 214001 PO 00000 Frm 00069 Fmt 4701 Sfmt 4702 23595 E:\FR\FM\30APP2.SGM 30APP2 23596 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued Proposed MS–LTC–DRG (version 26.0) 544 547 556 563 601 618 642 645 694 723 726 730 756 781 810 816 864 869 880 882 886 895 897 917 918 958 965 ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... Proposed MS–LTC–DRG description (version 26.0) Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC. Connective tissue disorders w/o CC/MCC. Signs & symptoms of musculoskeletal system & conn tissue w/o MCC. Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC. Non-malignant breast disorders w/o CC/MCC. Amputat of lower limb for endocrine, nutrit, & metabol dis w/o CC/MCC. Inborn errors of metabolism Endocrine disorders w/o CC/MCC. Urinary stones w/o esw lithotripsy w/o MCC. Malignancy, male reproductive system w CC. Benign prostatic hypertrophy w/o MCC. Other male reproductive system diagnoses w/o CC/MCC. Malignancy, female reproductive system w/o CC/MCC. Other antepartum diagnoses w medical complications. Major hematol/immun diag exc sickle cell crisis & coagul w/o CC/MCC. Reticuloendothelial & immunity disorders w/o CC/MCC. Fever of unknown origin. Other infectious & parasitic diseases diagnoses w/o CC/MCC. Acute adjustment reaction & psychosocial dysfunction. Neuroses except depressive. Behavioral & developmental disorders. Alcohol/drug abuse or dependence w rehabilitation therapy. Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC. Poisoning & toxic effects of drugs w MCC. Poisoning & toxic effects of drugs w/o MCC. Other O.R. procedures for multiple significant trauma w CC. Other multiple significant trauma w/o CC/MCC. jlentini on PROD1PC65 with PROPOSALS2 PROPOSED QUINTILE 2 59 ......................................... 60 ......................................... 75 ......................................... 78 ......................................... 83 ......................................... 84 ......................................... 99 ......................................... 102 ....................................... 103 ....................................... 121 ....................................... 122 ....................................... 124 ....................................... 153 ....................................... 156 ....................................... 157 ....................................... 158 ....................................... 182 ....................................... 188 ....................................... 203 ....................................... 254 ....................................... 294 ....................................... 354 ....................................... 376 ....................................... 379 ....................................... 381 ....................................... 390 ....................................... 409 ....................................... 433 ....................................... 440 ....................................... 446 ....................................... 489 ....................................... 533 ....................................... 534 ....................................... 553 ....................................... 578 ....................................... 584 ....................................... 624 ....................................... 661 ....................................... 663 ....................................... 665 ....................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Multiple sclerosis & cerebellar ataxia w CC. Multiple sclerosis & cerebellar ataxia w/o CC/MCC. Viral meningitis w CC/MCC. Hypertensive encephalopathy w CC. Traumatic stupor & coma, coma >1 hr w CC. Traumatic stupor & coma, coma >1 hr w/o CC/MCC. Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC. Headaches w MCC. Headaches w/o MCC. Acute major eye infections w CC/MCC. Acute major eye infections w/o CC/MCC. Other disorders of the eye w MCC. Otitis media & URI w/o MCC. Nasal trauma & deformity w/o CC/MCC. Dental & Oral Diseases w MCC. Dental & Oral Diseases w CC. Respiratory neoplasms w/o CC/MCC.* Pleural effusion w/o CC/MCC.* Bronchitis & asthma w/o CC/MCC. Other vascular procedures w/o CC/MCC. Deep vein thrombophlebitis w CC/MCC. Hernia procedures except inguinal & femoral w CC. Digestive malignancy w/o CC/MCC. G.I. hemorrhage w/o CC/MCC. Complicated peptic ulcer w CC. G.I. obstruction w/o CC/MCC. Biliary tract proc except only cholecyst w or w/o c.d.e. w CC. Cirrhosis & alcoholic hepatitis w CC. Disorders of pancreas except malignancy w/o CC/MCC. Disorders of the biliary tract w/o CC/MCC.* Knee procedures w/o pdx of infection w/o CC/MCC. Fractures of femur w MCC. Fractures of femur w/o MCC. Bone diseases & arthropathies w MCC. Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC. Breast biopsy, local excision & other breast procedures w CC/MCC. Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC. Kidney & ureter procedures for non-neoplasm w/o CC/MCC. Minor bladder procedures w CC. Prostatectomy w MCC.*** Jkt 214001 PO 00000 Frm 00070 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued Proposed MS–LTC–DRG (version 26.0) 669 671 688 696 722 759 815 835 842 844 845 866 876 881 923 929 964 976 ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... Proposed MS–LTC–DRG description (version 26.0) Transurethral procedures w CC. Urethral procedures w CC/MCC. Kidney & urinary tract neoplasms w/o CC/MCC. Kidney & urinary tract signs & symptoms w/o MCC. Malignancy, male reproductive system w MCC. Infections, female reproductive system w/o CC/MCC.* Reticuloendothelial & immunity disorders w CC. Acute leukemia w/o major O.R. procedure w CC.*** Lymphoma & non-acute leukemia w/o CC/MCC. Other myeloprolif dis or poorly diff neopl diag w CC. Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC. Viral illness w/o MCC. O.R. procedure w principal diagnoses of mental illness. Depressive neuroses Other injury, poisoning & toxic effect diag w/o MCC. Full thickness burn w skin graft or inhal inj w/o CC/MCC. Other multiple significant trauma w CC. HIV w major related condition w/o CC/MCC. jlentini on PROD1PC65 with PROPOSALS2 PROPOSED QUINTILE 3 23 ......................................... 27 ......................................... 53 ......................................... 58 ......................................... 82 ......................................... 98 ......................................... 113 ....................................... 116 ....................................... 136 ....................................... 152 ....................................... 165 ....................................... 168 ....................................... 238 ....................................... 241 ....................................... 261 ....................................... 262 ....................................... 284 ....................................... 287 ....................................... 369 ....................................... 370 ....................................... 380 ....................................... 384 ....................................... 424 ....................................... 471 ....................................... 472 ....................................... 476 ....................................... 482 ....................................... 494 ....................................... 497 ....................................... 502 ....................................... 504 ....................................... 505 ....................................... 510 ....................................... 511 ....................................... 535 ....................................... 542 ....................................... 555 ....................................... 562 ....................................... 598 ....................................... 599 ....................................... 600 ....................................... 626 ....................................... 630 ....................................... 665 ....................................... 666 ....................................... 668 ....................................... 686 ....................................... 687 ....................................... 693 ....................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Craniotomy w major device implant or acute complex CNS PDX w MCC.*** Craniotomy & endovascular intracranial procedures w/o CC/MCC. Spinal disorders & injuries w/o CC/MCC. Multiple sclerosis & cerebellar ataxia w MCC. Traumatic stupor & coma, coma >1 hr w MCC. Non-bacterial infect of nervous sys exc viral meningitis w CC. Orbital procedures w CC/MCC. Intraocular procedures w CC/MCC. Sinus & mastoid procedures w/o CC/MCC.*** Otitis media & URI w MCC. Major chest procedures w/o CC/MCC. Other resp system O.R. procedures w/o CC/MCC. Major cardiovascular procedures w/o MCC. Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC. Cardiac pacemaker revision except device replacement w CC.** Cardiac pacemaker revision except device replacement w/o CC/MCC.** Circulatory disorders w AMI, expired w CC.* Circulatory disorders except AMI, w card cath w/o MCC. Major esophageal disorders w CC. Major esophageal disorders w/o CC/MCC. Complicated peptic ulcer w MCC. Uncomplicated peptic ulcer w/o MCC. Other hepatobiliary or pancreas O.R. procedures w CC. Cervical spinal fusion w MCC. Cervical spinal fusion w CC. Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC. Hip & femur procedures except major joint w/o CC/MCC. Lower extrem & humer proc except hip, foot, femur w/o CC/MCC. Local excision & removal int fix devices exc hip & femur w/o CC/MCC.* Soft tissue procedures w/o CC/MCC. Foot procedures w CC. Foot procedures w/o CC/MCC. Shoulder, elbow or forearm proc, exc major joint proc w MCC.** Shoulder, elbow or forearm proc, exc major joint proc w CC.** Fractures of hip & pelvis w MCC. Pathological fractures & musculoskelet & conn tiss malig w MCC. Signs & symptoms of musculoskeletal system & conn tissue w MCC. Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC. Malignant breast disorders w CC. Malignant breast disorders w/o CC/MCC.** Non-malignant breast disorders w CC/MCC. Thyroid, parathyroid & thyroglossal procedures w CC. Other endocrine, nutrit & metab O.R. proc w/o CC/MCC. Prostatectomy w MCC.** Prostatectomy w CC.** Transurethral procedures w MCC. Kidney & urinary tract neoplasms w MCC. Kidney & urinary tract neoplasms w CC. Urinary stones w/o esw lithotripsy w MCC. Jkt 214001 PO 00000 Frm 00071 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23597 23598 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued Proposed MS–LTC–DRG (version 26.0) 725 744 755 800 809 814 824 834 835 836 843 883 903 905 922 941 963 989 ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... Proposed MS–LTC–DRG description (version 26.0) Benign prostatic hypertrophy w MCC. D&C, conization, laparoscopy & tubal interruption w CC/MCC. Malignancy, female reproductive system w CC. Splenectomy w CC. Major hematol/immun diag exc sickle cell crisis & coagul w CC. Reticuloendothelial & immunity disorders w MCC. Lymphoma & non-acute leukemia w other O.R. proc w CC. Acute leukemia w/o major O.R. procedure w MCC. Acute leukemia w/o major O.R. procedure w CC.** Acute leukemia w/o major O.R. procedure w/o CC/MCC.** Other myeloprolif dis or poorly diff neopl diag w MCC. Disorders of personality & impulse control. Wound debridements for injuries w/o CC/MCC. Skin grafts for injuries w/o CC/MCC. Other injury, poisoning & toxic effect diag w MCC. O.R. proc w diagnoses of other contact w health services w/o CC/MCC. Other multiple significant trauma w MCC. Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC. jlentini on PROD1PC65 with PROPOSALS2 PROPOSED QUINTILE 4 23 ......................................... 24 ......................................... 28 ......................................... 29 ......................................... 30 ......................................... 37 ......................................... 38 ......................................... 42 ......................................... 77 ......................................... 133 ....................................... 164 ....................................... 237 ....................................... 242 ....................................... 246 ....................................... 247 ....................................... 248 ....................................... 249 ....................................... 259 ....................................... 260 ....................................... 262 ....................................... 286 ....................................... 327 ....................................... 328 ....................................... 348 ....................................... 358 ....................................... 405 ....................................... 406 ....................................... 417 ....................................... 466 ....................................... 467 ....................................... 469 ....................................... 478 ....................................... 481 ....................................... 485 ....................................... 486 ....................................... 487 ....................................... 490 ....................................... 492 ....................................... 493 ....................................... 503 ....................................... 511 ....................................... 513 ....................................... 514 ....................................... 597 ....................................... 599 ....................................... 625 ....................................... 659 ....................................... 660 ....................................... 666 ....................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Craniotomy w major device implant or acute complex CNS PDX w MCC.** Craniotomy w major device implant or acute complex CNS PDX w/o MCC.** Spinal procedures w MCC. Spinal procedures w CC. Spinal procedures w/o CC/MCC. Extracranial procedures w MCC. Extracranial procedures w CC.** Periph & cranial nerve & other nerv syst proc w/o CC/MCC.* Hypertensive encephalopathy w MCC. Other ear, nose, mouth & throat O.R. procedures w CC/MCC. Major chest procedures w CC. Major cardiovascular procedures w MCC. Permanent cardiac pacemaker implant w MCC.*** Percutaneous cardiovascular proc w drug-eluting stent w MCC. Percutaneous cardiovascular proc w drug-eluting stent w/o MCC. Percutaneous cardiovasc proc w non-drug-eluting stent w MCC. Percutaneous cardiovasc proc w non-drug-eluting stent w/o MCC.** Cardiac pacemaker device replacement w/o MCC. Cardiac pacemaker revision except device replacement w MCC. Cardiac pacemaker revision except device replacement w/o CC/MCC.*** Circulatory disorders except AMI, w card cath w MCC. Stomach, esophageal & duodenal proc w CC. Stomach, esophageal & duodenal proc w/o CC/MCC.** Anal & stomal procedures w CC. Other digestive system O.R. procedures w/o CC/MCC.* Pancreas, liver & shunt procedures w MCC. Pancreas, liver & shunt procedures w CC.** Laparoscopic cholecystectomy w/o c.d.e. w MCC.*** Revision of hip or knee replacement w MCC. Revision of hip or knee replacement w CC. Major joint replacement or reattachment of lower extremity w MCC.*** Biopsies of musculoskeletal system & connective tissue w CC. Hip & femur procedures except major joint w CC. Knee procedures w pdx of infection w MCC. Knee procedures w pdx of infection w CC. Knee procedures w pdx of infection w/o CC/MCC.** Back & neck procedures except spinal fusion w CC/MCC or disc devices. Lower extrem & humer proc except hip, foot, femur w MCC. Lower extrem & humer proc except hip, foot, femur w CC. Foot procedures w MCC. Shoulder, elbow or forearm proc, exc major joint proc w CC.*** Hand or wrist proc, except major thumb or joint proc w CC/MCC. Hand or wrist proc, except major thumb or joint proc w/o CC/MCC.** Malignant breast disorders w MCC. Malignant breast disorders w/o CC/MCC.*** Thyroid, parathyroid & thyroglossal procedures w MCC. Kidney & ureter procedures for non-neoplasm w MCC. Kidney & ureter procedures for non-neoplasm w CC. Prostatectomy w CC.*** Jkt 214001 PO 00000 Frm 00072 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued Proposed MS–LTC–DRG (version 26.0) 695 711 717 739 749 754 802 808 823 896 909 928 933 957 969 970 984 985 ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... Proposed MS–LTC–DRG description (version 26.0) Kidney & urinary tract signs & symptoms w MCC. Testes procedures w CC/MCC. Other male reproductive system O.R. proc exc malignancy w CC/MCC. Uterine, adnexa proc for non-ovarian/adnexal malig w MCC. Other female reproductive system O.R. procedures w CC/MCC. Malignancy, female reproductive system w MCC. Other O.R. proc of the blood & blood forming organs w MCC. Major hematol/immun diag exc sickle cell crisis & coagul w MCC. Lymphoma & non-acute leukemia w other O.R. proc w MCC. Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC. Other O.R. procedures for injuries w/o CC/MCC.* Full thickness burn w skin graft or inhal inj w CC/MCC. Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft. Other O.R. procedures for multiple significant trauma w MCC. HIV w extensive O.R. procedure w MCC. HIV w extensive O.R. procedure w/o MCC.** Prostatic O.R. procedure unrelated to principal diagnosis w MCC. Prostatic O.R. procedure unrelated to principal diagnosis w CC. jlentini on PROD1PC65 with PROPOSALS2 PROPOSED QUINTILE 5 11 ......................................... 12 ......................................... 24 ......................................... 25 ......................................... 26 ......................................... 31 ......................................... 32 ......................................... 38 ......................................... 132 ....................................... 137 ....................................... 226 ....................................... 227 ....................................... 242 ....................................... 243 ....................................... 244 ....................................... 249 ....................................... 250 ....................................... 326 ....................................... 328 ....................................... 330 ....................................... 331 ....................................... 335 ....................................... 344 ....................................... 347 ....................................... 353 ....................................... 406 ....................................... 411 ....................................... 414 ....................................... 415 ....................................... 417 ....................................... 418 ....................................... 423 ....................................... 456 ....................................... 457 ....................................... 459 ....................................... 469 ....................................... 470 ....................................... 477 ....................................... 480 ....................................... 487 ....................................... 488 ....................................... 496 ....................................... 498 ....................................... 507 ....................................... 514 ....................................... 582 ....................................... 619 ....................................... 653 ....................................... 656 ....................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Tracheostomy for face, mouth & neck diagnoses w MCC. Tracheostomy for face, mouth & neck diagnoses w CC. Craniotomy w major device implant or acute complex CNS PDX w/o MCC.*** Craniotomy & endovascular intracranial procedures w MCC. Craniotomy & endovascular intracranial procedures w CC. Ventricular shunt procedures w MCC. Ventricular shunt procedures w CC. Extracranial procedures w CC.*** Cranial/facial procedures w/o CC/MCC. Mouth procedures w CC/MCC. Cardiac defibrillator implant w/o cardiac cath w MCC. Cardiac defibrillator implant w/o cardiac cath w/o MCC. Permanent cardiac pacemaker implant w MCC.** Permanent cardiac pacemaker implant w CC. Permanent cardiac pacemaker implant w/o CC/MCC. Percutaneous cardiovasc proc w non-drug-eluting stent w/o MCC.*** Perc cardiovasc proc w/o coronary artery stent or AMI w MCC. Stomach, esophageal & duodenal proc w MCC. Stomach, esophageal & duodenal proc w/o CC/MCC.*** Major small & large bowel procedures w CC. Major small & large bowel procedures w/o CC/MCC. Peritoneal adhesiolysis w MCC. Minor small & large bowel procedures w MCC. Anal & stomal procedures w MCC. Hernia procedures except inguinal & femoral w MCC. Pancreas, liver & shunt procedures w CC.*** Cholecystectomy w c.d.e. w MCC. Cholecystectomy except by laparoscope w/o c.d.e. w MCC. Cholecystectomy except by laparoscope w/o c.d.e. w CC. Laparoscopic cholecystectomy w/o c.d.e. w MCC.** Laparoscopic cholecystectomy w/o c.d.e. w CC. Other hepatobiliary or pancreas O.R. procedures w MCC. Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC. Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w CC. Spinal fusion except cervical w MCC. Major joint replacement or reattachment of lower extremity w MCC.** Major joint replacement or reattachment of lower extremity w/o MCC. Biopsies of musculoskeletal system & connective tissue w MCC. Hip & femur procedures except major joint w MCC. Knee procedures w pdx of infection w/o CC/MCC.*** Knee procedures w/o pdx of infection w CC/MCC. Local excision & removal int fix devices exc hip & femur w CC.* Local excision & removal int fix devices of hip & femur w CC/MCC. Major shoulder or elbow joint procedures w CC/MCC. Hand or wrist proc, except major thumb or joint proc w/o CC/MCC.*** Mastectomy for malignancy w CC/MCC. O.R. procedures for obesity w MCC. Major bladder procedures w MCC. Kidney & ureter procedures for neoplasm w MCC. Jkt 214001 PO 00000 Frm 00073 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23599 23600 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules PROPOSED COMPOSITION OF LOW-VOLUME QUINTILES FOR FY 2009—Continued Proposed MS–LTC–DRG (version 26.0) 662 709 713 746 826 827 829 836 855 906 927 970 ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... Proposed MS–LTC–DRG description (version 26.0) Minor bladder procedures w MCC. Penis procedures w CC/MCC. Transurethral prostatectomy w CC/MCC. Vagina, cervix & vulva procedures w CC/MCC. Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC. Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC. Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC. Acute leukemia w/o major O.R. procedure w/o CC/MCC.*** Infectious & parasitic diseases w O.R. procedure w/o CC/MCC.* Hand procedures for injuries. Extensive burns or full thickness burns w MV 96+ hrs w skin graft. HIV w extensive O.R. procedure w/o MCC.*** *One of the original 290 proposed low-volume MS–LTC–DRGs initially assigned to this proposed low-volume quintile; removed from this proposed low-volume quintile in addressing nonmonotonicity (refer to step 6 in section II.I.4..of the preamble of this proposed rule). **One of the original 290 proposed low-volume MS–LTC–DRGs initially assigned to a different proposed low-volume quintile but moved to this proposed low-volume quintile in addressing nonmonotonicity (refer to step 6 in section II.I.4. of the preamble of this proposed rule). ***One of the original 290 proposed low-volume MS–LTC–DRGs initially assigned to this proposed low-volume quintile but moved to a different proposed low-volume quintile in addressing nonmonotonicity (refer to step 6 in section II.I.4. of the preamble of this proposed rule). jlentini on PROD1PC65 with PROPOSALS2 We note that we will continue to monitor the volume (that is, the number of LTCH cases) in the low-volume quintiles to ensure that our proposed quintile assignment results in appropriate payment for such cases and does not result in an unintended financial incentive for LTCHs to inappropriately admit these types of cases. 4. Steps for Determining the Proposed FY 2009 MS–LTC–DRG Relative Weights In general, the proposed FY 2009 MS– LTC–DRG relative weights in this proposed rule were determined based on the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). In summary, for FY 2009, we are proposing to group LTCH cases to the appropriate proposed MS–LTC–DRG, while taking into account the proposed low-volume MS–LTC–DRGs (as described above), before the proposed FY 2009 MS–LTC– DRG relative weights are determined. After grouping the cases to the appropriate proposed MS–LTC–DRG (or proposed low-volume quintile), we would calculate the proposed relative weights for FY 2009 by first removing statistical outliers and cases with a length of stay of 7 days or less (as discussed in greater detail below). Next, we would adjust the number of cases in each proposed MS–LTC–DRG (or proposed low-volume quintile) for the effect of short-stay outlier cases (as also discussed in greater detail below). The short-stay adjusted discharges and corresponding charges are used to calculate ‘‘relative adjusted weights’’ in each proposed MS–LTC–DRG (or proposed low-volume quintile) using VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 the HSRV method (described above). In general, to determine the proposed FY 2009 MS–LTC–DRG relative weights in this proposed rule, we are proposing to use the same methodology we used in determining the FY 2008 MS–LTC–DRG relative weights in the FY 2008 IPPS final rule with comment period (72 FR 47281 through 47299). However, we are proposing to make a modification to our methodology for determining proposed relative weights for MS–LTC–DRGs with no LTCH cases (as discussed in greater detail in Step 5 below). Also, we note that, although we are generally proposing to use the same methodology in this proposed rule (with the exception noted above) as the methodology used in the FY 2008 IPPS final rule with comment, the discussion presented below of the steps for determining the proposed FY 2009 MS– LTC–DRG relative weights varies slightly from the discussion of the steps for determining the FY 2008 MS–LTC– DRG relative weights (presented in the FY 2008 IPPS final rule with comment) because we are taking this opportunity to refine our description to more precisely explain our methodology for determining the MS–LTC–DRG relative weights. As discussed in the FY 2008 IPPS final rule with comment when we adopted the MS–LTC–DRGs, the adoption of the MS–LTC–DRGs with either two or three severity levels resulted in some slight modifications of procedures for assigning relative weights in cases of zero volume and/or nonmonotonicity (described in detail below) from the methodology we established when we implemented the LTCH PPS in the August 30, 2002 LTCH PPS final rule. As also discussed in the PO 00000 Frm 00074 Fmt 4701 Sfmt 4702 FY 2008 IPPS final rule with comment when we adopted the MS–LTC–DRGs, we implemented the MS–LTC–DRGs with a 2-year transition beginning in FY 2008. For FY 2008, the first year of the transition, 50 percent of the relative weight for a MS–LTC–DRG was based on the average LTC–DRG relative weight under Version 24.0 of the LTC–DRG GROUPER. The remaining 50 percent of the relative weight was based on the MS–LTC–DRG relative weight under Version 25.0 of the MS–LTC–DRG GROUPER. In FY 2009, the MS–LTC– DRG relative weights are based on 100 percent of the MS–LTC–DRG relative weights. Accordingly, in determining the proposed FY 2009 MS–LTC–DRG relative weights in this proposed rule, there is no longer a need to include a step to calculate MS–LTC–DRG transition blended relative weights (see Step 7 in the FY 2008 IPPS final rule with comment period (72 FR 47295)). Therefore, in this proposed rule, we determined the proposed FY 2009 MS– LTC–DRG relative weights based solely on the proposed MS–LTC–DRG relative weight under proposed Version 26.0 of the MS–LTC–DRG GROUPER, which is discussed in section II.B. of the preamble of this proposed rule. Furthermore, we are proposing that we would determine the final FY 2009 MS– LTC–DRG relative weights in the final rule based on the final Version 26.0 of the MS–LTC–DRG GROUPER that will be presented in that same final rule. Below we discuss in detail the steps for calculating the proposed FY 2009 MS–LTC–DRG relative weights. We note that, as we stated above in section II.I.3.b. of the preamble of this proposed rule, we have excluded the data of allinclusive rate LTCHs and LTCHs that E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules are paid in accordance with demonstration projects that had claims in the FY 2007 MedPAR file. Step 1—Remove statistical outliers. The first step in the calculation of the proposed FY 2009 MS–LTC–DRG relative weights is to remove statistical outlier cases. Consistent with our historical relative weight methodology, we are proposing to continue to define statistical outliers as cases that are outside of 3.0 standard deviations from the mean of the log distribution of both charges per case and the charges per day for each proposed MS–LTC–DRG. These statistical outliers are removed prior to calculating the proposed relative weights because we believe that they may represent aberrations in the data that distort the measure of average resource use. Including those LTCH cases in the calculation of the proposed relative weights could result in an inaccurate proposed relative weight that does not truly reflect relative resource use among the proposed MS–LTC– DRGs. Step 2—Remove cases with a length of stay of 7 days or less. The MS–LTC–DRG relative weights reflect the average of resources used on representative cases of a specific type. Generally, cases with a length of stay of 7 days or less do not belong in a LTCH because these stays do not fully receive or benefit from treatment that is typical in a LTCH stay, and full resources are often not used in the earlier stages of admission to a LTCH. If we were to include stays of 7 days or less in the computation of the proposed FY 2009 MS–LTC–DRG relative weights, the value of many relative weights would decrease and, therefore, payments would decrease to a level that may no longer be appropriate. We do not believe that it would be appropriate to compromise the integrity of the payment determination for those LTCH cases that actually benefit from and receive a full course of treatment at a LTCH, by including data from these very short-stays. Therefore, consistent with our historical relative weight methodology, in determining the proposed FY 2009 MS–LTC–DRG relative weights, we are proposing to remove LTCH cases with a length of stay of 7 days or less. Step 3—Adjust charges for the effects of short-stay outliers. After removing cases with a length of stay of 7 days or less, we are left with cases that have a length of stay of greater than or equal to 8 days. As the next step in the calculation of the proposed FY 2009 MS–LTC–DRG relative weights, consistent with our historical relative weight methodology, we are proposing VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 to adjust each LTCH’s charges per discharge for those remaining cases for the effects of short-stay outliers (as defined in § 412.529(a) in conjunction with § 412.503 for LTCH discharges occurring on or after October 1, 2008). (We note that even if a case was removed in Step 2 (that is, cases with a length of stay of 7 days or less), it was paid as a short-stay outlier if its length of stay was less than or equal to fivesixths of the average length of stay of the MS–LTC–DRG.) We would make this adjustment by counting a short-stay outlier as a fraction of a discharge based on the ratio of the length of stay of the case to the average length of stay for the proposed MS–LTC–DRG for nonshort-stay outlier cases. This has the effect of proportionately reducing the impact of the lower charges for the short-stay outlier cases in calculating the average charge for the proposed MS–LTC–DRG. This process produces the same result as if the actual charges per discharge of a short-stay outlier case were adjusted to what they would have been had the patient’s length of stay been equal to the average length of stay of the proposed MS–LTC–DRG. Counting short-stay outlier cases as full discharges with no adjustment in determining the proposed FY 2009 MS– LTC–DRG relative weights would lower the proposed FY 2009 MS–LTC–DRG relative weight for affected proposed MS–LTC–DRGs because the relatively lower charges of the short-stay outlier cases would bring down the average charge for all cases within a proposed MS–LTC–DRG. This would result in an ‘‘underpayment’’ for nonshort-stay outlier cases and an ‘‘overpayment’’ for short-stay outlier cases. Therefore, we are proposing to adjust for short-stay outlier cases under § 412.529 in this manner because it results in more appropriate payments for all LTCH cases. Step 4—Calculate the proposed FY 2009 MS–LTC–DRG relative weights on an iterative basis. Consistent with our historical relative weight methodology, we are proposing to calculate the proposed MS–LTC–DRG relative weights using the HSRV methodology, which is an iterative process. First, for each LTCH case, we calculate a hospital-specific relative charge value by dividing the short-stay outlier adjusted charge per discharge (see step 3) of the LTCH case (after removing the statistical outliers (see step 1)) and LTCH cases with a length of stay of 7 days or less (see step 2) by the average charge per discharge for the LTCH in which the case occurred. The resulting ratio is then multiplied by the PO 00000 Frm 00075 Fmt 4701 Sfmt 4702 23601 LTCH’s case-mix index to produce an adjusted hospital-specific relative charge value for the case. An initial case-mix index value of 1.0 is used for each LTCH. For each proposed MS–LTC–DRG, the proposed FY 2009 relative weight is calculated by dividing the average of the adjusted hospital-specific relative charge values (from above) for the MS– LTC–DRG by the overall average hospital-specific relative charge value across all cases for all LTCHs. Using these recalculated MS–LTC–DRG relative weights, each LTCH’s average relative weight for all of its cases (that is, its case-mix) is calculated by dividing the sum of all the LTCH’s MS– LTC–DRG relative weights by its total number of cases. The LTCH’s hospitalspecific relative charge values above are multiplied by these hospital-specific case-mix indexes. These hospitalspecific case-mix adjusted relative charge values are then used to calculate a new set of MS–LTC–DRG relative weights across all LTCHs. This iterative process is continued until there is convergence between the weights produced at adjacent steps, for example, when the maximum difference is less than 0.0001. Step 5—Determine a proposed FY 2009 relative weight for proposed MS– LTC–DRGs with no LTCH cases. As we stated above, we determine the proposed FY 2009 relative weight for each proposed MS–LTC–DRG using total Medicare allowable charges reported in the best available LTCH claims data (that is, the December 2007 update of the FY 2007 MedPAR file for this proposed rule). Of the proposed FY 2009 MS–LTC–DRGs, we identified a number of proposed MS–LTC–DRGs for which there were no LTCH cases in the database. That is, based on data from the FY 2007 MedPAR file used for this proposed rule, no patients who would have been classified to those proposed MS–LTC–DRGs were treated in LTCHs during FY 2007 and, therefore, no charge data are available for those proposed MS–LTC–DRGs. Thus, in the process of determining the proposed MS–LTC–DRG relative weights, we are unable to calculate proposed relative weights for these proposed MS–LTC– DRGs with no LTCH cases using the methodology described in Steps 1 through 4 above. However, because patients with a number of the diagnoses under these proposed MS–LTC–DRGs may be treated at LTCHs, consistent with our historical methodology, we are proposing to assign relative weights to each of the proposed no-volume MS– LTC–DRGs based on clinical similarity and relative costliness (with the E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23602 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules exception of proposed ‘‘transplant’’ MS– LTC–DRGs and proposed ‘‘error’’ MS– LTC–DRGs as discussed below). In general, we are proposing to determine proposed FY 2009 relative weights for the proposed MS–LTC–DRGs with no LTCH cases in the FY 2007 MedPAR file used in this proposed rule (that is, proposed ‘‘no-volume MS–LTC–DRGs) by cross-walking each proposed novolume MS–LTC–DRG to another proposed MS–LTC–DRG with a proposed relative weight (determined in accordance with the proposed methodology described above). Then, under our proposed methodology presented in this proposed rule, the proposed ‘‘no-volume’’ MS–LTC–DRG would be assigned the same proposed relative weight of the proposed MS– LTC–DRG to which it would be crosswalked (as described in greater detail below). As noted above, we are proposing to make a modification to our methodology for determining proposed relative weights for MS–LTC–DRGs with no LTCH cases in this proposed rule, which is discussed in greater detail below. As also noted above, even where we are not proposing changes to our existing methodology, we are taking this opportunity to refine our description to more precisely explain our proposed methodology for determining the MS– LTC–DRG relative weights in this proposed rule. Specifically, in this proposed rule, we are proposing to determine the relative weight for each proposed MS–LTC–DRG using total Medicare allowable charges reported in the December 2007 update of the FY 2007 MedPAR file. Of the 746 proposed MS–LTC–DRGs for FY 2009, we identified 203 proposed MS–LTC– DRGs for which there were no LTCH cases in the database (including the 8 proposed ‘‘transplant’’ MS–LTC–DRGs and 2 proposed ‘‘error’’ MS–LTC– DRGs). For this proposed rule, as noted above, we are proposing to assign proposed relative weights for each of the 203 proposed no-volume MS–LTC– DRGs (with the exception of the 8 proposed ‘‘transplant’’ proposed MS– LTC–DRGs and the 2 proposed ‘‘error’’ MS–LTC–DRGs, which are discussed below) based on clinical similarity and relative costliness to one of the remaining 543 (746 ¥ 203 = 543) proposed MS–LTC–DRGs for which we are able to determine relative weights, based on FY 2007 LTCH claims data. (For the remainder of this discussion, VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 we refer to one of the 543 proposed MS– LTC–DRGs for which we are able to determine relative weight as the proposed ‘‘cross-walked’’ MS–LTC– DRG.) Then we are proposing to assign the proposed no-volume MS–LTC–DRG the proposed relative weight of the proposed cross-walked MS–LTC–DRG. This proposed approach differs from the one we used to determine the FY 2008 MS–LTC–DRG relative weights when there were no LTCH cases (see 72 FR 47290). Specifically, in determining the FY 2008 MS–LTC–DRG relative weights in the FY 2008 IPPS final rule with comment period, if the no volume MS– LTC–DRG was cross-walked to a MS– LTC–DRG that had 25 or more cases and, therefore, was not in a low-volume quintile, we assigned the relative weight of a quintile to a no-volume MS–LTC– DRG (rather than assigning the relative weight of the cross-walked MS–LTC– DRG). While we believe this approach would result in appropriate LTCH PPS payments (because it is consistent with our methodology for determining relative weights for MS–LTC–DRGs that have a low volume of LTCH cases (which is discussed above in section II.I.3.e. of this preamble)), upon further review during the development of the proposed FY 2009 MS–LTC–DRG relative weights in this proposed rule, we now believe that proposing to assign the proposed relative weight of the proposed cross-walked MS–LTC–DRG to the proposed no-volume MS–LTC– DRG would result in more appropriate LTCH PPS payments because those cases generally require equivalent relative resource (and therefore should generally have the same LTCH PPS payment). The relative weight of each MS–LTC–DRG should reflect relative resource of the LTCH cases grouped to that MS–LTC–DRG. Because the proposed no-volume MS–LTC–DRGs would be cross-walked to other proposed MS–LTC–DRGs based on clinical similarity and relative costliness, which usually require equivalent relative resource use, we believe that assigning the proposed novolume MS–LTC–DRG the proposed relative weight of the proposed crosswalked MS–LTC–DRG would result in appropriate LTCH PPS payments. (As explained below in Step 6, when necessary, we are proposing to make adjustments to account for nonmonotonicity.) PO 00000 Frm 00076 Fmt 4701 Sfmt 4702 Our proposed methodology for determining the proposed relative weights for the proposed no-volume MS–LTC–DRGs is as follows: We crosswalk the proposed no-volume MS–LTC– DRG to a proposed MS–LTC–DRG for which there are LTCH cases in the FY 2007 MedPAR file and to which it is similar clinically in intensity of use of resources and relative costliness as determined by criteria such as care provided during the period of time surrounding surgery, surgical approach (if applicable), length of time of surgical procedure, postoperative care, and length of stay. We then assign the proposed relative weight of the proposed cross-walked MS–LTC–DRG as the proposed relative weight for the proposed no-volume MS–LTC–DRG such that both of these proposed MS– LTC–DRGs (that is, the proposed novolume MS–LTC–DRG and the proposed cross-walked MS–LTC–DRG) would have the same proposed relative weight. We note that if the proposed cross-walked MS–LTC–DRG had 25 cases or more, its proposed relative weight, which was calculated using the proposed methodology described in steps 1 through 4 above, would be assigned to the proposed no-volume MS–LTC–DRG as well. Similarly, if the proposed MS–LTC–DRG to which the proposed no-volume MS–LTC–DRG is cross-walked has 24 or less cases, and therefore was designated to one of the proposed low-volume quintiles for purposes of determining the proposed relative weights, we would assign the proposed relative weight of the applicable proposed low-volume quintile to the proposed no-volume MS– LTC–DRG such that both of these proposed MS–LTC–DRGs (that is, the proposed no-volume MS–LTC–DRG and the proposed cross-walked MS–LTC– DRG) would have the same proposed relative weight. (As we noted above, in the infrequent case where nonmonotonicity involving a proposed no-volume MS–LTC–DRG results, additional measures as described in Step 6 would be required in order to maintain monotonically increasing relative weights.) For this proposed rule, a list of the proposed no-volume FY 2009 MS–LTC– DRGs and the proposed FY 2009 MS– LTC–DRG to which it is cross-walked (that is, the proposed cross-walked MS– LTC–DRG) is shown in the chart below. E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23603 PROPOSED NO-VOLUME MS–LTC–DRG CROSSWALK FOR FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Proposed MS–LTC–DRG (Version 26.0) Proposed MS–LTC–DRG description (version 26.0) 9 ..................................... 13 ................................... 20 ................................... 21 ................................... 22 ................................... 33 ................................... 34 ................................... 35 ................................... 36 ................................... 39 ................................... 61 ................................... 62 ................................... 63 ................................... 76 ................................... 88 ................................... 90 ................................... 114 ................................. 115 ................................. 117 ................................. 123 ................................. 129 ................................. 130 ................................. 131 ................................. 134 ................................. 138 ................................. 139 ................................. 150 ................................. 151 ................................. 215 ................................. 216 ................................. 217 ................................. 218 ................................. 219 ................................. 220 ................................. 221 ................................. 222 ................................. 223 ................................. 224 ................................. 225 ................................. 228 ................................. 229 ................................. 230 ................................. 231 ................................. 232 ................................. 233 ................................. 234 ................................. 235 ................................. 236 ................................. 245 ................................. 251 ................................. 258 ................................. 265 ................................. 285 ................................. 295 ................................. 296 ................................. 297 ................................. 298 ................................. 332 ................................. 333 ................................. 334 ................................. 336 ................................. 337 ................................. 338 ................................. 339 ................................. 340 ................................. 341 ................................. 342 ................................. 343 ................................. 345 ................................. 346 ................................. Bone marrow transplant ........................................................................................................................ Tracheostomy for face, mouth & neck diagnoses w/o CC/MCC .......................................................... Intracranial vascular procedures w PDX hemorrhage w MCC ............................................................. Intracranial vascular procedures w PDX hemorrhage w CC ................................................................ Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC .................................................... Ventricular shunt procedures w/o CC/MCC .......................................................................................... Carotid artery stent procedure w MCC ................................................................................................. Carotid artery stent procedure w CC .................................................................................................... Carotid artery stent procedure w/o CC/MCC ........................................................................................ Extracranial procedures w/o CC/MCC .................................................................................................. Acute ischemic stroke w use of thrombolytic agent w MCC ................................................................ Acute ischemic stroke w use of thrombolytic agent w CC ................................................................... Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC ....................................................... Viral meningitis w/o CC/MCC ................................................................................................................ Concussion w MCC ............................................................................................................................... Concussion w/o CC/MCC ..................................................................................................................... Orbital procedures w/o CC/MCC .......................................................................................................... Extraocular procedures except orbit ..................................................................................................... Intraocular procedures w/o CC/MCC .................................................................................................... Neurological eye disorders .................................................................................................................... Major head & neck procedures w CC/MCC or major device ............................................................... Major head & neck procedures w/o CC/MCC ...................................................................................... Cranial/facial procedures w CC/MCC ................................................................................................... Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC ......................................................... Mouth procedures w/o CC/MCC ........................................................................................................... Salivary gland procedures ..................................................................................................................... Epistaxis w MCC ................................................................................................................................... Epistaxis w/o MCC ................................................................................................................................ Other heart assist system implant ........................................................................................................ Cardiac valve & oth maj cardiothoracic proc w card cath w MCC ....................................................... Cardiac valve & oth maj cardiothoracic proc w card cath w CC .......................................................... Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC .............................................. Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC .................................................... Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC ....................................................... Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC ........................................... Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC ........................................................... Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC ........................................................ Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC ........................................................ Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC ..................................................... Other cardiothoracic procedures w MCC .............................................................................................. Other cardiothoracic procedures w CC ................................................................................................. Other cardiothoracic procedures w/o CC/MCC .................................................................................... Coronary bypass w PTCA w MCC ....................................................................................................... Coronary bypass w PTCA w/o MCC .................................................................................................... Coronary bypass w cardiac cath w MCC ............................................................................................. Coronary bypass w cardiac cath w/o MCC .......................................................................................... Coronary bypass w/o cardiac cath w MCC .......................................................................................... Coronary bypass w/o cardiac cath w/o MCC ....................................................................................... AICD generator procedures .................................................................................................................. Perc cardiovasc proc w/o coronary artery stent or AMI w/o MCC ....................................................... Cardiac pacemaker device replacement w MCC ................................................................................. AICD lead procedures ........................................................................................................................... Circulatory disorders w AMI, expired w/o CC/MCC .............................................................................. Deep vein thrombophlebitis w/o CC/MCC ............................................................................................ Cardiac arrest, unexplained w MCC ..................................................................................................... Cardiac arrest, unexplained w CC ........................................................................................................ Cardiac arrest, unexplained w/o CC/MCC ............................................................................................ Rectal resection w MCC ....................................................................................................................... Rectal resection w CC .......................................................................................................................... Rectal resection w/o CC/MCC .............................................................................................................. Peritoneal adhesiolysis w CC ............................................................................................................... Peritoneal adhesiolysis w/o CC/MCC ................................................................................................... Appendectomy w complicated principal diag w MCC ........................................................................... Appendectomy w complicated principal diag w CC .............................................................................. Appendectomy w complicated principal diag w/o CC/MCC ................................................................. Appendectomy w/o complicated principal diag w MCC ........................................................................ Appendectomy w/o complicated principal diag w CC ........................................................................... Appendectomy w/o complicated principal diag w/o CC/MCC .............................................................. Minor small & large bowel procedures w CC ....................................................................................... Minor small & large bowel procedures w/o CC/MCC ........................................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00077 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Proposed cross-walked MS–LTC–DRG 30APP2 823 12 31 32 32 32 37 38 38 38 70 71 72 75 89 89 113 125 125 125 146 148 132 133 137 137 152 153 238 237 238 238 237 238 238 242 243 242 243 252 253 254 237 238 237 238 237 238 244 250 259 259 284 294 283 284 284 356 357 358 335 335 371 372 373 371 372 373 344 344 23604 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules PROPOSED NO-VOLUME MS–LTC–DRG CROSSWALK FOR FY 2009—Continued jlentini on PROD1PC65 with PROPOSALS2 Proposed MS–LTC–DRG (Version 26.0) 349 350 351 352 355 383 407 408 410 412 413 416 419 420 421 422 425 434 453 454 455 458 460 461 462 473 479 483 484 491 499 506 508 509 512 517 538 583 585 614 615 620 621 627 654 655 657 658 664 667 670 672 675 691 692 697 707 708 710 712 714 715 716 718 724 734 735 736 737 738 ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. VerDate Aug<31>2005 Proposed cross-walked MS–LTC–DRG Proposed MS–LTC–DRG description (version 26.0) Anal & stomal procedures w/o CC/MCC .............................................................................................. Inguinal & femoral hernia procedures w MCC ...................................................................................... Inguinal & femoral hernia procedures w CC ......................................................................................... Inguinal & femoral hernia procedures w/o CC/MCC ............................................................................ Hernia procedures except inguinal & femoral w/o CC/MCC ................................................................ Uncomplicated peptic ulcer w MCC ...................................................................................................... Pancreas, liver & shunt procedures w/o CC/MCC ............................................................................... Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC .......................................................... Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC ................................................. Cholecystectomy w c.d.e. w CC ........................................................................................................... Cholecystectomy w c.d.e. w/o CC/MCC ............................................................................................... Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC ...................................................... Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC ...................................................................... Hepatobiliary diagnostic procedures w MCC ........................................................................................ Hepatobiliary diagnostic procedures w CC ........................................................................................... Hepatobiliary diagnostic procedures w/o CC/MCC ............................................................................... Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC ......................................................... Cirrhosis & alcoholic hepatitis w/o CC/MCC ......................................................................................... Combined anterior/posterior spinal fusion w MCC ............................................................................... Combined anterior/posterior spinal fusion w CC .................................................................................. Combined anterior/posterior spinal fusion w/o CC/MCC ...................................................................... Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w/o CC/MCC ............................................. Spinal fusion except cervical w/o MCC ................................................................................................ Bilateral or multiple major joint procs of lower extremity w MCC ......................................................... Bilateral or multiple major joint procs of lower extremity w/o MCC ...................................................... Cervical spinal fusion w/o CC/MCC ...................................................................................................... Biopsies of musculoskeletal system & connective tissue w/o CC/MCC .............................................. Major joint & limb reattachment proc of upper extremity w CC/MCC .................................................. Major joint & limb reattachment proc of upper extremity w/o CC/MCC ............................................... Back & neck procedures except spinal fusion w/o CC/MCC ............................................................... Local excision & removal int fix devices of hip & femur w/o CC/MCC ................................................ Major thumb or joint procedures ........................................................................................................... Major shoulder or elbow joint procedures w/o CC/MCC ...................................................................... Arthroscopy ........................................................................................................................................... Shoulder, elbow or forearm proc, exc major joint proc w/o CC/MCC .................................................. Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC ............................................................. Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC .................................................... Mastectomy for malignancy w/o CC/MCC ............................................................................................ Breast biopsy, local excision & other breast procedures w/o CC/MCC ............................................... Adrenal & pituitary procedures w CC/MCC .......................................................................................... Adrenal & pituitary procedures w/o CC/MCC ....................................................................................... O.R. procedures for obesity w CC ........................................................................................................ O.R. procedures for obesity w/o CC/MCC ............................................................................................ Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC ............................................................. Major bladder procedures w CC ........................................................................................................... Major bladder procedures w/o CC/MCC ............................................................................................... Kidney & ureter procedures forneoplasm w CC ................................................................................... Kidney & ureter procedures for neoplasm w/o CC/MCC ...................................................................... Minor bladder procedures w/o CC/MCC ............................................................................................... Prostatectomy w/o CC/MCC ................................................................................................................. Transurethral procedures w/o CC/MCC ................................................................................................ Urethral procedures w/o CC/MCC ........................................................................................................ Other kidney & urinary tract procedures w/o CC/MCC ........................................................................ Urinary stones w esw lithotripsy w CC/MCC ........................................................................................ Urinary stones w esw lithotripsy w/o CC/MCC ..................................................................................... Urethral stricture .................................................................................................................................... Major male pelvic procedures w CC/MCC ............................................................................................ Major male pelvic procedures w/o CC/MCC ......................................................................................... Penis procedures w/o CC/MCC ............................................................................................................ Testes procedures w/o CC/MCC .......................................................................................................... Transurethral prostatectomy w/o CC/MCC ........................................................................................... Other male reproductive system O.R. proc for malignancy w CC/MCC .............................................. Other male reproductive system O.R. proc for malignancy w/o CC/MCC ........................................... Other male reproductive system O.R. proc exc malignancy w/o CC/MCC .......................................... Malignancy, male reproductive system w/o CC/MCC .......................................................................... Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC .................................................. Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC ............................................... Uterine & adnexa proc for ovarian or adnexal malignancy w MCC ..................................................... Uterine & adnexa proc for ovarian or adnexal malignancy w CC ........................................................ Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC ............................................ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00078 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 348 348 348 348 354 384 406 409 409 411 411 415 418 424 424 424 424 433 457 457 457 457 459 480 482 472 478 480 482 490 498 514 507 505 511 516 537 582 584 629 630 619 619 626 653 653 656 656 663 666 669 671 674 694 694 688 660 661 709 711 713 717 717 717 723 717 717 754 755 756 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23605 PROPOSED NO-VOLUME MS–LTC–DRG CROSSWALK FOR FY 2009—Continued Proposed MS–LTC–DRG (Version 26.0) jlentini on PROD1PC65 with PROPOSALS2 740 741 742 743 745 747 748 750 760 761 765 766 767 768 769 770 774 775 776 777 778 779 780 782 789 790 791 792 793 794 795 799 801 803 804 820 821 822 825 828 830 837 838 839 848 887 894 915 916 955 956 959 986 ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. Uterine, adnexa proc for non-ovarian/adnexal malig w CC .................................................................. Uterine, adnexa proc for non-ovarian/adnexal malig w/o CC/MCC ..................................................... Uterine & adnexa proc for non-malignancy w CC/MCC ....................................................................... Uterine & adnexa proc for non-malignancy w/o CC/MCC .................................................................... D&C, conization, laparascopy & tubal interruption w/o CC/MCC ......................................................... Vagina, cervix & vulva procedures w/o CC/MCC ................................................................................. Female reproductive system reconstructive procedures ...................................................................... Other female reproductive system O.R. procedures w/o CC/MCC ...................................................... Menstrual & other female reproductive system disorders w CC/MCC ................................................. Menstrual & other female reproductive system disorders w/o CC/MCC .............................................. Cesarean section w CC/MCC ............................................................................................................... Cesarean section w/o CC/MCC ............................................................................................................ Vaginal delivery w sterilization &/or D&C ............................................................................................. Vaginal delivery w O.R. proc except steril &/or D&C ........................................................................... Postpartum & post abortion diagnoses w O.R. procedure ................................................................... Abortion w D&C, aspiration curettage or hysterotomy ......................................................................... Vaginal delivery w complicating diagnoses .......................................................................................... Vaginal delivery w/o complicating diagnoses ....................................................................................... Postpartum & post abortion diagnoses w/o O.R. procedure ................................................................ Ectopic pregnancy ................................................................................................................................. Threatened abortion .............................................................................................................................. Abortion w/o D&C .................................................................................................................................. False labor ............................................................................................................................................. Other antepartum diagnoses w/o medical complications ..................................................................... Neonates, died or transferred to another acute care facility ................................................................ Extreme immaturity or respiratory distress syndrome, neonate ........................................................... Prematurity w major problems .............................................................................................................. Prematurity w/o major problems ........................................................................................................... Full term neonate w major problems .................................................................................................... Neonate w other significant problems ................................................................................................... Normal newborn .................................................................................................................................... Splenectomy w MCC ............................................................................................................................. Splenectomy w/o CC/MCC ................................................................................................................... Other O.R. proc of the blood & blood forming organs w CC ............................................................... Other O.R. proc of the blood & blood forming organs w/o CC/MCC ................................................... Lymphoma & leukemia w major O.R. procedure w MCC .................................................................... Lymphoma & leukemia w major O.R. procedure w CC ....................................................................... Lymphoma & leukemia w major O.R. procedure w/o CC/MCC ........................................................... Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC .................................................... Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC ................................................. Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC .............................................. Chemo w acute leukemia as sdx or w high dose chemo agent w MCC ............................................. Chemo w acute leukemia as sdx or w high dose chemo agent w CC ................................................ Chemo w acute leukemia as sdx or w high dose chemo agent w/o CC/MCC .................................... Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC ......................................... Other mental disorder diagnoses .......................................................................................................... Alcohol/drug abuse or dependence, left ama ....................................................................................... Allergic reactions w MCC ...................................................................................................................... Allergic reactions w/o MCC ................................................................................................................... Craniotomy for multiple significant trauma ............................................................................................ Limb reattachment, hip & femur proc for multiple significant trauma ................................................... Other O.R. procedures for multiple significant trauma w/o CC/MCC ................................................... Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC ............................................. To illustrate this methodology for determining the proposed relative weights for the proposed MS–LTC– DRGs with no LTCH cases, we are providing the following example, which refers to the proposed no-volume MS– LTC–DRGs crosswalk information for FY 2009 provided in the chart above. Example: There were no cases in the FY 2007 MedPAR file used for this proposed rule for proposed MS–LTC– DRG 61 (Acute ischemic stroke w use of VerDate Aug<31>2005 Proposed cross-walked MS–LTC–DRG Proposed MS–LTC–DRG description (version 26.0) 19:42 Apr 29, 2008 Jkt 214001 thrombolytic agent w MCC). We determined that MS–LTC–DRG 70 (Nonspecific cebrovascular disorders w MCC) is similar clinically and based on resource use to proposed MS–LTC–DRG 61. Therefore, we are proposing to assign the same proposed relative weight of proposed MS–LTC–DRG 70 of 0.8718 for FY 2009 to proposed MS– LTC–DRG 61 (Table 11 of the Addendum of this proposed rule). PO 00000 Frm 00079 Fmt 4701 Sfmt 4702 739 739 755 756 744 746 749 749 744 744 744 744 744 744 744 744 744 744 744 744 759 759 759 781 781 781 781 781 781 781 781 800 800 802 802 823 824 824 824 827 829 829 829 829 847 881 881 918 918 26 482 958 985 Furthermore, for FY 2009, consistent with our historical relative weight methodology, we are proposing to establish MS–LTC–DRG relative weights of 0.0000 for the following proposed transplant MS–LTC–DRGs: Heart Transplant or Implant of Heart Assist System with MCC (MS–LTC–DRG 1); Heart Transplant or Implant of Heart Assist System without MCC (MS–LTC– DRG 2); Liver Transplant with MCC or Intestinal Transplant (MS–LTC–DRG 5); E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23606 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Liver Transplant without MCC (MS– LTC–DRG 6); Lung Transplant (MS– LTC–DRG 7); Simultaneous Pancreas/ Kidney Transplant (MS–LTC–DRG 8); Pancreas Transplant (MS–LTC–DRG 10); and Kidney Transplant (MS–LTC–DRG 652). This is because Medicare will only cover these procedures if they are performed at a hospital that has been certified for the specific procedures by Medicare and presently no LTCH has been so certified. Based on our research, we found that most LTCHs only perform minor surgeries, such as minor small and large bowel procedures, to the extent any surgeries are performed at all. Given the extensive criteria that must be met to become certified as a transplant center for Medicare, we believe it is unlikely that any LTCHs will become certified as a transplant center. In fact, in the more than 20 years since the implementation of the IPPS, there has never been a LTCH that even expressed an interest in becoming a transplant center. If in the future a LTCH applies for certification as a Medicare-approved transplant center, we believe that the application and approval procedure would allow sufficient time for us to determine appropriate weights for the MS–LTC–DRGs affected. At the present time, we would only include these eight proposed transplant MS–LTC–DRGs in the GROUPER program for administrative purposes only. Because we use the same GROUPER program for LTCHs as is used under the IPPS, removing these proposed MS–LTC– DRGs would be administratively burdensome. Again, we note that, as this system is dynamic, it is entirely possible that the number of proposed MS–LTC–DRGs with no volume of LTCH cases based on the system will vary in the future. We used the most recent available claims data in the MedPAR file to identify novolume proposed MS–LTC–DRGs and to determine the proposed relative weights in this proposed rule. Step 6—Adjust the proposed FY 2009 MS–LTC–DRG relative weights to account for nonmonotonically increasing relative weights. As discussed in section II.B. of the preamble of this proposed rule, the MS– DRGs (used under the IPPS) on which the MS–LTC–DRGs are based provide a significant improvement in the DRG system’s recognition of severity of illness and resource usage. The proposed MS–DRGs contain base DRGs that have been subdivided into one, two, or three severity levels. Where there are three severity levels, the most severe level has at least one code that is referred to as an MCC. The next lower VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 severity level contains cases with at least one code that is a CC. Those cases without a MCC or a CC are referred to as without CC/MCC. When data did not support the creation of three severity levels, the base was divided into either two levels or the base was not subdivided. The two-level subdivisions could consist of the CC/MCC and the without CC/MCC. Alternatively, the other type of two level subdivision could consist of the MCC and without MCC. In those base MS–LTC–DRGs that are split into either two or three severity levels, cases classified into the ‘‘without CC/MCC’’ MS–LTC–DRG are expected to have a lower resource use (and lower costs) than the ‘‘with CC/MCC’’ MS– LTC–DRG (in the case of a two-level split) or the ‘‘with CC’’ and ‘‘with MCC’’ MS–LTC–DRGs (in the case of a threelevel split). That is, theoretically, cases that are more severe typically require greater expenditure of medical care resources and will result in higher average charges. Therefore, in the three severity levels, relative weights should increase by severity, from lowest to highest. If the relative weights do not increase (that is, if within a base MS– LTC–DRG, a MS–LTC–DRG with MCC has a lower relative weight than one with CC, or the MS–LTC–DRG without CC/MCC has a higher relative weight than either of the others, they are nonmonotonic). We continue to believe that utilizing nonmonotonic relative weights to adjust Medicare payments would result in inappropriate payments. Consequently, in general, we are proposing to combine proposed MS– LTC–DRG severity levels within a base MS–LTC–DRG for the purpose of computing a relative weight when necessary to ensure that monotonicity is maintained. In determining the proposed FY 2009 MS–LTC–DRG relative weights in this proposed rule, in general, we are proposing to use the same methodology to adjust for nonmonotonicity that we used to determine the FY 2008 MS–LTC–DRG relative weights in the FY 2008 IPPS final rule with comment (72 FR 47293 through 47295). However, as noted above, we are taking this opportunity to refine our description to more precisely explain our methodology for determining the MS–LTC–DRG relative weights in this proposed rule. Specifically, in determining the proposed FY 2009 MS–LTC–DRG relative weights in this proposed rule, under each of the example scenarios provided below, we would combine severity levels within a base MS–LTC– DRG as follows: PO 00000 Frm 00080 Fmt 4701 Sfmt 4702 The first example of nonmonotonically increasing relative weights for a MS–LTC–DRG pertains to a base MS–LTC–DRG with a three-level split and each of the three levels has 25 or more LTCH cases and, therefore, none of those MS–LTC–DRGs is assigned to one of the five low-volume quintiles. In this proposed rule, if nonmonotonicity is detected in the proposed relative weights of the proposed MS–LTC–DRGs in adjacent severity levels (for example, the proposed relative weight of the ‘‘with MCC’’ (the highest severity level) is less than the ‘‘with CC’’ (the middle level), or the ‘‘with CC’’ is less than the ‘‘without CC/MCC’’), we would combine the nonmonotonic adjacent proposed MS–LTC–DRGs and re-determine a proposed relative weight based on the case-weighted average of the combined LTCH cases of the nonmonotonic proposed MS–LTC–DRGs. The caseweighted average charge is calculated by dividing the total charges for all LTCH cases in both severity levels by the total number of LTCH cases for both proposed MS–LTC–DRGs. The same proposed relative weight would be assigned to both affected levels of the base MS–LTC–DRG. If nonmonotonicity remains an issue because the above process results in a proposed relative weight that is still nonmonotonic to the remaining proposed MS–LTC–DRG relative weight within the base MS– LTC–DRG, we would combine all three of the severity levels to redetermine the proposed relative weights based on the case-weighted average charge of the combined severity levels. This same proposed relative weight is then assigned to each of the proposed MS– LTC–DRGs in that base MS–LTC–DRG. A second example of nonmonotonically increasing relative weights for a base MS–LTC–DRG pertains to the situation where there are three severity levels and one or more of the severity levels within a base MS– LTC–DRG has less than 25 LTCH cases (that is, low-volume). In this proposed rule, if nonmonotonicity occurs in the case where either the highest or lowest severity level (‘‘with MCC’’ or ‘‘without CC/MCC’’) has 25 LTCH cases or more and the other two severity levels are low-volume (and therefore the other two severity levels would otherwise be assigned the proposed relative weight of the applicable proposed low-volume quintile(s)), we would combine the data for the cases in the two adjacent proposed low-volume MS–LTC–DRGs for the purpose of determining a proposed relative weight. If the combination results in at least 25 cases, E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules we re-determine one proposed relative weight based on the case-weighted average charge of the combined severity levels and assign this same proposed relative weight to each of the severity levels. If the combination results in less than 25 cases, based on the caseweighted average charge of the combined proposed low-volume MS– LTC–DRGs, both proposed MS–LTC– DRGs would be assigned to the appropriate proposed low-volume quintile (discussed above in section II.I.3.e. of this preamble) based on the case-weighted average charge of the combined proposed low-volume MS– LTC–DRGs. Then the proposed relative weight of the affected proposed lowvolume quintile would be redetermined and that proposed relative weight would be assigned to each of the affected severity levels (and all of the proposed MS–LTC–DRGs in the affected proposed low-volume quintile). If nonmonotonicity persists, we would combine all three severity levels and redetermine one proposed relative weight based on the case-weighted average charge of the combined severity levels and this same proposed relative weight would be assigned to each of the three levels. Similarly, in nonmonotonic cases where the middle level has 25 cases or more but either or both of the lowest or highest severity level has less than 25 cases (that is, low volume), we would combine the nonmonotonic proposed low-volume MS–LTC–DRG with the middle level proposed MS–LTC–DRG of the base MS–LTC–DRG. We would redetermine one proposed relative weight based on the case-weighted average charge of the combined severity levels and assign this same proposed relative weight to each of the affected proposed MS–LTC–DRGs. If nonmonotonicity persists, we would combine all three levels for the purpose of redetermining a proposed relative weight based on the case-weighted average charge of the combined severity levels, and assign that proposed relative weight to each of the three severity levels. In the case where all three severity levels in the base MS–LTC–DRGs are proposed low-volume MS–LTC–DRGs and two of the severity levels are nonmonotonic in relation to each other, we would combine the two adjacent nonmonotonic severity levels. If that combination results in less than 25 cases, both proposed low-volume MS– LTC–DRGs would be assigned to the appropriate proposed low-volume quintile (discussed above in section II.I.3.e. of this preamble) based on the case-weighted average charge of the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 combined proposed low-volume MS– LTC–DRGs. Then the proposed relative weight of the affected proposed lowvolume quintile would be redetermined and that proposed relative weight would be assigned to each of the affected severity levels (and all of the proposed MS–LTC–DRGs in the affected proposed low-volume quintile). If the nonmonotonicity persists, we would combine all three levels of that base MS–LTC–DRG for the purpose of redetermining a proposed relative weight based on the case-weighted average charge of the combined severity levels, and assign that proposed relative weight to each of the three severity levels. If that combination of all three severity levels results in less than 25 cases, we would assign that ‘‘combined’’ base MS–LTC–DRG to the appropriate proposed low-volume quintile based on the case-weighted average charge of the combined proposed low-volume MS– LTC–DRGs. Then the proposed relative weight of the affected proposed lowvolume quintile would be redetermined and that proposed relative weight would be assigned to each of the affected severity levels (and all of the proposed MS–LTC–DRGs in the affected proposed low-volume quintile). Another example of nonmonotonicity involves a base MS–LTC–DRG with three severity levels where at least one of the severity levels has no cases. As discussed above in greater detail in Step 5, based on resource use intensity and clinical similarity, we propose to crosswalk a proposed no-volume MS–LTC– DRG to a proposed MS–LTC–DRG that has at least one case. Under our proposed methodology for the treatment of proposed no-volume MS–LTC–DRGs, the proposed no-volume MS–LTC–DRG would be assigned the same proposed relative weight as the proposed MS– LTC–DRG to which the proposed novolume MS–LTC–DRG is cross-walked. For many proposed no-volume MS– LTC–DRGs, as shown in the chart above in Step 5, the application of our proposed methodology results in a proposed cross-walk MS–LTC–DRG that is the adjacent severity level in the same base MS–LTC–DRG. Consequently, in most instances, the proposed no-volume MS–LTC–DRG and the adjacent proposed MS–LTC–DRG to which it is cross-walked would not result in nonmonotonicity because both of these severity levels would have the same proposed relative weight. (In this proposed rule, under our proposed methodology for the treatment of proposed no-volume MS–LTC–DRGs, in the case where the proposed no-volume MS–LTC–DRG is either the highest or PO 00000 Frm 00081 Fmt 4701 Sfmt 4702 23607 lowest severity level, the proposed cross-walk MS–LTC–DRG would be the middle level (‘‘with CC’’) within the same base MS–LTC–DRG, and therefore the proposed no-volume MS–LTC–DRG (either the ‘‘with MCC’’ or the ‘‘without CC/MCC’’) and the proposed cross-walk MS–LTC–DRG (the ‘‘with CC’’) would have the same proposed relative weight. Consequently, no adjustment for monotonicity would be necessary.) However, if our proposed methodology for determining proposed relative weights for proposed no-volume MS– LTC–DRGs results in nonmonotonicity with the third severity level in the baseMS–LTC–DRG, all three severity levels would be combined for the purpose of redetermining one proposed relative weight based on the case-weighted average charge of the combined severity levels. This same proposed relative weight would be assigned to each of the three severity levels in the base MS– LTC–DRG. Thus far in the discussion, we have presented examples of nonmonotonicity in a base MS–LTC–DRG that has three severity levels. We would apply the same process where the base MS–LTC– DRG contains only two severity levels. For example, if nonmonotonicity occurs in a base MS–LTC–DRG with two severity levels (that is, the proposed relative weight of the higher severity level is less than the lower severity level), where both of the proposed MS– LTC–DRGs have at least 25 cases or where one or both of the proposed MS– LTC–DRGs is low volume (that is, less than 25 cases), we would combine the two proposed MS–LTC–DRGs of that base MS–LTC–DRG for the purpose of redetermining a proposed relative weight based on the combined caseweighted average charge for both severity levels. This same proposed relative weight would be assigned to each of the two severity levels in the base MS–LTC–DRG. Specifically, if the combination of the two severity levels would result in at least 25 cases, we would redetermine one proposed relative weight based on the caseweighted average charge and assign that proposed relative weight to each of the two proposed MS–LTC–DRGs. If the combination results in less than 25 cases, we would assign both proposed MS–LTC–DRGs to the appropriate proposed low-volume quintile (discussed above in section II.I.3.e. of this preamble) based on their combined case-weighted average charge. Then the proposed relative weight of the affected proposed low-volume quintile would be redetermined and that proposed relative E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23608 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules weight would be assigned to each of the affected severity levels. Step 7—Calculate the proposed FY 2009 budget neutrality factor. As we established in the RY 2008 LTCH PPS final rule (72 FR 26882), under the broad authority conferred upon the Secretary under section 123 of Pub. L. 106–113 as amended by section 307(b) of Pub. L. 106–554 to develop the LTCH PPS, beginning with the MS– LTC–DRG update for FY 2008, the annual update to the MS–LTC–DRG classifications and relative weights will be done in a budget neutral manner such that estimated aggregate LTCH PPS payments would be unaffected, that is, would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the MS–LTC–DRG classification and relative weight changes. Specifically, in that same final rule, we established under § 412.517(b) that the annual update to the MS–LTC–DRG classifications and relative weights be done in a budget neutral manner. For a detailed discussion on the establishment of the requirement to update the MS–LTC–DRG classifications and relative weights in a budget neutral manner, we refer readers to the RY 2008 LTCH PPS final rule (72 FR 26880 through 26884). Updating the MS–LTC– DRGs in a budget neutral manner results in an annual update to the individual MS–LTC–DRG classifications and relative weights based on the most recent available data to reflect changes in relative LTCH resource use. To accomplish this, the MS–LTC–DRG relative weights are uniformly adjusted to ensure that estimated aggregate payments under the LTCH PPS would not be affected (that is, decreased or increased). Consistent with that provision, we are proposing to update the MS–LTC–DRG classifications and relative weights for FY 2009 based on the most recent available data and include a proposed budget neutrality adjustment that would be applied in determining the proposed MS–LTC– DRG relative weights. To ensure budget neutrality in updating the proposed MS–LTC–DRG classifications and proposed relative weights under § 412.517(b), consistent with the budget neutrality methodology we established in the FY 2008 IPPS final rule with comment period (72 FR 47295 through 47296), in determining the proposed budget neutrality adjustment for FY 2009 in this proposed rule, we are proposing to use a method that is similar to the methodology used under the IPPS. Specifically, for FY 2009, after recalibrating the proposed MS–LTC– DRG relative weights as we do under the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 methodology as described in detail in Steps 1 through 6 above, we would calculate and apply a normalization factor to those relative weights to ensure that estimated payments are not influenced by changes in the composition of case types or the changes being proposed to the classification system. That is, the proposed normalization adjustment is intended to ensure that the recalibration of the proposed MS–LTC–DRG relative weights (that is, the process itself) neither increases nor decreases total estimated payments. To calculate the proposed normalization factor for FY 2009, we would use the following steps: (1) We use the most recent available claims data (FY 2007) and the proposed MS– LTC–DRG relative weights (determined above in Steps 1 through 6 above) to calculate the average CMI; (2) we group the same claims data (FY 2007) using the FY 2008 GROUPER (Version 25.0) and FY 2008 relative weights (established in the FY 2008 IPPS final rule with comment period (72 FR 47295 through 47296)) and calculate the average CMI; and (3), we compute the ratio of these average CMIs by dividing the average CMI determined in step (2) by the average CMI determined in step (1). In determining the proposed MS– LTC–DRG relative weights for FY 2009, based on the latest available LTCH claims data, the normalization factor is estimated as 1.038266, which would be applied in determining each proposed MS–LTC–DRG relative weight. That is, each proposed MS–LTC–DRG relative weight would be multiplied by 1.038266 in the first step of the budget neutrality process. Accordingly, the proposed relative weights in Table 11 in the Addendum of this proposed rule reflect this proposed normalization factor. We also ensure that estimated aggregate LTCH PPS payments (based on the most recent available LTCH claims data) after reclassification and recalibration (the new proposed FY 2009 MS–LTC–DRG classifications and relative weights) are equal to estimated aggregate LTCH PPS payments (for the same most recent available LTCH claims data) before reclassification and recalibration (the existing FY 2008 MS–DRG classifications and relative weights). Therefore, we would calculate the proposed budget neutrality adjustment factor by simulating estimated total payments under both sets of GROUPERs and relative weights using current LTCH PPS payment policies (RY 2008) and the most recent available claims data (from the FY 2007 MedPAR file). Accordingly, we are proposing to use RY 2008 LTCH PPS rates and policies in PO 00000 Frm 00082 Fmt 4701 Sfmt 4702 determining the proposed FY 2009 budget neutrality adjustment in this proposed rule, using the following steps: (1) We simulate estimated total payments using the normalized proposed relative weights under GROUPER Version 26.0 (as described above); (2) we simulate estimated total payments using the FY 2008 GROUPER (Version 25.0) and FY 2008 MS–LTC– DRG relative weights (as established in the FY 2008 IPPS final rule (72 FR 47295 through 47296)); (3) we calculate the ratio of these estimated total payments by dividing the estimated total payments determined in step (2) by the estimated total payments determined in step (1). Then, each of the normalized proposed relative weights is multiplied by the proposed budget neutrality factor to determine the budget neutral proposed relative weight for each proposed MS–LTC–DRG. Accordingly, in determining the proposed MS–LTC–DRG relative weights for FY 2009 in this proposed rule, based on the most recent available LTCH claims data, we are proposing a budget neutrality factor of 0.99965, which would be applied to the normalized proposed relative weights (described above). The proposed FY 2009 MS–LTC–DRG relative weights in Table 11 in the Addendum of this proposed rule reflect this proposed budget neutrality factor. Furthermore, we expect that we will have established payments rates and policies for RY 2009 prior to the development of the FY 2009 IPPS final rule. Therefore, for purposes of determining the FY 2009 budget neutrality factor in the final rule, we are proposing that we would simulate estimated total payments using the most recent LTCH PPS payment policies and LTCH claims data that are available at that time. Table 11 in the Addendum to this proposed rule lists the proposed MS– LTC–DRGs and their respective proposed budget neutral relative weights, geometric mean length of stay, and five-sixths of the geometric mean length of stay (used in the determination of short-stay outlier payments under § 412.529) for FY 2009. J. Proposed Add-On Payments for New Services and Technologies 1. Background Sections 1886(d)(5)(K) and (L) of the Act establish a process of identifying and ensuring adequate payment for new medical services and technologies (sometimes collectively referred to in this section as ‘‘new technologies’’) under the IPPS. Section 1886(d)(5)(K)(vi) of the Act specifies E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules that a medical service or technology will be considered new if it meets criteria established by the Secretary after notice and opportunity for public comment. Section 1886(d)(5)(K)(ii)(I) of the Act specifies that the process must apply to a new medical service or technology if, ‘‘based on the estimated costs incurred with respect to discharges involving such service or technology, the DRG prospective payment rate otherwise applicable to such discharges under this subsection is inadequate.’’ The regulations implementing this provision establish three criteria for new medical services and technologies to receive an additional payment. First, 42CFR412.87(b)(2) states that a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments until such time as Medicare data are available to fully reflect the cost of the technology in the DRG weights through recalibration. Typically, there is a lag of 2 to 3 years from the point a new medical service or technology is first introduced on the market (generally on the date that the technology receives FDA approval/clearance) and when data reflecting the use of the medical service or technology are used to calculate the DRG weights. For example, data from discharges occurring during FY 2007 are used to calculate the FY 2009 DRG weights in this proposed rule. Section 412.87(b)(2) of our existing regulations provides that ‘‘a medical service or technology may be considered new within 2 or 3 years after the point at which data begin to become available reflecting the ICD–9–CM code assigned to the new medical service or technology (depending on when a new code is assigned and data on the new medical service or technology become available for DRG recalibration). After CMS has recalibrated the DRGs based on available data to reflect the costs of an otherwise new medical service or technology, the medical service or technology will no longer be considered ‘‘new’’ under the criterion for this section.’’ The 2-year to 3-year period during which a medical service or technology can be considered new would ordinarily begin on the date on which the medical service or technology received FDA approval or clearance. (We note that, for purposes of this section of the proposed rule, we refer to both FDA approval and FDA clearance as FDA ‘‘approval.’’) However, in some cases, initially there may be no Medicare data available for the new service or technology following FDA approval. For example, the newness period could extend beyond the 2-year to 3-year period after FDA VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 approval is received in cases where the product initially was generally unavailable to Medicare patients following FDA approval, such as in the case of a national noncoverage determination, or if there was some documented delay in bringing the product onto the market after that approval (for instance, component production or drug production has been postponed following FDA approval due to shelf life concerns or manufacturing issues). After the DRGs have been recalibrated to reflect the costs of an otherwise new medical service or technology, the medical service or technology is no longer eligible for special add-on payment for new medical services or technologies (§ 412.87(b)(2)). For example, an approved new technology that received FDA approval in October 2007 and entered the market at that time may be eligible to receive add-on payments as a new technology for discharges occurring before October 1, 2010 (the start of FY 2011). Because the FY 2011 DRG weights would be calculated using FY 2009 MedPAR data, the costs of such a new technology would be fully reflected in the FY 2011 DRG weights. Therefore, the new technology would no longer be eligible to receive add-on payments as a new technology for discharges occurring in FY 2011 and thereafter. Section 412.87(b)(3) further provides that, to be eligible for the add-on payment for new medical services or technologies, the DRG prospective payment rate otherwise applicable to the discharge involving the new medical services or technologies must be assessed for adequacy. Under the cost criterion, to assess whether a new technology would be inadequately paid under the applicable DRG-prospective payment rate, we evaluate whether the charges for cases involving the new technology exceed certain threshold amounts. In the FY 2004 IPPS final rule (68 FR 45385), we established the threshold at the geometric mean standardized charge for all cases in the DRG plus 75 percent of 1 standard deviation above the geometric mean standardized charge (based on the logarithmic values of the charges and converted back to charges) for all cases in the DRG to which the new medical service or technology is assigned (or the case-weighted average of all relevant DRGs, if the new medical service or technology occurs in more than one DRG). However, section 503(b)(1) of Pub. L. 108–173 amended section 1886(d)(5)(K)(ii)(I) of the Act to provide that, beginning in FY 2005, CMS will apply ‘‘a threshold * * * that is the PO 00000 Frm 00083 Fmt 4701 Sfmt 4702 23609 lesser of 75 percent of the standardized amount (increased to reflect the difference between cost and charges) or 75 percent of one standard deviation for the diagnosis-related group involved.’’ (We refer readers to section IV.D. of the preamble to the FY 2005 IPPS final rule (69 FR 49084) for a discussion of the revision of the regulations to incorporate the change made by section 503(b)(1) of Pub. L. 108–173.) Table 10 in section XIX. of the interim final rule with comment period published in the Federal Register on November 27, 2007, contained the final thresholds that are being used to evaluate applications for new technology add-on payments for FY 2009 (72 FR 66888 through 66892). An applicant must demonstrate that the cost threshold is met using information from inpatient hospital claims. With regard to the issue of whether the HIPAA Privacy Rule at 45 CFR Parts 160 and 164 applies to claims information that providers submit with applications for new technology add-on payments, we addressed this issue in the September 7, 2001 final rule that established the new technology add-on payment regulations (66 FR 46917). In the preamble to that final rule, we explained that health plans, including Medicare, and providers that conduct certain transactions electronically, including the hospitals that would be receiving payment under the FY 2001 IPPS final rule, are required to comply with the HIPAA Privacy Rule. We further explained how such entities could meet the applicable HIPAA requirements by discussing how the HIPAA Privacy Rule permitted providers to share with health plans information needed to ensure correct payment, if they had obtained consent from the patient to use that patient’s data for treatment, payment, or health care operations. We also explained that because the information to be provided within applications for new technology add-on payment would be needed to ensure correct payment, no additional consent would be required. The HHS Office of Civil Rights has since amended the HIPAA Privacy Rule, but the results remain. The HIPAA Privacy Rule no longer requires covered entities to obtain consent from patients to use or disclose protected health information for treatment, payment, or health care operations, and expressly permits such entities to use or to disclose protected health information for any of these purposes. (We refer readers to 45 CFR 164.502(a)(1)(ii), and 164.506(c)(1) and (c)(3), and the Standards for Privacy of Individually Identifiable Health Information published in the Federal E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23610 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Register on August 14, 2002, for a full discussion of changes in consent requirements.) Section 412.87(b)(1) of our existing regulations provides that a new technology is an appropriate candidate for an additional payment when it represents ‘‘an advance that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries.’’ For example, a new technology represents a substantial clinical improvement when it reduces mortality, decreases the number of hospitalizations or physician visits, or reduces recovery time compared to the technologies previously available. (We refer readers to the September 7, 2001 final rule for a complete discussion of this criterion (66 FR 46902).) The new medical service or technology add-on payment policy under the IPPS provides additional payments for cases with relatively high costs involving eligible new medical services or technologies while preserving some of the incentives inherent under an average-based prospective payment system. The payment mechanism is based on the cost to hospitals for the new medical service or technology. Under § 412.88, if the costs of the discharge (determined by applying CCRs as described in § 412.84(h)) exceed the full DRG payment, Medicare will make an add-on payment equal to the lesser of: (1) 50 percent of the estimated costs of the new technology (if the estimated costs for the case including the new technology exceed Medicare’s payment) or (2) 50 percent of the difference between the full DRG payment and the hospital’s estimated cost for the case. If the amount by which the actual costs of a new medical service or technology case exceeds the full DRG payment (including payments for IME and DSH, but excluding outlier payments) by more than the 50-percent marginal cost factor, Medicare payment is limited to the full DRG payment plus 50 percent of the estimated costs of the new technology. Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual DRG classifications and relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. Therefore, in the past, we accounted for projected payments under the new medical service and technology provision during the upcoming fiscal year at the same time we estimated the payment effect of changes to the DRG classifications and recalibration. The impact of additional payments under this provision was then included in the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 budget neutrality factor, which was applied to the standardized amounts and the hospital-specific amounts. However, section 503(d)(2) of Pub. L. 108–173 provides that there shall be no reduction or adjustment in aggregate payments under the IPPS due to add-on payments for new medical services and technologies. Therefore, add-on payments for new medical services or technologies for FY 2005 and later years have not been budget neutral. Applicants for add-on payments for new medical services or technologies for FY 2010 must submit a formal request, including a full description of the clinical applications of the medical service or technology and the results of any clinical evaluations demonstrating that the new medical service or technology represents a substantial clinical improvement, along with a significant sample of data to demonstrate the medical service or technology meets the high-cost threshold. Complete application information, along with final deadlines for submitting a full application, will be available on our Web site at: https:// www.cms.hhs.gov/AcuteInpatientPPS/ 08_newtech.asp#TopOfPage. To allow interested parties to identify the new medical services or technologies under review before the publication of the proposed rule for FY 2010, the Web site will also list the tracking forms completed by each applicant. The Council on Technology and Innovation (CTI) at CMS oversees the agency’s cross-cutting priority on coordinating coverage, coding and payment processes for Medicare with respect to new technologies and procedures, including new drug therapies, as well as promoting the exchange of information on new technologies between CMS and other entities. The CTI, composed of senior CMS staff and clinicians, was established under section 942(a) of Pub. L. 108–173. It is co-chaired by the Director of the Center for Medicare Management (CMM), who is also designated as the CTI’s Executive Coordinator, and the Director of the Office of Clinical Standards and Quality (OCSQ). The specific processes for coverage, coding, and payment are implemented by CMM, OCSQ, and the local claimspayment contractors (in the case of local coverage and payment decisions). The CTI supplements rather than replaces these processes by working to assure that all of these activities reflect the agency-wide priority to promote highquality, innovative care, and at the same time to streamline, accelerate, and improve coordination of these processes PO 00000 Frm 00084 Fmt 4701 Sfmt 4702 to ensure that they remain up to date as new issues arise. To achieve its goals, the CTI works to streamline and create a more transparent coding and payment process, improve the quality of medical decisions, and speed patient access to effective new treatments. It is also dedicated to supporting better decisions by patients and doctors in using Medicare-covered services through the promotion of better evidence development, which is critical for improving the quality of care for Medicare beneficiaries. The agency plans to continue its Open Door forums with stakeholders who are interested in CTI’s initiatives. In addition, to improve understanding of CMS processes for coverage, coding, and payment and how to access them, the CTI is developing an ‘‘innovator’s guide’’ to these processes. This guide will, for example, outline regulation cycles and application deadlines. The intent is to consolidate this information, much of which is already available in a variety of CMS documents and in various places on CMS’s Web site, in a user-friendly format. In the meantime, we invite any product developers with specific issues involving the agency to contact us early in the process of product development if they have questions or concerns about the evidence that would be needed later in the development process for the agency’s coverage decisions for Medicare. The CTI aims to provide information on CTI activities to stakeholders, including Medicare beneficiaries, advocates, medical product manufacturers, providers, and health policy experts, and other stakeholders with useful information on CTI initiatives. Stakeholders with further questions about Medicare’s coverage, coding, and payment processes, or who want further guidance about how they can navigate these processes, can contact the CTI at CTI@cms.hhs.gov or from the ‘‘Contact Us’’ section of the CTI home page (https://www.cms.hhs.gov/ CouncilonTechInnov/). 2. Public Input Before Publication of a Notice of Proposed Rulemaking on AddOn Payments Section 1886(d)(5)(K)(viii) of the Act, as amended by section 503(b)(2) of Pub. L. 108–173, provides for a mechanism for public input before publication of a notice of proposed rulemaking regarding whether a medical service or technology represents a substantial clinical improvement or advancement. The process for evaluating new medical service and technology applications requires the Secretary to— E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules • Provide, before publication of a proposed rule, for public input regarding whether a new service or technology represents an advance in medical technology that substantially improves the diagnosis or treatment of Medicare beneficiaries; • Make public and periodically update a list of the services and technologies for which applications for add-on payments are pending; • Accept comments, recommendations, and data from the public regarding whether a service or technology represents a substantial clinical improvement; and • Provide, before publication of a proposed rule, for a meeting at which organizations representing hospitals, physicians, manufacturers, and any other interested party may present comments, recommendations, and data regarding whether a new medical service or technology represents a substantial clinical improvement to the clinical staff of CMS. In order to provide an opportunity for public input regarding add-on payments for new medical services and technologies for FY 2009 before publication of the FY 2009 IPPS proposed rule, we published a notice in the Federal Register on December 28, 2007 (72 FR 73845 through 73847), and held a town hall meeting at the CMS Headquarters Office in Baltimore, MD, on February 21, 2008. In the announcement notice for the meeting, we stated that the opinions and alternatives provided during the meeting would assist us in our evaluations of applications by allowing public discussion of the substantial clinical improvement criterion for each of the FY 2009 new medical service and technology add-on payment applications before the publication of the FY 2009 IPPS proposed rule. Approximately 70 individuals attended the town hall meeting in person, while approximately 20 additional participants listened over an open telephone line. Each of the four FY 2009 applicants presented information on its technology, including a focused discussion of data reflecting the substantial clinical improvement aspect of the technology. We received two comments during the town hall meeting, which are summarized below. We considered each applicant’s presentation made at the town hall meeting, as well as written comments submitted on each applicant’s application, in our evaluation of the new technology add-on applications for FY 2009 in this proposed rule. We have summarized these comments below or, if applicable, indicated that no VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 comments were received at the end of the discussion of each application. Comment: One commenter addressed the substantial clinical improvement criterion. A medical device association stated that CMS’ interpretation of the statutory criteria for new technology add-on payments is narrow and makes it difficult for potential applicants, especially small manufacturing companies, to qualify for new technology add-on payments. The commenter urged CMS to ‘‘deem a device to satisfy the substantial clinical improvement criteria if it was granted a humanitarian device exemption or priority review based on the fact that it represents breakthrough technologies, which offer significant advantages over existing approved alternatives, for which no alternatives exist, or the availability of which is in the best interests of the patients.’’ In addition, the commenter remarked that this process would simplify CMS’ evaluation of applications for new technology addon payments and would promote access to innovative treatments, as intended by Congress. Although the commenter also made remarks that were unrelated to substantial clinical improvement, because the purpose of the town hall meeting was specifically to discuss substantial clinical improvement of pending new technology applications, those comments are not summarized in this proposed rule. Response: With respect to the comment that CMS has a narrow interpretation of the statute that makes it difficult for applicants to meet the statutory criteria for a new technology add-on payment, we note that we have already specifically addressed the issue in the past (71 FR 47997 and 72 FR 47301). In addition, we addressed the comment concerning automatically deeming technologies granted a humanitarian device exemption (HDE) at 72 FR 47302. Further, because the purpose of the new technology town hall meeting was to discuss substantial clinical improvement of pending applications, we are not providing a response to the unrelated comments in this proposed rule. Comment: One commenter, a medical technology association, submitted comments in reference to the MS–DRGs and the need to account for complexity as well as severity in making refinements to the DRG classification system. The commenter also made the following comments: CMS should raise the new technology marginal cost factor, adjust the newness policy to begin with the issuance of an ICD–9–CM code instead of the FDA approval date, provide access to the quarterly MedPAR PO 00000 Frm 00085 Fmt 4701 Sfmt 4702 23611 updates, and allow for the use of external data for determining new technology payments (when CMS determines that the external data are unbiased and valid). Response: Section 1886(d)(5)(K)(viii) of the Act requires that CMS accept comments, recommendations, and data from the public regarding whether a service or technology represents a substantial clinical improvement. Because the comments above are not related to the substantial clinical improvement criterion of pending applications, we are not providing a response to them in this proposed rule. 3. FY 2009 Status of Technologies Approved for FY 2008 Add-On Payments We did not approve any applications for new technology add-on payments for FY 2008. For additional information, refer to the FY 2008 IPPS final rule with comment period (72 FR 47305 through 47307). 4. FY 2009 Applications for New Technology Add-On Payments We received four applications to be considered for new technology add-on payment for FY 2009. A discussion of each of these applications is presented below. We note that, in the past, we have considered applications that had not yet received FDA approval, but were anticipating FDA approval prior to publication of the IPPS final rule. In such cases, we generally provide a more limited discussion of those technologies in the proposed rule because it is not known if these technologies will meet the newness criterion in time for us to conduct a complete analysis in the final rule. This year, three out of four applicants do not yet have FDA approval. Consequently, we have presented a limited analysis of them in this proposed rule. a. CardioWestTM Temporary Total Artificial Heart System (CardioWestTM TAH–t) SynCardia Systems, Inc. submitted an application for approval of the CardioWestTM temporary Total Artificial Heart system (TAH–t) for new technology add-on payments for FY 2009. The TAH–t is a technology that is used as a bridge to heart transplant device for heart transplant-eligible patients with end-stage biventricular failure. The TAH–t pumps up to 9.5 liters of blood per minute. This high level of perfusion helps improve hemodynamic function in patients, thus making them better heart transplant candidates. E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23612 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules The TAH–t was approved by the FDA on October 15, 2004, for use as a bridge to transplant device in cardiac transplant-eligible candidates at risk of imminent death from biventricular failure. The TAH–t is intended to be used in hospital inpatients. Some of the FDA’s post-approval requirements include that the manufacturer agree to provide a post-approval study demonstrating that the success of the device at one center can be reproduced at other centers. The study was to include at least 50 patients who will be followed up to 1 year, including (but not limited to) the following endpoints; survival to transplant, adverse events, and device malfunction. Presently, Medicare does not cover artificial heart devices, including the TAH–t. However, on February 01, 2008, CMS proposed to reverse a national noncoverage determination that would extend coverage to this technology within the confines of an FDA-approved clinical study. (To view the proposed National Coverage Determination (NCD), we refer readers to the CMS Web site at https://www.cms.hhs.gov/mcd/viewdraft decisionmemo.asp?from2= viewdraftdecisionmemo.asp&id=211&.) Should this proposal be finalized, it would become effective on May 01, 2008. Because Medicare’s existing coverage policy with respect to this device has precluded it from being paid for by Medicare, we would not expect the costs associated with this technology to be currently reflected in the data used to determine MS–DRGs relative weights. As we have indicated in the past, although we generally believe that the newness period would begin on the date that FDA approval was granted, in cases where the applicant can demonstrate a documented delay in market availability subsequent to FDA approval, we would consider delaying the start of the newness period. This technology’s situation represents one such case. We also note that section 1886(d)(5)(K)(ii)(II) of the Act requires that we provide for the collection of cost data for a new medical service or technology for a period of at least 2 years and no more than 3 years ‘‘beginning on the date on which an inpatient hospital code is issued with respect to the service or technology.’’ Furthermore, the statute specifies that the term ‘‘inpatient hospital code’’ means any code that is used with respect to inpatient hospital services for which payment may be made under the IPPS and includes ICD–9–CM codes and any subsequent revisions. Although the TAH–t has been described by the ICD– VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 9–CM code(s) (described below in the cost threshold discussion) since the time of its FDA approval, because the TAH–t has not been covered under the Medicare program (and, therefore, no Medicare payment has been made for this technology), this code is not ‘‘used with respect to inpatient hospital services for which payment’’ is made under the IPPS, and thus we assume that none of the costs associated with this technology would be reflected in the Medicare claims data used to recalibrate the MS–DRG weights. For this reason, despite its FDA approval date, it appears that this technology would still be eligible to be considered ‘‘new’’ for purposes of the new technology add-on payment if and when the proposal to reverse the national noncoverage determination concerning this technology is finalized. Therefore, based on this information, it appears that the TAH–t would meet the newness criterion on the date that Medicare coverage begins, should the proposed NCD be finalized. In an effort to demonstrate that TAH– t would meet the cost criterion, the applicant submitted data based on 28 actual cases of the TAH–t. The data included 6 cases (or 21.4 percent of cases) from 2005, 13 cases (or 46.5 percent of cases) from 2006, 7 cases (or 25 percent of cases) from 2007, and 2 cases (or 7.1 percent of cases) from 2008. Currently, cases involving the TAH–t are assigned to MS–DRG 215 (Other Heart Assist System Implant). As discussed below in this section, we are proposing to remove the TAH–t from MS–DRG 215 and reassign the TAH–t to MS–DRGs 001 (Heart Transplant or Implant of Heart Assist System with MCC) and 002 (Heart Transplant or Implant of Heart Assist System without MCC). Therefore, to determine if the technology meets the cost criterion, it is appropriate to compare the average standardized charge per case to the thresholds for MS–DRGs 001, 002, and 215 included in Table 10 of the November 27, 2007 interim final rule (72 FR 66888 through 66889). The thresholds for MS–DRGs 001, 002, and 215 from Table 10 are $345,031, $178,142, and $151,824, respectively. Based on the 28 cases the applicant submitted, the average standardized charge per case was $731,632. Because the average standardized charge per case is much greater than the thresholds cited above for MS–DRG 215 (and MS– DRGs 001 and 002, should the proposal to reassign the TAH–t be finalized), the applicant asserted that the TAH–t meets the cost criterion whether or not the costs were analyzed by using either a PO 00000 Frm 00086 Fmt 4701 Sfmt 4702 case-weighted threshold or caseweighted standardized charge per case. In addition to analyzing the costs of actual cases involving the TAH–t, the applicant searched the FY 2006 MedPAR file to identify cases involving patients who would have potentially been eligible to receive the TAH–t. The applicant submitted three different MedPAR analyses. The first MedPAR analysis involved a search for cases using ICD–9–CM diagnosis code 428.0 (Congestive heart failure) in combination with ICD–9–CM procedure code 37.66 (Insertion of implantable heart assist system), and an inpatient hospital length of stay greater than or equal to 60 days. The applicant found two cases that met this criterion, which had an average standardized charge per case of $821,522. The second MedPAR analysis searched for cases with ICD–9– CM diagnosis code 428.0 (Congestive heart failure) and one or more of the following ICD–9–CM procedure codes: 37.51 (Heart transplant), 37.52 (Implantation of total heart replacement system), 37.64 (Removal of heart assist system), 37.66 (Insertion of implantable heart assist system), or 37.68 (Insertion of percutaneous external heart assist device), and a length of stay greater than or equal to 60 days. The applicant found 144 cases that met this criterion, which had an average standardized charge per case of $841,827. The final MedPAR analysis searched for cases with ICD–9– CM procedure code 37.51 (Heart transplant) in combination with one of the following ICD–9–CM procedure codes: 37.52 (Implantation of total heart replacement system), 37.65 (Implantation of external heart system), or 37.66 (Insertion of implantable heart assist system). The applicant found 37 cases that met this criterion, which had an average standardized charge per case of $896,601. Because only two cases met the criterion for the first analysis, consistent with historical practice, we would not consider it to be of statistical significance and, therefore, would not rely upon it to demonstrate whether the TAH–t would meet the cost threshold. However, both of the additional analyses seem to provide an adequate number of cases to demonstrate whether the TAH–t would meet the cost threshold. We assume that none of the costs associated with this technology would be reflected in the MedPAR analyses that the applicant used to demonstrate that the technology would meet the cost criterion. We note that, under all three of the analyses the applicant performed, it identified cases that would have been eligible for the TAH–t, but did not remove charges that E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules were unrelated to the TAH–t, nor did the applicant insert a proxy of charges related to the TAH–t. However, as stated above, the average standardized charge per case is much greater than any of the thresholds for MS–DRGs 001, 002, and 215. Therefore, even if the applicant were to approximate what the costs of cases eligible to receive the TAH–t would have been by removing nonTAH–t associated charges and inserting charges related to the TAH–t, it appears that the average standardized charges per case for cases eligible for the TAH– t would exceed the relevant thresholds from Table 10 (as discussed above) and would therefore appear to meet the cost criterion. We invite public comment on whether TAH–t meets the cost criterion. As noted in section II.G. of this preamble, we are proposing to remove the TAH–t from MS–DRG 215 and reassign the TAH–t to MS–DRGs 001 and 002. As stated earlier, CMS is proposing to reverse a national noncoverage determination that would extend coverage to artificial heart devices within the confines of an FDAapproved clinical study, effective May 1, 2008. If this proposal is finalized, the MCE will require both the procedure code 37.52 (Implantation of total replacement heart system) and the diagnosis code reflecting clinical trial— V70.7 (Examination of participant in clinical trial). As we have previously mentioned, the TAH–t appears to meet the cost thresholds for MS–DRGs 001, 002, and 215. Therefore, its proposed reassignment from MS–DRG 215 to MS– DRGs 001 and 002 should have no material effect on meeting the cost thresholds in MS–DRGs 001 and 002 should the reassignment proposal be finalized. The manufacturer states that the TAH–t is the only mechanical circulatory support device intended as a bridge-to-transplant for patients with irreversible biventricular failure. It also asserts that the TAH–t improves clinical outcomes because it has been shown to reduce mortality in patients who are otherwise in end-stage heart failure. In addition, the manufacturer claims that the TAH–t provides greater hemodynamic stability and end-organ perfusion, thus making patients who receive it better candidates for eventual heart transplant. We welcome comments from the public regarding whether the TAH–t represents a substantial clinical improvement. We did not receive any written comments or public comments at the town hall meeting regarding the substantial clinical improvement aspects of this technology. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 b. Emphasys Medical Zephyr Endobronchial Valve (Zephyr EBV) Emphasys Medical submitted an application for new technology add-on payments for FY 2009 for the Emphasys Medical Zephyr Endobronchial Valve (Zephyr EBV). The Zephyr EBV is intended to treat patients with emphysema by reducing volume in the diseased, hyperinflated portion of the emphysematous lung with fewer risks and complications than with more invasive surgical alternatives. Zephyr EBV therapy involves placing small, one-way valves in the patients’ airways to allow air to flow out of, but not into, the diseased portions of the lung thus reducing the hyperinflation. A typical procedure involves placing three to four valves in the target lobe using a bronchoscope, and the procedure takes approximately 20 to 40 minutes to complete. The Zephyr EBVs are designed to be relatively easy to place, and are intended to be removable so that, unlike more risky surgical alternatives such as Lung Volume Reduction Surgery (LVRS) or Lung Transplant, the procedure has the potential to be fully reversible. Currently, the Zephyr EBV has yet to receive approval from the FDA, but the manufacturer indicated to CMS that it expects to receive its FDA approval in the second or third quarter of 2008. Because the technology is not yet approved by the FDA, we will limit our discussion of this technology to data that the applicant submitted, rather than make specific proposals with respect to whether the device would meet the new technology add-on criteria. In an effort to demonstrate that the Zephyr EBV would meet the cost criterion, the applicant searched the FY 2006 MedPAR file for cases with one of the following ICD–9–CM diagnosis codes: 492.0 (Emphysematous bleb), 492.8 (Other emphysema, NEC), or 496 (Chronic airway obstruction, NEC). Based on the diagnosis codes searched by the applicant, cases of the Zephyr EBV would be most prevalent in MS– DRGs 190 (Chronic Obstructive Pulmonary Disease with MCC), 191 (Chronic Obstructive Pulmonary Disease with CC), and 192 (Chronic Obstructive Pulmonary Disease without CC/MCC). The applicant found 1,869 cases (or 12.8 percent of cases) in MS–DRG 190, 5,789 cases (or 39.5 percent of cases) in MS– DRG 191, and 6,995 cases (or 47.7 percent of cases) in MS–DRG 192 (which equals a total of 14,653 cases). The average standardized charge per case was $21,567 for MS–DRG 190, $15,494 for MS–DRG 191, and $11,826 for MS–DRG 192. The average PO 00000 Frm 00087 Fmt 4701 Sfmt 4702 23613 standardized charge per case does not include charges related to the Zephyr EBV; therefore, it is necessary to add the charges related to the device to the average standardized charge per case in evaluating the cost threshold criteria. Although the applicant submitted data related to the estimated cost of the Zephyr EBV per case, the applicant noted that the cost of the device was proprietary information because the device is not yet available on the open market. The applicant estimates $23,920 in charges related to the Zephyr EBV (based on a 100 percent charge markup of the cost of the device). In addition to case-weighting the data based on the amount of cases that the applicant found in the FY 2006 MedPAR file, the applicant case-weighted the data based on its own projections of how many Medicare cases it would expect to map to MS–DRGs 190, 191, and 192 in FY 2009. The applicant projects that, 5 percent of the cases would map to MS– DRG 190, 15 percent of the cases would map to MS–DRG 191, and 80 percent of the cases would map to MS–DRG 192. Adding the charges related to the device to the average standardized charge per case (based on the applicant’s projected case distribution) resulted in a caseweighted average standardized charge per case of $36,782 ($12,862 plus $23,920). Using the thresholds published in Table 10 (72 FR 66889), the case-weighted threshold for MS– DRGs 190, 191, and 192 was $18,394. Because the case-weighted average standardized charge per case for the applicable MS–DRGs exceed the caseweighted threshold amount, the applicant maintains that the Zephyr EBV would meet the cost criterion. As noted above, the applicant also performed a case-weighted analysis of the data based on the 14,653 cases the applicant found in the FY 2006 MedPAR file. Based on this analysis, the applicant found that the case-weighted average standardized charge per case ($38,441 based on the 14,653 cases) exceeded the case-weighted threshold ($20,606 based on the 14,653 cases). Based on both analyses described above, it appears that the applicant would meet the cost criterion. We invite public comment on whether Zephyr EBV meets the cost criterion. The applicant asserts that the Zephyr EBV is a substantial clinical improvement because it provides a new therapy along the continuum of care for patients with emphysema that offers improvement in lung function over standard medical therapy while incurring significantly less risk than more invasive treatments such as LVRS E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23614 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules and lung transplant. Specifically, the applicant submitted data from the ongoing pivotal Endobronchial Valve for Emphysema Palliation (VENT) trial,14 which compared 220 patients who received EBV treatment to 101 patients who received standard medical therapy, including bronchodilators, steroids, mucolytics, and supplemental oxygen. At 6 months, patients who received the Zephyr EBV had an average of 7.2 percent and 5.8 percent improvement (compared to standard medical therapy) in the primary effectiveness endpoints of the Forced Expiratory Volume in 1 second test (FEV1), and the 6 Minute Walk Test (6MWT), respectively. Both results were determined by the applicant to be statistically significant. The FEV1 results were determined using the t-test parametric confidence intervals (the p value determined using the one-side t-test adjusted for unequal variance) and the 6MWT results were determined using the Mann-Whitney nonparametric confidence intervals (the p value was calculated using the onesided Wilcoxon rank sum test). However, the data also showed that patients who received the Zephyr EBV experienced a number of adverse events, including hemoptyis, pneumonia, respiratory failure, pneumothorax, and COPD exacerbations, as well as valve migrations and expectorations that, in some cases, required repeat bronchoscopy. The manufacturer also submitted the VENT pivotal trial 1-year follow-up data, but has requested that the data not be disclosed because it has not yet been presented publicly nor published in a peer-reviewed journal. While CMS recognizes that the Zephyr EBV therapy is significantly less risky than LVRS and lung transplant, we are concerned that the benefits as shown in the VENT pivotal trial may not outweigh the risks when compared with medical therapy alone. Further, we note that, according to the applicant, the Zephyr EBV is intended for use in many patients who are ineligible for LVRS and/or lung transplant (including those too sick to undergo more invasive surgery and those with lower lobe predominant disease distribution), but that certain patients (that is, those with upper lobe predominant disease distribution) could be eligible for either surgery or the Zephyr EBV. We welcome comments from the public on both the patient population who would be eligible for the technology, and whether the 14 Strange, Charlie., et al., design of the Endobronchial Valve for Emphysema Palliation trial (VENT): A Nonsurgical Method of Lung Volume Reduction, BMC Pulmonary Medicine. 2007; 7:10. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Zephyr EBV represents a substantial clinical improvement in the treatment of patients with emphysema. We received written comments from the manufacturer and its presenters at the town hall meeting clarifying some questions that were raised at the town hall meeting. Specifically, these commenters explained that, in general, the target population for the Zephyr EBV device was the same population that could benefit from LVRS, and also includes some patients who were too sick to undergo surgery. The commenters also explained that patients with emphysema with more heterogeneous lung damage were more likely to benefit from the device. We welcome public comments regarding where exactly this technology falls in the continuum of care of patients with emphysema, and for whom the risk/benefit ratio is most favorable. c. Oxiplex FzioMed, Inc. submitted an application for new technology add-on payments for FY 2009 for Oxiplex. Oxiplex is an absorbable, viscoelastic gel made of carboxymethylcellulose (CMC) and polyethylene oxide (PEO) that is intended to be surgically implanted during a posterior discectomy, laminotomy, or laminectomy. The manufacturer asserts that the gel reduces the potential for inflammatory mediators that injure, tether, or antagonize the nerve root in the epidural space by creating an acquiescent, semi-permeable environment to protect against localized debris. These proinflammatory mediators (phospholipase A and nitric oxide), induced or extruded by intervertebral discs, may be responsible for increased pain during these procedures. The manufacturer also asserts that Oxiplex is a unique material in that it coats tissue, such as the nerve root in the epidural space, to protect the nerve root from the effects of inflammatory mediators originating from either the nucleus pulposus, from blood derived inflammatory cells, or cytokines during the healing process. Oxiplex is expecting to receive premarket approval from the FDA by June 2008. Because the technology is not yet approved by the FDA, we will limit our discussion of this technology to data that the applicant submitted, rather than make specific proposals with respect to whether the device would meet the new technology add-on payment criteria. With regard to the newness criterion, we are concerned that Oxiplex may be substantially similar to adhesion barriers that have been on the market for PO 00000 Frm 00088 Fmt 4701 Sfmt 4702 several years. We also note that Oxiplex has been marketed as an adhesion barrier in other countries outside of the United States. The manufacturer maintains that Oxiplex is different from adhesion barriers in several ways, including chemical composition, method of action, surgical application (that is, it is applied liberally to the nerve root and surrounding neural tissues as opposed to minimally only to nerve elements), and tissue response (noninflammatory as opposed to inflammatory). We welcome comments from the public on this issue. In an effort to demonstrate that the technology meets the cost criterion, the applicant searched the FY 2006 MedPAR file for cases with ICD–9–CM procedure codes 03.09 (Other exploration and decompression of spinal canal) or 80.51 (Excision of interveterbral disc) that mapped to CMS DRGs 499 and 500 (CMS DRGs 499 and 500 are crosswalked to MS–DRGs 490 and 491 (Back and Neck Procedures except Spinal Fusion with or without CC)). Because these cases do not include charges associated with the technology, the applicant determined it was necessary to add an additional $7,143 in charges to the average standardized charge per case of cases that map to MS–DRGs 490 and 491. (To do this, the applicant used a methodology of inflating the costs of the technology by the average CCR computed by using the average costs and charges for supplies for cases with ICD–9–CM procedure codes 03.09 and 80.51 that map to MS– DRGs 490 and 491). Of the 221,505 cases the applicant found, 95,340 cases (or 43 percent of cases) would map to MS–DRG 490, which has an average standardized charge of $60,301, and 126,165 cases (or 57 percent of cases) would map to MS–DRG 491, which has an average standardized charge per case of $43,888. This resulted in a caseweighted average standardized charge per case of $50,952. The case-weighted threshold for MS–DRGs 490 and 491 was $27,481. Because the case-weighted average standardized charge per case exceeds the case-weighted threshold in MS–DRGs 490 and 491, the applicant maintains that Oxiplex would meet the cost criterion. We invite public comment on whether Oxiplex meets the cost criterion. The manufacturer maintains that Oxiplex is a substantial clinical improvement because it ‘‘creates a protective environment around the neural tissue that limits nerve root exposure to post-surgical irritants and damage and thus reduces adverse outcomes associated with Failed Back E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 Surgery Syndrome (FBSS) following surgery.’’ The manufacturer also claims that the Oxiplex gel reduces leg and back pain after discectomy, laminectomy, and laminotomy. The manufacturer also asserts that the use of Oxiplex is consistent with fewer revision surgeries. (During the FDA Investigational Device Exemption (IDE) trial, one Oxiplex patient required revision surgery compared to six control patients.) However, as we noted previously in this section, we are concerned that Oxiplex may be substantially similar to adhesion barriers that have been on the market for several years. We are also concerned that even if we were to determine that Oxiplex is not substantially similar to existing adhesion barriers, there may still be insufficient evidence to support the manufacturer’s claims that Oxiplex reduces pain associated with spinal surgery. In addition, we have found no evidence to support the manufacturer’s claims regarding mode of action, degree of dural healing, degree of wound healing, and local tissue response such as might be shown in animal studies. We welcome comments from the public regarding whether Oxiplex represents a substantial clinical improvement. We did not receive any written comments or public comments at the town hall meeting regarding the substantial clinical improvement aspects of this technology. d. TherOx Downstream System TherOx, Inc. submitted an application for new technology add-on payments for FY 2009 for the TherOx Downstream System (Downstream System). The Downstream System uses SuperSaturatedOxygen Therapy (SSO2) that is designed to limit myocardial necrosis by minimizing microvascular damage in acute myocardial infarction (AMI) patients following intervention with Percutaneous Transluminal Coronary Angioplasty (PTCA), and coronary stent placement by perfusing the affected myocardium with blood that has been supersaturated with oxygen. SSO2 therapy refers to the delivery of superoxygenated arterial blood directly to areas of myocardial tissue that have been reperfused using PTCA and stent placement, but which may still be at risk. The desired effect of SSO2 therapy is to reduce infarct size and thus preserve heart muscle and function. The DownStream System is the console portion of a disposable cartridge-based system that withdraws a small amount of the patient’s arterial blood, mixes it with a small amount of saline, and supersaturates it with oxygen to create highly oxygen-enriched VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 blood. The superoxygenated blood is delivered directly to the infarct-related artery via the TherOx infusion catheter. SSO2 therapy is a catheter laboratorybased procedure. Additional time in the catheter lab area is an average of 100 minutes. The manufacturer claims that the SSO2 therapy duration lasts 90 minutes and requires an additional 10 minutes post-procedure preparation for transfer time. The TherOx Downstream System is currently not FDA approved; however, the manufacturer states that it expects to receive FDA approval in the second quarter of 2008. Because the technology is not yet approved by the FDA, we will limit our discussion of this technology to data that the applicant submitted, rather than make specific proposals with respect to whether the device would meet the new technology add-on criteria. In an effort to demonstrate that it would meet the cost criterion, the applicant submitted two analyses. The applicant believes that cases that would be eligible for the Downstream System would most frequently group to MS– DRGs 246 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+Vessels/Stents), 247 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC), 248 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent with MCC or 4+Vessels/Stents), and 249 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent without MCC). The first analysis used data based on 83 clinical trial patients from 10 clinical sites. Of the 83 cases, 78 were assigned to MS–DRGs 246, 247, 248, or 249. The data showed that 32 of these patients were 65 years old or older. There were 12 cases (or 15.4 percent of cases) in MS–DRG 246, 56 cases (or 71.8 percent of cases) in MS–DRG 247, 2 cases (or 2.6 percent of cases) in MS– DRG 248, and 8 cases (or 10.3 percent of cases) in MS–DRG 249. (The remaining five cases grouped to MS– DRGs that the technology would not frequently group to and therefore are not included in this analysis.) The average standardized charge per case for MS– DRGs 246, 247, 248, and 249 was $66,730, $53,963, $54,977, and $41,594, respectively. The case-weighted average standardized charge per case for the four MS–DRGs listed above is $54,665. Based on the threshold from Table 10 (72 FR 66890), the case-weighted threshold for the four MS–DRGs listed above was $49,303. The applicant also searched the FY 2006 MedPAR file to identify cases that would be eligible for the Downstream System. The applicant PO 00000 Frm 00089 Fmt 4701 Sfmt 4702 23615 specifically searched for cases with primary ICD–9–CM diagnosis code 410.00 (Acute myocardial infarction of anterolateral wall with episode of care unspecified), 410.01 (Acute myocardial infarction of anterolateral wall with initial episode of care), 410.10 (Acute myocardial infarction of other anterior wall with episode of care unspecified), or 410.11 (Acute myocardial infarction of other anterior wall with initial episode of care) in combination with ICD–9–CM procedure code of 36.06 (Insertion of non-drug-eluting coronary artery stent(s)) or 36.07 (Insertion of drug-eluting coronary artery stent(s)). The applicant’s search found 13,527 cases within MS–DRGs 246, 247, 248, and 249 distributed as follows: 2,287 cases (or 16.9 percent of cases) in MS– DRG 246; 9,691 cases (or 71.6 percent of cases) in MS–DRG 247; 402 cases (or 3 percent of cases) in MS–DRG 248; and 1,147 cases (or 8.5 percent of cases) in MS–DRG 249. Not including the charges associated with the technology, the geometric mean standardized charge per case for MS–DRGs 246, 247, 248, and 249 was $59,631, $42,357, $49,718 and $37,446, respectively. Therefore, based on this analysis, the total case-weighted geometric mean standardized charge per case across these MS–DRGs was $45,080. The applicant estimated that it was necessary to add an additional $21,620 in charges to the total caseweighted geometric mean standardized charge per case. The applicant included charges for supplies and tests related to the technology, charges for 100 minutes of additional procedure time in the catheter laboratory and charges for the technology itself in the additional charge amount referenced above. The inclusion of these charges would result in a total case-weighted geometric mean standardized charge per case of $66,700. The case-weighted threshold for MS– DRGs 246, 247, 248, and 249 (from Table 10 (72 FR 66889)) was $49,714. Because the total case-weighted average standardized charge per case from the first analysis and the case-weighted geometric mean standardized charge per case from the second analysis exceeds the applicable case-weighted threshold, the applicant maintains the Downstream System would meet the cost criterion. We invite public comment on whether Downstream System meets the cost criterion. The applicant asserts that the Downstream System is a substantial clinical improvement because it reduces infarct size in acute AMI where PTCA and stent placement have also been performed. Data was submitted from the Acute Myocardial Infarction Hyperbaric E:\FR\FM\30APP2.SGM 30APP2 23616 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Oxygen Treatment (AMIHOT) II trial, which was presented at the October 2007 Transcatheter Cardiovascular Therapeutics conference, but has not been published in peer reviewed literature, that showed an average of 6.5 percent reduction in infarct size as measured with Tc–99m Sestamibi imaging in patients who received supersaturated oxygen therapy. We note that those patients also showed a significantly higher incidence of bleeding complications. While we recognize that a reduction of infarct size may correlate with improved clinical outcomes, we question whether the degree of infarct size reduction found in the trial represents a substantial clinical improvement, particularly in light of the apparent increase in bleeding complications. We welcome comments from the public on this matter. We received one written comment from the manufacturer clarifying questions that were raised at the town hall meeting. Specifically, the commenter explained the methodology of Tc–99m Sestamibi scanning and interpretation in the AMIHOT II trial. In addition, the commenter explained that the AMIHOT 15 and AMIHOT II trials did not attempt to measure differences in heart failure outcomes nor mortality outcomes. jlentini on PROD1PC65 with PROPOSALS2 5. Proposed Regulatory Change Section 1886(d)(5)(K)(i) of the Act directs us to establish a mechanism to recognize the cost of new medical services and technologies under the IPPS, with such mechanism established after notice and opportunity for public comment. In accordance with this authority, we established at § 412.87(b) of our regulations criteria that a medical service or technology must meet in order to qualify for the additional payment for new medical services and technologies. Specifically, we evaluate applications for new medical service or technology add-on payment by determining whether they meet the criteria of newness, adequacy of payment, and substantial clinical improvement. As stated in section III.J.1. of the preamble of this proposed rule, § 412.87(b)(2) of our existing regulations provides that a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments after the 15 Oneill, WW., et al., Acute Myocardial Infarction with Hyperoxemic Therapy (AMIHOT): A Prospective Randomized Trial of Intracoronary Hyperoxemic Reperfusion after Percutaneous Coronary Intervention. Journal of the American College of Cardiology, Vol. 50, No. 5, 2007, pp. 397– 405. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 point at which data begin to become available reflecting the ICD–9–CM code assigned to the new service or technology. The point at which these data become available typically begins when the new medical service or technology is first introduced on the market, generally on the date that the medical service or technology receives FDA approval. Accordingly, for purposes of the new medical service or technology add-on payment, a medical service or technology cannot be considered new prior to the date on which FDA approval is granted. In addition, as stated in section III.J.1. of the preamble of this proposed rule, § 412.87(b)(3) of our existing regulations provides that, to be eligible for the addon payment for new medical services or technologies, the DRG prospective payment rate otherwise applicable to the discharge involving the new medical service or technology must be assessed for adequacy. Under the cost criterion, to assess the adequacy of payment for a new medical service or technology paid under the applicable DRG prospective payment rate, we evaluate whether the charges for cases involving the new medical service or technology exceed certain threshold amounts. Section 412.87(b)(1) of our existing regulations provides that, to be eligible for the add-on payment for new medical services or technologies, the new medical service or technology must represent an advance that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries. In addition, § 412.87(b)(1) states that CMS will announce its determination as to whether a new medical service or technology meets the substantial clinical improvement criteria in the Federal Register as part of the annual updates and changes to the IPPS. Since the implementation of the policy on add-on payments for new medical services and technologies, we accept applications for add-on payments for new medical services and technologies on an annual basis by a specified deadline. For example, applications for FY 2009 were submitted in November 2007. After accepting applications, CMS then evaluates them in the annual IPPS proposed and final rules to determine whether the medical service or technology is eligible for the new medical service or technology add-on payment. If an application meets each of the eligibility criteria, the medical service or technology is eligible for new medical service or technology add-on payments beginning on the first day of the new fiscal year (that is, October 1). PO 00000 Frm 00090 Fmt 4701 Sfmt 4702 We have advised prior and potential applicants that we evaluate whether a medical service or technology is eligible for the new medical service or technology add-on payments prior to publication of the final rule setting forth the annual updates and changes to the IPPS, with the results of our determination announced in the final rule. We announce our results in the final rule for each fiscal year because we believe predictability is an important aspect of the IPPS and that it is important to apply a consistent payment methodology for new medical services or technologies throughout the entire fiscal year. For example, hospitals must train their billing and other staff after publication of the final rule to properly implement the coding and payment changes for the upcoming fiscal year set forth in the final rule. In addition, hospitals’ budgetary process and clinical decisions regarding whether to utilize new technologies are based in part on the applicable payment rates under the IPPS for the upcoming fiscal year, including whether the new medical services or technologies qualify for the new medical service or technology add-on payment. If CMS were to make multiple payment changes under the IPPS during a fiscal year, these changes could adversely affect the decisions hospitals implement at the beginning of the fiscal year. For these reasons, we believe applications for new medical service or technology add-on payments should be evaluated prior to publication of the final IPPS rule for each fiscal year. Therefore, if an application does not meet the new medical service or technology add-on payment criteria prior to publication of the final rule, it will not be eligible for the new medical service or technology add-on payments for the fiscal year for which it applied for the add-on payments. Because we make our determination regarding whether a medical service or technology meets the eligibility criteria for the new medical service or technology add-on payments prior to publication of the final rule, we have advised both past and potential applicants that their medical service or technology must receive FDA approval early enough in the IPPS rulemaking cycle to allow CMS enough time to fully evaluate the application prior to the publication of the IPPS final rule. Moreover, because new medical services or technologies that have not received FDA approval do not meet the newness criterion, it would not be necessary or prudent for us to make a final determination regarding whether a new E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules medical service or technology meets the cost threshold and substantial clinical improvement criteria prior to the medical service or technology receiving FDA approval. In addition, we do not believe it is appropriate for CMS to determine whether a medical service or technology represents a substantial clinical improvement over existing technologies before the FDA makes a determination as to whether the medical service or technology is safe and effective. For these reasons, we first determine whether a medical service or technology meets the newness criteria, and only if so, do we then make a determination as to whether the technology meets the cost threshold and represents a substantial clinical improvement over existing medical services or technologies. For example, even if an application has FDA approval, if the medical service or technology is beyond the timeline of 2– 3 years to be considered new, in the past we have not made a determination on the cost threshold and substantial clinical improvement. Further, as we have discussed in prior final rules (69 FR 49018–49019 and 70 FR 47344), it is our past and present practice to analyze the new medical service or technology add-on payment criteria in the following sequence: Newness, cost threshold, and finally substantial clinical improvement. Under our proposal in this proposed rule, we would continue this practice of analyzing the eligibility criteria in this sequence and announce in the annual Federal Register as part of the annual updates and changes to the IPPS our determination on whether a medical service or technology meets the eligibility criteria in § 412.87(b). In the interest of more clearly defining the parameters under which CMS can fully and completely evaluate new medical service or technology add-on payment applications, we are proposing to amend the regulations at § 412.87 by adding a new paragraph (c) to codify our current policy and specify that CMS will consider whether a new medical service or technology meets the eligibility criteria in § 412.87(b) and announce the results in the Federal Register as part of the annual updates and changes to the IPPS. As a result, we are proposing to remove the duplicative text in § 412.87(b)(1) that specifies that CMS will determine whether a new medical service or technology meets the substantial clinical improvement criteria and announce the results of its determination in the Federal Register as part of the annual updates and changes to the IPPS. We note that this proposal is not a change to our current policy, as VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 we have always given consideration to whether an application meets the new medical service or technology eligibility criteria in the annual IPPS proposed and final rules. Rather, this proposal simply codifies our current practice of fully evaluating new medical service or technology add-on payment applications prior to publication of the final rule in order to maintain predictability within the IPPS for the upcoming fiscal year. In addition, we are proposing in new paragraph (c) of § 412.87 to set July 1 of each year as the deadline by which IPPS new medical service or technology addon payment applications must receive FDA approval. This proposed deadline should provide us with enough time to fully consider all of the new medical service or technology add-on payment criteria for each application and maintain predictability in the IPPS for the coming fiscal year. Finally, under this proposal, applications that have not received FDA approval by July 1 would not be considered in the final rule, even if they were summarized in the corresponding IPPS proposed rule. However, applications that receive FDA approval of the medical service or technology after July 1 would be able to reapply for the new medical service or technology add-on payment the following year (at which time they would be given full consideration in both the IPPS proposed and final rules). In summary, for the reasons cited above, we are proposing to revise § 412.87 to remove the second sentence of (b)(1) and add a new paragraph (c) to codify our current practice of how CMS evaluates new medical service or technology add-on payment applications and establish in paragraph (c) a deadline of July 1 of each year as the deadline by which IPPS new medical service or technology add-on payment applications must receive FDA approval in order to be fully evaluated in the applicable IPPS final rule each year. III. Proposed Changes to the Hospital Wage Index A. Background Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts ‘‘for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.’’ In PO 00000 Frm 00091 Fmt 4701 Sfmt 4702 23617 accordance with the broad discretion conferred under the Act, we currently define hospital labor market areas based on the definitions of statistical areas established by the Office of Management and Budget (OMB). A discussion of the proposed FY 2009 hospital wage index based on the statistical areas, including OMB’s revised definitions of Metropolitan Areas, appears under section III.C. of this preamble. Beginning October 1, 1993, section 1886(d)(3)(E) of the Act requires that we update the wage index annually. Furthermore, this section provides that the Secretary base the update on a survey of wages and wage-related costs of short-term, acute care hospitals. The survey must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. The proposed adjustment for FY 2009 is discussed in section II.B. of the Addendum to this proposed rule. As discussed below in section III.I. of this preamble, we also take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating IPPS payment amounts. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. The proposed budget neutrality adjustment for FY 2009 is discussed in section II.A.4.b. of the Addendum to this proposed rule. Section 1886(d)(3)(E) of the Act also provides for the collection of data every 3 years on the occupational mix of employees for short-term, acute care hospitals participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. A discussion of the occupational mix adjustment that we are proposing to apply beginning October 1, 2008 (the FY 2009 wage index) appears under section III.D. of this preamble. B. Requirements of Section 106 of the MIEA–TRHCA 1. Wage Index Study Required Under the MIEA–TRHCA Section 106(b)(1) of the MIEA– TRHCA (Pub. L. 109–432) required E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23618 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare wage index classification system applied under the Medicare IPPS. Section 106(b) of MIEA–TRHCA required the report to include any alternatives that MedPAC recommends to the method to compute the wage index under section 1886(d)(3)(E) of the Act. In addition, section 106(b)(2) of the MIEA–TRHCA instructed the Secretary of Health and Human Services, taking into account MedPAC’s recommendations on the Medicare wage index classification system, to include in this FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS. The proposal (or proposals) must consider each of the following: • Problems associated with the definition of labor markets for the wage index adjustment. • The modification or elimination of geographic reclassifications and other adjustments. • The use of Bureau of Labor of Statistics data or other data or methodologies to calculate relative wages for each geographic area. • Minimizing variations in wage index adjustments between and within MSAs and statewide rural areas. • The feasibility of applying all components of CMS’ proposal to other settings. • Methods to minimize the volatility of wage index adjustments while maintaining the principle of budget neutrality. • The effect that the implementation of the proposal would have on health care providers on each region of the country. • Methods for implementing the proposal(s) including methods to phase in such implementations. • Issues relating to occupational mix such as staffing practices and any evidence on quality of care and patient safety including any recommendation for alternative calculations to the occupational mix. In its June 2007 Report to Congress, ‘‘Report to the Congress: Promoting Greater Efficiency in Medicare’’ (Chapter 6 with Appendix), MedPAC made three broad recommendations regarding the wage index: (1) Congress should repeal the existing hospital wage index statute, including reclassifications and exceptions, and give the Secretary authority to establish a new wage index system; (2) The Secretary should establish a hospital compensation index that— VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 • Uses wage data from all employers and industry-specific occupational weights; • Is adjusted for geographic differences in the ratio of benefits to wages; • Is adjusted at the county level and smoothes large differences between counties; and • Is implemented so that large changes in wage index values are phased in over a transition period; and (3) The Secretary should use the hospital compensation index for the home health and skilled nursing facility prospective payment systems and evaluate its use in the other Medicare fee-for-service prospective payment systems. The full June 2007 Report to Congress is available at the Web site: https:// www.medpac.gov/documents/ Jun07_EntireReport.pdf). In the presentation and analysis of its alternative wage index system, MedPAC addressed almost all of the nine points for consideration under section 106(b)(2) of Pub. L. 109–432. Following are the highlights of the alternative wage index system recommended by MedPAC: • Although the MedPAC recommended wage index generally retains the current labor market definitions, it supplements the metropolitan areas with county-level adjustments and eliminates single wage index values for rural areas. • In the MedPAC recommended wage index, the county-level adjustments, together with a smoothing process that constrains the magnitude of differences between and within contiguous wage areas, serve as a replacement for geographical reclassifications. • The MedPAC recommended wage index uses BLS data instead of the CMS hospital wage data collected on the Medicare cost report. MedPAC adjusts the BLS data for geographic differences in the ratio of benefits to wages using Medicare cost report data. • The BLS data are collected from a sample of all types of employers, not just hospitals. The MedPAC recommended wage index could be adapted to other providers such as HHAs and SNFs by replacing hospital occupational weights with occupational weights appropriate for other types of providers. • In the MedPAC recommended wage index, volatility over time is addressed by the use of BLS data, which is based on a 3-year rolling sample design. • MedPAC recommends a phased implementation for its recommended PO 00000 Frm 00092 Fmt 4701 Sfmt 4702 wage index in order to cushion the effect of large wage index changes on individual hospitals. • MedPAC suggests that using BLS data automatically addresses occupational mix differences, because the BLS data are specific to health care occupations, and national industry-wide occupational weights are applied to all geographic areas. • The MedPAC report does not provide any evidence of the impact of its wage index on staffing practices or the quality of care and patient safety. To assist CMS in meeting the requirements of section 106(b)(2) of Pub. L. 109–432, in February 2008, CMS awarded a Task Order under its Expedited Research and Demonstration Contract, to Acumen, LLC. The two general responsibilities of the Task Order are to (1) conduct a detailed impact analysis that compares the effects of MedPAC’s wage and hospital compensation indexes with the CMS wage index and (2) assist CMS in developing a proposal (or proposals) that addresses the nine points for consideration under section 106(b)(2) of Pub. L. 109–432. Specifically, the tasks under the Task Order include, but are not limited to, an evaluation of whether differences between the two types of wage data (that is, CMS cost report and occupational mix data and BLS data) produce significant differences in wage index values among labor market areas, a consideration of alternative methods of incorporating benefit costs into the construction of the wage index, a review of past and current research on alternative labor market area definitions, and a consideration of how aspects of the MedPAC recommended wage index can be applied to the CMS wage data in constructing a new methodology for the wage index. We will present any analyses and proposals resulting from this Task Order in the FY 2009 IPPS final rule or in a special Federal Register notice issued after the final rule is published. 2. CMS Proposals in Response to Requirements Under Section 106(b) of the MIEA–TRHCA As discussed in section III.A. of this preamble, the purpose of the hospital wage index is to adjust the IPPS standardized payment to reflect labor market area differences in wage levels. The geographic reclassification system exists in order to assist ‘‘hospitals which are disadvantaged by their current geographic classification because they compete with hospitals that are located in the geographic area to which they seek to be reclassified’’ (56 FR 25469). Geographic reclassification is E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 established under section 1886(d)(10) of the Act and is implemented through 42 CFR Part 412, Subpart L. (We refer readers to section III.I. of this preamble for a detailed discussion of the geographic reclassification system and other area wage index exceptions.) In its June 2007 Report to Congress, MedPAC discussed its findings that geographic reclassification, and numerous other area wage index exceptions added to the system over the years, have created major complexities and ‘‘troubling anomalies’’ in the hospital wage index. A review of the IPPS final rules reveals a long history of legislative changes that have permitted certain hospitals, that otherwise would not be able to reclassify under section 1886(d)(10) of the Act, to receive a higher wage index than calculated for their geographic area. MedPAC reports that more than one-third of hospitals now receive a higher wage index due to geographic reclassification or other wage index exceptions. We are concerned about the integrity of the current system, and agree with MedPAC that the process has become burdensome. As noted above, MedPAC recommended the elimination of geographic reclassification and other wage index exceptions. In addition, the President’s FY 2009 Budget included a proposal to apply the geographic reclassification budget neutrality requirement at the State level rather than by adjusting the standardized rate for hospitals nationwide. Given the language in section 1886(d)(10) of the Act establishing the MGCRB, we believe a statutory change would be required to make these changes. However, we do have the authority to make some regulatory changes to the reclassification system as discussed below. We note that these proposals do not preclude future consideration of MedPAC’s recommendations that could be implemented through additional changes to our regulations, once our analysis of those recommendations is complete (after the publication of the FY 2009 IPPS proposed rule). a. Proposed Revision of the Reclassification Average Hourly Wage Comparison Criteria Regulations at 42 CFR 413.230(d)(1) set forth the average hourly wage comparison criteria that an individual hospital must meet in order for the MGCRB to approve a geographic reclassification application. Our current criteria (requiring an urban hospital to demonstrate that its average hourly wage is at least 108 percent of the average hourly wage of hospitals in the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 area in which the hospital is located and at least 84 percent of the average hourly wage of hospitals in the area to which it seeks redesignation) were adopted in the FY 1993 IPPS final rule (57 FR 39825). In that final rule, we explained that the 108 percent threshold ‘‘is based on the national average hospital wage as a percentage of its area wage (96 percent) plus one standard deviation (12 percent).’’ We also explained that we would use the 84-percent threshold to reflect the average hospital wage of the hospital as a percentage of its area wage less one standard deviation. We stated that ‘‘to qualify for a wage index reclassification, a hospital must have an average hourly wage that is more than one national standard deviation above its original labor market area and not less than one national standard deviation below its new labor market area’’ (57 FR 39770). In response to numerous public comments we received, we expressed our policy and legal justifications for adopting the specific thresholds. Among other things, we stated that geographic reclassifications must be viewed not just in terms of those hospitals that are reclassifying, but also in terms of the nonreclassifying hospitals that, through a budget neutrality adjustment, are required to bear a financial burden associated with the higher wage indices received by those hospitals that reclassify. We also indicated that the Secretary has ample legal authority under section 1886(d)(10) of the Act to set the wage comparison thresholds and to revise such thresholds upon further review. We refer readers to that final rule for a full discussion of our justifications for the standards. In the FY 2000 IPPS final rule (65 FR 47089 through 47090), the wage comparison criteria for rural hospitals seeking individual hospital reclassifications were reduced to 82 percent and 106 percent to compensate for the historic economic underperformance of rural hospitals. The 2-percent drop in both thresholds was determined to allow a significant benefit to some hospitals that were close to meeting the existing criteria but would not make the reclassification standards overly liberal for rural hospitals. CMS has not evaluated or recalibrated the average hourly wage criteria for geographic reclassification since they were established in FY 1993. In consideration of the MIEA–TRHCA requirements and MedPAC’s finding that over one-third of hospitals are receiving a reclassified wage index or other wage index adjustment, we decided to reevaluate the average hourly PO 00000 Frm 00093 Fmt 4701 Sfmt 4702 23619 wage criteria for geographic reclassification. We ran simulations with more recent wage data to determine what would be the appropriate average hourly wage criteria. We found that the average hospital average hourly wage as a percentage of its area’s wage has increased from approximately 96 percent in FY 1993 to closer to 98 percent over FYs 2006, 2007, and 2008 (97.8, 98.2, and 98 percent, respectively). We also determined that the standard deviation has been reduced from approximately 12 percent in FY 1993 to closer to 10 percent over the same 3-year period (10.7, 10.4, and 10.4 percent, respectively); that is, assuming normal distributions, approximately 68 percent of all hospitals would have an average hourly wage that deviates less than 10 percentage points above or below the mean. This assessment indicates that the new baseline criteria for reclassification should be set to 88/ 108 percent. While the 108 criterion appears not to require adjustment, the current 84 percent standard appears to be too low a threshold to serve the purpose of establishing wage comparability with a proximate labor market area. To assess the impact that these changes would have had on hospitals that reclassified in FY 2008, we ran models that set urban individual reclassification standards to 88/108 percent and the county group reclassification standard to 88 percent. We retained the 2-percent benefit for rural hospitals by setting an 86/106 percent standard. We used 3-year average hourly wage figures from the 2005, 2006, and 2007 wage surveys and compared them to 3-year average hourly wage figures for CBSAs over the same 3year period. Of the 295 hospitals that applied for and received individual reclassifications in FY 2008, 45 of them (15.3 percent) would not meet the proposed 88/86 percent threshold. Of the 66 hospitals that applied for and received county group reclassification in FY 2008, 6 hospitals (9.1 percent) in 3 groups would not have qualified with the new standards. We also ran comparisons for hospitals that reclassified in FY 2006 and FY 2007 to determine if they would have been able to reclassify in FY 2008, using 3-year averages available in FY 2008. We found that, of all hospitals that were reclassified in FY 2008 (that is, applications approved for FYs 2006 through 2008), 14.7 percent of individual reclassifications and 8.5 percent of county group reclassification would not have qualified to reclassify in FY 2008. E:\FR\FM\30APP2.SGM 30APP2 23620 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Section 106 of MIEA–TRHCA requires us to propose revisions to the hospital wage index system after considering the recommendations of MedPAC. To address this requirement, we are proposing that the 84/108 criteria for urban hospital reclassifications and the 82/106 criteria for rural hospital reclassifications be recalibrated using the methodology published in the FY 1993 final rule and more recent wage data (that is, data used in computing the FYs 2006, 2007, 2008 wage indices). We believe that hospitals that are seeking to reclassify to another area should be required to demonstrate more similarity to the area than the current criteria permit, and our recent analysis demonstrates that those criteria are no longer appropriate. Therefore, we are proposing to change the criterion for the comparison of a hospital’s average hourly wage to that of the area to which the hospital seeks reclassification to 88 percent for urban hospitals and 86 percent for rural hospitals for new reclassifications beginning with the FY 2010 wage index and, accordingly, revise our regulations at 42 CFR 412.230 to reflect these changes. The criterion for the comparison of a hospital’s average hourly wage to that of its geographic area would be unchanged (108 percent for urban hospitals and 106 percent for rural hospitals). We also are proposing that, when there are significant changes in labor market area definitions, such as CMS’ adoption of new OMB CBSA definitions based upon the decennial census (69 FR 49027), we would again reevaluate and, if warranted, recalibrate these criteria. This would allow CMS to consider the effects of periodic changes in labor market boundaries and provide a regular timeline for updating and validating the reclassification criteria. Finally, we are proposing to adjust the 85 percent criterion for both urban and rural county group reclassifications to be equal to the proposed 88 percent standard for urban reclassifications, and to revise the regulations at 42 CFR 412.232 and 412.234 to reflect the change. The urban and rural county group average hourly wage standard has always been equivalent for both urban and rural county groups and has always been 1 percent higher than the 84 percent urban area individual reclassification standard. We would continue the policy of having an equivalent wage comparison criterion for both urban and rural county groups, as these groups have always used the same wage comparison criteria. We also would use the individual urban hospital reclassification standard of 88 percent because this threshold would ensure that the hospitals in the county group are at least as comparable to the proximate area as are individual hospitals within their own areas. Also, we do not believe it would be appropriate to have a group reclassification standard lower than the individual reclassification standards, thus potentially creating a situation where all of the hospitals in a county could reclassify, even though no single hospital within such county would be able to meet any average hourly wagerelated comparisons for an individual reclassification. We considered raising the group reclassification criterion to 89 percent in order to preserve the historical policy of the standard being set at 1 percent higher than the individual reclassification standard. However, we determined that making the group standard equal to the individual standard would adequately address our stated concerns. We note that the proposed changes in the reclassification criteria apply only to new reclassifications beginning with the FY 2010 wage index. Any hospital or county group that is in the midst of a 3-year reclassification in FY 2010 will not be affected by the proposed criteria change until they reapply for a geographic reclassification. Therefore, we are proposing the effective date for these changes would be September 1, 2008, the deadline for hospitals to submit applications for reclassification for the FY 2010 wage index. b. Within-State Budget Neutrality Adjustment for the Rural and Imputed Floors Section 4410 of the Balanced Budget Act of 1997 (BBA) established the rural floor by requiring that the wage index for a hospital in an urban area of a State cannot be less than the area wage index determined for that State’s rural area. Section 4410(b) of the BBA imposed the budget neutrality requirement and stated that the Secretary shall ‘‘adjust the area wage index referred to in subsection (a) for hospitals not described in such subsection.’’ Therefore, in order to compensate for the increased wage indices of urban hospitals receiving the rural floor, a nationwide budget neutrality adjustment is applied to the wage index to account for the additional payment to these hospitals. As a result, urban hospitals that qualify for their State’s rural floor wage index receive enhanced payments at the expense of all rural hospitals nationwide and all other urban hospitals that do not receive their State’s rural floor. In the FY 2009 proposed wage index, 266 hospitals in 27 States benefit from the rural floor. The first chart below lists the percentage of total payments each State either received or contributed to fund the current rural floor and imputed floor provisions with national budget neutrality adjustments (as indicated in the discussion of the imputed floor below in this section III.B.2.b.). The second chart below provides a graphical depiction of the proposed FY 2009 impacts. FY 2009 IPPS ESTIMATED PAYMENTS WITH PROPOSED WITHIN-STATE RURAL FLOOR AND IMPUTED FLOOR BUDGET NEUTRALITY Current policy application of national rural floor and imputed floor budget neutrality jlentini on PROD1PC65 with PROPOSALS2 State Proposed policy application of rural floor and imputed floor budget neutrality within each state ¥0.1 0.0 ¥0.2 ¥0.1 0.7 0.0 2.1 ¥0.2 ¥0.2 0.3 ¥0.2 0.3 0.3 ¥0.8 ¥0.1 ¥2.2 0.3 0.3 Alabama ....................................................................................................................................................... Alaska .......................................................................................................................................................... Arizona ......................................................................................................................................................... Arkansas ...................................................................................................................................................... California ...................................................................................................................................................... Colorado ...................................................................................................................................................... Connecticut .................................................................................................................................................. Delaware ...................................................................................................................................................... Washington, DC ........................................................................................................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00094 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23621 FY 2009 IPPS ESTIMATED PAYMENTS WITH PROPOSED WITHIN-STATE RURAL FLOOR AND IMPUTED FLOOR BUDGET NEUTRALITY—Continued Current policy application of national rural floor and imputed floor budget neutrality State Proposed policy application of rural floor and imputed floor budget neutrality within each state 0.0 ¥0.1 ¥0.1 ¥0.1 ¥0.2 ¥0.1 0.1 ¥0.1 ¥0.1 ¥0.1 ¥0.1 ¥0.2 ¥0.2 ¥0.2 ¥0.1 ¥0.1 ¥0.1 ¥0.1 ¥0.2 1.1 0.7 ¥0.1 ¥0.2 ¥0.1 0.1 ¥0.1 ¥0.1 ¥0.1 ¥0.1 ¥0.2 ¥0.1 ¥0.1 0.0 ¥0.1 ¥0.1 3.5 ¥0.1 ¥0.1 0.0 ¥0.1 0.0 0.0 0.3 0.3 0.3 0.1 0.0 ¥0.1 0.3 0.3 0.0 0.3 0.3 0.3 0.3 0.3 0.0 0.2 0.3 0.3 ¥1.2 ¥0.8 0.0 0.3 0.1 ¥0.1 0.1 0.1 0.0 0.1 0.3 0.0 0.3 0.0 0.1 0.3 ¥3.4 0.0 ¥0.1 ¥0.1 ¥0.1 0.1 jlentini on PROD1PC65 with PROPOSALS2 Florida .......................................................................................................................................................... Georgia ........................................................................................................................................................ Hawaii .......................................................................................................................................................... Idaho ............................................................................................................................................................ Illinois ........................................................................................................................................................... Indiana ......................................................................................................................................................... Iowa ............................................................................................................................................................. Kansas ......................................................................................................................................................... Kentucky ...................................................................................................................................................... Louisiana ...................................................................................................................................................... Maine ........................................................................................................................................................... Massachusetts ............................................................................................................................................. Michigan ....................................................................................................................................................... Minnesota .................................................................................................................................................... Mississippi .................................................................................................................................................... Missouri ........................................................................................................................................................ Montana ....................................................................................................................................................... Nebraska ...................................................................................................................................................... Nevada ......................................................................................................................................................... New Hampshire ........................................................................................................................................... New Jersey .................................................................................................................................................. New Mexico ................................................................................................................................................. New York ..................................................................................................................................................... North Carolina .............................................................................................................................................. North Dakota ................................................................................................................................................ Ohio ............................................................................................................................................................. Oklahoma ..................................................................................................................................................... Oregon ......................................................................................................................................................... Pennsylvania ................................................................................................................................................ Rhode Island ................................................................................................................................................ South Carolina ............................................................................................................................................. South Dakota ............................................................................................................................................... Tennessee ................................................................................................................................................... Texas ........................................................................................................................................................... Utah ............................................................................................................................................................. Vermont ....................................................................................................................................................... Virginia ......................................................................................................................................................... Washington .................................................................................................................................................. West Virginia ................................................................................................................................................ Wisconsin ..................................................................................................................................................... Wyoming ...................................................................................................................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00095 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules The above charts demonstrate how, at a State-by-State level, the rural floor is creating a benefit for a minority of States that is then funded by a majority of States, including States that are overwhelmingly rural in character. The intent behind the rural floor seems to have been to address anomalous occurrences where certain urban areas in a State have unusually depressed wages when compared to the State’s rural areas. However, because these comparisons occur at the State level, we believe it also would be sound policy to make the budget neutrality adjustment specific to the State, redistributing payments among hospitals within the State, rather than adjusting payments to hospitals in other States. In addition, a statewide budget neutrality adjustment would address the situation we discussed in the FY 2008 IPPS final rule with comment period (72 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FR 47324) in which rural CAHs were converting to IPPS status, apparently to raise the State’s rural wage index to a level whereby all urban hospitals in the State would receive the rural floor. Medicare payments to CAHs are based on 101 percent of reasonable costs while the IPPS pays hospitals a fixed rate per discharge. In addition, as a CAH, a hospital is guaranteed to recover its costs, while an IPPS hospital is provided with incentives to increase efficiency to cover its costs. Thus, we stated that the identified CAHs were converting back to IPPS, even though the conversion would not directly benefit them. Because these hospitals’ wage levels are higher than most, if not all, of the urban hospitals in the State, the wage indices for most, if not all, of the State’s urban hospitals would increase as a result of the rural floor provision if the CAHs convert to IPPS PO 00000 Frm 00096 Fmt 4701 Sfmt 4702 status. In simulating the effect of the hospitals setting the State’s rural floor, we estimated that payment to hospitals in the State would increase in excess of $220 million in a single year. The MedPAC, in its June 2007 Report to the Congress stated, ‘‘The fact that the movement of one or two CAHs in or out of the [I]PPS system can increase (or decrease) Medicare payments by $220 million suggests there is a flaw in the design of the wage index system.’’ (We refer readers to page 131 of the report.) For the above reasons, we are proposing to apply a State level rural floor budget neutrality adjustment to the wage index beginning in FY 2009. States that have no hospitals receiving a rural floor wage index would no longer have a negative budget neutrality adjustment applied to their wage indices. Conversely, hospitals in States with hospitals receiving a rural floor would E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.018</GPH> jlentini on PROD1PC65 with PROPOSALS2 23622 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules have their wage indices downwardly adjusted to achieve budget neutrality within the State. All hospitals within each State would, in effect, be responsible for funding the rural floor adjustment applicable within that specific State. In the FY 2005 IPPS final rule and the FY 2008 IPPS final rule with comment period (69 FR 49109 and 72 FR 47321, respectively), we temporarily adopted an ‘‘imputed’’ floor measure to address a concern by some individuals that hospitals in all-urban States were disadvantaged by the absence of rural hospitals. Because no rural wage index could be calculated, no rural floor could be applied within such States. We originally limited application of the policy to FYs 2005 through 2007 and then extended it one additional year, through FY 2008. We are proposing to extend the imputed floor for 3 additional years, through FY 2011, and to revise the introductory text of § 412.64(h)(4) of our regulations to reflect this extension. For FY 2009, 26 hospitals in New Jersey (33.8 percent) would receive the imputed floor. Rhode Island, the only other all-urban State, has no hospitals that would receive the imputed floor. In past years, we applied a national budget neutrality adjustment to the standardized amount to ensure that payments remained constant to payments that would have occurred in the absence of the imputed floor policy. As a result, payments to all other hospitals in the Nation were adjusted downward to subsidize the higher payments to New Jersey hospitals receiving the imputed floor. As the intent of the imputed floor is to create a protection to all-urban States similar to the protection offered to urban-rural mixed States by the rural floor, and the effect of the measure is also Statespecific like the rural floor, we believe that the budget neutrality adjustments for the imputed floor and the rural floor should be applied in the same manner. Therefore, beginning with FY 2009, we are also proposing to apply the imputed floor budget neutrality adjustment to the wage index and at the State level. Based on our impact analysis of these proposals for FY 2009, of the 49 States (Maryland is excluded because it is under a State waiver), the District of Columbia, and Puerto Rico, 39 would see either no change or an increase in total Medicare payments as a result of applying a budget neutrality adjustment to the wage index for the rural and imputed floors at the State level rather than the national level. The total payments of the remaining 12 States would decrease 0.1 percent to 3.4 percent compared to continuing our VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 prior national adjustment policy. The full impact analysis is reflected in the two charts presented earlier in this section III.B.2.b. of the preamble of this proposed rule. Tables 4D–1 and 4D–2 in the Addendum to this proposed rule reflect the proposed FY 2009 State level budget neutrality adjustments for the rural and imputed floors. We are specifically requesting public comments from national and State hospital associations regarding these proposals, particularly the national associations, as they represent member hospitals that are both positively and negatively affected by our proposed policies, and are, therefore, in the best position to comment on the policy merits of these proposals. We will view the absence of any comments from the national hospital associations as a sign that they do not object to our proposed policies. c. Within-State Budget Neutrality Adjustment for Geographic Reclassification Currently, section 1886(d)(8)(D) of the Act requires us to adjust the standardized amount to ensure that the effects of geographic reclassification do not increase aggregate IPPS payments. This means that, in the case of a reclassification, budget neutrality is achieved by reducing the standardized amount for all hospitals nationwide. The FY 2009 President’s Budget includes a legislative proposal to apply geographic reclassification budget neutrality at the State level (available at the Web site: www.hhs.gov/budget/ 09budget/2009BudgetInBrief.pdf under FY 2009 Medicare Proposals, page 54). If this proposal is enacted by the Congress, budget neutrality would be achieved by adjusting the wage index for all hospitals within the State rather than reducing the standardized amount for all hospitals nationwide. As noted also in MedPAC’s June 2007 Report to Congress, over the years, there have been many changes to the Medicare law that are intended to broaden the ability for a hospital to receive a wage index that is higher than the value that is calculated for its geographic area and not be subject to the proximity or wage level criteria for geographic reclassification established under section 1886(d)(10) of the Act. These more targeted geographic reclassification provisions are creating inequities in the wage index by sometimes allowing hospitals to be reclassified to areas where other hospitals that are closer in proximity are ineligible to reclassify. Applying budget neutrality at the State level would focus the costs of geographic reclassification closer to the areas where hospitals that PO 00000 Frm 00097 Fmt 4701 Sfmt 4702 23623 benefit from the reclassification are located. We expect that a legislative provision on applying geographic reclassification budget neutrality at the State level would be applied to all reclassifications and wage index exceptions that are implemented through 42 CFR Part 412, Subpart L, and certain provisions of the Social Security Act that permit hospitals to receive a higher wage index than is calculated for their geographic area. (As discussed above, as a proposed regulatory matter, there also would be a separate withinState budget neutrality adjustment for the imputed and rural floors.) We expect that reclassification budget neutrality at the State level would operate through adjustments to the IPPS payments to hospitals in the State in which the reclassifying hospital is geographically located. We are seeking public comments regarding MedPAC’s recommendations for reforming the wage index, our plan for our contractor’s review of the wage index, and the regulatory proposals for modifying the current hospital wage index system. We also welcome additional suggestions for reforming the hospital wage index. C. Core-Based Statistical Areas for the Hospital Wage Index The wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located. In accordance with the broad discretion under section 1886(d)(3)(E) of the Act, beginning with FY 2005, we define hospital labor market areas based on the Core-Based Statistical Areas (CBSAs) established by OMB and announced in December 2003 (69 FR 49027). For a discussion of OMB’s revised definitions of CBSAs and our implementation of the CBSA definitions, we refer readers to the preamble of the FY 2005 IPPS final rule (69 FR 49026 through 49032). As with the FY 2008 final rule, for FY 2009 we are proposing to provide that hospitals receive 100 percent of their wage index based upon the CBSA configurations. Specifically, for each hospital, we will determine a wage index for FY 2009 employing wage index data from FY 2005 hospital cost reports and using the CBSA labor market definitions. We consider CBSAs that are MSAs to be urban, and CBSAs that are Micropolitan Statistical Areas as well as areas outside of CBSAs to be rural. In addition, it has been our longstanding policy that where an MSA has been divided into Metropolitan Divisions, we consider the Metropolitan Division to comprise the labor market areas for purposes of calculating the E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23624 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules wage index (69 FR 49029). We are proposing to codify this longstanding policy into our regulations at § 412.64(b)(1)(ii)(A). On November 20, 2007, OMB announced the revision of titles for eight urban areas (OMB Bulletin No. 08–01). The revised titles are as follows: • Hammonton, New Jersey qualifies as a new principal city of the Atlantic City, New Jersey CBSA. The new title is Atlantic City-Hammonton, New Jersey CBSA; • New Brunswick, New Jersey, located in the Edison, New Jersey Metropolitan Division, qualifies as a new principal city of the New YorkNorthern New Jersey-Long Island, New York, New Jersey, Pennsylvania CBSA. The new title for the Metropolitan Division is Edison-New Brunswick, New Jersey CBSA; • Summerville, South Carolina qualifies as a new principal city of the Charleston-North Charleston, South Carolina CBSA. The new title is Charleston-North CharlestonSummerville, South Carolina; • Winter Haven, Florida qualifies as a new principal city of the Lakeland, Florida CBSA. The new title is Lakeland-Winter Haven, Florida; • Bradenton, Florida replaces Sarasota, Florida as the most populous principal city of the Sarasota-BradentonVenice, Florida CBSA. The new title is Bradenton-Sarasota-Venice, Florida. The new CBSA code is 14600; • Frederick, Maryland replaces Gaithersburg, Maryland as the second most populous principal city in the Bethesda-Gaithersburg-Frederick, Maryland CBSA. The new title is Bethesda-Frederick-Gaithersburg, Maryland; • North Myrtle Beach, South Carolina replaces Conway, South Carolina as the second most populous principal city of the Myrtle BeachConway-North Myrtle Beach, South Carolina CBSA. The new title is Myrtle Beach-North Myrtle Beach-Conway, South Carolina; • Pasco, Washington replaces Richland, Washington as the second most populous principal city of the Kennewick-Richland-Pasco, Washington CBSA. The new title is KennewickPasco-Richland, Washington. The OMB bulletin is available on the OMB Web site at https:// www.whitehouse.gov/OMB— go to ‘‘Bulletins’’ or ‘‘Statistical Programs and Standards.’’ CMS will apply these changes to the IPPS beginning October 1, 2008. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 D. Proposed Occupational Mix Adjustment to the Proposed FY 2009 Wage Index As stated earlier, section 1886(d)(3)(E) of the Act provides for the collection of data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index, for application beginning October 1, 2004 (the FY 2005 wage index). The purpose of the occupational mix adjustment is to control for the effect of hospitals’ employment choices on the wage index. For example, hospitals may choose to employ different combinations of registered nurses, licensed practical nurses, nursing aides, and medical assistants for the purpose of providing nursing care to their patients. The varying labor costs associated with these choices reflect hospital management decisions rather than geographic differences in the costs of labor. 1. Development of Data for the Proposed FY 2009 Occupational Mix Adjustment On October 14, 2005, we published a notice in the Federal Register (70 FR 60092) proposing to use a new survey, the 2006 Medicare Wage Index Occupational Mix Survey (the 2006 survey) to apply an occupational mix adjustment to the FY 2008 wage index. In the proposed 2006 survey, we included several modifications based on the comments and recommendations we received on the 2003 survey, including (1) allowing hospitals to report their own average hourly wage rather than using BLS data; (2) extending the prospective survey period; and (3) reducing the number of occupational categories but refining the subcategories for registered nurses. We made the changes to the occupational categories in response to MedPAC comments to the FY 2005 IPPS final rule (69 FR 49036). Specifically, MedPAC recommended that CMS assess whether including subcategories of registered nurses would result in a more accurate occupational mix adjustment. MedPAC believed that including all registered nurses in a single category may obscure significant wage differences among the subcategories of registered nurses, for example, the wages of surgical registered nurses and floor registered nurses may differ. Also, to offset additional reporting burden for hospitals, MedPAC recommended that CMS should combine the general service categories that account for only a small percentage of a hospital’s total hours with the ‘‘all other occupations’’ PO 00000 Frm 00098 Fmt 4701 Sfmt 4702 category because most of the occupational mix adjustment is correlated with the nursing general service category. In addition, in response to the public comments on the October 14, 2005 notice, we modified the 2006 survey. On February 10, 2006, we published a Federal Register notice (71 FR 7047) that solicited comments and announced our intent to seek OMB approval on the revised occupational mix survey (Form CMS–10079 (2006)). OMB approved the survey on April 25, 2006. The 2006 survey provides for the collection of hospital-specific wages and hours data, a 6-month prospective reporting period (that is, January 1, 2006, through June 30, 2006), the transfer of each general service category that comprised less than 4 percent of total hospital employees in the 2003 survey to the ‘‘all other occupations’’ category (the revised survey focuses only on the mix of nursing occupations), additional clarification of the definitions for the occupational categories, an expansion of the registered nurse category to include functional subcategories, and the exclusion of average hourly rate data associated with advance practice nurses. The 2006 survey included only two general occupational categories: nursing and ‘‘all other occupations.’’ The nursing category has four subcategories: Registered nurses, licensed practical nurses, aides, orderlies, attendants, and medical assistants. The registered nurse subcategory includes two functional subcategories: management personnel and staff nurses or clinicians. As indicated above, the 2006 survey provided for a 6-month data collection period, from January 1, 2006 through June 30, 2006. However, we allowed flexibility for the reporting period beginning and ending dates to accommodate some hospitals’ biweekly payroll and reporting systems. That is, the 6-month reporting period had to begin on or after December 25, 2005, and end before July 9, 2006. We are proposing to use the entire 6month 2006 survey data to calculate the occupational mix adjustment for the FY 2009 wage index. The original timelines for the collection, review, and correction of the 2006 occupational mix data were discussed in detail in the FY 2007 IPPS final rule (71 FR 48008). The revision and correction process for all of the data, including the 2006 occupational mix survey data to be used for computing the FY 2009 wage index, is discussed in detail in section III.K. of the preamble of this proposed rule. E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 2. Calculation of the Proposed Occupational Mix Adjustment for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 For FY 2009 (as we did for FY 2008), we are proposing to calculate the occupational mix adjustment factor using the following steps: Step 1—For each hospital, determine the percentage of the total nursing category attributable to a nursing subcategory by dividing the nursing subcategory hours by the total nursing category’s hours (registered nurse management personnel and registered nurse staff nurses or clinicians are treated as separate nursing subcategories). Repeat this computation for each of the five nursing subcategories: registered nurse management personnel; registered nurse staff nurses or clinicians; licensed practical nurses; nursing aides, orderlies, and attendants; and medical assistants. Step 2—Determine a national average hourly rate for each nursing subcategory by dividing a subcategory’s total salaries for all hospitals in the occupational mix survey database by the subcategory’s total hours for all hospitals in the occupational mix survey database. Step 3—For each hospital, determine an adjusted average hourly rate for each nursing subcategory by multiplying the percentage of the total nursing category (from Step 1) by the national average hourly rate for that nursing subcategory (from Step 2). Repeat this calculation for each of the five nursing subcategories. Step 4—For each hospital, determine the adjusted average hourly rate for the total nursing category by summing the adjusted average hourly rate (from Step 3) for each of the nursing subcategories. Step 5—Determine the national average hourly rate for the total nursing category by dividing total nursing category salaries for all hospitals in the occupational mix survey database by total nursing category hours for all VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 hospitals in the occupational mix survey database. Step 6—For each hospital, compute the occupational mix adjustment factor for the total nursing category by dividing the national average hourly rate for the total nursing category (from Step 5) by the hospital’s adjusted average hourly rate for the total nursing category (from Step 4). If the hospital’s adjusted average hourly rate is less than the national average hourly rate (indicating the hospital employs a less costly mix of nursing employees), the occupational mix adjustment factor would be greater than 1.0000. If the hospital’s adjusted average hourly rate is greater than the national average hourly rate, the occupational mix adjustment factor would be less than 1.0000. Step 7—For each hospital, calculate the occupational mix adjusted salaries and wage-related costs for the total nursing category by multiplying the hospital’s total salaries and wage-related costs (from Step 5 of the unadjusted wage index calculation in section III.G. of this preamble) by the percentage of the hospital’s total workers attributable to the total nursing category (using the occupational mix survey data, this percentage is determined by dividing the hospital’s total nursing category salaries by the hospital’s total salaries for ‘‘nursing and all other’’) and by the total nursing category’s occupational mix adjustment factor (from Step 6 above). The remaining portion of the hospital’s total salaries and wage-related costs that is attributable to all other employees of the hospital is not adjusted by the occupational mix. A hospital’s all other portion is determined by subtracting the hospital’s nursing category percentage from 100 percent. Step 8—For each hospital, calculate the total occupational mix adjusted salaries and wage-related costs for a hospital by summing the occupational PO 00000 Frm 00099 Fmt 4701 Sfmt 4702 23625 mix adjusted salaries and wage-related costs for the total nursing category (from Step 7) and the portion of the hospital’s salaries and wage-related costs for all other employees (from Step 7). To compute a hospital’s occupational mix adjusted average hourly wage, divide the hospital’s total occupational mix adjusted salaries and wage-related costs by the hospital’s total hours (from Step 4 of the unadjusted wage index calculation in section III.G. of this preamble). Step 9—To compute the occupational mix adjusted average hourly wage for an urban or rural area, sum the total occupational mix adjusted salaries and wage-related costs for all hospitals in the area, then sum the total hours for all hospitals in the area. Next, divide the area’s occupational mix adjusted salaries and wage-related costs by the area’s hours. Step 10—To compute the national occupational mix adjusted average hourly wage, sum the total occupational mix adjusted salaries and wage-related costs for all hospitals in the Nation, then sum the total hours for all hospitals in the Nation. Next, divide the national occupational mix adjusted salaries and wage-related costs by the national hours. The proposed FY 2009 occupational mix adjusted national average hourly wage is $32.2252. Step 11—To compute the occupational mix adjusted wage index, divide each area’s occupational mix adjusted average hourly wage (Step 9) by the national occupational mix adjusted average hourly wage (Step 10). Step 12—To compute the Puerto Rico specific occupational mix adjusted wage index, follow Steps 1 through 11 above. The proposed FY 2009 occupational mix adjusted Puerto Rico specific average hourly wage is $13.7851. The table below is an illustrative example of the proposed occupational mix adjustment. BILLING CODE 4120–01–P E:\FR\FM\30APP2.SGM 30APP2 VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00100 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30ap08.019</GPH> jlentini on PROD1PC65 with PROPOSALS2 23626 23627 BILLING CODE 4120–01–C VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00101 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 EP30ap08.020</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 23628 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Because the occupational mix adjustment is required by statute, all hospitals that are subject to payments under the IPPS, or any hospital that would be subject to the IPPS if not granted a waiver, must complete the occupational mix survey, unless the hospital has no associated cost report wage data that are included in the proposed FY 2009 wage index. For the FY 2008 wage index, if a hospital did not respond to the occupational mix survey, or if we determined that a hospital’s submitted data were too erroneous to include in the wage index, we assigned the hospital the average occupational mix adjustment for the labor market area (72 FR 47314). We believed this method had the least impact on the wage index for other hospitals in the area. For areas where no hospital submitted data for purposes of calculating the occupational mix adjustment, we applied the national occupational mix factor of 1.0000 in calculating the area’s FY 2008 occupational mix adjusted wage index. We indicated in the FY 2008 IPPS final rule that we reserve the right to apply a different approach in future years, including potentially penalizing nonresponsive hospitals (72 FR 47314). For the FY 2009 wage index, we are proposing to handle the data for hospitals that did not respond to the occupational mix survey (neither the 1st quarter nor 2nd quarter data) in the same manner as discussed above for the FY 2008 wage index. In addition, if a hospital submits survey data for either the 1st quarter or 2nd quarter, but not for both quarters, we are proposing to use the data the hospital submitted for one quarter to calculate the hospital’s proposed FY 2009 occupational mix adjustment factor. Lastly, if a hospital submits a survey(s), but that survey data can not be used because we determine it to be aberrant, we will also assign the hospital the average occupational mix adjustment for its labor market area. For example, if a hospital’s individual nurse category average hourly wages are out of range (that is, unusually high or low), and the hospital does not provide sufficient documentation to explain the aberrancy, or the hospital does not submit any registered nurse staff salaries or hours data, we will assign the hospital the average occupational mix adjustment for the labor market area in which it is located. In calculating the average occupational mix adjustment factor for a labor market area, we replicated Steps 1 through 6 of the calculation for the occupational mix adjustment. However, instead of performing these steps at the hospital level, we aggregated the data at VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 the labor market area level. In following these steps, for example, for CBSAs that contain providers that did not submit occupational mix survey data, the occupational mix adjustment factor ranged from a low of 0.8968 (CBSA 39820, Redding, CA), to a high of 1.0775 (CBSA 43300, Sherman-Denison, TX). Also, in computing a hospital’s occupational mix adjusted salaries and wage-related costs for nursing employees (Step 7 of the calculation), in the absence of occupational mix survey data, we multiplied the hospital’s total salaries and wage-related costs by the percentage of the area’s total workers attributable to the area’s total nursing category. For FY 2009, there was one CBSA for which we did not have occupational mix data for any of its providers (CBSA 12020, Athens-Clark County, GA). In the absence of any data in this labor market area, we applied an occupational mix adjustment factor of 1.0 to all provider(s). In the FY 2007 IPPS final rule, we also indicated that we would give serious consideration to applying a hospital-specific penalty if a hospital does not comply with regulations requiring submission of occupational mix survey data in future years. We stated that we believe that section 1886(d)(5)(I)(i) of the Act provides us with the authority to penalize hospitals that do not submit occupational mix survey data. That section authorizes us to provide for exceptions and adjustments to the payment amounts under IPPS as the Secretary deems appropriate. We also indicated that we would address this issue in the FY 2008 IPPS proposed rule. In the FY 2008 IPPS proposed rule, we solicited comments and suggestions for a hospital-specific penalty for hospitals that do not submit occupational mix survey data. In response to the FY 2008 IPPS proposed rule, some commenters suggested a 1percent to 2-percent reduction in the hospital’s wage index value or a set percentage of the standardized amount. We noted that any penalty that we would determine for nonresponsive hospitals would apply to a future wage index, not the FY 2008 wage index. In the FY 2008 final rule with comment period, we assigned nonresponsive hospitals the average occupational mix adjustment for the labor market area. For areas where no hospital submitted survey data, we applied the national occupational mix adjustment factor of 1.0000 in calculating the area’s FY 2008 occupational mix adjusted wage index. We appreciate the suggestions we received regarding future penalties for PO 00000 Frm 00102 Fmt 4701 Sfmt 4702 hospitals that do not submit occupational mix survey data. We stated in the FY 2008 final rule with comment period that we may consider proposing a policy to penalize hospitals that do not submit occupational mix survey data for FY 2010, the first year of the application of the new 2007–2008 occupational mix survey, and that we expected that any such penalty would be proposed in the FY 2009 IPPS proposed rule so hospitals would be aware of the policy before the deadline for submitting the data to the fiscal intermediaries/MAC. At this time, however, we are not proposing a penalty for FY 2010. Rather, we are reserving the right to propose a penalty in the FY 2010 IPPS proposed rule, once we collect and analyze the FY 2007–2008 occupational mix survey data. Hospitals are still on notice that any failure to submit occupational mix data for the FY 2007–2008 survey year may result in a penalty in FY 2010, thus achieving our policy goal of ensuring that hospitals are aware of the consequences of failure to submit data in response to the most recent survey. 3. 2007–2008 Occupational Mix Survey for the FY 2010 Wage Index As stated earlier, section 304(c) of Pub. L. 106–554 amended section 1886(d)(3)(E) of the Act to require CMS to collect data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program. We used occupational mix data collected on the 2006 survey to compute the proposed occupational mix adjustment for FY 2009. In the FY 2008 IPPS final rule with comment period (72 FR 47315), we discussed how we modified the occupational mix survey. The revised 2007–2008 occupational mix survey provides for the collection of hospital-specific wages and hours data for the 1-year period of July 1, 2007, through June 30, 2008, additional clarifications to the survey instructions, the elimination of the registered nurse subcategories, some refinements to the definitions of the occupational categories, and the inclusion of additional cost centers that typically provide nursing services. The revised 2007–2008 occupational mix survey will be applied beginning with the FY 2010 wage index. On February 2, 2007, we published in the Federal Register a notice soliciting comments on the proposed revisions to the occupational mix survey (72 FR 5055). The comment period for the notice ended on April 3, 2007. After considering the comments we received, we made a few minor editorial changes E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules and published the final 2007–2008 occupational mix survey on September 14, 2007 (72 FR 52568). OMB approved the survey without change on February 1, 2008 (OMB Control Number 0938 0907). The 2007–2008 Medicare occupational mix survey (Form CMS– 10079 (2008)) is available on the CMS Web site at: https://www.cms.hhs.gov/ AcuteInpatientPPS/WIFN/ list.asp#TopOfPage, and through the fiscal intermediaries/MAC. Hospitals must submit their completed surveys to their fiscal intermediaries/MAC by September 1, 2008. The preliminary, unaudited 2007–2008 occupational mix survey data will be released in early October 2008, along with the FY 2006 Worksheet S–3 wage data, for the FY 2010 wage index review and correction process. E. Worksheet S–3 Wage Data for the Proposed FY 2009 Wage Index The proposed FY 2009 wage index values (to be effective for hospital discharges occurring on or after October 1, 2008, and before October 1, 2009) in section II.B. of the Addendum to this proposed rule are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 2005 (the FY 2008 wage index was based on FY 2004 wage data). jlentini on PROD1PC65 with PROPOSALS2 1. Included Categories of Costs The proposed FY 2009 wage index includes the following categories of data associated with costs paid under the IPPS (as well as outpatient costs): • Salaries and hours from short-term, acute care hospitals (including paid lunch hours and hours associated with military leave and jury duty). • Home office costs and hours. • Certain contract labor costs and hours (which includes direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services, and certain contract indirect patient care services (as discussed in the FY 2008 final rule with comment period (72 FR 47315). • Wage-related costs, including pensions and other deferred compensation costs. We note that, on March 28, 2008, CMS published a technical clarification to the cost reporting instructions for pension and deferred compensation costs (sections 2140 through 2142.7 of the Provider Reimbursement Manual, Part I). These instructions are used for developing pension and deferred compensation costs for purposes of the wage index, as discussed in the instructions for Worksheet S–3, Part II, Lines 13 through VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 23629 3. Use of Wage Index Data by Providers Other Than Acute Care Hospitals Under the IPPS Data collected for the IPPS wage index are also currently used to calculate wage indices applicable to other providers, such as SNFs, home health agencies, and hospices. In addition, they are used for prospective payments to IRFs, IPFs, and LTCHs, and for hospital outpatient services. We note that, in the IPPS rules, we do not address comments pertaining to the wage indices for non-IPPS providers. Such comments should be made in response to separate proposed rules for those providers. include in the proposed wage index, although if data elements for some of these providers are corrected, we intend to include some of these providers in the FY 2009 final wage index. We instructed fiscal intermediaries/MACs to complete their data verification of questionable data elements and to transmit any changes to the wage data no later than April 14, 2008. We believe all unresolved data elements will be resolved by the date the final rule is issued. The revised data will be reflected in the FY 2009 IPPS final rule. In constructing the proposed FY 2009 wage index, we included the wage data for facilities that were IPPS hospitals in FY 2005; inclusive of those facilities that have since terminated their participation in the program as hospitals, as long as those data did not fail any of our edits for reasonableness. We believe that including the wage data for these hospitals is, in general, appropriate to reflect the economic conditions in the various labor market areas during the relevant past period and to ensure that the current wage index represents the labor market area’s current wages as compared to the national average of wages. However, we excluded the wage data for CAHs as discussed in the FY 2004 IPPS final rule (68 FR 45397). For this proposed rule, we removed 20 hospitals that converted to CAH status between February 16, 2007, the cut-off date for CAH exclusion from the FY 2008 wage index, and February 18, 2008, the cut-off date for CAH exclusion from the FY 2009 wage index. After removing hospitals with aberrant data and hospitals that converted to CAH status, the proposed FY 2009 wage index is calculated based on 3,533 hospitals. F. Verification of Worksheet S–3 Wage Data The wage data for the proposed FY 2009 wage index were obtained from Worksheet S–3, Parts II and III of the FY 2005 Medicare cost reports. Instructions for completing Worksheet S–3, Parts II and III are in the Provider Reimbursement Manual (PRM), Part II, sections 3605.2 and 3605.3. The data file used to construct the proposed wage index includes FY 2005 data submitted to us as of February 29, 2008. As in past years, we performed an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data. We asked our fiscal intermediaries/ MAC to revise or verify data elements that resulted in specific edit failures. For the proposed FY 2009 wage index, we identified and excluded 37 providers with data that was too aberrant to 1. Wage Data for Multicampus Hospitals In the FY 2008 final rule with comment period (72 FR 47317), we discussed our policy for allocating a multicampus hospital’s wages and hours data, by full-time equivalent (FTE) staff, among the different labor market areas where its campuses are located. During the FY 2009 wage index desk review process, we requested fiscal intermediaries/MACs to contact multicampus hospitals that had campuses in different labor market areas to collect the data for the allocation. The proposed FY 2009 wage index in this proposed rule includes separate wage data for campuses of three multicampus hospitals. As with the FY 2008 wage index, we allowed hospitals the option of allocating their wages and hours for the FY 2009 wage index based on either FTE staff or discharge data. Again, we 20 and in the FY 2006 final rule (70 FR 47369). 2. Excluded Categories of Costs Consistent with the wage index methodology for FY 2008, the proposed wage index for FY 2009 also excludes the direct and overhead salaries and hours for services not subject to IPPS payment, such as SNF services, home health services, costs related to GME (teaching physicians and residents) and certified registered nurse anesthetists (CRNAs), and other subprovider components that are not paid under the IPPS. The proposed FY 2009 wage index also excludes the salaries, hours, and wage-related costs of hospital-based rural health clinics (RHCs), and Federally qualified health centers (FQHCs) because Medicare pays for these costs outside of the IPPS (68 FR 45395). In addition, salaries, hours, and wage-related costs of CAHs are excluded from the wage index, for the reasons explained in the FY 2004 IPPS final rule (68 FR 45397). PO 00000 Frm 00103 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23630 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 are providing this option until a revised cost report is available that will allow a multicampus hospital to report the number of FTEs by location of its different campuses. Two of the three multicampus hospitals chose to have their wage data allocated by their Medicare discharge data. One of the hospitals provided FTE staff data for the allocation. The average hourly wage associated with each geographical location of a multicampus hospital is reflected in Table 2 of the Addendum to this proposed rule. 2. New Orleans’ Post-Katrina Wage Index Since 2005 when Hurricane Katrina devastated the Gulf States, we have received numerous comments suggesting that current Medicare payments to hospitals in New Orleans, Louisiana are inadequate, and the wage index does not accurately reflect the increase in labor costs experienced by the city after the storm. The post-Katrina effects on the New Orleans wage index will not be realized in the wage index until FY 2010, when the wage index will be based on cost reporting periods beginning during FY 2006 (that is, beginning on or after October 1, 2005 and before October 1, 2006). In responding to the health-related needs of people affected by the hurricane, the Federal Government, through the Deficit Reduction Act of 2005 (DRA), appropriated $2 billion in FY 2006. These funds allowed the Secretary to make available $160 million in February 2007 to Louisiana, Mississippi, and Alabama for payments to hospitals and skilled nursing facilities facing financial stress because of changing wage rates not yet reflected in Medicare payment methodologies. In March and May 2007, the Department provided two additional DRA grants of $15 million and $35 million, respectively, to Louisiana for professional health care workforce recruitment and sustainability in the greater New Orleans area, namely the Orleans, Jefferson, St. Bernard, and Plaquemines Parishes. In addition, the Department issued a supplemental award of $60 million in provider stabilization grant funding to Louisiana, Mississippi, and Alabama to continue to help health care providers meet changing wage rates not yet reflected by Medicare’s payment policies. On July 23, 2007, HHS awarded to Louisiana a new $100 million Primary Care Grant to help increase access to primary care in the Greater New Orleans area. The resulting stabilization and expansion of the community based primary care infrastructure, post Katrina, helps VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 provide a viable alternative to local hospital emergency rooms for all citizens of New Orleans, especially those who are poor and uninsured. In other Department efforts, the OIG has performed an in-depth review of the post-Katrina infrastructure of five New Orleans hospitals, including the hospitals’ staffing levels and wage costs. The OIG’s final reports and recommendations are scheduled to be published in Spring 2008. G. Method for Computing the Proposed FY 2009 Unadjusted Wage Index The method used to compute the proposed FY 2009 wage index without an occupational mix adjustment follows: Step 1—As noted above, we based the proposed FY 2009 wage index on wage data reported on the FY 2005 Medicare cost reports. We gathered data from each of the non-Federal, short-term, acute care hospitals for which data were reported on the Worksheet S–3, Parts II and III of the Medicare cost report for the hospital’s cost reporting period beginning on or after October 1, 2004, and before October 1, 2005. In addition, we included data from some hospitals that had cost reporting periods beginning before October 2004 and reported a cost reporting period covering all of FY 2004. These data are included because no other data from these hospitals would be available for the cost reporting period described above, and because particular labor market areas might be affected due to the omission of these hospitals. However, we generally describe these wage data as FY 2005 data. We note that, if a hospital had more than one cost reporting period beginning during FY 2005 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 2004, and before October 1, 2005), we included wage data from only one of the cost reporting periods, the longer, in the wage index calculation. If there was more than one cost reporting period and the periods were equal in length, we included the wage data from the later period in the wage index calculation. Step 2—Salaries—The method used to compute a hospital’s average hourly wage excludes certain costs that are not paid under the IPPS. (We note that, beginning with FY 2008 (72 FR 47315), we include lines 22.01, 26.01, and 27.01 of Worksheet S–3, Part II for overhead services in the wage index. However, we note that the wages and hours on these lines are not incorporated into line 101, column 1 of Worksheet A, which, through the electronic cost reporting software, flows directly to line 1 of PO 00000 Frm 00104 Fmt 4701 Sfmt 4702 Worksheet S–3, Part II. Therefore, the first step in the wage index calculation for FY 2009 is to compute a ‘‘revised’’ Line 1, by adding to the Line 1 on Worksheet S–3, Part II (for wages and hours respectively) the amounts on Lines 22.01, 26.01, and 27.01.) In calculating a hospital’s average salaries plus wage-related costs, we subtract from Line 1 (total salaries) the GME and CRNA costs reported on Lines 2, 4.01, 6, and 6.01, the Part B salaries reported on Lines 3, 5 and 5.01, home office salaries reported on Line 7, and exclude salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to SNF services, home health services, and other subprovider components not subject to the IPPS). We also subtract from Line 1 the salaries for which no hours were reported. To determine total salaries plus wage-related costs, we add to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services (Lines 9 and 10), home office salaries and wage-related costs reported by the hospital on Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14, and 18). We note that contract labor and home office salaries for which no corresponding hours are reported are not included. In addition, wage-related costs for nonteaching physician Part A employees (Line 18) are excluded if no corresponding salaries are reported for those employees on Line 4. Step 3—Hours—With the exception of wage-related costs, for which there are no associated hours, we compute total hours using the same methods as described for salaries in Step 2. Step 4—For each hospital reporting both total overhead salaries and total overhead hours greater than zero, we then allocate overhead costs to areas of the hospital excluded from the wage index calculation. First, we determine the ratio of excluded area hours (sum of Lines 8 and 8.01 of Worksheet S–3, Part II) to revised total hours (Line 1 minus the sum of Part II, Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, and Part III, Line 13 of Worksheet S–3). We then compute the amounts of overhead salaries and hours to be allocated to excluded areas by multiplying the above ratio by the total overhead salaries and hours reported on Line 13 of Worksheet S–3, Part III. Next, we compute the amounts of overhead wage-related costs to be allocated to excluded areas using three steps: (1) We determine the ratio of overhead hours (Part III, Line 13 minus the sum of lines 22.01, 26.01, and 27.01) to revised hours excluding the sum of lines 22.01, 26.01, and 27.01 (Line 1 minus the sum of E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, 8, 8.01, 22.01, 26.01, and 27.01). (We note that for the FY 2008 and subsequent wage index calculations, we are excluding the sum of lines 22.01, 26.01, and 27.01 from the determination of the ratio of overhead hours to revised hours, since hospitals typically do not provide fringe benefits (wage-related costs) to contract personnel. Therefore, it is not necessary for the wage index calculation to exclude overhead wage-related costs for contract personnel. Further, if a hospital does contribute to wage-related costs for contracted personnel, the instructions for lines 22.01, 26.01, and 27.01 require that associated wagerelated costs be combined with wages on the respective contract labor lines.); (2) we compute overhead wage-related costs by multiplying the overhead hours ratio by wage-related costs reported on Part II, Lines 13, 14, and 18; and (3) we multiply the computed overhead wagerelated costs by the above excluded area hours ratio. Finally, we subtract the computed overhead salaries, wagerelated costs, and hours associated with excluded areas from the total salaries (plus wage-related costs) and hours derived in Steps 2 and 3. Step 5—For each hospital, we adjust the total salaries plus wage-related costs to a common period to determine total adjusted salaries plus wage-related costs. To make the wage adjustment, we estimate the percentage change in the employment cost index (ECI) for compensation for each 30-day increment from October 14, 2003, through April 15, 2005, for private industry hospital workers from the BLS’ Compensation and Working Conditions. We use the ECI because it reflects the price increase associated with total compensation (salaries plus fringes) rather than just the increase in salaries. In addition, the ECI includes managers as well as other hospital workers. This methodology to compute the monthly update factors uses actual quarterly ECI data and assures that the update factors match the actual quarterly and annual percent changes. We also note that, since April 2006 with the publication of March 2006 data, the BLS’ ECI uses a different classification system, the North American Industrial Classification System (NAICS), instead of the Standard Industrial Codes (SICs), which no longer exist. We have consistently used the ECI as the data source for our wages and salaries and other price proxies in the IPPS market basket and are not proposing to make any changes to the usage at this time. The factors used to adjust the hospital’s data were based on VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 the midpoint of the cost reporting period, as indicated below. MIDPOINT OF COST REPORTING PERIOD After 10/14/2004 11/14/2004 12/14/2004 01/14/2005 02/14/2005 03/14/2005 04/14/2005 05/14/2005 06/14/2005 07/14/2005 08/14/2005 09/14/2005 10/14/2005 11/14/2005 12/14/2005 01/14/2006 02/14/2006 03/14/2006 Before ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ 11/15/2004 12/15/2004 01/15/2005 02/15/2005 03/15/2005 04/15/2005 05/15/2005 06/15/2005 07/15/2005 08/15/2005 09/15/2005 10/15/2005 11/15/2005 12/15/2005 01/15/2006 02/15/2006 03/15/2006 04/15/2006 Adjustment factor 1.05390 1.05035 1.04690 1.04342 1.03992 1.03641 1.03291 1.02940 1.02596 1.02264 1.01943 1.01627 1.01308 1.00987 1.00661 1.00333 1.00000 0.99670 For example, the midpoint of a cost reporting period beginning January 1, 2005, and ending December 31, 2005, is June 30, 2005. An adjustment factor of 1.02596 would be applied to the wages of a hospital with such a cost reporting period. In addition, for the data for any cost reporting period that began in FY 2005 and covered a period of less than 360 days or more than 370 days, we annualize the data to reflect a 1-year cost report. Dividing the data by the number of days in the cost report and then multiplying the results by 365 accomplishes annualization. Step 6—Each hospital is assigned to its appropriate urban or rural labor market area before any reclassifications under section 1886(d)(8)(B), section 1886(d)(8)(E), or section 1886(d)(10) of the Act. Within each urban or rural labor market area, we add the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in that area to determine the total adjusted salaries plus wage-related costs for the labor market area. Step 7—We divide the total adjusted salaries plus wage-related costs obtained under both methods in Step 6 by the sum of the corresponding total hours (from Step 4) for all hospitals in each labor market area to determine an average hourly wage for the area. Step 8—We add the total adjusted salaries plus wage-related costs obtained in Step5 for all hospitals in the Nation and then divide the sum by the national sum of total hours from Step 4 to arrive at a national average hourly wage. Using the data as described above, the proposed national average hourly wage (unadjusted for occupational mix) is $32.2489. PO 00000 Frm 00105 Fmt 4701 Sfmt 4702 23631 Step 9—For each urban or rural labor market area, we calculate the hospital wage index value, unadjusted for occupational mix, by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8. Step 10—Following the process set forth above, we develop a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. (The national Puerto Rico standardized amount is adjusted by a wage index calculated for all Puerto Rico labor market areas based on the national average hourly wage as described above.) We add the total adjusted salaries plus wage-related costs (as calculated in Step 5) for all hospitals in Puerto Rico and divide the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall proposed average hourly wage (unadjusted for occupational mix) of $13.7956 for Puerto Rico. For each labor market area in Puerto Rico, we calculate the Puerto Rico-specific wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage. Step 11—Section 4410 of Pub. L. 105– 33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. For FY 2009, this proposed change would affect 266 hospitals in 69 urban areas. The areas affected by this provision are identified by a footnote in Table 4A in the Addendum of this proposed rule. In the FY 2005 IPPS final rule (69 FR 49109), we adopted the ‘‘imputed’’ floor as a temporary 3-year measure to address a concern by some individuals that hospitals in all-urban States were disadvantaged by the absence of rural hospitals to set a wage index floor in those States. The imputed floor was originally set to expire in FY 2007, but we extended it an additional year in the FY 2008 IPPS final rule with comment period (72FR47321). As explained in section III.B.2.b. of the preamble of this proposed rule, we are proposing to extend the imputed floor for an additional 3 years, through FY 2011. H. Analysis and Implementation of the Proposed Occupational Mix Adjustment and the Proposed FY 2009 Occupational Mix Adjusted Wage Index As discussed in section III.D. of this preamble, for FY 2009, we are proposing to apply the occupational mix adjustment to 100 percent of the FY E:\FR\FM\30APP2.SGM 30APP2 23632 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 2009 wage index. We calculated the occupational mix adjustment using data from the 2006 occupational mix survey data, using the methodology described in section III.D.3. of this preamble. Using the 1st and 2nd quarter occupational mix survey data and applying the occupational mix adjustment to 100 percent of the proposed FY2009 wage index results in a proposed national average hourly wage of $32.2252 and a proposed Puerto-Rico specific average hourly wage of $13.7851. After excluding data of hospitals that either submitted aberrant data that failed critical edits, or that do not have FY 2005 Worksheet S– 3 cost report data for use in calculating the proposed FY2009 wage index, we calculated the proposed FY 2009 wage index using the occupational mix survey data from 3,364 hospitals. Using the Worksheet S–3 cost report data of 3,533 hospitals and occupational mix 1st and/or 2nd quarter survey data from 3,364 hospitals represents a 95.2 percent survey response rate. The proposed FY2009 national average hourly wages for each occupational mix nursing subcategory as calculated in Step 2 of the occupational mix calculation are as follows: Average hourly wage National RN Management ........ National RN Staff ...................... National LPN ............................ National Nurse Aides, Orderlies, and Attendants .............. National Medical Assistants ..... National Nurse Category .......... jlentini on PROD1PC65 with PROPOSALS2 Occupational mix nursing subcategory $38.6341 $33.4795 $19.2316 $13.6954 $15.7714 $28.7291 The proposed national average hourly wage for the entire nurse category as computed in Step 5 of the occupational mix calculation is $28.7291. Hospitals with a nurse category average hourly wage (as calculated in Step 4) of greater than the national nurse category average hourly wage receive an occupational mix adjustment factor (as calculated in Step 6) of less than 1.0. Hospitals with a nurse category average hourly wage (as calculated in Step 4) of less than the national nurse category average hourly wage receive an occupational mix adjustment factor (as calculated in Step 6) of greater than 1.0. Based on the January through June 2006 occupational mix survey data, we determined (in Step 7 of the occupational mix calculation) that the proposed national percentage of hospital employees in the Nurse category is 42.99 percent, and the proposed national percentage of hospital employees in the All Other Occupations category is 57.01 percent. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 At the CBSA level, the percentage of hospital employees in the Nurse category ranged from a low of 27.26 percent in one CBSA, to a high of 85.30 percent in another CBSA. The proposed wage index values for FY 2009 (except those for hospitals receiving wage index adjustments under section 1886(d)(13) of the Act) are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this proposed rule. Tables 3A and 3B in the Addendum to this proposed rule list the 3-year average hourly wage for each labor market area before the redesignation of hospitals based on FYs 2007, 2008, and 2009 cost reporting periods. Table 3A lists these data for urban areas and Table 3B lists these data for rural areas. In addition, Table 2 in the Addendum to this proposed rule includes the adjusted average hourly wage for each hospital from the FY 2003 and FY 2004 cost reporting periods, as well as the FY 2005 period used to calculate the proposed FY 2009 wage index. The 3year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described previously) across all 3 years, by the sum of the hours. If a hospital is missing data for any of the previous years, its average hourly wage for the 3-year period is calculated based on the data available during that period. The proposed wage index values in Tables 2, 4A, 4B, 4C, and 4F and the average hourly wages in Tables 2, 3A, and 3B in the Addendum to this proposed rule include the proposed occupational mix adjustment. The proposed wage index values in Tables 2, 4A, 4B, and 4C also include the proposed State-specific rural floor and imputed floor budget neutrality adjustments that are discussed in section III.B.2. of this preamble. The proposed State budget neutrality adjustments for the rural and imputed floors are included in Tables 4D–1 and 4D–2 in the Addendum to this proposed rule. I. Proposed Revisions to the Wage Index Based on Hospital Redesignations 1. General Under section 1886(d)(10) of the Act, the MGCRB considers applications by hospitals for geographic reclassification for purposes of payment under the IPPS. Hospitals must apply to the MGCRB to reclassify 13 months prior to the start of the fiscal year for which reclassification is sought (generally by September 1). Generally, hospitals must be proximate to the labor market area to which they are seeking reclassification and must demonstrate characteristics similar to PO 00000 Frm 00106 Fmt 4701 Sfmt 4702 hospitals located in that area. The MGCRB issues its decisions by the end of February for reclassifications that become effective for the following fiscal year (beginning October 1). The regulations applicable to reclassifications by the MGCRB are located in 42 CFR 412.230 through 412.280. Section 1886(d)(10)(D)(v) of the Act provides that, beginning with FY 2001, a MGCRB decision on a hospital reclassification for purposes of the wage index is effective for 3 fiscal years, unless the hospital elects to terminate the reclassification. Section 1886(d)(10)(D)(vi) of the Act provides that the MGCRB must use average hourly wage data from the 3 most recently published hospital wage surveys in evaluating a hospital’s reclassification application for FY 2003 and any succeeding fiscal year. Section 304(b) of Pub. L. 106–554 provides that the Secretary must establish a mechanism under which a statewide entity may apply to have all of the geographic areas in the State treated as a single geographic area for purposes of computing and applying a single wage index, for reclassifications beginning in FY 2003. The implementing regulations for this provision are located at 42 CFR 412.235. Section 1886(d)(8)(B) of the Act requires the Secretary to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards for designating MSAs and if the commuting rates used in determining outlying counties were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs. In light of the CBSA definitions and the Census 2000 data that we implemented for FY 2005 (69 FR 49027), we undertook to identify those counties meeting these criteria. Eligible counties are discussed and identified under section III.I.5. of this preamble. 2. Effects of Reclassification/ Redesignation Section 1886(d)(8)(C) of the Act provides that the application of the wage index to redesignated hospitals is dependent on the hypothetical impact that the wage data from these hospitals would have on the wage index value for the area to which they have been redesignated. These requirements for determining the wage index values for E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules redesignated hospitals are applicable both to the hospitals deemed urban under section 1886(d)(8)(B) of the Act and hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. Therefore, as provided in section 1886(d)(8)(C) of the Act, the wage index values were determined by considering the following: • If including the wage data for the redesignated hospitals would reduce the wage index value for the area to which the hospitals are redesignated by 1 percentage point or less, the area wage index value determined exclusive of the wage data for the redesignated hospitals applies to the redesignated hospitals. • If including the wage data for the redesignated hospitals reduces the wage index value for the area to which the hospitals are redesignated by more than 1 percentage point, the area wage index determined inclusive of the wage data for the redesignated hospitals (the combined wage index value) applies to the redesignated hospitals. • If including the wage data for the redesignated hospitals increases the wage index value for the urban area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value. Otherwise, the hospitals located in the urban area receive a wage index excluding the wage data of hospitals redesignated into the area. Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred (otherwise, redesignated rural hospitals are excluded from the calculation of the rural wage index). The wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. CMS has also adopted the following policies: • The wage data for a reclassified urban hospital is included in both the wage index calculation of the area to which the hospital is reclassified (subject to the rules described above) and the wage index calculation of the urban area where the hospital is physically located. • In cases where urban hospitals have reclassified to rural areas under 42 CFR 412.103, the urban hospital wage data are: (a) Included in the rural wage index calculation, unless doing so would reduce the rural wage index; and (b) included in the urban area where the hospital is physically located. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 3. FY 2009 MGCRB Reclassifications Under section 1886(d)(10) of the Act, the MGCRB considers applications by hospitals for geographic reclassification for purposes of payment under the IPPS. The specific procedures and rules that apply to the geographic reclassification process are outlined in 42 CFR 412.230 through 412.280. At the time this proposed rule was constructed, the MGCRB had completed its review of FY 2009 reclassification requests. There were 314 hospitals approved for wage index reclassifications by the MGCRB for FY 2009. Because MGCRB wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2007 or FY 2008 are eligible to continue to be reclassified based on prior reclassifications to current MSAs during FY 2009. There were 175 hospitals approved for wage index reclassifications in FY 2007 and 324 hospitals approved for wage index reclassifications in FY 2008. Of all of the hospitals approved for reclassification for FY 2007, FY 2008, and FY 2009, 813 hospitals are in a reclassification status for FY 2009. Under 42 CFR 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of a proposed rule. The request for withdrawal of an application for reclassification or termination of an existing 3-year reclassification that would be effective in FY 2009 must be received by the MGCRB within 45 days of the publication of this proposed rule. If a hospital elects to withdraw its wage index application after the MGCRB has issued its decision, but within 45 days of publication of this proposed rule date, it may later cancel its withdrawal in a subsequent year and request the MGCRB to reinstate its wage index reclassification for the remaining fiscal year(s) of the 3-year period (42 CFR 412.273(b)(2)(i)). The request to cancel a prior withdrawal or termination must be in writing to the MGCRB no later than the deadline for submitting reclassification applications for the following fiscal year (42 CFR 412.273(d)). For further information about withdrawing, terminating, or canceling a previous withdrawal or termination of a 3-year reclassification for wage index purposes, we refer the reader to 42 CFR 412.273, as well as the August 1, 2002 IPPS final rule (67 FR 50065), and the August 1, 2001 IPPS final rule (66 FR 39887). Changes to the wage index that result from withdrawals of requests for reclassification, wage index corrections, PO 00000 Frm 00107 Fmt 4701 Sfmt 4702 23633 appeals, and the Administrator’s review process will be incorporated into the wage index values published in the FY 2009 final rule. These changes may affect not only the wage index value for specific geographic areas, but also the wage index value redesignated hospitals receive; that is, whether they receive the wage index that includes the data for both the hospitals already in the area and the redesignated hospitals. Further, the wage index value for the area from which the hospitals are redesignated may be affected. Applications for FY 2010 reclassifications are due to the MGCRB by September 2, 2008 (the first working day of September 2008). We note that this is also the deadline for canceling a previous wage index reclassification withdrawal or termination under 42 CFR 412.273(d). Applications and other information about MGCRB reclassifications may be obtained, beginning in mid-July 2008, via the CMS Internet Web site at: https:// cms.hhs.gov/providers/prrb/ mgcinfo.asp, or by calling the MGCRB at (410) 786-1174. The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244– 2670. 4. FY 2008 Policy Clarifications and Revisions We note below several policies related to geographic reclassification that were clarified or revised in the FY 2008 IPPS final rule with comment period (72 FR 47333): • Reinstating Reclassifications—As provided for in 42 CFR 412.273(b)(2), once a hospital (or hospital group) accepts a newly approved reclassification, any previous reclassification is permanently terminated. • Geographic Reclassification for Multicampus Hospitals—Because campuses of a multicampus hospital can now have their wages and hours data allocated by FTEs or discharge data, a hospital campus located in a geographic area distinct from the geographic area associated with the provider number of the multicampus hospital will have official wage data to supplement an individual or group reclassification application (§ 412.230(d)(2)(v)). • New England Deemed Counties— Hospitals in New England deemed counties are treated the same as Lugar hospitals in calculating the wage index. That is, the area is considered rural, but the hospitals within the area are deemed to be urban (§ 412.64(b)(3)(ii)). • ‘‘Fallback’’ Reclassifications—A hospital will automatically be given its most recently approved reclassification E:\FR\FM\30APP2.SGM 30APP2 23634 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules (thereby permanently terminating any previously approved reclassifications) unless it provides written notice to the MGCRB within 45 days of publication of the notice of proposed rulemaking that it wishes to withdraw its most recently approved reclassification and ‘‘fall back’’ to either its prior reclassification or its home area wage index for the following fiscal year. 5. Redesignations of Hospitals Under Section 1886(d)(8)(B) of the Act Section 1886(d)(8)(B) of the Act requires us to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA if certain criteria are met. Effective beginning FY 2005, we use OMB’s 2000 CBSA standards and the Census 2000 data to identify counties in which hospitals qualify under section 1886(d)(8)(B) of the Act to receive the wage index of the urban area. Hospitals located in these counties have been known as ‘‘Lugar’’ hospitals and the counties themselves are often referred to as ‘‘Lugar’’ counties. We provide the proposed FY 2009 chart below with the listing of the rural counties containing the hospitals designated as urban under section 1886(d)(8)(B) of the Act. For discharges occurring on or after October 1, 2008, hospitals located in the rural county in the first column of this chart will be redesignated for purposes of using the wage index of the urban area listed in the second column. RURAL COUNTIES CONTAINING HOSPITALS REDESIGNATED AS URBAN UNDER SECTION 1886(D)(8)(B) OF THE ACT [Based on CBSAs and Census 2000 Data] jlentini on PROD1PC65 with PROPOSALS2 Rural county CBSA Cherokee, AL .............................................................................................................................. Macon, AL ................................................................................................................................... Talladega, AL .............................................................................................................................. Hot Springs, AR .......................................................................................................................... Windham, CT .............................................................................................................................. Bradford, FL ................................................................................................................................ Hendry, FL .................................................................................................................................. Levy, FL ...................................................................................................................................... Walton, FL .................................................................................................................................. Banks, GA ................................................................................................................................... Chattooga, GA ............................................................................................................................ Jackson, GA ............................................................................................................................... Lumpkin, GA ............................................................................................................................... Morgan, GA ................................................................................................................................ Peach, GA .................................................................................................................................. Polk, GA ...................................................................................................................................... Talbot, GA ................................................................................................................................... Bingham, ID ................................................................................................................................ Christian, IL ................................................................................................................................. DeWitt, IL .................................................................................................................................... Iroquois, IL .................................................................................................................................. Logan, IL ..................................................................................................................................... Mason, IL .................................................................................................................................... Ogle, IL ....................................................................................................................................... Clinton, IN ................................................................................................................................... Henry, IN ..................................................................................................................................... Spencer, IN ................................................................................................................................. Starke, IN .................................................................................................................................... Warren, IN .................................................................................................................................. Boone, IA .................................................................................................................................... Buchanan, IA .............................................................................................................................. Cedar, IA ..................................................................................................................................... Allen, KY ..................................................................................................................................... Assumption Parish, LA ............................................................................................................... St. James Parish, LA .................................................................................................................. Allegan, MI .................................................................................................................................. Montcalm, MI .............................................................................................................................. Oceana, MI ................................................................................................................................. Shiawassee, MI .......................................................................................................................... Tuscola, MI ................................................................................................................................. Fillmore, MN ............................................................................................................................... Dade, MO ................................................................................................................................... Pearl River, MS .......................................................................................................................... Caswell, NC ................................................................................................................................ Davidson, NC .............................................................................................................................. Granville, NC .............................................................................................................................. Harnett, NC ................................................................................................................................. Lincoln, NC ................................................................................................................................. Polk, NC ...................................................................................................................................... Los Alamos, NM ......................................................................................................................... Lyon, NV ..................................................................................................................................... Cayuga, NY ................................................................................................................................ Columbia, NY .............................................................................................................................. Genesee, NY .............................................................................................................................. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00108 Fmt 4701 Sfmt 4702 Rome, GA Auburn-Opelika, AL Anniston-Oxford, AL Hot Springs, AR Hartford-West Hartford-East Hartford, CT Gainesville, FL West Palm Beach-Boca Raton-Boynton, FL Gainesville, FL Fort Walton Beach-Crestview-Destin, FL Gainesville, GA Chattanooga, TN-GA Atlanta-Sandy Springs-Marietta, GA Atlanta-Sandy Springs-Marietta, GA Atlanta-Sandy Springs-Marietta, GA Macon, GA Atlanta-Sandy Springs-Marietta, GA Columbus, GA-AL Idaho Falls, ID Springfield, IL Bloomington-Normal, IL Kankakee-Bradley, IL Springfield, IL Peoria, IL Rockford, IL Lafayette, IN Indianapolis-Carmel, IN Evansville, IN-KY Gary, IN Lafayette, IN Ames, IA Waterloo-Cedar Falls, IA Iowa City, IA Bowling Green, KY Baton Rouge, LA Baton Rouge, LA Holland-Grand Haven, MI Grand Rapids-Wyoming, MI Muskegon-Norton Shores, MI Lansing-East Lansing, MI Saginaw-Saginaw Township North, MI Rochester, MN Springfield, MO Gulfport-Biloxi, MS Burlington, NC Greensboro-High Point, NC Durham, NC Raleigh-Cary, NC Charlotte-Gastonia-Concord, NC-SC Spartanburg, NC Santa Fe, NM Carson City, NV Syracuse, NY Albany-Schenectady-Troy, NY Rochester, NY E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23635 RURAL COUNTIES CONTAINING HOSPITALS REDESIGNATED AS URBAN UNDER SECTION 1886(D)(8)(B) OF THE ACT— Continued [Based on CBSAs and Census 2000 Data] Rural county CBSA jlentini on PROD1PC65 with PROPOSALS2 Greene, NY ................................................................................................................................. Schuyler, NY ............................................................................................................................... Sullivan, NY ................................................................................................................................ Wyoming, NY .............................................................................................................................. Ashtabula, OH ............................................................................................................................ Champaign, OH .......................................................................................................................... Columbiana, OH ......................................................................................................................... Cotton, OK .................................................................................................................................. Linn, OR ...................................................................................................................................... Adams, PA .................................................................................................................................. Clinton, PA .................................................................................................................................. Greene, PA ................................................................................................................................. Monroe, PA ................................................................................................................................. Schuylkill, PA .............................................................................................................................. Susquehanna, PA ....................................................................................................................... Clarendon, SC ............................................................................................................................ Lee, SC ....................................................................................................................................... Oconee, SC ................................................................................................................................ Union, SC ................................................................................................................................... Meigs, TN ................................................................................................................................... Bosque, TX ................................................................................................................................. Falls, TX ...................................................................................................................................... Fannin, TX .................................................................................................................................. Grimes, TX .................................................................................................................................. Harrison, TX ................................................................................................................................ Henderson, TX ............................................................................................................................ Milam, TX .................................................................................................................................... Van Zandt, TX ............................................................................................................................ Willacy, TX .................................................................................................................................. Buckingham, VA ......................................................................................................................... Floyd, VA .................................................................................................................................... Middlesex, VA ............................................................................................................................. Page, VA ..................................................................................................................................... Shenandoah, VA ......................................................................................................................... Island, WA .................................................................................................................................. Mason, WA ................................................................................................................................. Wahkiakum, WA ......................................................................................................................... Jackson, WV ............................................................................................................................... Roane, WV ................................................................................................................................. Green, WI ................................................................................................................................... Green Lake, WI .......................................................................................................................... Jefferson, WI ............................................................................................................................... Walworth, WI .............................................................................................................................. As in the past, hospitals redesignated under section 1886(d)(8)(B) of the Act are also eligible to be reclassified to a different area by the MGCRB. Affected hospitals are permitted to compare the reclassified wage index for the labor market area in Table 4C in the Addendum to this proposed rule into which they have been reclassified by the MGCRB to the wage index for the area to which they are redesignated under section 1886(d)(8)(B) of the Act. Hospitals may withdraw from an MCGRB reclassification within 45 days of the publication of this proposed rule. 6. Reclassifications Under Section 1886(d)(8)(B) of the Act As discussed in last year’s FY 2008 IPPS final rule with comment period (72 FR 47336–47337), Lugar hospitals are VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Albany-Schenectady-Troy, NY Ithaca, NY Poughkeepsie-Newburgh-Middletown, NY Buffalo-Niagara Falls, NY Cleveland-Elyria-Mentor, OH Springfield, OH Youngstown-Warren-Boardman, OH-PA Lawton, OK Corvallis, OR York-Hanover, PA Williamsport, PA Pittsburgh, PA Allentown-Bethlehem-Easton, PA-NJ Reading, PA Binghamton, NY Sumter, SC Sumter, SC Greenville, SC Spartanburg, SC Cleveland, TN Waco, TX Waco, TX Dallas-Plano-Irving, TX College Station-Bryan, TX Longview, TX Dallas-Plano-Irving, TX Austin-Round Rock, TX Dallas-Plano-Irving, TX Brownsville-Harlingen, TX Charlottesville, VA Blacksburg-Christiansburg-Radford, VA Virginia Beach-Norfolk-Newport News, VA Harrisonburg, VA Winchester, VA-WV Seattle-Bellevue-Everett, WA Olympia, WA Longview, WA Charleston, WV Charleston, WV Madison, WI Fond du Lac, WI Milwaukee-Waukesha-West Allis, WI Milwaukee-Waukesha-West Allis, WI treated like reclassified hospitals for purposes of determining their applicable wage index and receive the reclassified wage index (Table 4C in the Addendum to this proposed rule) for the urban area to which they have been redesignated. Because Lugar hospitals are treated like reclassified hospitals, when they are seeking reclassification by the MCGRB, they are subject to the rural reclassification rules set forth at 42 CFR 412.230. The procedural rules set forth at § 412.230 list the criteria that a hospital must meet in order to reclassify as a rural hospital. Lugar hospitals are subject to the proximity criteria and payment thresholds that apply to rural hospitals. Specifically, the hospital must be no more than 35 miles from the area to which it seeks reclassification (§ 412.230(b)(1)); and the hospital must PO 00000 Frm 00109 Fmt 4701 Sfmt 4702 show that its average hourly wage is at least 106 percent of the average hourly wage of all other hospitals in the area in which the hospital is located (§ 412.230(d)(1)(iii)(C)). Under current rules, the hospital must also demonstrate that its average hourly wage is equal to at least 82 percent of the average hourly wage of hospitals in the area to which it seeks redesignation (§ 412.230(d)(1)(iv)(C)). However, we are proposing to increase this threshold to 86 percent (as discussed in section III.B.2.a. of this preamble). Hospitals not located in a Lugar County seeking reclassification to the urban area where the Lugar hospitals have been redesignated are not permitted to measure to the Lugar County to demonstrate proximity (no more than 15 miles for an urban E:\FR\FM\30APP2.SGM 30APP2 23636 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 hospital, and no more than 35 miles for a rural hospital or the closest urban or rural area for RRCs or SCHs) in order to be reclassified to such urban area. These hospitals must measure to the urban area exclusive of the Lugar County to meet the proximity or nearest urban or rural area requirement. As discussed in the FY 2008 final rule with comment period, we treat New England deemed counties in a manner consistent with how we treat Lugar counties. (We refer readers to 72 FR 47337 for a discussion of this policy.) J. Proposed FY 2009 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees In accordance with the broad discretion under section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108–173, beginning with FY 2005, we established a process to make adjustments to the hospital wage index based on commuting patterns of hospital employees (the ‘‘out-migration’’ adjustment). The process, outlined in the FY 2005 IPPS final rule (69 FR 49061), provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county but work in a different county (or counties) with a higher wage index. Such adjustments to the wage index are effective for 3 years, unless a hospital requests to waive the application of the adjustment. A county will not lose its status as a qualifying county due to wage index changes during the 3-year period, and counties will receive the same wage index increase for those three years. However, a county that qualifies in any given year may no longer qualify after the 3-year period, or it may qualify but receive a different adjustment to the wage index level. Hospitals that receive this adjustment to their wage index are not eligible for reclassification under section 1886(d)(8) or section 1886(d)(10) of the Act. Adjustments under this provision are not subject to the budget neutrality requirements under section 1886(d)(3)(E) of the Act. Hospitals located in counties that qualify for the wage index adjustment are to receive an increase in the wage index that is equal to the average of the differences between the wage indices of the labor market area(s) with higher wage indices and the wage index of the resident county, weighted by the overall percentage of hospital workers residing in the qualifying county who are employed in any labor market area with a higher wage index. Beginning with the FY 2008 wage index, we use postreclassified wage indices when VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 determining the out-migration adjustment (72 FR 47339). For the proposed FY 2009 wage index, we calculated the out-migration adjustment using the same formula described in the FY 2005 IPPS final rule (69 FR 49064), with the addition of using the post-reclassified wage indices, to calculate the out-migration adjustment. This adjustment is calculated as follows: Step 1. Subtract the wage index for the qualifying county from the wage index of each of the higher wage area(s) to which hospital workers commute. Step 2. Divide the number of hospital employees residing in the qualifying county who are employed in such higher wage index area by the total number of hospital employees residing in the qualifying county who are employed in any higher wage index area. For each of the higher wage index areas, multiply this result by the result obtained in Step 1. Step 3. Sum the products resulting from Step 2 (if the qualifying county has workers commuting to more than one higher wage index area). Step 4. Multiply the result from Step 3 by the percentage of hospital employees who are residing in the qualifying county and who are employed in any higher wage index area. These adjustments will be effective for each county for a period of 3 fiscal years. For example, hospitals that received the adjustment for the first time in FY 2008 will be eligible to retain the adjustment for FY 2009. For hospitals in newly qualified counties, adjustments to the wage index are effective for 3 years, beginning with discharges occurring on or after October 1, 2008. Hospitals receiving the wage index adjustment under section 1886(d)(13)(F) of the Act are not eligible for reclassification under sections 1886(d)(8) or (d)(10) of the Act unless they waive the out-migration adjustment. Consistent with our FY 2005, 2006, 2007, and 2008 IPPS final rules, we are proposing that hospitals redesignated under section 1886(d)(8) of the Act or reclassified under section 1886(d)(10) of the Act will be deemed to have chosen to retain their redesignation or reclassification. Section 1886(d)(10) hospitals that wish to receive the out-migration adjustment, rather than their reclassification, should follow the termination/withdrawal procedures specified in 42 CFR 412.273 and section III.I.3. of the preamble of this proposed rule. Otherwise, they will be deemed to have waived the outmigration adjustment. Hospitals PO 00000 Frm 00110 Fmt 4701 Sfmt 4702 redesignated under section 1886(d)(8) of the Act will be deemed to have waived the out-migration adjustment, unless they explicitly notify CMS within 45 days from the publication of this proposed rule that they elect to receive the out-migration adjustment instead. These notifications should be sent to the following address: Centers for Medicare and Medicaid Services, Center for Medicare Management, Attention: Wage Index Adjustment Waivers, Division of Acute Care, Room C4–08–06, 7500 Security Boulevard, Baltimore, MD 21244–1850. Table 4J in the Addendum to this proposed rule lists the proposed outmigration wage index adjustments for FY 2009. Hospitals that are not otherwise reclassified or redesignated under section 1886(d)(8) or section 1886(d)(10) of the Act will automatically receive the listed adjustment. In accordance with the procedures discussed above, redesignated/reclassified hospitals would be deemed to have waived the out-migration adjustment unless CMS is otherwise notified. Hospitals that are eligible to receive the out-migration wage index adjustment and that withdraw their application for reclassification would automatically receive the wage index adjustment listed in Table 4J in the Addendum to this proposed rule. K. Process for Requests for Wage Index Data Corrections The preliminary, unaudited Worksheet S–3 wage data and occupational mix survey data files for the FY 2009 wage index were made available on October 5, 2007, through the Internet on the CMS Web site at: https://www.cms.hhs.gov/ AcuteInpatientPPS/WIFN/ list.asp#TopOfPage. In the interest of meeting the data needs of the public, beginning with the proposed FY 2009 wage index, we posted an additional public use file on our Web site that reflects the actual data that are used in computing the proposed wage index. The release of this new file does not alter the current wage index process or schedule. We notified the hospital community of the availability of these data as we do with the current public use wage data files through our Hospital Open Door forum. We encourage hospitals to sign up for automatic notifications of information about hospital issues and the scheduling of the Hospital Open Door forums at: https://www.cms.hhs.gov/ OpenDoorForums/. In a memorandum dated October 5, 2007, we instructed all fiscal E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules intermediaries/MACs to inform the IPPS hospitals they service of the availability of the wage index data files and the process and timeframe for requesting revisions (including the specific deadlines listed below). We also instructed the fiscal intermediaries/ MACs to advise hospitals that these data were also made available directly through their representative hospital organizations. If a hospital wished to request a change to its data as shown in the October 5, 2007 wage and occupational mix data files, the hospital was to submit corrections along with complete, detailed supporting documentation to its fiscal intermediary/MAC by December 7, 2007. Hospitals were notified of this deadline and of all other possible deadlines and requirements, including the requirement to review and verify their data as posted on the preliminary wage index data files on the Internet, through the October 5, 2007 memorandum referenced above. In the October 5, 2007 memorandum, we also specified that a hospital requesting revisions to its 1st and/or 2nd quarter occupational mix survey data was to copy its record(s) from the CY 2006 occupational mix preliminary files posted to our Web site in October, highlight the revised cells on its spreadsheet, and submit its spreadsheet(s) and complete documentation to its fiscal intermediary/MAC no later than December 7, 2007. The fiscal intermediaries (or, if applicable, the MACs) notified the hospitals by mid-February 2008 of any changes to the wage index data as a result of the desk reviews and the resolution of the hospitals’ earlyDecember revision requests. The fiscal intermediaries/MACs also submitted the revised data to CMS by mid-February 2008. CMS published the proposed wage index public use files that included hospitals’ revised wage index data on February 25, 2008. In a memorandum also dated February 25, 2008, we instructed fiscal intermediaries/MACs to notify all hospitals regarding the availability of the proposed wage index public use files and the criteria and process for requesting corrections and revisions to the wage index data. Hospitals had until March 11, 2008 to submit requests to the fiscal intermediaries/MACs for reconsideration of adjustments made by the fiscal intermediaries/MACs as a result of the desk review, and to correct errors due to CMS’s or the fiscal intermediary’s (or, if applicable, the MAC’s) mishandling of the wage index data. Hospitals were also required to VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 submit sufficient documentation to support their requests. After reviewing requested changes submitted by hospitals, fiscal intermediaries/MACs are to transmit any additional revisions resulting from the hospitals’ reconsideration requests by April 14, 2008. The deadline for a hospital to request CMS intervention in cases where the hospital disagreed with the fiscal intermediary’s (or, if applicable, the MAC’s) policy interpretations is April 21, 2008. Hospitals should also examine Table 2 in the Addendum to this proposed rule. Table 2 in the Addendum to this proposed rule contains each hospital’s adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 2005 data used to construct the proposed FY 2009 wage index. We note that the hospital average hourly wages shown in Table 2 only reflect changes made to a hospital’s data and transmitted to CMS by February 29, 2008. We will release the final wage index data public use files in early May 2008 on the Internet at https:// www.cms.hhs.gov/AcuteInpatientPPS/ WIFN/list.asp#TopOfPage. The May 2008 public use files will be made available solely for the limited purpose of identifying any potential errors made by CMS or the fiscal intermediary/MAC in the entry of the final wage index data that result from the correction process described above (revisions submitted to CMS by the fiscal intermediaries/MACs by April 14, 2008). If, after reviewing the May 2008 final files, a hospital believes that its wage or occupational mix data are incorrect due to a fiscal intermediary or MAC or CMS error in the entry or tabulation of the final data, the hospital should send a letter to both its fiscal intermediary or MAC and CMS that outlines why the hospital believes an error exists and to provide all supporting information, including relevant dates (for example, when it first became aware of the error). CMS and the fiscal intermediaries (or, if applicable, the MACs) must receive these requests no later than June 9, 2008. Requests mailed to CMS should be sent to: Centers for Medicare & Medicaid Services, Center for Medicare Management, Attention: Wage Index Team, Division of Acute Care, C4–08– 06, 7500 Security Boulevard, Baltimore, MD 21244–1850. Each request also must be sent to the fiscal intermediary or the MAC. The fiscal intermediary or the MAC will review requests upon receipt and contact CMS immediately to discuss its findings. PO 00000 Frm 00111 Fmt 4701 Sfmt 4702 23637 At this point in the process, that is, after the release of the May 2008 wage index data files, changes to the wage and occupational mix data will only be made in those very limited situations involving an error by the fiscal intermediary or the MAC or CMS that the hospital could not have known about before its review of the final wage index data files. Specifically, neither the fiscal intermediary or the MAC nor CMS will approve the following types of requests: • Requests for wage index data corrections that were submitted too late to be included in the data transmitted to CMS by fiscal intermediaries or the MACs on or before April 21, 2008. • Requests for correction of errors that were not, but could have been, identified during the hospital’s review of the February 25, 2008 wage index public use files. • Requests to revisit factual determinations or policy interpretations made by the fiscal intermediary or the MAC or CMS during the wage index data correction process. Verified corrections to the wage index data received timely by CMS and the fiscal intermediaries or the MACs (that is, by June 9, 2008) will be incorporated into the final wage index in the FY 2009 IPPS final rule, which will be effective October 1, 2008. We created the processes described above to resolve all substantive wage index data correction disputes before we finalize the wage and occupational mix data for the FY 2009 payment rates. Accordingly, hospitals that do not meet the procedural deadlines set forth above will not be afforded a later opportunity to submit wage index data corrections or to dispute the fiscal intermediary’s (or, if applicable the MAC’s) decision with respect to requested changes. Specifically, our policy is that hospitals that do not meet the procedural deadlines set forth above will not be permitted to challenge later, before the Provider Reimbursement Review Board, the failure of CMS to make a requested data revision. (See W. A. Foote Memorial Hospital v. Shalala, No. 99– CV–75202–DT (E.D. Mich. 2001) and Palisades General Hospital v. Thompson, No. 99–1230 (D.D.C. 2003).) We refer the reader also to the FY 2000 final rule (64 FR 41513) for a discussion of the parameters for appealing to the PRRB for wage index data corrections. Again, we believe the wage index data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage and occupational mix data to the fiscal intermediary’s (or, if applicable, the MAC’s) attention. Moreover, because E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23638 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules hospitals will have access to the final wage index data by early May 2008, they have the opportunity to detect any data entry or tabulation errors made by the fiscal intermediary or the MAC or CMS before the development and publication of the final FY 2009 wage index by August 1, 2008, and the implementation of the FY 2009 wage index on October 1, 2008. If hospitals availed themselves of the opportunities afforded to provide and make corrections to the wage and occupational mix data, the wage index implemented on October 1 should be accurate. Nevertheless, in the event that errors are identified by hospitals and brought to our attention after June 9, 2008, we retain the right to make midyear changes to the wage index under very limited circumstances. Specifically, in accordance with 42 CFR 412.64(k)(1) of our existing regulations, we make midyear corrections to the wage index for an area only if a hospital can show that: (1) The fiscal intermediary or the MAC or CMS made an error in tabulating its data; and (2) the requesting hospital could not have known about the error or did not have an opportunity to correct the error, before the beginning of the fiscal year. For purposes of this provision, ‘‘before the beginning of the fiscal year’’ means by the June deadline for making corrections to the wage data for the following fiscal year’s wage index. This provision is not available to a hospital seeking to revise another hospital’s data that may be affecting the requesting hospital’s wage index for the labor market area. As indicated earlier, since CMS makes the wage index data available to hospitals on the CMS Web site prior to publishing both the proposed and final IPPS rules, and the fiscal intermediaries or the MAC notify hospitals directly of any wage index data changes after completing their desk reviews, we do not expect that midyear corrections will be necessary. However, under our current policy, if the correction of a data error changes the wage index value for an area, the revised wage index value will be effective prospectively from the date the correction is made. In the FY 2006 IPPS final rule (70 FR 47385), we revised 42 CFR 412.64(k)(2) to specify that, effective on October 1, 2005, that is beginning with the FY 2006 wage index, a change to the wage index can be made retroactive to the beginning of the Federal fiscal year only when: (1) The fiscal intermediary (or, if applicable, the MAC) or CMS made an error in tabulating data used for the wage index calculation; (2) the hospital knew about the error and requested that VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 the fiscal intermediary (or if applicable the MAC) and CMS correct the error using the established process and within the established schedule for requesting corrections to the wage index data, before the beginning of the fiscal year for the applicable IPPS update (that is, by the June 9, 2008 deadline for the FY 2009 wage index); and (3) CMS agreed that the fiscal intermediary (or if applicable, the MAC) or CMS made an error in tabulating the hospital’s wage index data and the wage index should be corrected. In those circumstances where a hospital requested a correction to its wage index data before CMS calculates the final wage index (that is, by the June deadline), and CMS acknowledges that the error in the hospital’s wage index data was caused by CMS’s or the fiscal intermediary’s (or, if applicable, the MAC’s) mishandling of the data, we believe that the hospital should not be penalized by our delay in publishing or implementing the correction. As with our current policy, we indicated that the provision is not available to a hospital seeking to revise another hospital’s data. In addition, the provision cannot be used to correct prior years’ wage index data; it can only be used for the current Federal fiscal year. In other situations where our policies would allow midyear corrections, we continue to believe that it is appropriate to make prospectiveonly corrections to the wage index. We note that, as with prospective changes to the wage index, the final retroactive correction will be made irrespective of whether the change increases or decreases a hospital’s payment rate. In addition, we note that the policy of retroactive adjustment will still apply in those instances where a judicial decision reverses a CMS denial of a hospital’s wage index data revision request. L. Labor-Related Share for the Proposed Wage Index for FY 2009 Section 1886(d)(3)(E) of the Act directs the Secretary to adjust the proportion of the national prospective payment system base payment rates that are attributable to wages and wagerelated costs by a factor that reflects the relative differences in labor costs among geographic areas. It also directs the Secretary to estimate from time to time the proportion of hospital costs that are labor-related: ‘‘The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of hospitals’ costs which are attributable to wages and wage-related costs of the DRG prospective payment rates * * *’’ We refer to the portion of hospital costs attributable to wages and wage-related PO 00000 Frm 00112 Fmt 4701 Sfmt 4702 costs as the labor-related share. The labor-related share of the prospective payment rate is adjusted by an index of relative labor costs, which is referred to as the wage index. Section 403 of Pub. L. 108–173 amended section 1886(d)(3)(E) of the Act to provide that the Secretary must employ 62 percent as the labor-related share unless this ‘‘would result in lower payments to a hospital than would otherwise be made.’’ However, this provision of Pub. L. 108–173 did not change the legal requirement that the Secretary estimate ‘‘from time to time’’ the proportion of hospitals costs that are ‘‘attributable to wages and wage-related costs.’’ We interpret this to mean that hospitals receive payment based on either a 62-percent labor-related share, or the labor-related share estimated from time to time by the Secretary, depending on which labor-related share resulted in a higher payment. We have continued our research into the assumptions employed in calculating the labor-related share. Our research involves analyzing the compensation share separately for urban and rural hospitals, using regression analysis to determine the proportion of costs influenced by the area wage index, and exploring alternative methodologies to determine whether all or only a portion of professional fees and nonlabor intensive services should be considered labor-related. In the FY 2006 IPPS final rule (70 FR 47392), we presented our analysis and conclusions regarding the methodology for updating the labor-related share for FY 2006. We also recalculated a laborrelated share of 69.731 percent, using the FY 2002-based PPS market basket for discharges occurring on or after October 1, 2005. In addition, we implemented this revised and rebased labor-related share in a budget neutral manner, but consistent with section 1886(d)(3)(E) of the Act, we did not take into account the additional payments that would be made as a result of hospitals with a wage index less than or equal to 1.0 being paid using a laborrelated share lower than the laborrelated share of hospitals with a wage index greater than 1.0. The labor-related share is used to determine the proportion of the national PPS base payment rate to which the area wage index is applied. In this proposed rule, we are not proposing to make any changes to the national average proportion of operating costs that are attributable to wages and salaries, fringe benefits, professional fees, contract labor, and labor intensive services. Therefore, we are proposing to continue to use a labor-related share of 69.731 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 percent for discharges occurring on or after October 1, 2008. Tables 1A and 1B in the Addendum to this proposed rule reflect this proposed labor-related share. We note that section 403 of Pub. L. 108– 173 amended sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act to provide that the Secretary must employ 62 percent as the labor-related share unless this employment ‘‘would result in lower payments to a hospital than would otherwise be made.’’ We also are proposing to continue to use a labor-related share for the Puerto Rico-specific standardized amounts of 58.7 percent for discharges occurring on or after October 1, 2008. Consistent with our methodology for determining the national labor-related share, we added the Puerto Rico-specific relative weights for wages and salaries, fringe benefits, contract labor, nonmedical professional fees, and other labor-intensive services to determine the labor-related share. Puerto Rico hospitals are paid based on 75 percent of the national standardized amounts and 25 percent of the Puerto Rico-specific standardized amounts. For Puerto Rico hospitals, the national labor-related share will always be 62 percent because the wage index for all Puerto Rico hospitals is less than 1.0. A Puerto Rico-specific wage index is applied to the Puerto Rico-specific portion of payments to the hospitals. The labor-related share of a hospital’s Puerto Rico-specific rate will be either 62 percent or the Puerto Rico-specific labor-related share depending on which results in higher payments to the hospital. If the hospital has a Puerto Rico-specific wage index of greater than 1.0, we will set the hospital’s rates using a labor-related share of 62 percent for the 25 percent portion of the hospital’s payment determined by the Puerto Rico standardized amounts because this amount will result in higher payments. Conversely, a hospital with a Puerto Rico-specific wage index of less than 1.0 will be paid using the Puerto Ricospecific labor-related share of 58.7 percent of the Puerto Rico-specific rates because the lower labor-related share will result in higher payments. The proposed Puerto Rico labor-related share of 58.7 percent for FY 2008 is reflected in the Table 1C of the Addendum to this proposed rule. IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs A. Proposed Changes to the Postacute Care Transfer Policy (§ 412.4) 1. Background Existing regulations at § 412.4(a) define discharges under the IPPS as VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 situations in which a patient is formally released from an acute care hospital or dies in the hospital. Section 412.4(b) defines transfers from one acute care hospital to another. Section 412.4(c) establishes the conditions under which we consider a discharge to be a transfer for purposes of our postacute care transfer policy. In transfer situations, the transferring hospital is paid based on a per diem rate for each day of the stay, not to exceed the full MS–DRG payment that would have been made if the patient had been discharged without being transferred. The per diem rate paid to a transferring hospital is calculated by dividing the full MS–DRG payment by the geometric mean length of stay for the MS–DRG. Based on an analysis that showed that the first day of hospitalization is the most expensive (60 FR 5804), our policy generally provides for payment that is double the per diem amount for the first day, with each subsequent day paid at the per diem amount up to the full DRG payment (§ 412.4(f)(1)). Transfer cases are also eligible for outlier payments. The outlier threshold for transfer cases is equal to the fixed-loss outlier threshold for nontransfer cases (adjusted for geographic variations in costs), divided by the geometric mean length of stay for the MS–DRG, multiplied by the length of stay for the case plus one day. The purpose of the IPPS postacute care transfer payment policy is to avoid providing an incentive for a hospital to transfer patients to another hospital, a SNF, or home under a written plan of care for home health services early in the patients’’ stay in order to minimize costs while still receiving the full MS– DRG payment. The transfer policy adjusts the payments to approximate the reduced costs of transfer cases. Beginning with the FY 2006 IPPS, the regulations at § 412.4 specified that, effective October 1, 2005, a DRG would be subject to the postacute care transfer policy if, based on Version 23.0 of the DRG Definitions Manual (FY 2006), using data from the March 2005 update of FY 2004 MedPAR file, the DRG meets the following criteria: • The DRG had a geometric mean length of stay of at least 3 days; • The DRG had at least 2,050 postacute care transfer cases; and • At least 5.5 percent of the cases in the DRG were discharged to postacute care prior to the geometric mean length of stay for the DRG. In addition, if the DRG was one of a paired set of DRGs based on the presence or absence of a CC or major cardiovascular condition (MCV), both PO 00000 Frm 00113 Fmt 4701 Sfmt 4702 23639 paired DRGs would be included if either one met the three criteria above. If a DRG met the above criteria based on the Version 23.0 DRG Definitions Manual and FY 2004 MedPAR data, we made the DRG subject to the postacute care transfer policy. We noted in the FY 2006 final rule that we would not revise the list of DRGs subject to the postacute care transfer policy annually unless we made a change to a specific CMS DRG. We established this policy to promote certainty and stability in the postacute care transfer payment policy. Annual reviews of the list of CMS DRGs subject to the policy would likely lead to great volatility in the payment methodology with certain DRGs qualifying for the policy in one year, deleted the next year, only to be reinstated the following year. However, we noted that, over time, as treatment practices change, it was possible that some CMS DRGs that qualified for the policy will no longer be discharged with great frequency to postacute care. Similarly, we explained that there may be other CMS DRGs that at that time had a low rate of discharges to postacute care, but which might have very high rates in the future. The regulations at § 412.4 further specify that if a DRG did not exist in Version 23.0 of the DRG Definitions Manual or a DRG included in Version 23.0 of the DRG Definitions Manual is revised, the DRG will be a qualifying DRG if it meets the following criteria based on the version of the DRG Definitions Manual in use when the new or revised DRG first became effective, using the most recent complete year of MedPAR data: • The total number of discharges to postacute care in the DRG must equal or exceed the 55th percentile for all DRGs; and • The proportion of short-stay discharges to postacute care to total discharges in the DRG exceeds the 55th percentile for all DRGs. A short-stay discharge is a discharge before the geometric mean length of stay for the DRG. A DRG also is a qualifying DRG if it is paired with another DRG based on the presence or absence of a CC or MCV that meets either of the above two criteria. The MS–DRGs that we adopted for FY 2008 were a significant revision to the CMS DRG system (72 FR 47141). Because the MS–DRGs were not reflected in Version 23.0 of the DRG Definitions Manual, consistent with § 412.4, we established policy to recalculate the 55th percentile thresholds in order to determine which MS–DRGs would be subject to the postacute care transfer policy (72 FR 47186 through 47188). Further, under E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23640 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules the MS–DRGs, the subdivisions within the base DRGs are different than those under the previous CMS DRGs. Unlike the CMS DRGs, the MS–DRGs are not divided based on the presence or absence of a CC or MCV. Rather, the MS–DRGs have up to three subdivisions based on: (1) The presence of a MCC; (2) the presence of a CC; or (3) the absence of either an MCC or CC. Consistent with our previous policy under which both CMS DRGs in a CC/non-CC pair were qualifying DRGs if one of the pair qualified, we established that each MS– DRG that shared a base MS–DRG will be a qualifying DRG if one of the MS–DRGs that shared the base DRG qualifies. We revised § 412.4(d)(3)(ii) to codify this policy. Similarly, the adoption of the MS– DRGs also necessitated a revision to one of the criteria used in § 412.4(f)(5) of the regulations to determine whether a DRG meets the criteria for payment under the ‘‘special payment methodology.’’ Under the special payment methodology, a case subject to the special payment methodology that is transferred early to a postacute care setting will be paid 50 percent of the total IPPS payment plus the average per diem for the first day of the stay. In addition, the hospital will receive 50 percent of the per diem amount for each subsequent day of the stay, up to the full MS–DRG payment amount. A CMS DRG was subject to the special payment methodology if it met the criteria of § 412.4(f)(5). Section 412.4(f)(5)(iv) specifies that, for discharges occurring on or after October 1, 2005, and prior to October 1, 2007, if a DRG meets the criteria specified under § 412.4(f)(5)(i) through (f)(5)(iii), any DRG that is paired with it based on the presence or absence of a CC or MCV is also subject to the special payment methodology. Given that this criterion was no longer applicable under the MS– DRG system, in the FY 2008 final rule with comment period, we added a new § 412.4(f)(6) (42 FR 47188 and 47410). Section 412.4(f)(6) provides that, for discharges on or after October 1, 2007, if an MS–DRG meets the criteria specified under §§ 412.4(f)(6)(i) through (f)(6)(iii), any other MS–DRG that is part of the same MS–DRG group is also subject to the special payment methodology. We updated this criterion so that it conformed to the changes associated with adopting MS–DRGs for FY 2008. The revision makes an MS– DRG subject to the special payment methodology if it shares a base MS–DRG with an MS–DRG that meets the criteria for receiving the special payment methodology. Section 1886(d)(5)(J) of the Act provides that, effective for discharges on VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 or after October 1, 1998, a ‘‘qualified discharge’’ from one of DRGs selected by the Secretary to a postacute care provider would be treated as a transfer case. This section required the Secretary to define and pay as transfers all cases assigned to one of the DRGs selected by the Secretary, if the individuals are discharged to one of the following postacute care settings: • A hospital or hospital unit that is not a subsection 1886(d) hospital. (Section 1886(d)(1)(B) of the Act identifies the hospitals and hospital units that are excluded from the term ‘‘subsection (d) hospital’’ as psychiatric hospitals and units, rehabilitation hospitals and units, children’s hospitals, long-term care hospitals, and cancer hospitals.) • A SNF (as defined at section1819(a) of the Act). • Home health services provided by a home health agency, if the services relate to the condition or diagnosis for which the individual received inpatient hospital services, and if the home health services are provided within an appropriate period (as determined by the Secretary). In the FY 1999 IPPS final rule (63 FR 40975 through 40976 and 40979 through 40981), we specified that a patient discharged to home would be considered transferred to postacute care if the patient received home health services within 3 days after the date of discharge. In addition, in the FY 1999 IPPS final rule, we did not include patients transferred to a swing-bed for skilled nursing care in the definition of postacute care transfer cases (63 FR 40977). 2. Proposed Policy Change Relating to Transfers to Home with a Written Plan for the Provision of Home Health Services As noted above, in the FY 1999 IPPS final rule (63 FR 40975 through 40976 and 40979 through 40981), we determined that 3 days is an appropriate period within which home health services should begin following a beneficiary’s discharge to the home in order for the discharge to be considered a ‘‘qualified discharge’’ subject to the payment adjustment for postacute care transfer cases. In that same final rule, we noted that we would monitor whether 3 days would remain an appropriate timeframe. Section 1886(d)(5)(J)(ii)(III) of the Act provides that the discharge of an individual who receives home health services upon discharge will be treated as a transfer if ‘‘such services are provided within an appropriate period as determined by the Secretary * * *’’. The statute thus confers upon the PO 00000 Frm 00114 Fmt 4701 Sfmt 4702 Secretary the authority to determine an appropriate timeframe for the application of the postacute care transfer policy in cases where home health services commence subsequent to discharge from an acute care hospital. In the FY 1999 final IPPS rule, we established the policy that the postacute care transfer policy would apply to cases in which the home health care begins within 3 days of the discharge from an acute care policy. We noted in that rule that we did not believe that it was appropriate to limit the transfer definition to cases in which home health care begins on the same day as the patient is discharged from the hospital. We observed that data indicated that less than 8 percent of discharged patients who receive home health care begin receiving those services on the date of discharge. It is unreasonable to expect that patients who are discharged later in the day would receive a home health visit that same day. Furthermore, we believed that the financial incentive to delay needed home health care for only a matter of hours would be overwhelming if we limited the timeframe to one day. At the time of that final rule, we explained that we believed that 3 days would be a more appropriate timeframe because it would mitigate the incentive to delay home health services to avoid the application of the postacute care transfer policy, and because a 3-day timeframe was consistent with existing patterns of care. In that final rule, we also noted that a number of commenters had raised issues and questions concerning the proposal to adopt 3 days as the appropriate timeframe for the application of the postacute care transfer policy in these cases. While most of the commenters advocated shorter timeframes, on the grounds that postacute care beginning 3 days after a discharge should not be considered a substitute for inpatient hospital care, others suggested that a 3-day window might still allow for needlessly prolonged hospital care or delayed home health in order to avoid the application of the postacute care transfer policy. Although MedPAC agreed with the commenters who asserted that home health care services furnished after a delay of more than one day may not necessarily be regarded as substituting for inpatient acute care, they also noted that a 3-day window allows for the fact that most home health patients do not receive care every day, as well as for those occasions in which there may be a delay in arranging for the provision of planned care (for E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules example, an intervening weekend). The commission also stated that a shorter period may create a stronger incentive to delay the provision of necessary care beyond the window so that the hospital will receive the full DRG payment. In the light of these comments and, in particular, of the concern that a 3-day timeframe still allowed for some incentive to delay necessary home health services in order to avoid the application of the postacute care transfer policy, we indicated that we would continue to monitor this policy in order to track any changes in practices that may indicate the need for revising the window. Since the adoption of this policy in FY 1999, we have continued to receive reports that some providers discharge patients prior to the geometric mean length of stay but intentionally delay home health services beyond 3 days after the acute hospital discharge in order to avoid the postacute care transfer payment adjustment policy. These reports, and the concerns expressed by some commenters in FY 1999 about the adequacy of a 3-day window to reduce such incentives, have prompted us to examine the available data concerning the initiation and program payments for home health care subsequent to discharge from postacute care. We merged the FY 2004 MedPAR file with postacute care bill files matching beneficiary identification numbers and discharge and admission dates and looked at the 10 DRGs that were subject to the postacute care transfer policy from FYs 1999 through 2003 (DRG 14 (Intracranial Hemorrhage and Stroke with Infarction (formerly ‘‘Specific Cerebrovascular Disorders Except Transient Ischemic Attack’’)); DRG 113 (Amputation for Circulatory System Disorders Except Upper Limb and Toe); DRG 209 (Major Joint Limb Reattachment Procedures of Lower Extremity); DRG 210 (Hip and Femur Procedures Except Major Joint Procedures ≤17 with CC); DRG 211 (Hip and Femur Procedures Except Major Joint Procedures Age ≤17 without CC); DRG 236 (Fractures of Hip and Pelvis); DRG 263 (Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC); DRG 264 (Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC); DRG 429 (Organic Disturbances and Mental Retardation); and DRG 483 (Tracheostomy with Mechanical Ventiliation 96+ Hours or Principal Diagnosis Except Face, Mouth, and Neck Diagnoses (formerly ‘‘Tracheostomy Except for Face, Mouth, and Neck Diagnoses’’)). We selected the original 10 ‘‘qualified DRGs’’ because VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 they were the DRGs to which the postacute care transfer policy applied for FYs 1999 through 2003 and because we expect that trends that we found in the data with those DRGs would be likely to accurately reflect provider practices after the inception of the postacute care transfer policy. We expect that provider practices for the original 10 DRGs would be consistent even with the expansion of the DRGs that are subject to the postacute care transfer policy. We note that providers may have even a greater incentive to delay the initiation of home health care in an effort to avoid the postacute care transfer policy now that there are more DRGs to which the policy applies. We compared data on home health services provided to patients who were discharged prior to the geometric mean length of stay to patients who were discharged at or beyond the geometric mean length of stay. For purposes of this analysis, we assumed that home health was the first discharge designation from the acute care hospital setting. The data showed that, on average, the Medicare payment per home health visit was higher for patients who were discharged prior to the geometric mean length of stay (as compared to patients who were discharged at or beyond the geometric mean length of stay). Additionally, we found some evidence in the data suggesting that, for patients discharged prior to the geometric mean length of stay for many DRGs, hospitals may indeed be discharging patients earlier than advisable, providing less than the optimal amount of acute inpatient care, and are instead substituting home health care for inpatient services, resulting in higher home health care payments under the Medicare program. One generally would expect that patients discharged prior to the geometric mean length of stay are genuinely less severely ill than patients discharged at or after the geometric mean length of stay because patients in the former group are judged to be appropriate for discharge after less acute inpatient care. However, our data paint a different picture. For example, the data on the average per day Medicare payments for home health care for those patients who are discharged from the hospital prior to the geometric mean length of stay in the DRGs to which the postacute care transfer policy applies, as compared to Medicare payments for patients discharged from the hospital at or after the geometric mean length of stay, show patterns other than what might be expected if hospitals are generally discharging patients for home health care only after the full amount of PO 00000 Frm 00115 Fmt 4701 Sfmt 4702 23641 acute inpatient care. Specifically, average Medicare payments per home health care visit are consistently higher for patients discharged prior to the geometric mean length of stay than for patients discharged at or after the geometric mean length of stay. The average home health care per visit payments for patients treated for the relevant DRGs and discharged before the geometric mean length of stay are $204 when the initiation of home health care began on the second day after discharge, $199 on the third day, and $182 on the sixth day, compared to $177, $163, and $171, respectively for patients discharged on or after the geometric mean length of stay. Furthermore, the ratio of the payments for these two groups actually increases from 1.16 on the third day after discharge to 1.22 on the fourth day, before falling again to 1.04, 1.07, and 1.08 on the fifth, sixth, and seventh days. This suggests the possibility that home health care for some relatively sicker patients is being delayed until just beyond the 3-day window during which the postacute care transfer policy applies. In the light of these data, we believe that it is appropriate to propose extending the applicable timeframe in order to reduce the incentive for providers to delay home health care when discharging patients from the acute care setting. Further examination of the data indicates that the average per day Medicare payments for home health care for those patients, in the DRGs to which the postacute care transfer policy applies, who are discharged from the hospital prior to the geometric mean length of stay, stabilizes at a somewhat lower amount when the initiation of home health visits begins on the seventh and subsequent days after discharge. Specifically, average payments per visit for this group fall from $182 when home health services began on the sixth day after the acute care hospital discharge to $174 on the seventh day, and then remain relatively steady at $171, $177, and $172 on the eighth, ninth, and tenth days. This suggests that a 7-day period would be an appropriate point at which to establish a new timeframe. The stabilization of average home health care visit payments at and after the seventh day suggests that this may be the point at which the incentives to delay the start of home health care in order to avoid the application of the postacute care transfer policy are reduced. As a consequence of this analysis, in this proposed rule, we are proposing to revise § 412.4(c)(3) to extend the timeframe to within 7 days of discharge to home under a written E:\FR\FM\30APP2.SGM 30APP2 23642 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 plan for the provision of home health services, effective October 1, 2008. We believe that extending the applicable timeframe will lessen the incentive for providers to delay the start of home health care after discharging patients from the acute care hospital setting. During the comment period on this proposed rule, we plan to continue to search our data on postacute care discharges to home health services. We welcome comments and suggestions on other data analyses that can be performed to determine an appropriate timeframe for which the postacute care transfer policy would apply. In addition to the reasons noted above, we believe that 7 days is currently an appropriate timeframe because we believe that accommodates current practices and it is sufficiently long enough to lessen the likelihood that providers would delay the initiation of necessary home health services. At the same time, we believe that 7 days is narrow enough that we would still expect the majority of the home health services to be related to the condition to which the acute inpatient hospital stay was necessary. Further, we note that there may be some cases for which it is not clinically appropriate to begin home health services immediately following an acute care discharge, and that even when home health services are clinically appropriate sooner than within 7 days of acute care discharge, home health services may not be immediately available. We note that, as we stated in the FY 2000 IPPS final rule (65 FR 47081), if the hospital’s continuing care plan for the patient is not related to the purpose of the inpatient hospital admission, a condition code 42 must be entered on the claim. If the continuing care plan is related to the purpose of the inpatient hospital admission but begins after 7 days (formerly after 3 days) of discharge, a condition code 43 must be entered on the claim. The presence of either of these condition codes in conjunction with patient status discharge code 06 (Discharged/Transferred to Home under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care) will result in full payment rather than the transfer payment amount. 3. Evaluation of MS–DRGs Under Postacute Care Transfer Policy for FY 2009 For FY 2009, we are not proposing to make any changes to the criteria by which an MS–DRG would qualify for inclusion in the postacute care transfer policy. However, because we are proposing to revise some existing MS– VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 DRGs and to add one new MS–DRG (discussed under section II.G. of this preamble), we are proposing to evaluate those MS–DRGs under our existing postacute care transfer criteria in order to determine whether any of the revised or new MS–DRGs will meet the postacute care transfer criteria for FY 2009. Therefore, for 2009, we are evaluating MS–DRGs 001, 002, 215, 245, 901 through 909, 913 through 923, 955 through 959, and 963 through 965. Any revisions made would not constitute a change to the application of the postacute care transfer policy. A list indicating which MS–DRGs would be subject to the postacute care transfer policy for FY 2009 can be found in Table 5 in the Addendum to this proposed rule. B. Reporting of Hospital Quality Data for Annual Hospital Payment Update (§ 412.64(d)(2)) 1. Background a. Overview CMS is transforming the Medicare program from a passive payer to an active purchaser of higher quality, more efficient health care. Such care will contribute to the sustainability of the Medicare program, encourage the delivery of high quality care while avoiding unnecessary costs, and help ensure high value for beneficiaries. To support this transformation, CMS has worked with stakeholders to develop and implement quality measures, make provider and plan performance public, link payment incentives to reporting on measures, and ultimately is working to link payment to actual performance on these measures. Commonly referred to as value-based purchasing, this policy aligns payment incentives with the quality of care as well as the resources used to deliver care to encourage the delivery of high-value health care. The success of this transformation is supported by and dependent upon an increasing number of widely-agreed upon quality measures. The Medicare program has defined measures of quality in almost every setting and measures some aspect of care for almost all Medicare beneficiaries. These measures include clinical processes, patient perception of their care experience, and, increasingly, outcomes. The Medicare program has established mechanisms for collecting information on these measures, such as QualityNet, an Internet-based process that hospitals use to report all-payer information. Initial voluntary efforts were supplemented beginning in FY 2005 by a provision in the Medicare Prescription Drug Improvement and PO 00000 Frm 00116 Fmt 4701 Sfmt 4702 Modernization Act (MMA), which provided the full annual payment update only to ‘‘subsection (d) hospitals’’ (that is, hospitals paid under the IPPS) that successfully reported on a set of widely-agreed upon quality measures. Since FY 2007, as required by subsequent legislation (the Deficit Reduction Act (DRA)) the number of quality measures and the amount of the financial incentive have increased. As a result, the great majority of hospitals now report on quality measures for heart failure, heart disease, pneumonia, and surgical infection and received the full annual update for FY 2008. The number of measures has continued to grow and the types of measures have grown as well, with the addition of outcomes measures, such as heart attack and heart failure mortality measures, and the HCAHPS measure of patient satisfaction. In section IV.B.2. of this preamble, we are seeking public comments on proposed additional quality measures. Reporting on these measures provides hospitals a greater awareness of the quality of care they provide and provides actionable information for consumers to make more informed decisions about their health care providers and treatments. Moving beyond reporting to performance, CMS has designed a Hospital Value-Based Purchasing Plan that would link hospital payments to their actual performance on quality measures. In accordance with the DRA, the Plan was submitted to Congress in November 2007. We discuss the Plan more fully in section IV.C. of this preamble. The ongoing CMS Premier Hospital Quality Incentive Demonstration project is another effort linking payments to quality performance. Launched in 2003, the Premier Hospital Quality Incentive Demonstration project promotes measurable improvements in the quality of care, examining whether economic incentives to hospitals are effective at improving the quality of care. Early evidence from the project indicates that linking payments to quality performance can be effective. As required by section 5001(c) the DRA, CMS also has implemented a program intended to encourage the prevention of certain avoidable or preventable hospital-acquired conditions (HACs), including infections, that may occur during a hospital stay. Beginning October 1, 2007, CMS required hospitals to begin reporting information on Medicare claims specifying whether certain diagnoses were present on admission (POA). Beginning October 1, 2008, CMS will no E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 longer pay hospitals for a DRG using the higher-paying CC or MCC associated with one or more of these conditions (if no other condition meeting the higher paying CC or MCC criteria is present) unless the condition was POA (that is, not acquired during the hospital stay). Linking a payment incentive to hospitals’ prevention of avoidable or preventable HACs is a strong approach for encouraging high quality care. Combating these HACs can reduce morbidity and mortality as well as reducing unnecessary costs. In the FY 2008 IPPS final rule with comment period (72 FR 47217), CMS identified eight HACs. In section II.F. of this preamble, CMS is seeking comment on additional proposed conditions. CMS is committed to enhancing these value-based purchasing programs, in close collaboration with stakeholders, through the development and use of new measures for quality reporting, expanded public reporting, greater and more widespread incentives in the payment system for reporting on such measures, and ultimately performance on those measures. These initiatives hold the potential to transform the delivery of health care by rewarding quality of care and delivering higher value to Medicare beneficiaries. A critical element of value-based purchasing is well-accepted measures. Hospitals can then measure their performance relative to other hospitals. Further, this information can be posted for consumers to use to make more informed choices about their care. In this section IV.B. of this preamble, we describe past and current efforts to make this information available and proposals to expand these efforts and make even more useful hospital quality information available to the public. b. Voluntary Hospital Quality Data Reporting In December 2002, the Secretary announced a partnership with several collaborators intended to promote hospital quality improvement and public reporting of hospital quality information. These collaborators included the American Hospital Association (AHA), the Federation of American Hospitals (FAH), the Association of American Medical Colleges (AAMC), the Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission), the National Quality Forum (NQF), the American Medical Association (AMA), the Consumer-Purchaser Disclosure Project, the American Association of Retired Persons (AARP), the American Federation of Labor-Congress of Industrial Organizations (AFL–CIO), the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Agency for Healthcare Research and Quality (AHRQ), as well as CMS and others. In July 2003, CMS began the National Voluntary Hospital Reporting Initiative. This initiative is now known as the Hospital Quality Alliance: Improving Care through Information (HQA). We established the following ‘‘starter set’’ of 10 quality measures for voluntary reporting as of November 1, 2003: Heart Attack (Acute Myocardial Infarction or AMI) • Was aspirin given to the patient upon arrival to the hospital? • Was aspirin prescribed when the patient was discharged? • Was a beta blocker given to the patient upon arrival to the hospital? • Was a beta blocker prescribed when the patient was discharged? • Was an Angiotensin Converting Enzyme (ACE) Inhibitor given for the patient with heart failure? Heart Failure (HF) • Did the patient get an assessment of his or her heart function? • Was an Angiotensin Converting Enzyme (ACE) Inhibitor given to the patient? Pneumonia (PN) • Was an antibiotic given to the patient in a timely way? • Had the patient received a pneumococcal vaccination? • Was the patient’s oxygen level assessed? This starter set of 10 quality measures was endorsed by the NQF. The NQF is a voluntary consensus standard-setting organization established to standardize health care quality measurement and reporting through its consensus development process. In addition, this starter set is a subset of measures currently collected for the Joint Commission as part of its hospital inpatient certification program. We chose these 10 quality measures in order to collect data that would: (1) Provide useful and valid information about hospital quality to the public; (2) provide hospitals with a sense of predictability about public reporting expectations; (3) begin to standardize data and data collection mechanisms; and (4) foster hospital quality improvement. Hospitals submit quality data through the QualityNet secure Web site (formerly known as QualityNet Exchange) (www.qualitynet.org). This Web site meets or exceeds all current Health Insurance Portability and Accountability Act requirements for PO 00000 Frm 00117 Fmt 4701 Sfmt 4702 23643 security of personal health information. Data from this initiative are used to populate the Hospital Compare Web site, www.hospitalcompare.hhs.gov. This Web site assists beneficiaries and the general public by providing information on hospital quality of care for consumers who need to select a hospital. It further serves to encourage consumers to work with their doctors and hospitals to discuss the quality of care hospitals provide to patients, thereby providing an additional incentive to improve the quality of care that they furnish. c. Hospital Quality Data Reporting Under Section 501(b) of Pub. L. 108–173 Section 1886(b)(3)(B)(vii) of the Act, as added by section 501(b) of Pub. L. 108–173, revised the mechanism used to update the standardized amount of payment for inpatient hospital operating costs. Specifically, the statute provided for a reduction of 0.4 percentage points to the update percentage increase (also known as the market basket update) for each of FYs 2005 through 2007 for any subsection (d) hospital that does not submit data on a set of 10 quality indicators established by the Secretary as of November 1, 2003. The statute also provided that any reduction would apply only to the fiscal year involved, and would not be taken into account in computing the applicable percentage increase for a subsequent fiscal year. This measure established an incentive for IPPS hospitals to submit data on the quality measures established by the Secretary. We initially implemented section 1886(b)(3)(B)(vii) of the Act in the FY 2005 IPPS final rule (69 FR 49078). In addition, we established the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program and added 42 CFR 412.64(d)(2) to our regulations. We adopted additional requirements under the RHQDAPU program in the FY 2006 IPPS final rule (70 FR 47420). d. Hospital Quality Data Reporting Under Section 5001(a) of Pub. L. 109– 171 Section 5001(a) of the Deficit Reduction Act of 2005, Pub. L. 109–171 (DRA), further amended section 1886(b)(3)(B) of the Act to revise the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. Specifically, sections 1886(b)(3)(B)(viii)(I) and (II) of the Act provide that the payment update for FY 2007 and each subsequent fiscal year be reduced by 2.0 percentage points for any subsection (d) hospital that does not E:\FR\FM\30APP2.SGM 30APP2 23644 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules submit certain quality data in a form and manner, and at a time, specified by the Secretary. Section 1886(b)(3)(B)(viii)(III) of the Act requires that the Secretary expand the ‘‘starter set’’ of 10 quality measures that were established by the Secretary as of November 1, 2003, as the Secretary determines to be appropriate for the measurement of the quality of care furnished by a hospital in inpatient settings. In expanding this set of measures, section 1886(b)(3)(B)(viii)(IV) of the Act requires that, effective for payments beginning with FY 2007, the Secretary begin to adopt the baseline set of performance measures as set forth in a December 2005 report issued by the Institute of Medicine (IOM) of the National Academy of Sciences under section 238(b) of the MMA.16 The IOM measures include: 21 HQA quality measures (including the ‘‘starter set’’ of 10 quality measures); the HCAHPS patient experience of care survey; and 3 structural measures. The structural measures are: (1) Implementation of computerized provider order entry for prescriptions; (2) staffing of intensive care units with intensivists; and (3) evidence-based hospital referrals. These structural measures constitute the Leapfrog Group’s original ‘‘three leaps,’’ and are part of the NQF’s 30 Safe Practices for Better Healthcare. Sections 1886(b)(3)(B)(viii)(V) and (VI) of the Act require that, effective for payments beginning with FY 2008, the Secretary add other quality measures that reflect consensus among affected parties, and to the extent feasible and practicable, have been set forth by one or more national consensus building entities, and provide the Secretary with the discretion to replace any quality measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance with a measure, or the measures or indicators have been subsequently shown to not represent the best clinical practice. Thus, the Secretary is granted broad discretion to replace measures that are no longer appropriate for the RHQDAPU program. Section 1886(b)(3)(B)(viii)(VII) of the Act requires that the Secretary establish procedures for making quality data available to the public after ensuring that a hospital would have the opportunity to review its data before these data are made public. In addition, this section requires that the Secretary report quality measures of process, structure, outcome, patients’ perspective of care, efficiency, and costs of care that relate to services furnished in inpatient settings on the CMS Web site. Section 1886(b)(3)(B)(viii)(I) of the Act also provides that any reduction in a hospital’s payment update will apply only with respect to the fiscal year involved, and will not be taken into account for computing the applicable percentage increase for a subsequent fiscal year. In the FY 2007 IPPS final rule (71 FR 48045), we amended our regulations at 42 CFR 412.64(d)(2) to reflect the 2.0 percentage point reduction in the payment update for FY 2007 and subsequent fiscal years for subsection (d) hospitals that do not comply with requirements for reporting quality data, as provided for under section 1886(b)(3)(B)(viii) of the Act. In the FY 2007 IPPS final rule, we also added 11 additional quality measures to the 10measure starter set to establish an expanded set of 21 quality measures (71 FR 48033 through 48037). Commenters on the FY 2007 IPPS proposed rule requested that we notify the public as far in advance as possible of any proposed expansions of the measure set and program procedures in order to encourage broad collaboration and to give hospitals time to prepare for any anticipated change. Taking these concerns into account, in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68201), we adopted six additional quality measures for the FY 2008 IPPS update, for a total of 27 measures. The measure set that we adopted for the FY 2008 payment determination was as follows: Quality measure Heart Attack (Acute Myocardial Infarction). ............................................. • Aspirin at arrival.* • Aspirin prescribed at discharge.* • Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction.* • Beta blocker at arrival.* • Beta blocker prescribed at discharge.* • Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival.** • Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival.** • Adult smoking cessation advice/counseling.** Heart Failure (HF) .................................................................................... • Left ventricular function assessment.* • Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction. • Discharge instructions.** • Adult smoking cessation advice/counseling.** Pneumonia (PN) ....................................................................................... jlentini on PROD1PC65 with PROPOSALS2 Topic • • • • • • • Surgical Care Improvement Project (SCIP)—named SIP for discharges prior to July 2006 (3Q06). • Prophylactic antibiotic received within 1 hour prior to surgical incision.** • Prophylactic antibiotics discontinued within 24 hours after surgery end time.** 16 Institute of Medicine, ‘‘Performance Measurement: Accelerating Improvement,’’ VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Initial antibiotic received within 4 hours of hospital arrival * Oxygenation assessment.* Pneumococcal vaccination status.* Blood culture performed before first antibiotic received in hospital.** Adult smoking cessation advice/counseling.** Appropriate initial antibiotic selection.** Influenza vaccination status.** December 1, 2005, available at: www.iom.edu/CMS/ 3809/19805/31310.aspx. PO 00000 Frm 00118 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Topic 23645 Quality measure • SCIP–VTE–1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients.*** • SCIP–VTE–2: VTE prophylaxis within 24 hours pre/post surgery.*** • SCIP Infection 2: Prophylactic antibiotic selection for surgical patients.*** Mortality Measures (Medicare patients) ................................................... • Acute Myocardial Infarction 30-day mortality Medicare patients*** • Heart Failure 30-day mortality Medicare patients.*** Patients’ Experience of Care. ................................................................... HCAHPS patient survey.*** *Measure included in 10 measure starter set. **Measure included in 21 measure expanded set. ***Measure added in CY 2007 OPPS/ASC final rule with comment period (data submission required as of January 2007 for three additional SCIP measures). For FY 2008, hospitals were required to submit data on 25 of the 27 measures. No data submission was required for the two mortality outcome measures (30Day Risk Standardized Mortality Rates for Heart Failure and AMI), because they were calculated using existing administrative Medicare claims data. The measures used for the payment determination included, for the first time, the HCAHPS patient experience of care survey as well as two outcome measures. These measures expanded the types of measures available for public reporting as required under section 1886(b)(3)(B)(viii) of the Act. In addition, the outcome measures, which are claims-based measures, did not increase the data submission requirements for hospitals, thereby reducing the burden associated with collection of data for quality reporting. In the FY 2008 IPPS proposed rule (72 FR 24805), we proposed to add 1 outcome measure and 4 process measures to the existing 27-measure set to establish a new set of 32 quality measures to be used under the RHQDAPU program for the FY 2009 IPPS annual payment determination. We proposed to add the following five measures for the FY 2009 IPPS annual payment determination: • PN 30-day mortality measure (Medicare patients) • SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose • SCIP Infection 6: Surgery Patients with Appropriate Hair Removal • SCIP Infection 7: Colorectal Patients with Immediate Postoperative Normothermia • SCIP Cardiovascular 2: Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the Perioperative Period We stated that we planned to formally adopt these measures a year in advance in order to provide time for hospitals to prepare for changes related to the RHQDAPU program. We also stated that we anticipated that the proposed measures would be endorsed by the NQF, as a national consensus building entity. Finally, we stated that any proposed measure that was not endorsed by the NQF by the time that we published the FY 2008 IPPS final rule with comment period would not be finalized in that final rule. At the time we published the FY 2008 IPPS final rule with comment period, only the PN 30-day mortality measure had been endorsed by the NQF. Therefore, we finalized only that measure as part of the FY 2009 IPPS measure set and stated that we would further address adding additional measures in the CY 2008 OPPS/ASC final rule and, if necessary, in the FY 2009 IPPS proposed and final rules. We also responded to comments we had received on the five proposed measures (72 FR 47348 through 47351). In the CY 2008 OPPS/ASC final rule with comment period (72 FR 66875), we noted that the NQF had endorsed the following additional process measures that we had proposed to include in the FY 2009 RHQDAPU program measure set: • SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose • SCIP Infection 6: Surgery Patients with Appropriate Hair Removal As we stated in the FY 2008 IPPS proposed rule (72 FR 24805), these measures reflect our continuing commitment to quality improvement in both clinical care and quality. These quality measures reflect consensus among affected parties as demonstrated by endorsement by a national consensus building entity. The addition of these two measures for the FY 2009 measure set bring the total number of measures in that measure set to 30 (72 FR 66876). The measure set to be used for FY 2009 annual payment determination is as follows: Quality measure Heart Attack (Acute Myocardial Infarction) .............................................. jlentini on PROD1PC65 with PROPOSALS2 Topic • Aspirin at arrival*. • Aspirin prescribed at discharge*. • Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction*. • Beta blocker at arrival*. • Beta blocker prescribed at discharge*. • Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival**. • Primary Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival**. • Adult smoking cessation advice/counseling**. Heart Failure (HF) .................................................................................... • Left ventricular function assessment*. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00119 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23646 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Topic Quality measure • Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction*. • Discharge instructions**. • Adult smoking cessation advice/counseling**. Pneumonia (PN) ....................................................................................... • • • • • • • Surgical Care Improvement Project (SCIP)—named SIP for discharges prior to July 2006 (3Q06). • Prophylactic antibiotic received within 1 hour prior to surgical incision**. • Prophylactic antibiotics discontinued within 24 hours after surgery end time**. • SCIP–VTE–1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients***. • SCIP–VTE–2: VTE prophylaxis within 24 hours pre/post surgery***. • SCIP Infection 2: Prophylactic antibiotic selection for surgical patients***. • SCIP–Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose*****. • SCIP Infection 6: Surgery Patients with Appropriate Hair Removal*****. Mortality Measures (Medicare patients) ................................................... • Acute Myocardial Infarction 30-day mortality Medicare patients***. • Heart Failure 30-day mortality Medicare patients***. • Pneumonia 30-day mortality Medicare patients****. Patients’ Experience of Care .................................................................... • HCAHPS patient survey***. Initial antibiotic received within 4 hours of hospital arrival*. Oxygenation assessment*. Pneumococcal vaccination status*. Blood culture performed before first antibiotic received in hospital**. Adult smoking cessation advice/counseling**. Appropriate initial antibiotic selection**. Influenza vaccination status**. jlentini on PROD1PC65 with PROPOSALS2 * Measure included in 10 measure starter set. ** Measure included in 21 measure expanded set. *** Measure added in CY 2007 OPPS/ASC final rule with comment period. **** Measure added in FY 2008 IPPS final rule with comment period. ***** Measure added in CY 2008 OPPS/ASC final rule with comment period (data submission required effective with discharges starting January 1, 2008). We also stated in the FY 2008 IPPS final rule with comment period and the CY 2008 OPPS/ASC final rule with comment period that the RHQDAPU program participation requirements for the FY 2009 program would apply to additional measures we adopt for the FY 2009 program (72 FR 47361; 72 FR 66877). Therefore, hospitals are required to start submitting data for SCIP Infection 4 and SCIP Infection 6 starting with first quarter calendar year 2008 discharges and subsequent quarters until further notice. Hospitals must submit their aggregate population and sample size counts for Medicare and non-Medicare patients. These requirements are consistent with the requirements for the other AMI, HF, PN, and SCIP process measures included in the FY 2009 measure set. The complete list of procedures for participating in the RHQDAPU program for FY 2009 are provided in the FY 2008 IPPS final rule with comment period (72 FR 47359 through 47361). Because SCIP Cardiovascular 2 and SCIP Infection 7 had not been endorsed by a national consensus building entity VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 by the publishing deadline for the CY 2008 OPPS/ASC final rule with comment period, we did not adopt these measures as part of the FY 2009 IPPS measure set. In the FY 2008 IPPS proposed rule, we also solicited public comments on 18 measures and 8 measure sets that could be selected for future inclusion in the RHQDAPU program (72 FR 24805). These measures and measure sets highlight our interest in improving patient safety and outcomes of care, with a particular focus on the quality of surgical care and patient outcomes. In order to engender a broad review of potential performance measures, the list included measures that have not yet received endorsement by a national consensus review process for public reporting. The list also included measures developed by organizations other than CMS as well as measures that can be calculated using administrative data (such as claims). We solicited public comment not only on the measures and measure sets that were listed, but also on whether there were any critical gaps or ‘‘missing’’ measures or measure sets. We PO 00000 Frm 00120 Fmt 4701 Sfmt 4702 specifically requested input concerning the following issues: • Which of the measures or measure sets should be included in the FY 2009 RHQDAPU program or in subsequent years? • What challenges for data collection and reporting are posed by the identified measures and measure sets? • What improvements could be made to data collection or reporting that might offset or otherwise address those challenges? In the FY 2008 IPPS final rule with comment period (72 FR 47351), after consideration of the public comments received, we decided not to adopt any of these measures or measure sets for FY 2009. We indicated that we will continue to consider some of these measures and measure sets for subsequent years. 2. Proposed Quality Measures for FY 2010 and Subsequent Years a. Proposed Quality Measures for FY 2010 For FY 2010, we are proposing to require continued submission of data on 26 of the 30 existing AMI, Heart Failure, E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Pneumonia, HCAHPS, and SCIP measures adopted for FY 2009. As noted above, the three outcome measures do not require hospitals to submit data. In addition, we are proposing to remove the Pneumonia Oxygenation Assessment measure from the RHQDAPU program measure set. We are proposing to discontinue requiring hospitals to submit data on the Pneumonia Oxygenation Assessment measure, effective with discharges beginning January 1, 2009. Section 1886(b)(3)(B)(viii)(VI) of the Act provides the Secretary with the discretion to replace any quality measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance with a measure. We interpret this to authorize the Secretary to remove or retire measures from the RHQDAPU program. In the case of the Pneumonia Oxygenation Assessment measure, the vast majority of hospitals are performing near 100 percent. In addition, oxygenation assessment is routinely performed by hospitals for admitted patients without regard to the specific diagnosis. Thus, the measure is topped out so completely across virtually all hospitals as to provide no significant opportunity for improvement. We believe that the burden to hospitals to abstract and report these data outweighs the benefit in publicly reporting hospital level data with very little variation among hospitals. We do not expect that the retirement of the Pneumonia Oxygenation Assessment measure will result in the deterioration of care. However, if we determine otherwise, we may seek to reintroduce the measure. The proposed removal of the Pneumonia Oxygenation Assessment measure for FY 2010 represents the first instance of retiring a measure. We intend to review other existing chartabstracted measures recognizing the significant burden to hospitals that chart abstraction requires. In this way, we seek to maximize the value of the RHQDAPU program to promote quality improvement by hospitals and to report information that the public will find beneficial in choosing inpatient hospital services. We invite comment on the retirement of the Pneumonia Oxygenation Assessment measure. In addition, we invite comment on other measures that may be suitable for retirement from the RHQDAPU program measure set. Finally, we invite comment on the following general considerations relevant to retiring measures: • Should CMS retire a RHQDAPU program measure when hospital performance on the measure has VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 reached a high threshold (that is, performance on the measure has topped out) even if the measure still reflects best practice? • Are there reasons to consider retiring a measure other than high overall performance? • When a measure is retired on the basis of substantially complete compliance by hospitals, should data collection on the measure again be required after 1 or 2 years to assure that a high compliance level remains, or should some other way of monitoring continued hospital compliance be used? The specifications for two of the existing measures have been updated by the NQF, effective May 2007, with respect to the applicable timing interval. For the measures previously identified as: • AMI—Primary Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival, the NQF has revised its endorsement of the specifications to reflect that the timing interval has been changed to PCI within 90 minutes of arrival. • Pneumonia—Initial antibiotic received within 4 hours of hospital arrival, the NQF has revised its endorsement of the specifications to reflect that the initial antibiotic must be received within 6 hours of arrival. In the FY 2008 IPPS final rule with comment period, one commenter ‘‘urged CMS to develop a policy to harmonize measures that related to payment, such as the NQF’s move from a 4-hour timeframe for initial antibiotic administration for pneumonia patients to a 6-hour timeframe (72 FR 47357).’’ Another commenter raised the issue of the timing for PCI in the AMI topic (72 FR 47347–8). In response to these comments, we responded that if we believe that a change is an appropriate change for the RHQDAPU program, we would expect to adopt it. Because the NQF is now endorsing different timing intervals with respect to these measures, we are proposing to also update these measures for the purposes of the FY 2010 RHQDAPU program. The updated measures are as follows: • AMI—Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI); and • Pneumonia—Timing of receipt of initial antibiotic following hospital arrival. We note that the technical specifications for these measures will not change, and hospitals will continue to submit the same data that they currently submit. However, beginning with discharges on or after January 1, 2009, CMS will calculate the measures using the updated timing intervals. PO 00000 Frm 00121 Fmt 4701 Sfmt 4702 23647 The NQF updated these two measures to reflect the most current consensus standards effective May 2007. Because this was after we issued the FY 2008 IPPS proposed rule, we could not adopt the updated measures in the FY 2008 IPPS final rule with comment period or CY 2008 OPPS/ASC final rule with comment period. We also recognized that we did not have in place a subregulatory process that would have permitted us to update the measures. Therefore, we announced that hospitals could suppress the public reporting of the quality data for the two measures for hospital discharges starting with April 1, 2007 discharges. We did this because we believe that hospitals should not be held to out-of-date consensus standards for public reporting pending the next regulatory cycle. We propose, in the future, to act on updates to existing RHQDAPU program measures made by a consensus building entity such as the NQF through a subregulatory process. This is necessary to be able to utilize the most up-to-date consensus standards in the RHQDAPU program, and recognizes that neither scientific advances nor consensus building entity standard updates are linked to the timing of regulatory actions. We propose to implement updates to existing RHQDAPU program measures and provide notification through the Qualitynet Web site, and additionally in the CMS/Joint Commission Specifications Manual for National Hospital Inpatient Quality Measures where data collection and measure specifications changes are necessary. We invite comment on this proposal. Under section 1886(b)(3)(B)(viii)(III) of the Act, the Secretary shall expand the RHQDAPU program measures beyond the measures specified as of November 1, 2003. Under section 1886(b)(3)(B)(viii)(V) of the Act, these measures, to the extent feasible and practicable, shall include measures set forth by one or more national consensus building entities. We are proposing to add the following 43 measures for the FY 2010 payment determination: a SCIP measure that we proposed last year; 4 nursing sensitive measures; 3 readmission measures; 6 Venous Thromboembolism measures; 5 stroke measures; 9 AHRQ measures; and 15 cardiac surgery measures. We are proposing to add SCIP Cardiovascular 2, Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the Perioperative Period. This measure was initially proposed last year in the FY 2008 IPPS proposed rule, but because the NQF had not endorsed this measure E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23648 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules at the time we issued the FY 2008 IPPS final rule with comment period or the CY 2008 OPPS/ASC final rule with comment period, we did not adopt it. For the purposes of proposing the FY 2010 RHQDAPU program measure set, CMS believes that NQF endorsement of a measure represents a standard for consensus among affected parties as specified in section 1886(b)(3)(B)(viii)(V) of the Act. The NQF is an independent health care quality endorsement organization with a diverse representation of consumer, purchaser, provider, academic, clinical, and other health care stakeholder organizations. In November 2007, the NQF endorsed SCIP Cardiovascular 2. CMS believes that this measure targets an important process of care, beta blocker administration for noncardiac surgery patients. Therefore, we are now proposing to add SCIP Cardiovascular 2 to the RHQDAPU program measures for FY 2010. The specifications and data collection tools are currently available through the Qualitynet Web site and in the CMS/Joint Commission Specifications Manual for National Hospital Inpatient Quality Measures for hospitals to utilize and submit data for this measure. We are proposing that hospitals be required to submit data on this measure beginning with January 1, 2009 discharges. We also are proposing to add four nursing sensitive measures to the RHQDAPU program measure set for FY 2010. The four measures are: • Failure to Rescue • Pressure Ulcer Prevalence and Incidence by Severity (Joint Commission developed measure; all patient data from chart abstraction) • Patient Falls Prevalence • Patient Falls with Injury These measures broaden the ability of the RHQDAPU program measure set to assess care generally associated with nursing staff. In addition, these measures are directed toward outcomes that are underrepresented among the RHQDAPU program measures. These measures apply to the vast majority of inpatient stays and provide a great deal of critical information about hospital quality to consumers and stakeholders. The specifications and data collection tools are scheduled to be available in the specifications manual by December 2008 for hospitals to utilize and submit data for these measures. We are proposing that hospitals be required to submit data on these four measures effective with discharges beginning April 1, 2009. While these measures are endorsed by NQF, the Joint Commission has initiated rigorous field testing of the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 measures, which may not be completed until late 2008. Therefore, it is possible that the endorsement status of these measures may change in the next several months. If this rigorous field testing results in uncertainty as to the NQF endorsement status at the time we issue the FY 2009 IPPS final rule, we will defer our final decision on whether to require these measures for the RHQDAPU program for FY 2010 until the time that we issue the CY 2009 OPPS/ASC final rule with comment period. This deferral is consistent with our measure expansion during the past 2 years, when we finalized some RHQDAPU program measures in the annual OPPS/ASC final rules. We are proposing to adopt three readmission measures for FY 2010 that will be calculated using Medicare administrative claims data. The proposed measures are: • Pneumonia (PN) 30-Day Risk Standardized Readmission Measure (Medicare patients) • Heart Attack (AMI) 30-Day Risk Standardized Readmission Measure (Medicare patients) • Heart Failure (HF) 30-Day Risk Standardized Readmission Measure (Medicare patients) These readmission measures assess both quality of care and efficiency of care. They also promote coordination of care among hospitals and other providers. They compliment the existing 30-Day Risk Standardized Mortality Measures for Pneumonia, Heart Attack, and Heart Failure. These measures require no additional data collection from hospitals. The measures are risk adjusted to account for differences between hospitals in the characteristics of their patient populations. These three claims-based readmission measures are pending NQF endorsement. The NQF endorsement decision on these three measures is expected before we issue the FY 2009 IPPS final rule. We are proposing to add these three measures contingent upon NQF endorsement. We are also proposing to defer our decision on whether to include these measures until we issue the CY 2009 OPPS/ASC final rule, in the event that NQF endorsement status is still pending when we issue the FY 2009 IPPS final rule. This deferral is consistent with our measure expansion during the past 2 years, when we finalized some RHQDAPU program measures in the annual OPPS/ASC final rules. We are also proposing to add six Venous Thromboembolism (VTE) measures. These measures comprehensively address a major cause PO 00000 Frm 00122 Fmt 4701 Sfmt 4702 of morbidity and mortality among hospitalized patients. • VTE–1: VTE Prophylaxis • VTE–2: VTE Prophylaxis in the ICU • VTE–4: Patients with overlap in anticoagulation therapy • VTE–5/6: (as combined measure) Patients with UFH dosages who have platelet count monitoring and adjustment of medication per protocol or nomogram • VTE–7: Discharge instructions to address: follow-up monitoring, compliance, dietary restrictions and adverse drug reactions/interactions • VTE–8: Incidence of preventable VTE These VTE measures are pending NQF endorsement. The NQF endorsement decision on these measures is expected before we issue the FY 2009 IPPS final rule. We are proposing to add these measures contingent upon NQF endorsement. We also are proposing to defer our decision on whether to include these measures until we issue the CY 2009 OPPS/ASC final rule with comment period, in the event that NQF endorsement status is still pending when we issue the FY 2009 IPPS final rule. This deferral is consistent with our measure expansion during the past 2 years, when we finalized some RHQDAPU program measures in the annual OPPS/ASC final rules. We are proposing that hospitals be required to submit data on these six measures effective with discharges beginning January 1, 2009. We also are proposing to add five Stroke measures that will apply only to certain identified groups under specific ICD–9–CM codes as specified in the specifications manual. These measures comprehensively address an important condition not currently covered by the RHQDAPU program that is associated with significant morbidity and mortality. • STK–1 DVT Prophylaxis • STK–2 Discharged on Antithrombotic Therapy • STK–3 Patients with Atrial Fibrillation Receiving Anticoagulation Therapy • STK–5 Antithrombotic Medication By End of Hospital Day Two • STK–7 Dysphasia Screening These Stroke measures are pending NQF endorsement. The NQF endorsement decision on these measures is expected before we issue the FY 2009 IPPS final rule. We are proposing to add these measures contingent upon NQF endorsement. We also are proposing to defer our adoption of these measures until we issue the CY 2009 OPPS/ASC final rule with comment period in the event that NQF E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules endorsement status is still pending as of the time we issue the FY 2009 IPPS final rule. This approach is consistent with our measure expansion during the past 2 years, when CMS finalized some RHQDAPU program measures in the annual OPPS/ASC final rules. We are proposing that hospitals be required to submit data on these five measures effective with discharges beginning July 1, 2009. We also are proposing to add the following nine AHRQ Patient Safety Indicators (PSI) and Inpatient Quality Indicators (IQI) that have been endorsed by the NQF: • Patient Safety Indicator (PSI) 4— Death among surgical patients with treatable serious complications • PSI 6—Iatrogenic pneumothorax, adult • PSI 14—Postoperative wound dehiscence • PSI 15—Accidental puncture or laceration • Inpatient Quality Indicator (IQI) 4 and 11—Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) • IQI 19—Hip fracture morality rate • IQI Mortality for selected medical conditions (composite) • IQI Mortality for selected surgical procedures (composite) • IQI Complication/patient safety for selected indicators (composite) These are claims-based outcome measures. They are important additional measures that can be calculated for hospital inpatients without the burden of additional chart abstraction. Hospitals currently collect and submit these data to CMS and other insurers for reimbursement. These measures will be calculated using all-payer claims data that hospitals currently collect with respect to each patient discharge. We are proposing to require hospitals to submit to CMS the all-payer claims data that we specify in the technical specifications manual as necessary to calculate the AHRQ PSI/IQI measures. We are proposing that hospitals begin submitting data on a quarterly basis on these measures to CMS by April 1, 2010 beginning with October 1, 2009 discharges. However, we are aware that a large number of hospitals already submit these data on a voluntary basis to third party data aggregators such as State health agencies or State hospital associations. We seek comments on whether a hospital that already submits the data necessary to calculate these measures to such entities should be permitted to authorize such an entity to transmit these data to CMS, in accordance with applicable confidentiality laws, on their behalf. This would relieve the hospital of the burden of having to submit the same data directly to CMS via the QIO Clinical Warehouse. As an alternative to requiring that hospitals submit all-payer claims data for purposes of calculating the AHRQ PSI/IQI measures, CMS is considering whether it should initially calculate the AHRQ PSI/IQI measures using Medicare claims data only, and at a subsequent date require submission of all-payer claims data. We also seek comment on this alternative. We also are proposing to add 15 cardiac surgery measures. Cardiac surgical procedures carry a significant risk of morbidity and mortality. We believe that the nationwide public reporting of these cardiac surgery measures would provide highly meaningful information for the public. Currently, over 85 percent of hospitals with a cardiac surgery program submit data on the proposed cardiac surgery measures listed below to the Society of Thoracic Surgeons (STS) Cardiac Surgery Clinical Data Registry. We are proposing to accept these data from the STS registry beginning on July 1, 2009, on a quarterly basis for discharges on or after January 1, 2009. Hospitals that participate in the RHQDAPU program, but that do not submit data on the proposed cardiac surgery measures to 23649 the STS registry for discharges on or after January 1, 2009, would need to submit such data to CMS. Although we would accept cardiac surgery data from other clinical data registries, we are unaware of any other registries that collect all of the data necessary to support calculation of the proposed cardiac surgery measures. Hospitals and CMS would need to establish appropriate legal arrangements, to the extent such arrangements are necessary, to ensure that the transfer of these data from the STS registry to CMS complies with all applicable laws. By accepting these registry-based data, only those hospitals with cardiac surgery programs that do not already collect such data to submit to the STS registry will have any additional data submission burden. All of the proposed measures are currently NQF-endorsed. We are proposing that hospitals begin submitting data by July 1, 2009, on a quarterly basis on the following 15 cardiac surgery measures to the STS data registry or CMS for 1st quarter calendar year 2009 discharges: • Participation in a Systematic Database for Cardiac Surgery • Pre-Operative Beta Blockade • Prolonged Intubation • Deep Sternal Wound Infection Rate • Stroke/CVA • Post-Operative Renal Insufficiency • Surgical Reexploration • Anti-Platelet Medication at Discharge • Beta Blockade Therapy at Discharge • Anti-Lipid Treatment at Discharge • Risk-Adjusted Operative Mortality for CABG • Risk-Adjusted Operative Mortality for Aortic Valve Replacement • Risk-Adjusted Operative Mortality for Mitral Valve Replacement/Repair • Risk-Adjusted Mortality for Mitral Valve Replacement and CABG Surgery • Risk-Adjusted Mortality for Aortic Valve Replacement and CABG Surgery The following table lists the 72 proposed measures for FY 2010: Quality measure Heart Attack (Acute Myocardial Infarction) .............................................. jlentini on PROD1PC65 with PROPOSALS2 Topic • AMI–1 Aspirin at arrival *. • AMI–2 Aspirin prescribed at discharge *. • AMI–3 Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction *. • AMI 6 Beta blocker at arrival *. • AMI–5 Beta blocker prescribed at discharge *. • AMI–7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival**. • AMI–4 Adult smoking cessation advice/counseling**. • AMI–8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI). Heart Failure (HF) .................................................................................... • HF–2 Left ventricular function assessment *. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00123 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23650 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Topic Quality measure • HF–3 Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction *. • HF–1 Discharge instructions**. • HF–4 Adult smoking cessation advice/counseling**. • PN–2 Pneumococcal vaccination status *. • PN–3b Blood culture performed before first antibiotic received in hospital**. • PN–4 Adult smoking cessation advice/counseling**. • PN–6 Appropriate initial antibiotic selection**. • PN–7 Influenza vaccination status**. • PN–5c Timing of receipt of initial antibiotic following hospital arrival******. Surgical Care Improvement Project (SCIP)—named SIP for discharges prior to July 2006 (3Q06). • SCIP–1 Prophylactic antibiotic received within 1 hour prior to surgical incision**. • SCIP–3 Prophylactic antibiotics discontinued within 24 hours after surgery end time**. • SCIP–VTE–1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients***. • SCIP–VTE–2: VTE prophylaxis within 24 hours pre/post surgery***. • SCIP Infection 2: Prophylactic antibiotic selection for surgical patients***. • SCIP–Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose*****. • SCIP Infection 6: Surgery Patients with Appropriate Hair Removal*****. • SCIP Cardiovascular 2: Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the Perioperative Period******. Mortality Measures (Medicare patients) ................................................... • MORT–30–AMI Acute Myocardial Infarction 30-day mortality Medicare patients***. • MORT–30–HF Heart Failure 30-day mortality Medicare patients***. • MORT–30–PN Pneumonia 30-day mortality Medicare patients****. Patients’ Experience of Care .................................................................... • HCAHPS patient survey***. Readmission Measures (Medicare patients) ............................................ • Heart Attack (AMI) 30-Day Risk Standardized Readmission Measure (Medicare patients)******. • Heart Failure (HF) 30-Day Risk Standardized Readmission Measure (Medicare patients)******. • Pneumonia (PN) 30-Day Risk Standardized Readmission Measure (Medicare patients) ******. Inpatient Stroke Care ............................................................................... • STK–1 DVT Prophylaxis******. • STK–2 Discharged on Antithrombotic Therapy******. • STK–3 Patients with Atrial Fibrillation Receiving Anticoagulation Therapy******. • STK–5 Antithrombotic Medication By End of Hospital Day Two******. • STK–7 Dysphasia Screening******. Venous Thromboembolic Care ................................................................. • • • • AHRQ Patient Safety Indicators ............................................................... jlentini on PROD1PC65 with PROPOSALS2 Pneumonia (PN) ....................................................................................... • Death among surgical patients complications******. • Iatrogenic pneumothorax, adult******. • Postoperative wound dehiscence******. • Accidental puncture or laceration******. AHRQ Inpatient Quality Indicators (IQI) ................................................... • Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) ******. • Hip fracture morality rate******. AHRQ IQI Composite Measures .............................................................. • Mortality for selected surgical procedures (composite) ******. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00124 Fmt 4701 VTE–1: VTE Prophylaxis******. VTE–2: VTE Prophylaxis in the ICU******. VTE–4: Patients with overlap in anticoagulation therapy******. VTE–5/6: (as combined measure) patients with UFH dosages who have platelet count monitoring and adjustment of medication per protocol or nomagram******. • VTE–7: Discharge instructions to address: followup monitoring, compliance, dietary restrictions, and adverse drug reactions/ interactions******. • VTE–8: Incidence of preventable VTE******. Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 with treatable serious Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Topic 23651 Quality measure • Complication/patient safety for selected indicators (composite) ******. • Mortality for selected medical conditions (composite) ******. Nursing Sensitive Measures ..................................................................... • • • • Cardiac Surgery Measures ....................................................................... • • • • • • • • • • • • • Failure to Rescue******. Pressure Ulcer Prevalence and Incidence by Severity ******. Patient Falls Prevalence******. Patient Falls with Injury******. Participation in a Systematic Database for Cardiac Surgery ******. Pre-operative Beta Blockade******. Prolonged Intubation******. Deep Sternal Wound Infection Rate******. Stroke/CVA******. Postoperative Renal Insufficiency******. Surgical Reexploration******. Anti-platelet Medication at Discharge******. Beta Blockade Therapy at Discharge******. Anti-lipid Treatment at Discharge******. Risk-Adjusted Operative Mortality for CABG******. Risk-Adjusted Operative Mortality for Aortic Valve Replacement******. Risk-Adjusted Operative Mortality for Mitral Valve Replacement/ Repair******. • Risk-Adjusted Mortality for Mitral Valve Replacement and CABG Surgery******. • Risk-Adjusted Mortality for Aortic Valve Replacement and CABG Surgery ******. *Measure included in 10 measure starter set. **Measure included in 21 measure expanded set. ***Measure added in CY 2007 OPPS/ASC final rule with comment period. ****Measure added in FY 2008 IPPS final rule with comment period. *****Measure added in CY 2008 OPPS/ASC final rule with comment period. ******Measure proposed in FY 2009 IPPS proposed rule. In summary, we are proposing to increase the RHQDAPU program measures from 30 measures for FY 2009 to a total of 72 measures for FY 2010. The following table lists the increase in Number of RHQDAPU program quality measures IPPS payment year jlentini on PROD1PC65 with PROPOSALS2 2005–2006 ................................................................................................................... 2007 ............................................................................................................................. 2008 ............................................................................................................................. 2009 ............................................................................................................................. 2010 ............................................................................................................................. The above measures reflect our continuing commitment to quality improvement in both clinical care and patient safety. These additional measures also demonstrate our commitment to include in the RHQDAPU program only those quality measures that reflect consensus among the affected parties and that have been reviewed by a consensus building process. To the extent that the proposed measures have not already been endorsed by a consensus building entity such as the NQF, we anticipate that they will be endorsed prior to the time that we issue the FY 2009 IPPS final rule. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 10 21 27 30 72 We intend to finalize the FY 2010 RHQDAPU program measure set in the FY 2009 IPPS final rule, contingent on the endorsement status of the proposed measures. However, to the extent that a measure has not received NQF endorsement by the time we issue the FY 2009 IPPS final rule, we intend to finalize that measure for the FY 2010 RHQDAPU program measure set in the CY 2009 OPPS/ASC final rule with comment period if the measure is endorsed prior to the time we issue the CY–2009–OPPS/ASC final rule with comment period. We are requesting public comment on these measures. PO 00000 the RHQDAPU program measure set since the program’s inception: Frm 00125 Fmt 4701 Sfmt 4702 Topics covered AMI, HF, PN. AMI, HF, PN, SCIP. AMI, HF, PN, SCIP, Mortality, HCAHPS. AMI, HF, PN, SCIP, Mortality, HCAHPS. AMI, HF, PN, SCIP, Mortality, HCAHPS, Nursing Sensitive, Readmission, VTE, Stroke, AHRQ IQI/PSI measures and composites, Cardiac Surgery. b. Possible New Quality Measures, Measure Sets, and Program Requirements for FY 2011 and Subsequent Years The following table contains a list of 59 measures and 4 measure sets from which additional quality measures could be selected for inclusion in the RHQDAPU program. It includes measures and measure sets that highlight CMS’ interest in improving patient safety and outcomes of care, with a particular focus on the quality of surgical care and patient outcomes. In order to engender a broad review of potential performance measures, the list includes measures that have not yet E:\FR\FM\30APP2.SGM 30APP2 23652 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules been considered for approval by the HQA or endorsed by a consensus review process such as the NQF. It also includes measures developed by organizations other than CMS as well as measures that are to be derived from administrative data (such as claims) that may need to be modified for specific use by the Medicare program if implemented under the RHQDAPU program. We are seeking public comment on the measures and measure sets that are listed as well as any critical gaps or missing measures or measure sets. We specifically request input concerning the following: • Which of the measures or measure sets should be included in the RHQDAPU program for FY 2011 or in subsequent years? • What challenges for data collection and reporting are posed by the identified measures and measure sets? What improvements could be made to data collection or reporting that might offset or otherwise address those challenges? We are soliciting public comment on the following measure sets for consideration in FY 2011 and subsequent years: POSSIBLE MEASURES AND MEASURE SETS FOR THE RHQDAPU PROGRAM FOR FY 2011 AND SUBSEQUENT YEARS Topic Quality measure Chronic Pulmonary Obstructive Disease Measures: Complications of Vascular Surgery ................................................... Inpatient Diabetes Care Measures: Healthcare Associated Infection ........................................................ Timeliness of Emergency Care Measures, including Timeliness ............ Surgical Care Improvement Project (SCIP)—named SIP for discharges prior to July 2006 (3Q06). Complication Measures (Medicare patients): Healthcare Acquired Conditions ........................................................ AAA stratified by open and endovascular methods. Carotid Endarterectomy. Lower extremity bypass. Central Line-Associated Blood Stream Infections. Surgical Site Infections. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Median Time from ED Arrival to ED Departure for Discharged ED Patients. Admit Decision Time to ED Departure Time for Admitted Patients. SCIP Infection 8—Short Half-life Prophylactic Administered Preoperatively Redosed Within 4 Hours After Preoperative Dose. SCIP Cardiovascular 3—Surgery Patients on a Beta Blocker Prior to Arrival Receiving a Beta Blocker on Postoperative Days 1 and 2. Serious reportable events in healthcare (never events). Pressure ulcer prevalence and incidence by severity. Catheter-associated UTI. Patients with early stage breast cancer who have evaluation of the axilla. College of American Pathologists breast cancer protocol. Surgical resection includes at least 12 nodes. College of American Pathologists Colon and rectum protocol. Completeness of pathologic reporting. Serious Reportable Events in Healthcare (‘‘Never Events’’) ................... jlentini on PROD1PC65 with PROPOSALS2 Hospital Inpatient Cancer Care Measures ............................................... Surgery performed on the wrong body part. Surgery performed on the wrong patient. Wrong surgical procedure on a patient. Retention of a foreign object in a patient after surgery or other procedure. Intraoperative or immediately post-operative death in a normal health patient (defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative). Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility. Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility. Patient death or serious disability associated with patient elopement (disappearance) for more than four hours. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility. Patient death or serious disability associated with a medication error (e.g., error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration). Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00126 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23653 POSSIBLE MEASURES AND MEASURE SETS FOR THE RHQDAPU PROGRAM FOR FY 2011 AND SUBSEQUENT YEARS— Continued Topic Quality measure Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility. Stage 3 or 4 pressure ulcers acquired after admission to a health care facility. Patient death or serious disability due to spinal manipulative therapy. Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility. Patient death associated with a fall while being cared for in a health care facility. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider. Abduction of a patient of any age. Sexual assault on a patient within or on the grounds of a health care facility. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care facility. Average Length of Stay Coupled with Global Readmission Measure: Preventable Hospital-Acquired Conditions (HACs) ........................... jlentini on PROD1PC65 with PROPOSALS2 c. Considerations in Expanding and Updating Quality Measures Under the RHQDAPU Program The RHQDAPU program has significantly expanded from an initial set of 10 measures to 30 measures for the FY 2009 payment determination. Initially, the conditions covered by the RHQDAPU program measures were limited to Acute Myocardial Infarction, Heart Failure, and Pneumonia, three high-cost and high-volume conditions. In expanding the process measures, Surgical Infection Prevention was the first additional focus, now supplemented by the two Venous Thromboembolism SCIP measures SCIP VTE–1 and SCIP VTE–2 for surgical patients. Of the 30 current measures, 27 require data collection from chart VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Catheter-Associated Urinary Tract Infection (UTI). Vascular Catheter-Associated Infection. Surgical Site Infections—Mediastinitis after Coronary Artery Bypass Graft (CABG). Surgical Site Infections following Elective Procedures—Total Knee Replacement, Laparoscopic Gastric Bypass, Litigation and Stripping of Varicose Veins. Legionnaires’ Disease. Glycemic Control—Diabetic Ketoacidosis, Nonketotic Hypersmolar Coma, Hypoglycemic Coma. Iatrogenic pneumothorax. Delirium. Ventilator-Associated Pneumonia (VAP). Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE). Staphylococcus aureus Septicemia. Clostridium-Difficile Associated Disease (CDAD). Methicillin-Resistant Staphylococcus aureus (MRSA). abstraction and surveying patients and submission of detailed data elements. In looking forward to further expansion of the RHQDAPU program, we believe it is important to take several goals into consideration. These include: (a) Expanding the types of measures beyond process of care measures to include an increased number of outcome measures, efficiency measures, and experience-of-care measures; (b) expanding the scope of hospital services to which the measures apply; (c) considering the burden on hospitals in collecting chart-abstracted data; (d) harmonizing the measures used in the RHQDAPU program with other CMS quality programs to align incentives and promote coordinated efforts to improve quality; (e) seeking to use measures PO 00000 Frm 00127 Fmt 4701 Sfmt 4702 based on alternative sources of data that do not require chart abstraction or that utilize data already being broadly reported by hospitals, such as clinical data registries or all-payer claims data bases; and (f) weighing the meaningfulness and utility of the measures compared to the burden on hospitals in submitting data under the RHQDAPU program. We request comments on how to reduce burden on the hospitals participating in the RHQDAPU program. We realize that our proposal to expand the RHQDAPU program measure set from submission of 30 measures in FY 2009 to 72 measures in FY 2010 is potentially burdensome. However, to minimize hospitals’ burden, the proposed expansion uses many existing E:\FR\FM\30APP2.SGM 30APP2 23654 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules data sources, including Medicare claims and registry data. We also request comment about which measures would be most useful while minimizing burden. jlentini on PROD1PC65 with PROPOSALS2 (1) Expanding the Types of Measures Section 1886(b)(3)(B)(viii)(III) of the Act requires the Secretary to add other quality measures that the Secretary determines to be appropriate for the measurement of the quality of care furnished by hospitals in inpatient settings. We intend to expand outcome measures such as mortality measures and measures of complications. For FY 2010, the proposed measure set includes: • Patient Experience of Care. HCAHPS collects data regarding a patient’s experience of care in the hospital and provides a very meaningful perspective from the patient standpoint. • Efficiency. Efficiency is a Quality Domain, as defined by the IOM, that relates Quality and Cost. The three proposed readmission measures address hospital efficiency. These are considered efficiency measures because higher hospital readmission rates are linked to higher costs and also to lower quality of care received during hospitalization and after the initial hospital stay. We are also seeking additional ways in which to address efficiency. • Outcomes. The three 30-day mortality measures, the STS cardiac surgery measures, the AHRQ PSI/IQI measures, and the four outcome-related nursing sensitive measures represent significant expansion of the RHQDAPU program outcome measures. Additional outcome measures are provided in the list under consideration for inclusion in the RHQDAPU program for FY 2010 and beyond. (2) Expanding the Scope of Hospital Services To Which Measures Apply Many of the most common and highcost Medicare DRGs were posted on the Hospital Compare Web site in March 2008 as part of the President’s transparency initiative. We have assessed these DRGs and have found that the FY 2009 RHQDAPU program measure set does not capture data regarding care in important areas such as Inpatient Diabetes Care, Chronic Obstructive Pulmonary Disease (COPD), and Chest Pain. These are areas for which we currently do not have quality measures but which constitute a significant portion of the top paying DRGs for Medicare beneficiaries. We intend to develop measures in these areas in order to provide additional quality information on the most VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 common and high-cost conditions that affect Medicare beneficiaries. In the proposed FY 2010 measure set, measures have been expanded to comprehensively address services related to preventing Venous Thromboembolism, treatment of stroke, and nursing services. (3) Considering the Burden on Hospitals in Collecting Chart-Abstracted Data for Measures Although we are proposing to add additional chart-abstracted measures for FY 2010, we also are proposing to stagger the dates for which data collection for these measures must begin, which we believe will lessen the burden on hospitals as they incorporate these new measures into their systems. We also intend to work to simplify the data abstraction specifications that add to the burden of data collection. (4) Harmonizing With Other CMS Programs We intend to harmonize measures across settings and other CMS programs as evidenced by the implementation of the readmission measures not only for the RHQDAPU program but also for the QIOs’ 9th Scope of Work (SOW) Patient Pathways/Care Transitions Theme, which also uses the 30-Day Readmission Measures and will provide assistance to engage hospitals in improving care. The 9th SOW also focuses on disparities in health care, which is another important area of interest for CMS. We plan to analyze current RHQDAPU measures to identify particular RHQDAPU program measures needed to evaluate the existence of health care disparities, to require data elements that would support better identification of health care disparities, and to find more efficient ways to ascertain this information from claims data. In addition, at least some of the CY 2008 Physician Quality Reporting Initiative (PQRI) measures align with the current RHQDAPU program AMI and SCIP measures reported starting with the FY 2007 RHQDAPU measure set. In other words, there are financial incentives that cover the same clinical processes of care across different providers and settings. For example, Aspirin for Heart Attack corresponds to PQRI measure number 28, and Surgical Infection Antibiotic Timing corresponds to PQRI measure number 20. Outpatient quality measures under the Hospital Outpatient Data Quality Data Reporting Program (HOP QDRP) are also aligned with the RHQDAPU program measures. For example, the HOP QDRP addresses Acute Myocardial Infarction treatment for transferred patients and surgical PO 00000 Frm 00128 Fmt 4701 Sfmt 4702 infection prevention for outpatient surgery. (5) Using Alternative Data Sources Not Requiring Chart Abstraction We are actively pursuing alternative data sources, including data sources that are electronically maintained. Alternative data submission methodologies that we are proposing in this rule include: • Use of registry-collected clinical data for which there is broad existing hospital participation as previously described with the STS registry. • Use of data collected by State data organizations, State hospital associations, Federal entities such as AHRQ, and/or other data warehouses. In addition, we are considering adopting the following methods of data collection in the future and request comments on these methods: • Use of the CMS Continuity Assessment Record & Evaluation (CARE) tool, a standardized data collection instrument, which would allow data to be transmitted in ‘‘real time.’’ This recently developed, Internet-based, quality data collection tool was developed as a part of the Post Acute Care Reform Demonstration Program mandated by section 5008 of the DRA. The CARE tool consists of a core set of assessment items, common to all patients and all care settings (meeting criteria of being predictive of cost, utilization, outcomes, among others), organized under five major domains: Medical, Functional, Social, Environmental, and Cognitive— Continuity of Care. The Internet-based CARE tool will communicate critical information across settings accurately, quickly, and efficiently with reduced time burden to providers and is intended to enhance beneficiaries’ safe transitions between settings to prevent avoidable, costly events such as unnecessary rehospitalizations or medication errors. We believe that the CARE tool may provide a vehicle for collection of data elements to be used for calculating RHQDAPU program quality measures. CMS is considering utilizing the CARE tool in this manner. The Care tool is available at: www.cms.hhs.gov/PaperworkReduction Actof1995/PRAL/list.asp#TopOfPage. (Viewers should select ‘‘Show only items with the word ‘‘10243’’, click on show items, select CMS–10243, click on downloads, and open Appendices A & B, pdf files.) We are particularly interested in receiving public comment on this tool. Our goal is to have a standardized, efficient, effective, interoperable, common assessment tool to capture key E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules patient characteristics that will help CMS capture information related to resource utilization; expected costs as well as clinical outcomes; and postdischarge disposition. The CARE tool will also be useful for guiding payment and quality policies. Specifically, we are interested in receiving public comments on how CARE might advance the use of health information technology in automating the process for collecting and submitting quality data. • Submission of data derived from electronic versions of laboratory test reports that are issued by the laboratory in accordance with CLIA to the ordering provider and maintained by the hospital as part of the patient’s medical record during and after the patient’s course of treatment at the hospital. We are considering using these data to support risk adjustment for claims-based outcome measures (for example, mortality measures) and to develop other outcomes measures. This would support use of electronically maintained data and our goal of reducing manual data collection burden on hospitals. • Submission of data currently being collected by clinical data registries in addition to the STS registry. This would support and leverage existing clinical data registries and existing voluntary clinical data collection efforts, such as: • American College of Cardiology (ACC) data registry for Cardiac Measures. • ACC data registry for ICD. • ACC data registry for Carotid Stents. • Vascular Surgery Registry for Vascular Surgical Procedures. • ACC-sponsored ‘‘Get with the Guidelines’’ registry for Stroke Care. jlentini on PROD1PC65 with PROPOSALS2 (6) Weighing the Meaningfulness and Utility of the Measures Compared to the Burden on Hospitals in Submitting Data Under the RHQDAPU Program We are proposing to retire one measure from the RHQDAPU program for FY 2010 because we have determined that the burden on hospitals in abstracting the data outweighs the meaningful benefit that we can ascertain from the measure. As we explained more fully above, we are seeking comments on the applicability to the RHQDAPU program of criteria currently described in the Hospital VBP Issues Paper for inclusion and retirement of measures. The Hospital VBP Issues Paper is located on the CMS Web site at the following location: https:// www.cms.hhs.gov/AcuteInpatientPPS/ downloads/hospital_VBP_plan_issues_ paper.pdf. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 3. Form and Manner and Timing of Quality Data Submission In the FY 2007 IPPS final rule (71 FR 48031 through 48045), we set out RHQDAPU program procedures for data submission, program withdrawal, data validation, attestation, public display of hospitals’’ quality data, and reconsiderations. Section 1886(b)(3)(B)(viii)(I) of the Act requires that subsection (d) hospitals submit data on measures selected under that clause with respect to the applicable fiscal year. In addition, section 1886(b)(3)(B)(viii)(II) of the Act requires that each subsection (d) hospital submit data on measures selected under that clause to the Secretary in a form and manner, and at a time, specified by the Secretary. The technical specifications for each RHQDAPU program measure are listed in the CMS/Joint Commission Specifications Manual for National Inpatient Hospital Quality Measures (Specifications Manual). We update this manual semiannually or more frequently in unusual cases, and include detailed instructions and calculation algorithms for hospitals to collect and submit the data for the required measures. The maintenance of the specifications for the measures selected by the Secretary occurs through publication of the Specifications Manual. Thus, measure selection by the Secretary occurs through the rulemaking process; whereas the maintenance of the technical specifications for the selected measures occurs through a subregulatory process so as to best maintain the specifications consistent with current science and consensus. The data submission, Specifications Manual, and submission deadlines are posted on the QualityNet Web site at www.qualitynet.org. We require that hospitals submit data in accordance with the specifications for the appropriate discharge periods. When measure specifications are updated, we are proposing to require that hospitals submit all of the data required to calculate the required measures as outlined in the Specifications Manual current as of the patient discharge date. 4. Current and Proposed RHQDAPU Program Procedures a. RHQDAPU Program Procedures for FY 2009 In the FY 2008 IPPS final rule with comment period, we stated that the requirements for FY 2008 would continue to apply for FY 2009 (72 FR 47361). The ‘‘Reporting Hospital Quality Data for Annual Payment Update Reference Checklist’’ section of the PO 00000 Frm 00129 Fmt 4701 Sfmt 4702 23655 QualityNet Web site contains all of the forms to be completed by hospitals participating in the RHQDAPU program. Under these requirements hospitals must— • Register with QualityNet, before participating hospitals initially begin reporting data, regardless of the method used for submitting data. › Identify a QualityNet Administrator who follows the registration process located on the QualityNet Web site (www.qualitynet.org). › Complete the revised RHQDAPU program Notice of Participation form (only for hospitals that did not submit a form prior to August 15, 2007). For hospitals that share the same Medicare Provider Number (now CMS Certification Number (CCN)), report the name and address of each hospital on this form. › Collect and report data for each of the required measures except the Medicare mortality measures (AMI, HF, and PN 30-day Mortality for Medicare Patients). Hospitals must continuously report these data. Hospitals must submit the data to the QIO Clinical Warehouse using the CMS Abstraction & Reporting Tool (CART), The Joint Commission ORYX Core Measures Performance Measurement System, or another thirdparty vendor tool that has met the measurement specification requirements for data transmission to QualityNet. All submissions will be executed through QualityNet. Because the information in the QIO Clinical Warehouse is considered QIO information, it is subject to the stringent QIO confidentiality regulations in 42 CFR Part 480. The QIO Clinical Warehouse will submit the data to CMS on behalf of the hospitals. • Submit complete data regarding the quality measures in accordance with the joint CMS/Joint Commission sampling requirements located on the QualityNet Web site for each quality measure that requires hospitals to collect and report data. These requirements specify that hospitals must submit a random sample or complete population of cases for each of the topics covered by the quality measures. Hospitals must meet the sampling requirements for these quality measures for discharges in each quarter. • Submit to CMS on a quarterly basis aggregate population and sample size counts for Medicare and non-Medicare discharges for the four topic areas (AMI, HF, PN, and SCIP). • Continuously collect and submit HCAHPS data in accordance with the HCAHPS Quality Assurance Guidelines, Version 3.0, located at the Web site: www.hcahpsonline.org. The QIO E:\FR\FM\30APP2.SGM 30APP2 23656 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 Clinical Warehouse has been modified to accept zero HCAHPS-eligible discharges. We remind the public to refer to the QualityNet Web site for any questions about how to submit ‘‘zero cases’’ information. For the AMI 30-day, HF 30-day, and PN 30-day mortality measures, CMS uses Part A and Part B claims for Medicare fee-for-service patients to calculate the mortality measures. For FY 2009, hospital inpatient claims (Part A) from July 1, 2006 to June 30, 2007, will be used to identify the relevant patients and the index hospitalizations. Inpatient claims for the index hospitalizations and Part A and Part B claims for all inpatient, outpatient, and physician services received one year prior to the index hospitalizations are used to determine patient comorbidity, which is used in the risk adjustment calculation (see the Web site: www.qualitynet.org/ dcs/ContentServer?cid=1163010398556 &pagename=QnetPublic%2FPage%2F QnetTier2&c=Page). No other hospital data submission is required to calculate the mortality rates. b. Proposed RHQDAPU Program Procedures for FY 2010 We are proposing to continue requiring the FY 2009 RHQDAPU program procedures for FY 2010 for hospitals participating in the RHQDAPU program, with the following modifications: • Notice of Participation. New subsection (d) hospitals and existing hospitals that wish to participate in RHQDAPU for the first time must complete a revised ‘‘Reporting Hospital Quality Data for Annual Payment Update Notice of Participation’’ that includes the name and address of each hospital that shares the same CCN. • Data Submission. In order to reduce the burden on hospitals that treat a low number of patients who are covered by the submission requirements, we are proposing the following: › AMI. We are proposing that a hospital that has five or fewer AMI discharges (both Medicare and nonMedicare combined) in a quarter will not be required to submit AMI patient level data for that quarter. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009. However, the hospital must still submit its aggregate AMI population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission. › HCAHPS. We are proposing that a hospital that has five or fewer HCAHPSeligible discharges in any month will not be required to submit HCAHPS surveys for that month. However, the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 hospital must still submit its total number of HCAHPS-eligible cases for that month as part of its quarterly HCAHPS data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009. › HF. We are proposing that a hospital that has five or fewer HF discharges (both Medicare and nonMedicare combined) in a quarter will not be required to submit HF patient level data for that quarter. However, the hospital must still submit its aggregate HF population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009. › PN. We are proposing that a hospital that has five or fewer PN discharges (both Medicare and nonMedicare combined) in a quarter will not be required to submit PN patient level data for that quarter. However, the hospital must still submit its aggregate PN population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009. › SCIP. We are proposing that a hospital that has five or fewer SCIP discharges (both Medicare and nonMedicare combined) in a quarter will not be required to submit SCIP patient level data for that quarter. However, the hospital must still submit its aggregate SCIP population and sample size counts to CMS for that quarter as part of its quarterly RHQDAPU data submission. We are proposing to begin implementing this requirement with discharges on or after January 1, 2009. In addition, we are proposing the following quarterly deadlines for hospitals to submit the FY 2010 AMI, HF, SCIP, PN, Stroke, VTE, and nursing sensitive measure data: • The data submission deadline for hospitals to submit the patient level measure data for 1st calendar quarter of 2009 discharges would be August 15, 2009. Data must be submitted for each of these measures 4.5 months after the end of the preceding quarter. The specific deadlines will be listed on the QualityNet Web site. • Even though data on applicable measures will not be due until 4.5 months after the end of the preceding quarter, hospitals must submit their aggregate population and sample size counts no later than 4 months after the end of the preceding quarter (the exact dates will be posted on the QualityNet Web site). This deadline falls PO 00000 Frm 00130 Fmt 4701 Sfmt 4702 approximately 15 days before the data submission deadline for the clinical process measures, and we are proposing it so that we can inform hospitals about their data submission status for the quarter before the 4.5 month clinical process measure deadline. We have found from past experience that hospitals need sufficient time to submit additional data when their counts differ from Medicare claims counts generated by CMS. We will provide hospitals with these Medicare claims counts and submitted patient level data counts on the QualityNet Web site approximately 2 weeks before the quarterly submission deadline. We plan to use the aggregate population and sample size data to assess submission completeness and adherence to sampling requirements for Medicare and non-Medicare patients. We propose the following quarterly deadlines for hospitals to submit cardiac surgery and the AHRQ PSI/IQI measure data to CMS or other entities: • The data submission deadline for hospitals to submit cardiac surgery patient level measure data to CMS or STS data registry for 1st calendar quarter of 2009 discharges would be June 1, 2009. Data must be submitted for each of these measures 2 months after the end of the preceding quarter. The specific deadlines will be listed on the QualityNet Web site. • The data submission deadline for hospitals to submit the AHRQ PSI/IQI measure data to CMS for 4th calendar quarter of 2009 discharges would be April 1, 2010. Data must be submitted for each of these measures 3 months after the end of the preceding quarter. The specific deadlines will be listed on the QualityNet Web site. We are proposing these quarterly submission deadlines for cardiac surgery and AHRQ PSI/IQI measure data to coordinate submission deadlines with external data registries and provide more timely information to the consumers. We are proposing this quarterly submission deadline for cardiac surgery measure data to coincide with the STS quarterly submission deadline that is approximately 2 months following the discharge quarter. We also propose to shorten the time lag between the date of discharge and the public reporting of these quality measures to provide more timely consumer information. 5. Current and Proposed HCAHPS Requirements a. FY 2009 HCAHPS Requirements For FY 2009, hospitals must continuously collect and submit HCAHPS data to the QIO Clinical E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Warehouse by the data submission deadlines posted on the Web site at: www.hcahpsonline.org. The data submission deadline for first quarter CY 2008 (January through March) discharges is July 9, 2008. To collect HCAHPS data, a hospital can either contract with an approved HCAHPS survey vendor that will conduct the survey and submit data on the hospital’s behalf to the QIO Clinical Warehouse, or a hospital can self-administer the survey without using a survey vendor, provided that the hospital meets Minimum Survey Requirements as specified on the Web site at: www.hcahpsonline.org. A current list of approved HCAHPS survey vendors can be found on the Web site at: www.hcahpsonline.org. Every hospital choosing to contract with a survey vendor should provide the sample frame of hospital-eligible discharges to its survey vendor with sufficient time to allow the survey vendor to begin contacting each sampled patient within 6 weeks of discharge from the hospital (see the Quality Assurance Guidelines for details about HCAHPS eligibility and sample frame creation) and must authorize the survey vendor to submit data via QualityNet on the hospital’s behalf. CMS strongly recommends that the hospitals employing a survey vendor promptly review the two HCAHPS Feedback Reports (the Provider Survey Status Summary Report and the Data Submission Detail Report) that are available after the survey vendor submits the data to the QIO Clinical Warehouse. These reports enable a hospital to ensure that its survey vendor has submitted the data on time and it has been accepted into the Warehouse. In the FY 2008 IPPS final rule with comment period (72 FR 47362), we stated that hospitals and survey vendors must participate in a quality oversight process conducted by the HCAHPS project team. Starting in July 2007, we began asking hospitals/survey vendors to correct any problems that were found and provide followup documentation of corrections for review within a defined time period. If the HCAHPS project team finds that the hospital has not made these corrections, CMS may determine that the hospital is not submitting HCAHPS data that meet the requirements for the RHQDAPU program. As part of these activities, HCAHPS project staff reviews and discusses with survey vendors and hospitals self-administering the survey their specific Quality Assurance Plans, survey management procedures, sampling and data collection protocols, VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 and data preparation and submission procedures. b. Proposed FY 2010 HCAHPS Requirements For FY 2010, we are proposing continuous collection of HCAHPS in accordance with the Quality Assurance Guidelines located at the Web site: www.hcahpsonline.org, by the quarterly data submission deadlines posted on the Web site: www.hcahpsonline.org. As stated above, starting with January 1, 2009 discharges, we are proposing that hospitals that have five or fewer HCAHPS-eligible discharges in a month would not be required to submit HCAHPS patient-level data for that month as part of the quarterly data submission that includes that month, but they would still be required to submit the number of HCAHPS-eligible cases for that month as part of their HCAHPS quarterly data submission. With respect to HCAHPS oversight, we are proposing that the HCAHPS Project Team will continue to conduct site visits and/or conference calls with hospitals/survey vendors to ensure the hospital’s compliance with the HCAHPS requirements. During the onsite visit or conference call, the HCAHPS Project Team will review the hospital’s/survey vendor’s survey systems and will assess protocols based upon the most recent Quality Assurance Guidelines. All materials relevant to survey administration will be subject to review. The systems and program review includes, but it is not necessarily limited to: (a) survey management and data systems; (b) printing and mailing materials and facilities; (c) telephone/ IVR materials and facilities; (d) data receipt, entry and storage facilities; and (e) written documentation of survey processes. Organizations will be given a defined time period in which to correct any problems and provide followup documentation of corrections for review. Hospitals/survey vendors will be subject to followup site visits and/or conference calls, as needed. If CMS determines that a hospital is noncompliant with HCAHPS program requirements, CMS may determine that the hospital is not submitting HCAHPS data that meet the requirements of the RHQDAPU program. 6. Current and Proposed Chart Validation Requirements a. Chart Validation Requirements for FY 2009 In the FY 2008 IPPS final rule with comment period (72 FR 47361), we stated that, until further notice, we would continue to require that hospitals PO 00000 Frm 00131 Fmt 4701 Sfmt 4702 23657 meet the chart validation requirements that we implemented in the FY 2006 IPPS final rule (70 FR 47421 and 47422). These requirements, as well as additional information on validation requirements, continue and are being placed on the QualityNet Web site. We also stated in the FY 2008 IPPS final rule with comment period that, until further notice, hospitals must pass our validation requirement that requires a minimum of 80-percent reliability, based upon our chart-audit validation process (72 FR 47361). In the FY 2008 IPPS final rule with comment period (72 FR 47362), we indicated that, for the FY 2009 update, all FY 2008 validation requirements would apply, except for the following modifications. We would modify the validation requirement to pool the quarterly validation estimates for 4th quarter CY 2006 through 3rd quarter 2007 discharges. We would also expand the list of validated measures in the FY 2009 update to add SCIP Infection-2, SCIP VTE–1, and SCIP VTE–2 (starting with 4th quarter CY 2006 discharges). We would also drop the current twostep process to determine if the hospital is submitting validated data. For the FY 2009 update, we stated that we will pool validation estimates covering the four quarters (4th quarter CY 2006 discharges through 3rd quarter 2007 discharges) in a similar manner to the current 3rd quarter pooled confidence interval. In summary, the following chart validation requirements apply for the FY 2009 RHQDAPU program: • The 21-measure expanded set will be validated using 4th quarter CY 2006 (4Q06) through 3rd quarter CY 2007 (3Q07) discharges. • SCIP VTE-1, VTE-2, and SCIP Infection 2 will be validated using 2nd quarter CY 2007 and 3rd quarter CY 2007 discharges. • SCIP Infection 4 and SCIP Infection 6 must be submitted starting with 1st quarter CY 2008 discharges but will not be validated. • HCAHPS data must continuously be submitted and will be reviewed as discussed above. • AMI, HF, and PN 30-day mortality measures will be calculated as discussed below. In the FY 2008 IPPS final rule with comment period (72 FR 47364), we stated that, for the FY 2008 update and in subsequent years, we would revise and post up-to-date confidence interval information on the QualityNet Web site explaining the application of the confidence interval to the overall validation results. The data are being validated at several levels. There are consistency and internal edit checks to E:\FR\FM\30APP2.SGM 30APP2 23658 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules ensure the integrity of the submitted data; there are external edit checks to verify expectations about the volume of the data received. b. Proposed Chart Validation Requirements for FY 2010 For FY 2010, we are proposing the following chart validation requirements to reflect the proposed 72-measure set: • The following 21 measures from the FY 2009 RHQDAPU program measure set will be validated using data from 4th quarter 2007 through 3rd quarter 2008 discharges. Topic Quality measure validated from 4th quarter 2007 through 3rd quarter 2008 discharges Heart Attack (Acute Myocardial Infarction) .............................................. Aspirin at arrival Aspirin prescribed at discharge Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction Beta blocker at arrival Beta blocker prescribed at discharge Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival Adult smoking cessation advice/counseling Heart Failure (HF) .................................................................................... Left ventricular function assessment Angiotensin Converting Enzyme Inhibitor (ACE–I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction Discharge instructions Adult smoking cessation advice/counseling Pneumonia (PN) ....................................................................................... Pneumococcal vaccination status Blood culture performed before first antibiotic received in hospital Adult smoking cessation advice/counseling Appropriate initial antibiotic selection Influenza vaccination status Surgical Care Improvement Project (SCIP)—named SIP for discharges prior to July 2006 (3Q06). Prophylactic antibiotic received within 1 hour prior to surgical incision jlentini on PROD1PC65 with PROPOSALS2 SCIP–VTE–1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients*** SCIP–VTE–2: VTE prophylaxis within 24 hours pre/post surgery*** SCIP Infection 2: Prophylactic antibiotic selection for surgical patients*** SCIP-Infection 3: Prophylactic antibiotics discontinued within 24 hours after surgery end time • SCIP Infection 4 and Infection 6 will be validated using data from 2nd and 3rd quarter CY 2008 discharges. In addition, we are proposing to include the following three measures in the FY 2010 RHQDAPU program validation process that are included the FY 2009 RHQDAPU program measure set but have been updated or deleted for the FY 2010 measure set: • Pneumonia antibiotic prophylaxis timing within 4 hours will be validated using data from 4th quarter 2007 through 3rd quarter 2008 discharges. • Percutaneous Coronary Intervention (PCI) Timing within 120 minutes will be validated using data from 4th quarter 2007 through 3rd quarter 2008 discharges. • Pneumonia Oxygenation Assessment will be validated using data from 4th quarter through 3rd quarter 2008 discharges. These measures will be submitted by hospitals during 2008 and early 2009, and are available to be validated by CMS in time for the FY 2010 RHQDAPU program payment eligibility determination. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 As explained above, will also revise and post up-to-date confidence interval information on the QualityNet Web site explaining the application of the confidence interval to the overall validation results. c. Chart Validation Methods and Requirements Under Consideration for FY 2011 and Subsequent Years Under the current and proposed RHQDAPU program chart validation process, we validate measures by reabstracting on a quarterly basis a random sample of five patient records for each hospital. This quarterly sample results in an annual combined sample of 20 patient records across 4 calendar quarters, but because the samples are random, they do not necessarily include patient records covering each of the clinical topics. We anticipate that the proposed expansion of the RHQDAPU program measure set to include additional clinical topics will decrease the percentage of RHQDAPU clinical topics, as well as the total number of measures, covered in many hospitals’ annual chart PO 00000 Frm 00132 Fmt 4701 Sfmt 4702 validation. In addition to the measures for which hospitals must submit data for FY 2009 (with the exception of the Pneumonia Oxygenation Assessment measure), we have proposed that hospitals will submit data on the proposed five stroke measures, six VTE measures, and four nursing sensitive measures for FY 2010 using chart abstraction. CMS is considering the addition of these measures to the current RHQDAPU program validation process for FY 2011 and future years. However, we are considering whether registries and other external parties that may be collecting data on proposed RHQDAPU program measures could validate the accuracy of those measures beginning in FY 2011. In addition, we note that the proposed readmission measures are calculated using Medicare claims information and do not require chart validation. We are interested in receiving public comments from a broad set of stakeholders on the impact of adding measures to the validation process, as well as modifications to the current validation process that could improve E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules the reliability and validity of the methodology. We specifically request input concerning the following: • Which of the measures or measure sets should be included in the FY 2010 RHQDAPU program chart validation process or in the chart validation process for subsequent years? • What validation challenges are posed by the RHQDAPU program measures and measure sets? What improvements could be made to validation or reporting that might offset or otherwise address those challenges? • Should CMS switch from its current quarterly validation sample of five charts per hospital to randomly selecting a sample of hospitals, and selecting more charts on an annual basis to improve reliability of hospital level validation estimates? • Should CMS select the validation sample by clinical topic to ensure that all publicly reported measures are covered by the validation sample? 7. Data Attestation Requirements a. Proposed Change to Requirements for FY 2009 In the FY 2008 IPPS final rule with comment period (72 FR 47364), we stated that we would require for FY 2008 and subsequent years that hospitals attest each quarter to the completeness and accuracy of their data, including the volume of data, submitted to the QIO Clinical Warehouse in order to improve aspects of the validation checks. We stated that we would provide additional information to explain this attestation requirement, as well as provide the relevant form to be completed on the QualityNet Web site, at the same time as the publication of the FY 2008 IPPS final rule with comment period. We are now proposing to defer the requirement in FY 2009 for hospitals to separately attest to the accuracy and completeness of their submitted data due to the burden placed on hospitals to report paper attestation forms on a quarterly basis. We continue to expect that hospitals will submit quality data that are accurate to the best of their knowledge and ability. jlentini on PROD1PC65 with PROPOSALS2 b. Proposed Requirements for FY 2010 For FY 2010 and subsequent years, we are soliciting public comment on the electronic implementation of the attestation requirement at the point of data submission to the QIO Clinical Warehouse. Hospitals would electronically pledge to CMS that their submitted data are accurate and complete to the best of their knowledge. Hospitals would be required to VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 designate an authorized contact to CMS for attestation in their patient-level data submission. Resubmissions would continue to be allowed before the quarterly submission deadline, and hospitals would be required to electronically update their pledges about data accuracy at the time of resubmission. We welcome comments on this approach. 8. Public Display Requirements Section 1886(b)(3)(B)(viii)(VII) of the Act provides that the Secretary shall establish procedures for making data submitted under the RHQDAPU program available to the public. The RHQDAPU program quality measures are posted on the Hospital Compare Web site (https:// www.hospitalcompare.hhs.gov). CMS requires that hospitals sign a ‘‘Reporting Hospital Quality Data for Annual Payment Update Notice of Participation’’ form when they first register to participate in the RHQDAPU program. Once a hospital has submitted a form, the hospital is considered to be an active RHQDAPU program participant until such time as the hospital submits a withdrawal form to CMS (72 FR 47360). Hospitals signing this form agree that they will allow CMS to publicly report the quality measures as required in the applicable year’s RHQDAPU program requirements. We are proposing to continue to display quality information for public viewing as required by section 1886(b)(3)(B)(viii)(VII) of the Act. Before we display this information, hospitals will be permitted to review their information as recorded in the QIO Clinical Warehouse. Currently, hospitals that share the same CCN (formerly known as Medicare Provider Number (MPN)) must combine data collection and submission across their multiple campuses (for both clinical measures and for HCAHPS). These measures are then publicly reported as if they apply to a single hospital. We estimate that approximately 5 to 10 percent of the hospitals reported on the Hospital Compare Web site share CCNs. Beginning with the FY 2008 RHQDAPU program, hospitals must report the name and address of each hospital that shares the same CCN. This information will be gathered through the RHQDAPU program Notice of Participation form for new hospitals participating in the RHQDAPU program. To increase transparency in public reporting and improve the usefulness of the Hospital Compare Web site, we will note on the Web site where publicly reported PO 00000 Frm 00133 Fmt 4701 Sfmt 4702 23659 measures combine results from two or more hospitals. 9. Proposed Reconsideration and Appeal Procedures For FY 2009, we are proposing to continue the current RHQDAPU program reconsideration and appeal procedures finalized in the FY 2008 IPPS final rule with comment period. The deadline for submitting a request for reconsideration in connection with the FY 2009 payment determination is November 1, 2008. We also are proposing to use the same procedural rules finalized in the FY 2008 IPPS final rule with comment period (72 FR 47365). We posted these rules on the QualityNet Web site for the FY 2008 RHQDAPU program reconsideration process. Under the procedural rules, in order to receive reconsideration for FY 2009, the hospital must— • Submit to CMS, via QualityNet, a Reconsideration Request form (available on the QualityNet Web site) containing the following information: Æ Hospital Medicare ID number. Æ Hospital Name. Æ CMS-identified reason for failure (as provided in the CMS notification of failure letter to the hospital). Æ Hospital basis for requesting reconsideration. (This must identify the hospital’s specific reason(s) for believing it met the RHQDAPU program requirements and should receive the full FY 2009 IPPS annual payment update.) Æ CEO contact information, including name, e-mail address, telephone number, and mailing address (must include physical address, not just the post office box). Æ QualityNet System Administrator contact information, including name, email address, telephone number, and mailing address (must include physical address, not just the post office box). • The request must be signed by the hospital’s CEO. • Following receipt of a request for reconsideration, CMS will— • Provide an e-mail acknowledgement, using the contact information provided in the reconsideration request, to the CEO and the QualityNet Administrator that the letter has been received. • Provide a formal response to the hospital CEO, using the contact information provided in the reconsideration request, notifying the facility of the outcome of the reconsideration process. CMS expects the process to take 60 to 90 days from the due date of November 1, 2008. If a hospital is dissatisfied with the result of a RHQDAPU program E:\FR\FM\30APP2.SGM 30APP2 23660 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules reconsideration decision, the hospital may file a claim under 42 CFR part 405, subpart R (a Provider Reimbursement Review Board (PRRB) appeal). jlentini on PROD1PC65 with PROPOSALS2 10. Proposed RHQDAPU Program Withdrawal Deadline for FYs 2009 and 2010 We propose to accept RHQDAPU program withdrawal forms for FY 2009 from hospitals through August 15, 2008. We are proposing this deadline to provide CMS with sufficient time to update the RHQDAPU FY 2009 payment to hospitals starting on October 1, 2008. If a hospital withdraws from the program for FY 2009, it will receive a 2.0 percentage point reduction in its FY 2009 annual payment update. We also propose to accept RHQDAPU program withdrawal forms for FY 2010 from hospitals through August 15, 2009. If a hospital withdraws from the program for FY 2010, it will receive a 2.0 percentage point reduction in its FY 2010 annual payment update. 11. Requirements for New Hospitals In the FY 2008 IPPS final rule with comment period (72 FR 47366), we stated that a new hospital that receives a provider number on or after October 1 of each year (beginning with October 1, 2007) will be required to report RHQDAPU program data beginning with the first day of the quarter following the date the hospital registers to participate in the RHQDAPU program. For example, a hospital that receives its CCN on October 2, 2008, and signs up to participate in the RHQDAPU program on November 1, 2007, will be expected to meet all of the data submission requirements for discharges on or after January 1, 2009. In addition, we strongly recommend that each new hospital participate in an HCAHPS dry run, if feasible, prior to beginning to collect HCAHPS data on an ongoing basis to meet RHQDAPU program requirements. We refer readers to the Web site at www.hcahpsonline.org for a schedule of upcoming dry runs. The dry run will give newly participating hospitals the opportunity to gain first-hand experience collecting and transmitting HCAHPS data without the public reporting of results. Using the official survey instrument and the approved modes of administration and data collection protocols, hospitals/survey vendors will collect HCAHPS data and submit the data to QualityNet. 12. Electronic Medical Records In the FY 2006 IPPS final rule, we encouraged hospitals to take steps toward the adoption of electronic VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 medical records (EMRs) that will allow for reporting of clinical quality data from the EMRs directly to a CMS data repository (70 FR 47420). We intend to begin working toward creating measures’ specifications, and a system or mechanism, or both, that will accept the data directly without requiring the transfer of the raw data into an XML file as is currently done. The Department continues to work cooperatively with other Federal agencies in the establishment of Federal Health Architecture (FHA) data standards. We encouraged hospitals that are developing systems to conform them to industry standards, and in particular to FHA data standards, once identified, taking measures to ensure that the data necessary for quality measures are captured. Ideally, such systems will also provide point-of-care decision support that enables detection of high levels of performance on the measures. Hospitals using EMRs to produce data on quality measures will be held to the same performance expectations as hospitals not using EMRs. Due to the low volume of comments we received on this issue in response to the FY 2006 proposed IPPS rule, in the FY 2007 IPPS proposed (71 FR 24095), we again invited public comment on these requirements and related options. In the FY 2007 IPPS final rule (71 FR 48045), we summarized and addressed the additional comments we received. In the FY 2008 IPPS proposed rule (72 FR 24809), we noted that we would welcome additional comments on this issue. In the FY 2008 IPPS final rule with comment period (72 FR 47366), we responded to the additional comments we received and noted that CMS plans to continue working with the American Health Information Community (AHIC) and other entities to explore processes through which an EMR could speed the collection and minimize the resources necessary for quality reporting. (The AHIC is a Federal advisory body, chartered in 2005 to make recommendations to the Secretary on how to accelerate the development and adoption of health information technology.) In addition, we noted that we will continue to participate in appropriate HHS studies and workgroups, as mentioned by a GAO report (GAO–07–320) about hospital quality data and their use of information technology. As appropriate, CMS will inform interested parties regarding progress in the implementation of HIT for the collection and submission of hospital quality data as specific steps, including timeframes and milestones, are identified. Current mechanisms PO 00000 Frm 00134 Fmt 4701 Sfmt 4702 include publication in the Federal Register as well as ongoing collaboration with external stakeholders such as the HQA, the AHA, the FAH, the AAMC, and the Joint Commission. We further anticipate that as HIT is implemented, a formal plan, including training, will be developed to assist providers in understanding and utilizing HIT in reporting quality data. In addition, we will assess the effectiveness of our communications with providers and stakeholders as it relates to all information dissemination pertinent to collecting hospital quality data as part of an independent and comprehensive external evaluation of the RHQDAPU program. We are again soliciting comments on the issues and challenges associated with EMRs. Specifically, we invite comment on our proposed changes to our data submission requirements to be more aligned with currently implemented HIT systems, including data collection from registries and laboratory data. We recognize the potential burden on hospitals of increased data reporting requirements for process measures that require chart abstraction. In FY 2007 IPPS rulemaking, we listed a variety of additional possible measures for future years. The measures included and emphasized additional outcomes measures. Additional measures were included for which the data sources are claims. For these, no additional data abstraction or submission would be required for reporting hospitals beyond the claims data. In proposing measures for FY 2010, we seek to emphasize outcome measures and to minimize any additional data collection burden. In addition, as provided in section 1886(b)(3)(B)(viii)(VI) and discussed in section IV.B.2.a. of this proposed rule, we are proposing to retire one measure where there is no meaningful difference among hospitals as a means of reducing data collection burden. C. Medicare Hospital Value-Based Purchasing (VBP) 1. Medicare Hospital VBP Plan Report to Congress Through section 5001(b) of the Deficit Reduction Act of 2005, Congress authorized the development of a plan to implement value-based purchasing (VBP) beginning FY 2009 for IPPS hospital services. By statute, the plan must address: (a) The ongoing development, selection, and modification process for measures of quality and efficiency in hospital inpatient settings; (b) reporting, collection, and validation of quality E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules data; (c) the structure, size, and source of value-based payment adjustments; and (d) public disclosure of hospital performance data. To develop the plan, CMS created a Hospital VBP Workgroup with members from various CMS components and the Office of the Assistant Secretary for Planning and Evaluation. The Workgroup completed an environmental scan of existing hospital VBP programs, an issue paper outlining the topics to be addressed in the plan, and an options paper presenting design alternatives for the plan. CMS hosted two public Listening Sessions in early 2007 to solicit comments from interested parties on outstanding design questions associated with development of the plan. The perspectives expressed by stakeholders (including hospitals, consumers, and purchasers) during these sessions and in writing assisted the Workgroup in creating the Medicare Hospital VBP Plan Report to Congress. The Report was submitted to Congress on November 21, 2007. The Medicare Hospital VBP Plan builds on the foundation of Medicare’s current RHQDAPU program (discussed in section IV.B. of the preamble of this proposed rule), which, since FY 2005, has provided differential payments to hospitals that report their performance on a defined set of inpatient measures for public posting on the Hospital Compare Web site. If authorized by Congress, the VBP Plan would replace the current quality reporting program with a new program that would include both public reporting and financial incentives to drive improvements in clinical quality, patient-centeredness, and efficiency. The proposed plan contains the following key components: (a) A performance assessment model that incorporates measures from different quality domains (that is, clinical process of care, patient experience of care, outcomes, among others) to calculate a hospital’s total performance score; (b) options for translating this score into an incentive payment that would make a portion of the hospital’s base DRG payment contingent on its total performance score; (c) criteria for selecting performance measures for the financial incentive and candidate measures for FY 2009 and beyond; (d) a phased approach for transitioning from the RHQDAPU program to the VBP plan; (e) proposed enhancements to the current data transmission and validation infrastructure to support VBP program requirements; (f) refinements to the Hospital Compare Web site to support VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 expanded public reporting; and (g) an approach to monitoring VBP impacts. The Medicare Hospital VBP Plan Report to Congress is available on the CMS Web site at: https:// www.cms.hhs.gov/AcuteInpatientPPS/ downloads/HospitalVBPPlanRTCFINAL SUBMITTED2007.pdf. 2. Testing and Further Development of the Medicare Hospital VBP Plan The Hospital VBP Workgroup has undertaken testing of the VBP Plan. This ‘‘dry run’’ or ‘‘simulation’’ of the Plan will use the most recent clinical process-of-care and HCAHPS measurement data available from the RHQDAPU program. New information generated by the VBP Plan testing will include: (a) Performance scores by domain; (b) total performance scores; and (c) financial impacts. Following a process similar to that used in developing the Plan, CMS will analyze this information by individual IPPS hospital, by segment of the hospital industry (that is, geographic location, size, teaching status, among others), and in aggregate for all IPPS hospitals. The results of VBP Plan testing will be used to further develop the Plan. Priorities for Plan completion include addressing the small numbers issue (described on pages 74 and 75 of the Hospital VBP Plan Report to Congress) and developing a scoring methodology for the outcomes domain (pages 57–58 of the Hospital VBP Plan Report to Congress), which will become an additional aspect of the performance model. After completion, the Plan will be retested. We are seeking public comments on how to take full advantage of the new information generated through this testing and further Plan development. For example: Should the testing and retesting results be publicly posted? If the testing results were to be posted, would the best location be the Hospital Compare Web site or the CMS Web site at: https://www.cms.hhs.gov? In what format would public posting be most useful to potential audiences? At what level would the data be posted— individual hospital or some higher level? Which data elements from the testing results would be most useful to share? D. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small Rural Hospitals (MDHs): Volume Decrease Adjustment (§§ 412.92 and 412.108) 1. Background Under the IPPS, special payment protections are provided to a sole community hospital (SCH). Section PO 00000 Frm 00135 Fmt 4701 Sfmt 4702 23661 1886(d)(5)(D)(iii) of the Act defines an SCH as a hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, absence of other like hospitals (as determined by the Secretary), or historical designation by the Secretary as an essential access community hospital, is the sole source of inpatient hospital services reasonably available to Medicare beneficiaries. The regulations that set forth the criteria that a hospital must meet to be classified as an SCH are located in 42 CFR 412.92 of the regulations. Under the IPPS, separate special payment protections also are provided to a Medicare-dependent, small rural hospital (MDH). Section 1886(d)(5)(G)(iv) of the Act defines an MDH as a hospital that is located in a rural area, has not more than 100 beds, is not an SCH, and has a high percentage of Medicare discharges (not less than 60 percent in its 1987 cost reporting year or in 2 of its most recent 3 audited and settled Medicare cost reporting years). The regulations that set forth the criteria that a hospital must meet to be classified as an MDH are located in 42 CFR 412.108. Although SCHs and MDHs are paid under special payment methodologies, they are hospitals that are paid under section 1886(d) of the Act. Like all IPPS hospitals paid under section 1886(d) of the Act, SCHs and MDHs are paid for their discharges based on the DRG weights calculated under section 1886(d)(4) of the Act. Effective with hospital cost reporting periods beginning on or after October 1, 2000, section 1886(d)(5)(D)(i) of the Act (as amended by section 6003(e) of Pub. L. 101–239) and section 1886(b)(3)(I) of the Act (as added by section 405 of Pub. L. 106–113 and further amended by section 213 of Pub. L. 106–554), provide that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment to the hospital for the cost reporting period: • The Federal rate applicable to the hospital; • The updated hospital-specific rate based on FY 1982 costs per discharge; • The updated hospital-specific rate based on FY 1987 costs per discharge; or • The updated hospital-specific rate based on FY 1996 costs per discharge. For purposes of payment to SCHs for which the FY 1996 hospital-specific rate yields the greatest aggregate payment, payments for discharges during FYs 2001, 2002, and 2003 were based on a blend of the FY 1996 hospital-specific rate and the greater of the Federal rate or the updated FY 1982 or FY 1987 E:\FR\FM\30APP2.SGM 30APP2 23662 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 hospital-specific rate. For discharges during FY 2004 and subsequent fiscal years, payments based on the FY 1996 hospital-specific rate are 100 percent of the updated FY 1996 hospital-specific rate. Through and including FY 2006, under section 1886(d)(5)(G) of the Act, MDHs are paid based on the Federal rate or, if higher, the Federal rate plus 50 percent of the difference between the Federal rate and the updated hospitalspecific rate based on FY 1982 or FY 1987 costs per discharge, whichever is higher. However, section 5003 of Pub. L. 109–171 (DRA) modified these rules for discharges occurring on or after October 1, 2006. Section 5003(c) changed the 50 percent adjustment to 75 percent. Section 5003(b) requires that an MDH use the 2002 cost reporting year as its base year (that is, the FY 2002 updated hospital-specific rate), if that use results in a higher payment. MDHs do not have the option to use their FY 1996 hospitalspecific rate. For each cost reporting period, the fiscal intermediary/MAC determines which of the payment options will yield the highest aggregate payment. Interim payments are automatically made at the highest rate using the best data available at the time the fiscal intermediary/MAC makes the determination. However, it may not be possible for the fiscal intermediary/MAC to determine in advance precisely which of the rates will yield the highest aggregate payment by year’s end. In many instances, it is not possible to forecast the outlier payments, the amount of the DSH adjustment, or the IME adjustment, all of which are applicable only to payments based on the Federal rate and not to payments based on the hospitalspecific rate. The fiscal intermediary/ MAC makes a final adjustment at the close of the cost reporting period after it determines precisely which of the payment rates would yield the highest aggregate payment to the hospital. If a hospital disagrees with the fiscal intermediary’s or MAC’s determination regarding the final amount of program payment to which it is entitled, it has the right to appeal the fiscal intermediary’s or MAC’s decision in accordance with the procedures set forth in 42 CFR Part 405, Subpart R, which concern provider payment determinations and appeals. 2. Volume Decrease Adjustment for SCHs and MDHs: Data Sources for Determining Core Staff Values Section 1886(d)(5)(D)(ii) of the Act requires that the Secretary make a payment adjustment to an SCH that experiences a decrease of more than 5 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 percent in its total number of inpatient discharges from one cost reporting period to the next, if the circumstances leading to the decline in discharges were beyond the SCH’s control. Section 1886(d)(5)(G)(iii) of the Act requires that the Secretary make a payment adjustment to an MDH that experiences a decrease of more than 5 percent in its total number of inpatient discharges from one cost reporting period to the next, if the circumstances leading to the decline in discharges were beyond the MDH’s control. These adjustments were designed to compensate an SCH or MDH for the fixed costs it incurs in the year in which the reduction in discharges occurred, which it may be unable to reduce. Such costs include the maintenance of necessary core staff and services. Our records indicate that less than 10 SCHs/MDHs request and receive this payment adjustment each year. We believe that not all staff costs can be considered fixed costs. Using a standardized formula specified by us, the SCH or MDH must demonstrate that it appropriately adjusted the number of staff in inpatient areas of the hospital based on the decrease in the number of inpatient days. This formula examines nursing staff in particular. If an SCH or MDH has an excess number of nursing staff, the cost of maintaining those staff members is deducted from the total adjustment. One exception to this policy is that no SCH or MDH may reduce its number of staff to a level below what is required by State or local law. In other words, an SCH or MDH will not be penalized for maintaining a level of staff that is consistent with State or local requirements. The process for determining the amount of the volume decrease adjustment can be found in Section 2810.1 of the Provider Reimbursement Manual, Part 1 (PRM–1). Fiscal intermediaries/MACs are responsible for establishing whether an SCH or MDH is eligible for a volume decrease adjustment and, if so, the amount of the adjustment. To qualify for this adjustment, the SCH or MDH must demonstrate that: (a) a decrease of more than 5 percent in total number of inpatient discharges has occurred; and (b) the circumstance that caused the decrease in discharges was beyond the control of the hospital. Once the fiscal intermediary/MAC has established that the SCH or MDH satisfies these two requirements, it will calculate the adjustment. The adjustment amount is determined by subtracting the second year’s DRG payment from the lesser of: (a) the second year’s costs minus any adjustment for excess staff; or (b) the previous year’s costs multiplied by the PO 00000 Frm 00136 Fmt 4701 Sfmt 4702 appropriate IPPS update factor minus any adjustment for excess staff. The SCH or MDH receives the difference in a lump-sum payment. In order to determine whether or not the hospital’s nurse staffing level is appropriate, the fiscal intermediary/ MAC compares the hospital’s actual number of nursing staff in each area with the staffing of like-size hospitals in the same census region. If a hospital employs more than the reported average number of nurses for hospitals of its size and census region, the fiscal intermediary/MAC reduces the amount of the adjustment by the cost of maintaining the additional staff. The amount of the reduction is calculated by multiplying the actual number of nursing staff above the reported average by the average nurse salary for that hospital as reported on the Medicare cost report. The complete process for determining the amount of the adjustment can be found at Section 2810.1 of the PRM–1. Prior to FY 2007, our policy was for fiscal intermediaries/MACs to obtain average nurse staffing data from the AHA HAS/Monitrend Data Book. However, in light of concerns that the Data Book had been published in 1989 and is no longer updated, in the FY 2007 IPPS rule, we proposed and finalized our policy to update the data sources and methodology used to determine the core staffing factors (that is, the average nursing staff for similar bed size and census region) for purposes of calculating the volume decrease adjustment (71 FR 48056 through 48060). We specified that for adjustment requests for decreases in discharges beginning with FY 2007 (that is, a decrease in discharges in 2007 as compared to 2006), an SCH or MDH could opt to use one of two data sources: the AHA Annual Survey or the Occupational Mix Survey, but could not use the HAS/Monitrend Data Book. (For any open adjustment requests prior to FY 2007, we allowed SCHs and MDHs the option of using the results of any of three sources: (1) The 2006 Occupational Mix Survey for cost reporting periods beginning in FY 2006; (2) the AHA Annual Survey (where available); or (3) the AHA HAS/ Monitrend Data Book. We also specified a methodology for calculating those core staffing factors. For purposes of explaining the methodology, we applied it to the 2003 Occupational Mix Survey data. In our explanation, we recognized that some of the 2003 data seemed anomalous, and we solicited comments on a possible alternative methodology. However, there were no suggested alternative methodologies from the E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 commenters. We also explained that, while we used the 2003 Occupational Mix Survey data ‘‘for purposes of describing how we would implement this methodology,’’ the final policy was to use FY 2006 Occupational Mix Survey data going forward. At the time we published the proposed and final rules, however, we had not yet processed the FY 2006 data, and could not present the core staffing figures that resulted from such data. We have now processed the 2006 Occupational Mix Survey data using the methodology specified in the FY 2007 IPPS final rule and continue to see some results that cause us to believe that the methodology for calculating the core staffing factors should be slightly revised from the methodology discussed in the FY 2007 IPPS final rule (71 FR 48056 through 48060). The new methodology uses a revised formula to remove outliers from the core staffing values. a. Occupational Mix Survey In the FY 2007 IPPS final rule (71 FR 48055), we explained the methodology we would use for calculating core staffing values from the Occupational Mix Survey. We stated that we would calculate the nursing hours per patient day for each SCH or MDH by dividing the number of paid nursing hours (for registered nurses, licensed practical nurses and nursing aides) reported on the Occupational Mix Survey by the number of patients days reported on the Medicare cost report. The results would be grouped in the same bed-size groups and census regions as were used in the HAS/Monitrend Data Book. We indicated that we would publish the mean number of nursing hours per patient day, for each census region and bed-size group, in the Federal Register and on the CMS Web site. For purposes of the volume decrease adjustment, the published data would be utilized in the same way as the HAS/Monitrend data: The fiscal intermediary/MAC would multiply the SCH’s and MDH’s number of patient days by the applicable published hours per patient day. This figure would be divided by the average number of worked hours per year per nurse (for example, 2,080 for a standard 40-hour week). The result would be the target number of core nursing staff for the particular SCH or MDH. If necessary, the cost of any excess staff (number of FTEs that exceed the published number) would be removed from the second year’s costs or, if applicable, the previous year’s costs multiplied by the IPPS update factor when determining the volume decrease adjustment. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 In the FY 2007 IPPS final rule (71 FY 48057), we stated that we would use the results of the FY 2006 Occupational Mix Survey and begin applying the methodology for adjustments resulting from a decrease in discharges in FY 2007. Because the occupational mix survey is conducted once every 3 years, we would update the data set every 3 years. However, at the time of the FY 2007 IPPS final rule, the FY 2006 Occupational Mix Survey data were not available. In that final rule, we described our methodology using the FY 2003 occupational mix data and the FY 2003 Medicare cost report file. However, these data were used only in order to present an example of how our methodology would work. Our final policy was to use FY 2006 occupational mix and cost report data when actually processing adjustment requests. In the FY 2007 IPPS final rule, to illustrate how we would calculate the average number of nursing hours per patient day by bed size and region, we first merged the FY 2003 Occupational Mix Survey data with the FY 2003 Medicare cost report file. We eliminated all observations for non-IPPS providers, providers who failed to complete the occupational mix survey and the providers for which provider numbers, bed counts, and/or days counts were missing. For each provider in the pool, we calculated the number of nursing hours by adding the number of registered nurses, licensed practical nurses, and nursing aide hours reported on the Occupational Mix Survey. We divided the result of this calculation by the total number of inpatient days reported on the cost report to determine the number of nursing hours per patient day. For purposes of calculating the census regional averages for the various bedsize groups, we finalized our rule to only include observations that fell within three standard deviations of the mean of all observations, thus removing potential outliers in the data. When the FY 2006 Occupational Mix Survey data became available, our analysis of the results indicated that the methodology for computing core staffing factors should be further revised in order to further eliminate outlier data. After consulting with the Office of the Actuary on appropriate statistical methods to remove outlier data, we are proposing to modify our methodology for calculating the average nursing hours per patient day using the FY 2006 Occupational Mix Survey data and FY 2006 Medicare cost report data. Similar to what was finalized in the FY 2007 IPPS rule, we are proposing to merge the FY 2006 Occupational Mix Survey data PO 00000 Frm 00137 Fmt 4701 Sfmt 4702 23663 with the FY 2006 Medicare cost report file. We would then eliminate all observations for non-IPPS providers, providers who failed to complete the occupational mix survey and the providers for which provider numbers, bed counts and/or days counts were missing. We would annualize the results so that the nursing hours from the Occupational Mix Survey and the patient days reported on the Medicare cost report is representative of one year. For each provider in the pool, we would calculate the number of nursing hours by adding the number of registered nurses, licensed practical nurses, and nursing aide hours reported on the Occupational Mix Survey. We would divide the result of this calculation by the total number of patient days reported on line 12 on Worksheet S–3, Part I, Column 6 of the Medicare cost report. This includes patient days in the general acute care area and the intensive care unit area. The result is the number of nursing hours per patient day. For purposes of calculating the census regional averages for the various bedsize groups, we are proposing a different method to remove outliers in the data. First, we would calculate the difference between the observations in the 75th percentile and the 25th percentile, which is the inter-quartile range. We would remove observations that are greater than the 75th percentile plus 1.5 times the inter-quartile range and less than the 25th percentile minus 1.5 times the inter-quartile range. This methodology, known as the Tukey method, is a common statistical method used by the Office of the Actuary. Under the standard deviation method described in the FY 2007 IPPS final rule, the mean and standard deviation can be influenced by extreme values (because the standard deviation is increased by the very observations that would otherwise be discarded from the analysis). Our proposed methodology is a more robust technique because it uses the quartile values instead of variance to describe the spread of the data, and quartiles are less influenced by extreme outlier values that may be present in the data. Our proposed method would prevent the mean from being influenced by extreme observations and assumes that the middle 50 percent of the data has no outlier observations. The application of this methodology would result in a pool of approximately 2,578 providers. Each census region and bed group category required at least three providers in order for their average to be published. The results of the average nursing hours per patient day by bed size and region using E:\FR\FM\30APP2.SGM 30APP2 23664 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules the FY 2006 Occupational Mix Survey Data and the FY 2006 hospital cost report data are shown in the table below. As stated in the FY 2007 IPPS final rule (71 FR 48059), the results of the FY 2006 Occupational Mix Survey may be used for the volume decrease adjustment calculations for decreases in discharges beginning with cost reporting periods beginning in FYs 2006, 2007, and 2008. PAID NURSING HOURS PER PATIENT DAY Census Region Number of beds New England Middle Atlantic South Atlantic East North Central East South Central West North Central West South Central Mountain Pacific (1) (2) (3) (4) (5) (6) (7) (8) (9) 0–49 ........................... 50–99 ......................... 100–199 ..................... 200–399 ..................... 400+ ........................... 25.47 20.99 18.12 16.92 17.52 20.60 18.51 16.31 13.80 14.43 b. AHA Annual Survey In the FY 2007 IPPS final rule (71 FR 48058), we also allowed SCHs or MDHs that experienced a greater than 5 percent reduction in the number of discharges in a cost reporting period the option of using the AHA Annual Survey results, where available, to compare the number of hospital’s core staff with other like-sized hospitals in its geographic area. Our methodology for calculating the nursing hours per patient day using the AHA Annual Survey data and the Medicare hospital cost report was similar to the methodology using the Occupational Mix Survey data (eliminating outliers outside of three standard deviations from the mean). For this reason, as with the occupational mix data, both standard deviations and the mean could be influenced by extreme values. Therefore, we are proposing to refine our methodology to calculate the core staffing factors using the AHA Annual Survey data as well. The AHA Annual Survey contains FTE counts for registered nurses, practical and vocational nurses, nursing assistive personnel, and other personnel in both inpatient and outpatient areas of the hospital. This is consistent with the Occupational Mix Survey which collects data on both the inpatient and outpatient areas of the hospital. 21.08 20.36 17.31 16.23 16.68 24.52 23.44 18.87 17.79 18.41 20.27 19.00 17.43 16.06 14.14 25.92 22.44 19.50 18.66 16.90 In the FY 2007 IPPS final rule, we stated we would calculate the nursing hours per patient day using the AHA Annual Survey data in a similar method to the Occupational Mix Survey. Consistent with the HAS/Monitrend Data book, we would only calculate the average number of nursing staff for a bed-size/census group if there are data available for three or more hospitals. First, we would merge the AHA Annual Survey Data with the corresponding Medicare cost report. We would eliminate all observations for non-IPPS providers, providers with hospital-based SNFs, and the providers for which provider numbers, bed counts, and/or days counts were missing. We would multiply the number of nurse, licensed practical nurse, and nursing aide FTEs reported on the AHA Annual Survey by 2,080 hours to derive the number of nursing hours per year (based on a 40hour work week). We would then divide this number by the total number of patient days reported on line 12 on Worksheet S–3, Part I, Column 6 of the Medicare cost report. In the FY 2007 IPPS final rule (71 FR 48060), we had stated that we would eliminate all providers with results beyond three standard deviations from the mean. However, to be consistent with our methodology with the Occupational Mix Survey data, we are also proposing that we would remove outliers from the AHA Annual Survey data by calculating 22.16 20.44 17.01 14.56 16.25 24.52 22.54 18.70 16.82 15.50 20.99 18.89 16.25 16.63 18.15 the difference between the observations in the 75th percentile and the 25th percentile, which is the inter-quartile range. Then, we are proposing to remove observations that are greater than the 75th percentile plus 1.5 times the inter-quartile range and less than the 25th percentile minus 1.5 times the inter-quartile range. After removing the outliers, we would group the hospitals by bed size and census area to calculate the average number of nursing hours per patient day for each category. Using the 2006 AHA Annual Survey data as an example, this would result in a pool of approximately 1,205 providers. The results of the nursing hours per patient day using the 2006 AHA Annual Survey data and the Medicare cost report data are shown below. The 2006 Survey would be used for the volume decrease adjustment calculations for decreases in discharges occurring during cost reporting periods beginning in FY 2006. As we stated in the FY 2007 IPPS final rule, for other years, the corresponding AHA Annual Survey would be used for the year in which the decreased occurred. For example, if a hospital experienced a decrease between its 2004 and 2005 cost reporting periods, the fiscal intermediary/MAC would compare the hospital’s 2005 staffing with the results of the 2005 AHA Annual Survey, using the methodology discussed above. PAID NURSING HOURS PER PATIENT DAY jlentini on PROD1PC65 with PROPOSALS2 Census Region Number of beds New England Middle Atlantic South Atlantic East North Central East South Central West North Central West South Central Mountain Pacific (1) (2) (3) (4) (5) (6) (7) (8) (9) 0–49 ........................... 50–99 ......................... VerDate Aug<31>2005 19:42 Apr 29, 2008 25.82 23.42 Jkt 214001 23.48 19.40 PO 00000 21.77 20.69 Frm 00138 26.12 23.47 Fmt 4701 Sfmt 4702 17.25 22.06 24.75 23.28 E:\FR\FM\30APP2.SGM 23.66 20.55 30APP2 25.44 19.28 24.50 19.91 23665 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules PAID NURSING HOURS PER PATIENT DAY—Continued Census Region Number of beds New England Middle Atlantic South Atlantic East North Central East South Central West North Central West South Central Mountain Pacific (1) (2) (3) (4) (5) (6) (7) (8) (9) 100–199 ..................... 200–399 ..................... 400+ ........................... 18.89 18.89 18.98 17.46 14.96 16.66 E. Rural Referral Centers (RRCs) (§ 412.96) jlentini on PROD1PC65 with PROPOSALS2 Under the authority of section 1886(d)(5)(C)(i) of the Act, the regulations at § 412.96 set forth the criteria that a hospital must meet in order to qualify under the IPPS as an RRC. For discharges occurring before October 1, 1994, RRCs received the benefit of payment based on the other urban standardized amount rather than the rural standardized amount. Although the other urban and rural standardized amounts are the same for discharges occurring on or after October 1, 1994, RRCs continue to receive special treatment under both the DSH payment adjustment and the criteria for geographic reclassification. Section 402 of Pub. L. 108–173 raised the DSH adjustment for other rural hospitals with less than 500 beds and RRCs. Other rural hospitals with less than 500 beds are subject to a 12-percent cap on DSH payments. RRCs are not subject to the 12-percent cap on DSH payments that is applicable to other rural hospitals (with the exception of rural hospitals with 500 or more beds). RRCs are not subject to the proximity criteria when applying for geographic reclassification, and they do not have to meet the requirement that a hospital’s average hourly wage must exceed the average hourly wage of the labor market area where the hospital is located by a certain percentage (106/108 percent in FY 2008). Section 4202(b) of Pub. L. 105–33 states, in part, ‘‘[a]ny hospital classified as an RRC by the Secretary * * * for fiscal year 1991 shall be classified as such an RRC for fiscal year 1998 and each subsequent year.’’ In the August 29, 1997 final rule with comment period (62 FR 45999), we reinstated RRC status for all hospitals that lost the status due 18.43 15.75 17.39 20.08 17.02 21.59 19.64 15.07 16.47 to triennial review or MGCRB reclassification, but did not reinstate the status of hospitals that lost RRC status because they were now urban for all purposes because of the OMB designation of their geographic area as urban. However, subsequently, in the August 1, 2000 final rule (65 FR 47089), we indicated that we were revisiting that decision. Specifically, we stated that we would permit hospitals that previously qualified as an RRC and lost their status due to OMB redesignation of the county in which they are located from rural to urban to be reinstated as an RRC. Otherwise, a hospital seeking RRC status must satisfy the applicable criteria. We used the definitions of ‘‘urban’’ and ‘‘rural’’ specified in Subpart D of 42 CFR Part 412. One of the criteria under which a hospital may qualify as a RRC is to have 275 or more beds available for use (§ 412.96(b)(1)(ii)). A rural hospital that does not meet the bed size requirement can qualify as an RRC if the hospital meets two mandatory prerequisites (a minimum CMI and a minimum number of discharges), and at least one of three optional criteria (relating to specialty composition of medical staff, source of inpatients, or referral volume) (§ 412.96(c)(1) through (c)(5) and the September 30, 1988 Federal Register (53 FR 38513)). With respect to the two mandatory prerequisites, a hospital may be classified as an RRC if— • The hospital’s CMI is at least equal to the lower of the median CMI for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median CMI for all urban hospitals nationally; and • The hospital’s number of discharges is at least 5,000 per year, or, if fewer, the median number of discharges for urban hospitals in the census region in which the hospital is located. (The number of 20.23 19.81 17.71 19.02 15.85 15.06 1. Case-Mix Index Section 412.96(c)(1) provides that CMS establish updated national and regional CMI values in each year’s annual notice of prospective payment rates for purposes of determining RRC status. The methodology we used to determine the national and regional CMI values is set forth in the regulations at § 412.96(c)(1)(ii). The proposed national median CMI value for FY 2009 includes all urban hospitals nationwide, and the proposed regional values for FY 2009 are the median CMI values of urban hospitals within each census region, excluding those hospitals with approved teaching programs (that is, those hospitals that train residents in an approved GME program as provided in § 413.75). These values are based on discharges occurring during FY 2007 (October 1, 2006 through September 30, 2007), and include bills posted to CMS’ records through December 2007. We are proposing that, in addition to meeting other criteria, if rural hospitals with fewer than 275 beds are to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2008, they must have a CMI value for FY 2007 that is at least— • 1.4285; or • The median CMI value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved teaching programs as identified in § 413.75) calculated by CMS for the census region in which the hospital is located. The proposed median CMI values by region are set forth in the following table: Case-mix index value 1. New England (CT, ME, MA, NH, RI, VT) .................................................................................................................................... 2. Middle Atlantic (PA, NJ, NY) ....................................................................................................................................................... 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) ........................................................................................................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00139 Fmt 4701 18.71 18.01 21.11 discharges criterion for an osteopathic hospital is at least 3,000 discharges per year, as specified in section 1886(d)(5)(C)(i) of the Act.) Region VerDate Aug<31>2005 18.80 18.17 17.76 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 1.2515 1.2691 1.3589 23666 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Case-mix index value Region 4. 5. 6. 7. 8. 9. East North Central (IL, IN, MI, OH, WI) ...................................................................................................................................... East South Central (AL, KY, MS, TN) ......................................................................................................................................... West North Central (IA, KS, MN, MO, NE, ND, SD) .................................................................................................................. West South Central (AR, LA, OK, TX) ........................................................................................................................................ Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) ........................................................................................................................... Pacific (AK, CA, HI, OR, WA) ..................................................................................................................................................... The preceding numbers will be revised in the FY 2009 IPPS final rule to the extent required to reflect the updated FY 2007 MEDPAR file, which will contain data from additional bills received through March 2008. Hospitals seeking to qualify as RRCs or those wishing to know how their CMI value compares to the criteria should obtain hospital-specific CMI values (not transfer-adjusted) from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these CMI values are computed based on all Medicare patient discharges subject to the IPPS DRG-based payment. 2. Discharges Section 412.96(c)(2)(i) provides that CMS set forth the national and regional numbers of discharges in each year’s annual notice of prospective payment rates for purposes of determining RRC status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. We are proposing to update the regional standards based on discharges for urban hospitals’ cost reporting periods that began during FY 2006 (that is, October 1, 2005 through September 30, 2006), which is the latest cost report data available at the time this proposed rule was developed. Therefore, we are proposing that, in addition to meeting other criteria, a hospital, if it is to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2008, must have as the number of discharges for its cost reporting period that began during FY 2006 a figure that is at least— • 5,000 (3,000 for an osteopathic hospital); or • The median number of discharges for urban hospitals in the census region in which the hospital is located, as indicated in the following table. Number of discharges Region 1. 2. 3. 4. 5. 6. 7. 8. 9. New England (CT, ME, MA, NH, RI, VT) .................................................................................................................................... Middle Atlantic (PA, NJ, NY) ....................................................................................................................................................... South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) ........................................................................................................... East North Central (IL, IN, MI, OH, WI) ...................................................................................................................................... East South Central (AL, KY, MS, TN) ......................................................................................................................................... West North Central (IA, KS, MN, MO, NE, ND, SD) .................................................................................................................. West South Central (AR, LA, OK, TX) ........................................................................................................................................ Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) ........................................................................................................................... Pacific (AK, CA, HI, OR, WA) ..................................................................................................................................................... These numbers will be revised in the FY 2009 IPPS final rule based on the latest available cost reports. We note that the median number of discharges for hospitals in each census region is greater than the national standard of 5,000 discharges. Therefore, 5,000 discharges is the minimum criterion for all hospitals. We reiterate that, if an osteopathic hospital is to qualify for RRC status for cost reporting periods beginning on or after October 1, 2008, the hospital would be required to have at least 3,000 discharges for its cost reporting period that began during FY 2005. F. Indirect Medical Education (IME) Adjustment (§ 412.105) jlentini on PROD1PC65 with PROPOSALS2 1. Background Section 1886(d)(5)(B) of the Act provides for an additional payment amount under the IPPS for hospitals that have residents in an approved graduate medical education (GME) program in order to reflect the higher VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 indirect patient care costs of teaching hospitals relative to nonteaching hospitals. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are located at § 412.105. The Balanced Budget Act of 1997 (Pub. L. 105–33) established a limit on the number of allopathic and osteopathic residents that a hospital may include in its full-time equivalent (FTE) resident count for direct GME and IME payment purposes. Under section 1886(h)(4)(F) of the Act, for cost reporting periods beginning on or after October 1, 1997, a hospital’s unweighted FTE count of residents for purposes of direct GME may not exceed the hospital’s unweighted FTE count for its most recent cost reporting period ending on or before December 31, 1996. Under section 1886(d)(5)(B)(v) of the Act, a similar limit on the FTE resident count for IME purposes is effective for discharges occurring on or after October 1, 1997. PO 00000 Frm 00140 Fmt 4701 1.3572 1.3040 1.3557 1.4405 1.4692 1.3872 Sfmt 4702 8,158 10,443 10,344 8,900 7,401 7,988 5,816 9,919 8,600 2. IME Adjustment Factor for FY 2009 The IME adjustment to the MS–DRG payment is based in part on the applicable IME adjustment factor. The IME adjustment factor is calculated by using a hospital’s ratio of residents to beds, which is represented as r, and a formula multiplier, which is represented as c, in the following equation: c x [{1 + r} .405 ¥ 1]. The formula is traditionally described in terms of a certain percentage increase in payment for every 10-percent increase in the resident-to-bed ratio. Section 502(a) of Pub. L. 108–173 modified the formula multiplier (c) to be used in the calculation of the IME adjustment. Prior to the enactment of Pub. L. 108–173, the formula multiplier was fixed at 1.35 for discharges occurring during FY 2003 and thereafter. In the FY 2005 IPPS final rule, we announced the schedule of formula multipliers to be used in the calculation of the IME adjustment and incorporated the schedule in our E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules regulations at § 412.105(d)(3)(viii) through (d)(3)(xii). Section 502(a) modifies the formula multiplier beginning midway through FY 2004 and provides for a new schedule of formula multipliers for FYs 2005 and thereafter as follows: • For discharges occurring on or after April 1, 2004, and before October 1, 2004, the formula multiplier is 1.47. • For discharges occurring during FY 2005, the formula multiplier is 1.42. • For discharges occurring during FY 2006, the formula multiplier is 1.37. • For discharges occurring during FY 2007, the formula multiplier is 1.32. • For discharges occurring during FY 2008 and fiscal years thereafter, the formula multiplier is 1.35. Accordingly, for discharges occurring during FY 2009, the formula multiplier would be 1.35. We estimate that application of this formula multiplier for FY 2009 IME adjustment will result in an increase in IME payment of 5.5 percent for every approximately 10percent increase in the hospital’s resident-to-bed ratio. G. Medicare GME Affiliation Provisions for Teaching Hospitals in Certain Emergency Situations; Technical Correction (§ 413.79(f)(6)(iv)) jlentini on PROD1PC65 with PROPOSALS2 1. Background Under section 1886(h) of the Act, as amended by section 9202 of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Pub. L. 99–272), the Secretary is authorized to make payments to hospitals for the direct costs of approved GME programs. Section 1886(d)(5)(B) of the Act provides that prospective payment acute care hospitals that have residents in an approved GME program receive an additional payment for a Medicare discharge to reflect the higher patient care costs of teaching hospitals, that is, IME costs. Sections 1886(h)(4)(F) and 1886(d)(5)(B)(v) of the Act establish limits on the number of allopathic and osteopathic residents that hospitals may count for purposes of calculating direct GME payments and the IME adjustment, respectively, establishing hospitalspecific direct GME and IME FTE resident caps. Under the authority granted by section 1886(h)(4)(H)(ii) of the Act, the Secretary issued rules to allow institutions that are members of the same affiliated group to apply their direct GME and IME FTE resident caps on an aggregate basis through a Medicare GME affiliation agreement. The Medicare regulations at §§ 413.75 and 413.76 permit hospitals, through a Medicare GME affiliation agreement, to VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 adjust IME and direct GME FTE resident caps to reflect the rotation of residents among affiliated hospitals. In response to circumstances in the aftermath of Hurricanes Katrina and Rita, we supplemented regulations in the April 12, 2006 interim final rule with comment period published in the Federal Register (71 FR 18654). The regulatory changes allowed certain hospitals to engage in emergency Medicare GME affiliations so that Medicare funding for GME is maintained while there are displaced residents training at various host hospitals even as the hurricane-affected hospitals are rebuilding their training programs. The modifications to the regulations at § 413.75(b) and § 413.76(f) provided flexibility for home hospitals whose residency programs have been disrupted due to an emergency to enter into emergency Medicare GME affiliation agreements with host hospitals where the hospitals may not otherwise meet the regulatory requirements to form Medicare GME affiliations. (We note that on November 27, 2007, we issued a second interim final rule with comment period providing further flexibility relating to emergency Medicare GME affiliation agreements (72 FR 66893 through 66898). We expect to address the public comments received on both interim final rules with comment period and finalize our policies in the FY 2009 IPPS final rule scheduled to be published in August 2008.) 2. Technical Correction In the April 12, 2006 interim final rule, we revised § 413.79(f) by adding a new paragraph (6) to provide for more flexibility in Medicare GME affiliations for home hospitals located in section 1135 emergency areas to allow the home hospitals to efficiently find training sites for displaced residents. We have discovered that, under § 413.79(f)(6)(iv), in our provisions on the host hospital exception from the rolling average for the period from August 29, 2005 to June 30, 2006, we included an incorrect cross-reference to the rolling average requirements for direct GME as ‘‘§ 413.75(d).’’ The correct citation to the rolling average requirements for direct GME is § 413.79(d). We are proposing to correct the cross-reference under § 413.79(f)(6)(iv) to read ‘‘paragraph (d) of this section’’. H. Payments to Medicare Advantage Organizations: Collection of Risk Adjustment Data (§ 422.310) Section 1853 of the Act requires CMS to make advance monthly payments to a Medicare Advantage (MA) PO 00000 Frm 00141 Fmt 4701 Sfmt 4702 23667 organization for each beneficiary enrolled in an MA plan offered by the organization for coverage of Medicare Part A and Part B benefits. Section 1853(a)(1)(C) of the Act requires CMS to adjust the monthly payment amount for each enrollee to take into account the health status of the MA plan’s enrollees. Under the CMS-Hierarchical Condition Category (HCC) risk adjustment payment methodology, CMS determines risk scores for MA enrollees for a year and adjusts the monthly payment amount using the appropriate enrollee risk score. Under section 1853(a)(3)(B) of the Act, MA organizations are required to ‘‘submit data regarding inpatient hospital services . . . and data regarding other services and other information as the Secretary deems necessary’’ in order to implement a methodology for ‘‘risk adjusting’’ payments made to MA organizations. Risk adjustments to payments are made in order to take into account ‘‘variations in per capita costs based on [the] health status’’ of the Medicare beneficiaries enrolled in an MA plan offered by the organization. Submission of data on inpatient hospital services has been required with respect to services beginning on or after July 1, 1997. Submission of data on other services has been required since July 1, 1998. While we initially required the submission of comprehensive data regarding services provided by MA organizations, including comprehensive inpatient hospital encounter data, we subsequently permitted MA organizations to submit an ‘‘abbreviated’’ set of data. Our regulations at 42 CFR 422.310(d)(1) currently explicitly provide MA organizations with the option of submitting an abbreviated data set. Under this provision, we currently collect limited risk adjustment data from MA organizations, primarily diagnosis data. From calendar years 2000 through 2006, application of risk adjustment to MA payments was ‘‘phased in’’ with an increasing percentage of the monthly capitation payment subjected to risk adjustment. Beginning with calendar year 2007, 100 percent of payments to MA organizations are risk-adjusted. Given the increased importance of the accuracy of our risk adjustment methodology, we are proposing to amend § 422.310 to provide that CMS will collect data from MA organizations regarding each item and service provided to an MA plan enrollee. This will allow us to include utilization data and other factors that CMS can use in developing the CMS–HCC risk E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23668 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules adjustment models in order to reflect patterns of diagnoses and expenditures in the MA program. Specifically, we are proposing to revise § 422.310(a) to clarify that risk adjustment data are data used not only in the application of risk adjustment to MA payments, but also in the development of risk adjustment models. For example, once encounter data for MA enrollees are available, CMS would have beneficiary-specific information on the utilization of services by MA plan enrollees. These data could be used to calibrate the CMS–HCC risk adjustment models using MA patterns of diagnoses and expenditures. We are proposing to revise §§ 422.310(b), (c), (d)(3), and (g) to clarify that the term ‘‘services’’ includes items and services. We are proposing to revise § 422.310(d) to clarify that CMS has the authority to require MA organizations to submit encounter data for each item and service provided to an MA plan enrollee. The proposed revision also would clarify that CMS will determine the formats for submitting encounter data, which may be more abbreviated than those used for the fee-for-service claims data submission process. We are proposing to revise § 422.310(f) to clarify that one of the ‘‘other’’ purposes for which CMS may use risk adjustment data collected under this section would be to update risk adjustment models with data from MA enrollees. In addition, when providing that CMS may use risk adjustment data for purposes other than adjusting payments as described at §§ 422.304(a) and (c), we are proposing to delete the phrase ‘‘except for medical records data’’ from paragraph (f). Any use of medical records data collected under paragraph (e) of § 422.310 is governed by the Privacy Act and the privacy provisions in the HIPAA. Furthermore, there may be occasions when we learn from analysis of medical record review data that some organizations have misunderstood our guidance on how to implement an operational instruction. We want to be able to provide improved guidance to MA organizations based on any insights that may emerge during analysis of the medical record review data. In addition, we are proposing a technical correction to § 422.310(f) to clarify that risk adjustment data are used not only to adjust payments to plans described at §§ 422.301(a)(1), (a)(2), and (a)(3) (which refer to coordinated care plans and private feefor-service plans), but also to adjust payments for ESRD enrollees and payments to MSA plans and Religious VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Fraternal Benefit society plans, as described at § 422.301(c). Under § 422.310(g), we would continue to provide that data that CMS receives after the final deadline for a payment year will not be accepted for purposes of the reconciliation. However, we are proposing to revise paragraph (g)(2) of § 422.310 to change the deadline from ‘‘December 31’’ of the payment year to ‘‘January 31’’ of the year following the payment year. We are also proposing to add language to provide that CMS may adjust deadlines as appropriate. I. Hospital Emergency Services under EMTALA (§ 489.24) 1. Background Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose specific obligations on certain Medicareparticipating hospitals and CAHs. (Throughout this section of this proposed rule, when we reference the obligation of a ‘‘hospital’’ under these sections of the Act and in our regulations, we mean to include CAHs as well.) These obligations concern individuals who come to a hospital emergency department and request examination or treatment for a medical condition, and apply to all of these individuals, regardless of whether they are beneficiaries of any program under the Act. The statutory provisions cited above are frequently referred to as the Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient antidumping statute. EMTALA was passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Pub. L. 99–272. Congress incorporated these antidumping provisions within the Social Security Act to ensure that individuals with emergency medical conditions are not denied essential lifesaving services. Under section 1866(a)(1)(I)(i) of the Act, a hospital that fails to fulfill its EMTALA obligations under these provisions may be subject to termination of its Medicare provider agreement, which would result in loss of all Medicare and Medicaid payments. Section 1867 of the Act sets forth requirements for medical screening examinations for individuals who come to the hospital and request examination or treatment for a medical condition. The section further provides that if a hospital finds that such an individual has an emergency medical condition, it is obligated to provide that individual with either necessary stabilizing treatment or an appropriate transfer to PO 00000 Frm 00142 Fmt 4701 Sfmt 4702 another medical facility where stabilization can occur. The EMTALA statute also outlines the obligation of hospitals to receive appropriate transfers from other hospitals. Section 1867(g) of the Act states that a participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or, with respect to rural areas, regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires these specialized capabilities or facilities if the hospital has the capacity to treat the individual. The regulations implementing section 1867 of the Act are found at 42 CFR 489.24. The regulations at 42 CFR 489.20(l), (m), (q), and (r) also refer to certain EMTALA requirements. The Interpretive Guidelines concerning EMTALA are found at Appendix V of the CMS State Operations Manual. 2. EMTALA Technical Advisory Group (TAG) Recommendations Section 945 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Pub. L. 108–173, required the Secretary to establish a Technical Advisory Group (TAG) to advise the Secretary on issues related to the regulations and implementation of EMTALA. The MMA specified that the EMTALA TAG be composed of 19 members, including the Administrator of CMS, the Inspector General of HHS, hospital representatives and physicians representing specific specialties, patient representatives, and representatives of organizations involved in EMTALA enforcement. The EMTALA TAG’s functions, as identified in the charter for the EMTALA TAG, were as follows: (1) Review EMTALA regulations; (2) provide advice and recommendations to the Secretary concerning these regulations and their application to hospitals and physicians; (3) solicit comments and recommendations from hospitals, physicians, and the public regarding the implementation of such regulations; and (4) disseminate information concerning the application of these regulations to hospitals, physicians, and the public. The TAG met 7 times during its 30-month term, which ended on September 30, 2007. At its meetings, the TAG heard testimony from representatives of physician groups, hospital associations, and others regarding EMTALA issues and concerns. During each meeting, the three subcommittees established by the TAG (the On-Call Subcommittee, the Action Subcommittee, and the Framework Subcommittee) developed E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules recommendations, which were then discussed and voted on by members of the TAG. In total, the TAG submitted 55 recommendations to the Secretary. If implemented, some of the recommendations would require regulatory changes. Of the 55 recommendations developed by the TAG, 5 have already been implemented by CMS. A complete list of TAG recommendations will be available shortly in the Emergency Medical Treatment and Labor Act Technical Advisory Group final report available at the Web site: https://www.cms.hhs.gov/ FACA/07_emtalatag.asp. The following recommendations have already been implemented by CMS: • That CMS revise, in the EMTALA regulations [42 CFR 489.24(b)], the following sentence contained in the definition of ‘‘labor’’: ‘‘A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor.’’ This recommendation was adopted with modification in the FY 2007 IPPS final rule (71 FR 48143). We revised the definition of ‘‘labor’’ in the regulations at § 489.24(b) to permit a physician, certified nurse-midwife, or other qualified medical person, acting within his or her scope of practice in accordance with State law and hospital bylaws, to certify that a woman is experiencing false labor. We issued Survey and Certification Letter S&C–06– 32 on September 29, 2006, to clarify the regulation change. (The Survey and Certification Letter can be found at the following Web site: https:// www.cms.hhs.gov/ SurveyCertificationGenInfo/PMSR/ list.asp). • That hospitals with specialized capabilities (as defined in the EMTALA regulations) that do not have a dedicated emergency department be bound by the same responsibilities under EMTALA as hospitals with specialized capabilities that do have a dedicated emergency department. This recommendation was adopted in the FY 2007 IPPS final rule (71 FR 48143). We added language at § 489.24(f) that makes explicit the current policy that all Medicareparticipating providers with specialized capabilities are required to accept an appropriate transfer if they have the capacity to treat the individual. We issued Survey and Certification Letter S&C–06–32 on September 29, 2006, to clarify the regulation change. (The Survey and Certification Letter can be found at the following Web site: https:// www.cms.hhs.gov/ VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 SurveyCertificationGenInfo/PMSR/ list.asp). • That CMS clarify the intent of regulations regarding obligations under EMTALA to receive individuals who arrive by ambulance. Specifically, the TAG recommended that CMS revise a letter of guidance that had been issued by the agency to clarify its position on the practice of delaying the transfer of an individual from an emergency medical service provider’s stretcher to a bed in a hospital’s emergency department. This recommendation was adopted with modification by CMS in Survey and Certification Letter S&C–07–20, which was released on April 27, 2007. (The Survey and Certification Letter can be found at the following Web site: https://www.cms.hhs.gov/ SurveyCertificationGenInfo/PMSR/ list.asp). • That CMS clarify that a hospital may not refuse to accept an individual appropriately transferred under EMTALA on the grounds that it (the receiving hospital) does not approve the method of transfer arranged by the attending physician at the sending hospital (for example, a receiving hospital may not require the sending hospital to use an ambulance transport designated by the receiving hospital). In addition, CMS should improve its communication of such clarifications with its regional offices. This recommendation was adopted and implemented by CMS in Survey and Certification Letter S&C–07–20, which was released on April 27, 2007. (The Survey and Certification Letter can be found at the following Web site: https://www.cms.hhs.gov/ SurveyCertificationGenInfo/PMSR/ list.asp). • That CMS strike the language in the Interpretive Guidelines (CMS State Operations Manual, Appendix V) that addresses telehealth/telemedicine (relating to the regulations at § 489.24(j)(1)) and replace it with language that clarifies that the treating physician ultimately determines whether an on-call physician should come to the emergency department and that the treating physician may use a variety of methods to communicate with the on-call physician. A potential violation occurs only if the treating physician requests that the on-call physician come to the emergency department and the on-call physician refuses. This recommendation was adopted and implemented by CMS in Survey and Certification Letter S&C–07–23, which was released on June 22, 2007. (The Survey and Certification Letter can PO 00000 Frm 00143 Fmt 4701 Sfmt 4702 23669 be found at the following Web site: https://www.cms.hhs.gov/ SurveyCertificationGenInfo/PMSR/ list.asp). We are considering the remaining recommendations of the EMTALA TAG and may address them through future changes to or clarifications of the existing regulations or the Interpretive Guidelines, or both. At the end of its term, the EMTALA TAG compiled a final report to the Secretary. This report includes, among other materials, minutes from each TAG meeting as well as a comprehensive list of all of the TAG’s recommendations. The final report will be available shortly at the following Web site: https:// www.cms.hhs.gov/FACA/ 07_emtalatag.asp. 3. Proposed Changes Relating to Applicability of EMTALA Requirements to Hospital Inpatients While many issues pertaining to EMTALA involve individuals presenting to a hospital’s dedicated emergency department, questions have been raised regarding the applicability of the EMTALA requirements to inpatients. We have previously discussed the applicability of the EMTALA requirements to hospital inpatients in both the May 9, 2002 IPPS proposed rule (67 FR 31475) and the September 9, 2003 stand alone final rule on EMTALA (68 FR 53243). As we stated in both of the aforementioned rules, in 1999, the United States Supreme Court considered a case (Roberts v. Galen of Virginia, 525 U.S. 249 (1999)) that involved, in part, the question of whether EMTALA applies to inpatients in a hospital. In the context of that case, the United States Solicitor General advised the Court that HHS would develop a regulation clarifying its position on that issue. In the 2003 final rule, CMS took the position that a hospital’s obligation under EMTALA ends when that hospital, in good faith, admits an individual with an unstable emergency medical condition as an inpatient to that hospital. In that rule, CMS noted that other patient safeguards protected inpatients, including the CoPs as well as State malpractice law. However, in the 2003 final rule, CMS did not directly address the question of whether EMTALA’s ‘‘specialized care’’ requirements (section 1867(g) of the Act) applied to inpatients. As noted in section IV.I.2. of this preamble, the EMTALA TAG has developed a set of recommendations to the Secretary. One of those recommendations calls for CMS to revise its regulations to address the situation of an individual who: (1) E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23670 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Presents to a hospital that has a dedicated emergency department and is determined to have an unstabilized emergency medical condition; (2) is admitted to the hospital as an inpatient; and (3) the hospital subsequently determines that stabilizing the individual’s emergency medical condition requires specialized care only available at another hospital. We believe that the obligation of EMTALA does not end for all hospitals once an individual has been admitted as an inpatient to the hospital where the individual first presented with a medical condition that was determined to be an emergency medical condition. Rather, once the individual is admitted, admission only impacts on the EMTALA obligation of the hospital where the individual first presented. (Throughout this section of the preamble of this proposed rule, we will refer to the hospital where the individual first presented as the ‘‘admitting hospital.’’) Section 1867(g) of the Act states: ‘‘Nondiscrimination— A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.’’ Section 1867(g) of the Act therefore requires a receiving hospital with specialized capabilities to accept a request to transfer an individual with an unstable emergency medical condition as long as the hospital has the capacity to treat that individual, regardless of whether the individual had been an inpatient at the admitting hospital. Furthermore, in the September 9, 2003 final rule (68 FR 53263), we amended the regulations at § 489.24(d)(2)(i) to state: ‘‘If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual’’ (emphasis added). We did not intend for the regulation to end the EMTALA obligation for any other hospital to which the individual may appropriately be transferred to stabilize his or her emergency medical condition. Permitting inpatient admission at the admitting hospital to end EMTALA obligations for another hospital to VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 which an unstabilized individual is being appropriately transferred to receive specialized care would seemingly contradict the intent of section 1867(g) of the Act to ensure that hospitals with specialized capabilities provide medical treatment to individuals with emergency medical conditions to stabilize their conditions. We also note that, as we discussed in the preamble of the September 9, 2003 stand alone final rule, once a hospital has admitted an individual as an inpatient, the individual is protected under the Medicare CoPs and may also have additional protections under State law. Accordingly, we believe it is consistent with the intent of EMTALA to limit its protections to individuals who need them most; for example, individuals who present to a hospital but may not have been formally admitted as patients and thus are not covered by other protections applicable to inpatients of the hospital. As noted above, once the individual is admitted, the CoPs apply to the admitting hospital’s care of that individual. A hospital that fails to provide treatment to such individuals could face termination of its Medicare provider agreement for a violation of the CoPs. However, these CoPs do not, of course, apply to a hospital with specialized capabilities to which the individual might be transferred unless and until the individual is formally admitted as a patient at that hospital. Therefore, in order to ensure an individual the protections intended by the EMTALA statute, especially section 1867(g) of the Act (obligating a hospital with specialized capabilities to accept an appropriately transferred individual if it has the capacity to treat that individual), we believe it is appropriate to propose to clarify that section 1867(g) of the Act continues to apply so as to protect even an individual who has been admitted as an inpatient to the admitting hospital who has not been stable since becoming an inpatient. We believe that this proposed clarification is necessary to ensure that EMTALA protections are continued for individuals who are not otherwise protected by the hospital CoPs. (We note that this proposed clarification is consistent with the EMATLA TAG’s recommendation that EMTALA does not apply when an individual is admitted to the hospital for an elective procedure and subsequently develops an emergency medical condition.) We recognize that this proposed clarification that EMTALA applies to a hospital with specialized capabilities when an inpatient (who presented to the admitting hospital under EMTALA) is PO 00000 Frm 00144 Fmt 4701 Sfmt 4702 in need of specialized care to stabilize his or her emergency medical condition may raise concerns among the provider community that such a clarification in policy could hypothetically result in an increase in the number of transfers. However, the intention of this proposed clarification is not to encourage patient dumping to hospitals with specialized capabilities. Rather, even if the hospital with specialized capabilities has an EMTALA obligation to accept an individual who was an inpatient at the admitting hospital, the admitting hospital transferring the individual should take all steps necessary to ensure that it is providing needed treatment within its capabilities prior to transferring the individual. This means that an individual with an unstabilized emergency medical condition should be transferred only when the capabilities of the admitting hospital have been exceeded. Accordingly, we are proposing to revise § 489.24(f) by adding to the existing text a provision that specifies that paragraph (f) also applies to an individual who has been admitted under paragraph (d)(2)(i) of the section and who has not been stabilized. While we are not including the following in our proposed clarification, we are seeking public comments on whether the EMTALA obligation imposed on hospitals with specialized capabilities to accept appropriate transfers should apply to a hospital with specialized capabilities in the case of an individual who had a period of stability during his or her stay at the admitting hospital and is in need of specialized care available at the hospital with specialized capabilities. CMS takes seriously its duty to protect patients with emergency medical conditions as required by EMTALA. Thus, we are seeking public comments as to whether, with respect to the EMTALA obligation on the hospital with specialized capabilities, it should or should not matter if an individual who currently has an unstabilized emergency medical condition (which is beyond the capability of the admitting hospital) (1) remained unstable after coming to the hospital emergency department or (2) subsequently had a period of stability after coming to the hospital emergency department. In summary, to implement the recommendation by the EMTALA TAG and clarify our policy regarding the applicability of EMTALA to hospital inpatients, we are proposing to amend § 489.24(f) to add a provision to state that when an individual covered by EMTALA was admitted as an inpatient and remains unstabilized with an E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules emergency medical condition, a receiving hospital with specialized capabilities has an EMTALA obligation to accept that individual, assuming that the transfer of the individual is an appropriate transfer and the participating hospital with specialized capabilities has the capacity to treat the individual. 4. Proposed Changes to the EMTALA Physician On-Call Requirements jlentini on PROD1PC65 with PROPOSALS2 a. Relocation of Regulatory Provisions During its term, the EMTALA TAG dedicated a significant portion of its discussion to a hospital’s physician oncall obligations under EMTALA and made several recommendations to the Secretary regarding physician on-call requirements that are included in its final report (will be available shortly at the Web site: https://www.cms.hhs/gov/ FACA/07_emtalatag.asp). The TAG recommended that CMS move the regulation discussing the obligation to maintain an on-call list from the EMTALA regulations at § 489.24(j)(1) to the regulations implementing provider agreements at § 489.20(r)(2). We agree with the TAG’s recommendation. The requirement to maintain an on-call list is found at section 1866(a)(1)(I)(iii) of the Act, the section of the Act that refers to provider agreements. Section 1867 of the Act, which outlines the EMTALA requirements, makes no mention of the requirement to maintain an on-call list. To implement the EMTALA TAG’s recommendation, we are proposing to delete the provision relating to maintaining a list of on-call physicians from § 489.24(j)(1). We note that a provision for an on-call physician list is already included in the regulations as a hospital provider agreement requirement at § 489.20(r)(2). We are proposing to incorporate the language of § 489.24(j)(1) as replacement language for the existing § 489.20(r)(2) and amend the regulatory language to make it more consistent with the statutory language found at section 1866(a)(1)(I)(iii) of the Act. Proposed revised § 489.20(r)(2) would read: ‘‘An on-call list of physicians on its medical staff available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services required under § 489.24 in accordance with the resources available to the hospital; and’’. These proposed changes would make the regulations consistent with the statutory basis for maintaining an on-call list. The EMTALA TAG made additional recommendations regarding how a hospital would satisfy its on-call list VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 obligations, including calling for an annual plan by the hospital and medical staff for on-call coverage that would include an assessment of factors such as the hospital’s capabilities and services, community need for emergency department services as indicated by emergency department visits, emergent transfers, physician resources, and past performance of previous on-call plans. The TAG also recommended that a hospital have a backup plan for viable patient care options when an on-call physician is not available, including such factors as telemedicine, other staff physicians, transfer agreements, and regional or community call arrangements. While community call arrangements are discussed below, we intend to address the remainder of the TAG recommendations at a later date. b. Shared/Community Call As noted in the previous section, section 1866(a)(1)(I)(iii) of the Act states, as a requirement for participation in the Medicare program, that a hospital must keep a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition. If a physician on the list is called by a hospital to provide stabilizing treatment and either fails or refuses to appear within a reasonable period of time, the hospital and that physician may be in violation of EMTALA as provided for under section 1867(d)(1)(C) of the Act. Thus, hospitals are required to maintain a list of on-call physicians, and physicians or hospitals, or both, may be held responsible under the EMTALA statute if a physician who is on call fails or refuses to appear within a reasonable period of time. In the May 9, 2002 proposed rule (67 FR 31471), we stated that we were aware of hospitals’ increasing concerns regarding their physician on-call requirements. Specifically, we noted that we were aware of reports of physicians, particularly specialty physicians, severing their relationships with hospitals because of on-call obligations, especially when those physicians belong to more than one hospital medical staff. We further noted that physician attrition from these medical staffs could result in hospitals having no specialty physician service coverage for their patients. In the September 9, 2003 final rule (68 FR 53264), we clarified the regulations at § 489.24(j) to permit on-call physicians to schedule elective surgery during the time that they are on call and to permit on-call physicians to have simultaneous on-call duties. We also specified that PO 00000 Frm 00145 Fmt 4701 Sfmt 4702 23671 physicians, including specialists and subspecialists, are not required to be on call at all times, and that the hospital must have policies and procedures to be followed when a particular specialty is not available or the on-call physician cannot respond because of situations beyond his or her control. We expected these clarifications would help to improve access to physician services for all hospital patients by permitting hospitals flexibility to determine how best to maximize their available physician resources. Furthermore, we expected that these clarifications would permit hospitals to continue to attract physicians to serve on their medical staffs, thereby continuing to provide services to all patients, including those individuals who are covered by EMTALA. As part of its recommendations concerning physician on-call requirements, the EMTALA TAG recommended that hospitals be permitted to participate in ‘‘community call.’’ Specifically, the language of the recommendation states: ‘‘The TAG recommends that CMS clarify its position regarding shared or community call: that such community call arrangements are acceptable if the hospitals involved have formal agreements recognized in their policies and procedures, as well as backup plans. It should also be clarified that a community call arrangement does not remove a hospital’s obligation to perform an MSE [medical screening examination].’’ The TAG also recommended in a subsequent recommendation that ‘‘A hospital may satisfy its on-call coverage obligation by participation in an approved community/regional call coverage program. (CMS to determine appropriate approval process).’’ We believe that community call (as described below) would afford additional flexibility to hospitals providing on-call services and improve access to specialty physician services for individuals in an emergency department. Therefore, we are proposing to amend our regulations at § 489.24(j) to provide that hospitals may comply with the on-call list requirement specified at § 489.20(r)(2) (under our proposed revision), by participating in a formal community call plan so long as the plan meets the elements outlined below. We are further proposing to revise the regulations to state that, notwithstanding participation in a community call plan, hospitals are still required to perform medical screening examinations on individuals who present seeking treatment and to E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23672 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules provide for an appropriate transfer when appropriate. We propose ‘‘community call,’’ to be a formal on-call plan that permits a specific hospital in a region to be designated as the on-call facility for a specific time period, or for a specific service, or both. For example, if there are two hospitals that choose to participate in community call, Hospital A could be designated as the on-call facility for the first 15 days of each month and Hospital B could be designated as the on-call facility for the rest of each month. Alternatively, Hospital A could be designated as oncall for cases requiring specialized interventional cardiac care, while Hospital B could be designated as oncall for neurosurgical cases. We anticipate that hospitals and their communities would have the flexibility to develop a plan that reflects their local resources and needs. Such a community on-call plan will allow various physicians in a certain specialty in the aggregate to be on continuous call (24 hours a day, 7 days a week), without putting a continuous call obligation on any one physician. We note that generally if an individual arrives at a hospital other than the designated oncall facility, is determined to have an unstabilized emergency medical condition, and requires the services of an on-call specialist, the individual would be transferred to the designated on-call facility in accordance with the community call plan. As noted above, we are proposing that a community call plan must be a formal plan among the participating hospitals. While we do not believe it is necessary for the formal community call plan to be subject to preapproval by CMS, if an EMTALA complaint investigation is initiated, the plan will be subject to review and enforcement by CMS. We are proposing that, at a minimum, hospitals must include the following elements when devising a formal community call plan: • The community call plan would include a clear delineation of on-call coverage responsibilities, that is, when each hospital participating in the plan is responsible for on-call coverage. • The community call plan would define the specific geographic area to which the plan applies. • The community call plan would be signed by an appropriate representative of each hospital participating in the plan. • The community call plan would ensure that any local and regional EMS system protocol formally includes information on community on-call arrangements. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 • Hospitals participating in the community call plan would engage in an analysis of the specialty on-call needs of the community for which the plan is effective. • The community call plan would include a statement specifying that even if an individual arrives at the hospital that is not designated as the on-call hospital, that hospital still has an EMTALA obligation to provide a medical screening examination and stabilizing treatment within its capability, and hospitals participating in community call must abide by the EMTALA regulations governing appropriate transfers. • There would be an annual reassessment of the community call plan by the participating hospitals. Proposed revised § 489.24(j) would read ‘‘Availability of on-call physicians. In accordance with the on-call list requirements specified in § 489.20(r)(2), a hospital must have written policies and procedures in place—(1) To respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control; and (2) To provide that emergency services are available to meet the needs of individuals with emergency medical conditions if a hospital elects to—(i) Permit on-call physicians to schedule elective surgery during the time that they are on call; (ii) Permit on-call physicians to have simultaneous on-call duties; and (iii) Participate in a formal community call plan. Notwithstanding participation in a community call plan, hospitals are still required to perform medical screening examinations on individuals who present seeking treatment and to conduct appropriate transfers. The formal community call plan must include the following elements: [proposed elements noted above in the bullets are included in regulations text].’’ We welcome public comments on the proposed elements of the formal community call plan noted above. We are also soliciting public comments on whether individuals believe it is important that, in situations where there is a governing State or local agency that would have authority over the development of a formal community call plan, the plan be approved by that agency. In summary, we are proposing that, as part of the obligation to have an on-call list, hospitals may choose to participate in community call, provided that the formal community call plan includes, at a minimum, the elements noted in bullets above. Additionally, each hospital participating in the PO 00000 Frm 00146 Fmt 4701 Sfmt 4702 community call plan must have written policies and procedures in place to respond to situations in which the oncall physician is unable to respond due to situations beyond his or her control. We are further proposing that a hospital would still be responsible for performing medical screening examinations on individuals who present to the hospital seeking treatment and conducting appropriate transfers, regardless of which hospital has on-call responsibilities on a particular day. 5. Proposed Technical Change to Regulations In the FY 2008 IPPS final rule with comment period (72 FR 47413), we revised § 489.24(a)(2) (which refers to the nonapplicability of the EMTALA provisions in an emergency area during an emergency period) to conform it to the changes made to section 1135 of the Act by the Pandemic and All-Hazards Preparedness Act. When we made the change to the regulations, we inadvertently left out language consistent with the following statutory language found in section 1135: ‘‘pursuant to an appropriate State emergency preparedness plan; or in the case of a public health emergency described in subsection (g)(1)(B) that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan or a plan referred to in clause (i), whichever is applicable in the State.’’ We also inadvertently left out the phrase in section 1135 ‘‘during an emergency period’’ when we state the nonapplicability of the sanctions in an emergency area. We are proposing to revise the language at § 489.24(a)(2) to include the aforementioned language to conform the regulation text to the statutory language. Proposed revised § 489.24(a)(2) would read as follows: ‘‘Nonapplicability of provisions of this section. Sanctions under this section for an inappropriate transfer during a national emergency or for the direction or relocation of an individual to receive medical screening at an alternate location pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan do not apply to a hospital with a dedicated emergency department located in an emergency area during an emergency period, as specified in section 1135(g)(1) of the Act. A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided for by section 1135(e)(1)(B) of the Act.’’ jlentini on PROD1PC65 with PROPOSALS2 J. Application of Incentives To Reduce Avoidable Readmissions to Hospitals 1. Introduction A significant portion of Medicare spending—$15 billion each year—is related to hospital readmissions. According to a 2005 MedPAC analysis ,17 nearly 18 percent of beneficiaries who are discharged from the hospital are readmitted within 30 days, resulting in approximately 2 million readmissions. By MedPAC’s method, over 13 percent of 30-day hospital readmissions and an associated $12 billion in spending (4⁄5 of all Medicare spending for readmissions) were found to be potentially avoidable. Beyond cost considerations, readmissions may reflect poor quality of care and affect beneficiaries’’ quality of life. Though not all readmissions are avoidable, hospitals should share accountability for readmission rates that could be much lower through the application of evidence-based best practices. Interventions that have been shown to reduce readmissions include better quality of care during the hospitalization, more complete care plans, emphasis on coordination of care at the point of transitions to home or postacute care, better use of afterhospital care, and more active involvement of patients and caregivers in decision making. The application of incentives to reduce hospital readmissions, including payment and public reporting approaches, could promote the adoption and development of best practice interventions for averting avoidable readmissions, resulting in higher quality of care for Medicare beneficiaries and reduction in unnecessary costs for the program. Under the current payment system, readmissions are financially rewarding for hospitals. Application of payment incentives to encourage reduction of avoidable readmissions could help address unintended incentives in the current payment system. In this section, following discussion of readmission issues related to measurement, accountability, and interventions, we are presenting three approaches to applying incentives to reduce avoidable readmissions for public comment: (1) Direct adjustment 17 Medicare Payment Advisory Commission: Report to Congress: Promoting Greater Efficiency in Medicare. June 2007, Chapter 5, page 103. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 to hospital DRG payments for avoidable readmissions, (2) adjustments to hospital DRG payments through a performance-based payment methodology, and (3) public reporting of readmission rates. We note that either type of adjustment to hospital payments for readmissions would likely require new statutory authority for the Medicare program. We are seeking public comments on all of the ideas presented in this section. 2. Measurement Routine, valid, and reliable measurement of hospital-specific rates of readmissions would be a prerequisite to any method of applying incentives for reducing hospital readmissions. Measurement data should be meaningful and actionable for hospitals and should be fair to encourage trust and engagement in the effort. Risk adjustment of measurement data is necessary to account for patientπspecific factors that influence the likelihood of readmission, such as age, disease severity, and comorbidities. Another important consideration in measurement of readmission rates is the time period from discharge to readmission (for example, 7, 15, 30, or 90 days). In section IV.B. of the preamble of this proposed rule, measures of risk-adjusted 30-day readmission rates are proposed for the RHQDAPU program. The 9th Scope of Work for Medicare Quality Improvement Organizations (QIO 9th SOW) also includes 30-day readmission measures for communities. Measures should be aligned across settings of care. Hospitals are not the only providers that affect the occurrence of readmissions. For example, the care delivered by SNFs and HHAs also has an important impact on whether a beneficiary is readmitted. Data from aligned readmissions measures, applicable to various settings of care, would provide better information about care coordination problems within and between settings. Alignment of readmissions measures would also facilitate more powerful application of incentives across Medicare’s payment systems. Another consideration is whether to focus on all readmissions or to focus on those that are known to be higher cost, more easily preventable, or most frequently occurring. For example, numerous hospitals have successfully implemented programs to reduce readmissions of heart failure patients, so more is known about the prevention of heart failure readmissions. Further, heart failure readmissions may be more costly than readmissions for other PO 00000 Frm 00147 Fmt 4701 Sfmt 4702 23673 conditions. Another focus of efforts to prevent readmissions could be patients with multiple chronic conditions, who may be at the highest risk to experience readmissions. 3. Accountability In the assignment of accountability for readmissions, risk adjustment of measurement data is one consideration of fairness; however, other factors must also be considered, including avoidability and shared accountability. Most clinicians would agree that a goal of zero readmissions may not be appropriate, as an extremely low rate of readmissions could indicate restricted access to needed medical services, overuse of hospital resources during the initial hospitalization (for example, prolonged length of stay), or excessive intensity of post-acute care services. Adequate risk adjustment could help to elucidate the avoidability of readmissions by identifying an expected readmission rate for a given patient or patient population. Shared accountability is another important consideration. Hospitals are clearly accountable for the care provided during hospitalization and can also affect the quality of care provided after the hospitalization, but hospitals are not the only accountable entity. Both during and after hospitalization, physicians and other health professionals share accountability for the quality of care. Other provider entities, including skilled nursing facilities, rehabilitation facilities, home health agencies, and end-stage renal disease facilities, also share accountability for avoidable readmissions. Medicare beneficiaries themselves and their caregivers and social support systems play important roles in avoiding readmissions, particularly when beneficiaries have been discharged to home. Assignment of accountability also requires consideration of situations where the patient presents for readmission with a different diagnosis or presents to a different hospital. If the 18 Coleman, E.A., C. Parry, S. Chalmers, et al. 2006. The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166 (September 25): 1822–1828. 19 Coleman, E.A., J.D. Smith, R. Devbani, et al. 2005. Posthospital medication discrepancies: Prevalence and contributing factors. Archives of Internal Medicine 165, (September 12): 1842–1847. 20 Coleman, E., and R. Berenson. 2004. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine, 141, no. 7 (October 5): 533– 536. 21 Institute for Healthcare Improvement. 2004a. Reducing readmissions for heart failure patients: E:\FR\FM\30APP2.SGM Continued 30APP2 23674 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Demonstration and have contributed to improvements in the quality and costefficiency of care provided to Medicare beneficiaries. For example, the University of Michigan Faculty Group Practice’s transitional care call-back program contacts Medicare patients discharged from the emergency department and acute care hospital to address gaps in care during the transition between care settings. The program provides short-term care 4. Interventions coordination with linkages to visiting A number of interventions have been nurse and community services, as well identified as best practices for averting as coordination with primary care and avoidable specialty clinics. The Everett Clinic readmissions.18,19,20,21,22,23,24,25,26 Some utilizes hospital coaches to guide patients and caregivers through of these evidence-based interventions complicated care processes during are listed below: • Better, safer care during the hospital stays and on discharge. The hospitalization. clinic proactively reaches out to • Improved communication among recently hospitalized patients to assure providers and with the patient and that they have a physician followup caregivers. visit within 10 days after discharge to • Care planning that begins with address any unresolved or new health assessment at admission. problems. • Clear discharge instructions, with CMS is considering strategies for specific attention to medication distributing a discharge checklist that management. the agency developed to help • Shared accountability for care beneficiaries and their caregivers coordination, with attention to prepare for discharge from a hospital or transitions and hand-offs. nursing home. The checklist includes a • Discharge to a proper setting of range of issues to consider and address care. with physicians and other health care • Better, safer care in the post-acute providers to facilitate a smooth setting of care. transition to home or postacute care • Appropriate use of palliative care setting. In addition, the checklist and honest planning for the likely provides information about supportive course. home and community-based services. • Timely physician follow up visits. The QIO 9th SOW includes a theme • Active involvement of patients and entitled Patient Pathways (Care their caregivers. Transitions). The goal of this theme is Interventions such as these have been to measurably improve the quality of employed by several participants in care for Medicare beneficiaries who CMS Physician Group Practice transition among care settings, resulting in reduced readmissions and replicable Hackensack University Medical Center. Available at strategies to sustain reduced https://www.ihi.org. readmission rates. The QIO 8th SOW 22 Institute for Healthcare Improvement. 2004b. included initiatives to reduce avoidable The MedProvider inpatient care unit-congestive heart failure project. Available at: https:// readmissions of home health patients. jlentini on PROD1PC65 with PROPOSALS2 locus of accountability were at the hospital level, a second hospital should not be held accountable for a readmission resulting from a first hospital’s lack of adherence to evidencebased best practices for averting readmissions. If the locus of accountability were at the community level, then shared accountability could encourage hospitals to work together to reduce readmissions. www.ihi.org. 23 Lappe, J.M., J.B. Muhlestein, D.L. Lappe, et al. 2004. Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program. Annals of Internal Medicine, 141, no.6 (September 21): 446–453. 24 Naylor, M.D., D. Brooton, R. Campbell, et al. 1999. Comprehensive discharge planning and home follow-up of hospitalized elders. Journal of the American Medical Association, 281, no.7 (February 17): 613–620. 25 VanSuch, M., J.M. Naessens, R.J. Stroebel, et al. 2006. Effect of discharge instructions on readmission of hospitalized patients with heart failure: Do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care? Quality and Safety in Healthcare, 15: 414–417. 26 Weinberg D.B., J.H. Gittell, R.W. Lusenhop, et al. 2007. Beyond our walls: Impact of patient and provider coordination across the continuum on outcomes for surgical patients. Health Services Research, 42, no. 1, pt. 1 (February): 7–24. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 5. Financial Incentive: Direct Payment Adjustment The first of three approaches presented for comment is direct adjustment to hospital DRG payments for readmissions. This approach would likely require new statutory authority for the Medicare program. In section II.F. of the preamble of this proposed rule, we discuss direct adjustments to MS–DRG payment for selected preventable HACs. Similarly, a payment adjustment could be applied for readmissions determined to be avoidable because the hospital did not follow evidence-based best practices for averting readmissions. The magnitude of the payment adjustment could be PO 00000 Frm 00148 Fmt 4701 Sfmt 4702 based on patient-specific risk factors and on the apportionment of shared accountability among the involved entities. A variation of this approach could be adjustment of all hospital payments for readmissions, nationwide or by some regional designation, based on aggregate information about avoidable readmissions for the entire relevant Medicare population (national or regional) under typical circumstances. Under this approach, hospitals would receive less Medicare payment for readmissions for conditions with lower expected rates of readmission and less shared accountability. Potential unintended consequences resulting from a financial incentive to avert readmissions also need to be considered. For example, hospitals could begin discharging patients to settings that provide more intensive postacute care to avoid readmissions, thereby potentially driving up total costs for episodes of care and total Medicare spending. As another example of potential unintended consequences, hospitals could begin to resist medically necessary readmissions from postacute care providers, creating an access problem. 6. Financial Incentive: PerformanceBased Payment Adjustment The second approach presented for comment is adjustment to hospital MS– DRG payments using a performancebased payment methodology, such as the Medicare Hospital VBP Plan referenced in section IV.C. of the preamble of this proposed rule and available at: https://www.cms.hhs.gov/ AcuteInpatientPPS/downloads/ HospitalVBPPlan RTCFINALSUBMITTED2007.pdf. The intent of the VBP Plan methodology is to promote adherence to evidence-based best practices in the delivery of care and to provide rewards for those who are successful in improving their measured performance. Implementation of the VBP methodology would require new statutory authority for the Medicare program. Under the VBP Plan, measures of clinical processes of care, patient experience (HCAHPS), and outcomes (30-day mortality) would be scored and translated into an incentive payment. These measures of process, outcome, and patient-centeredness address areas of quality that are important to reducing readmissions; however, other measures could be added to more fully adjust payments for readmissions. Direct measures of hospital-specific, risk adjusted readmission rates could be included in the VBP Plan performance E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules assessment model. In addition, other measures of care coordination that indirectly address readmissions could also be included. The direct adjustment approach and the VBP Plan approaches for applying financial incentives to the reduction of avoidable readmissions could be implemented separately or in combination. 7. Nonfinancial Incentive: Public Reporting A third approach presented for comment is public reporting of hospitalspecific, risk adjusted readmission rates. The Administration’s Value-Driven Health Care initiative, which stems from the President’s Executive Order Promoting Quality and Efficient Health Care in Federal Government Health Care Programs, calls for Federal agencies to make health care quality and cost information more transparent. Health care consumers, including Medicare beneficiaries, and their providers and caregivers need better information to support more informed decision making about their care. The public reporting of readmission rates would likely not require new statutory authority for the Medicare program. The Hospital Compare Web site could be used to report readmission rates along with the other quality and cost of care parameters displayed on that site. Public reporting has been demonstrated to be a strong non-financial incentive with a competitive effect, as hospitals appropriately focus on maintaining and enhancing their reputations as providers of high quality of care. The VBP Plan envisions public reporting in concert with the VBP financial incentive, but the public reporting incentive could be applied regardless of statutory authority to implement the VBP Plan. jlentini on PROD1PC65 with PROPOSALS2 8. Conclusion The purpose of this section is to solicit and encourage public comments on considerations and options for applying incentives to reduce avoidable hospital readmissions. We welcome public comments on readmission issues related to measurement, accountability, and interventions, as well as on potential approaches to applying financial and nonfinancial incentives to reduce avoidable readmissions. K. Rural Community Hospital Demonstration Program In accordance with the requirements of section 410A(a) of Pub. L. 108–173, the Secretary has established a 5-year demonstration program (beginning with selected hospitals’ first cost reporting period beginning on or after October 1, VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 2004) to test the feasibility and advisability of establishing ‘‘rural community hospitals’’ for Medicare payment purposes for covered inpatient hospital services furnished to Medicare beneficiaries. A rural community hospital, as defined in section 410A(f)(1), is a hospital that— • Is located in a rural area (as defined in section 1886(d)(2)(D) of the Act) or is treated as being located in a rural area under section 1886(d)(8)(E) of the Act; • Has fewer than 51 beds (excluding beds in a distinct part psychiatric or rehabilitation unit) as reported in its most recent cost report; • Provides 24-hour emergency care services; and • Is not designated or eligible for designation as a CAH. Section 410A(a)(4) of Pub. L. 108–173 states that no more than 15 such hospitals may participate in the demonstration program. As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in accordance with sections 410A(a)(2) and (a)(4) of Pub. L. 108–173 and using 2002 data from the U.S. Census Bureau, we identified 10 States with the lowest population density from which to select hospitals: Alaska, Idaho, Montana, Nebraska, Nevada, New Mexico, North Dakota, South Dakota, Utah, and Wyoming (Source: U.S. Census Bureau Statistical Abstract of the United States: 2003). Nine rural community hospitals located within these States are currently participating in the demonstration program. (Of the 13 hospitals that participated in the first 2 years of the demonstration program, 4 hospitals located in Nebraska have become CAHs and have withdrawn from the program.) In a notice published in the Federal Register on February 6, 2008 (73 FR 6971 through 6973), we announced a solicitation for up to six additional hospitals to participate in the demonstration program. Hospitals that enter the demonstration under this solicitation will be able to participate for no more than 2 years. The February 6, 2008 notice specifies the eligibility requirements for the demonstration program. Under the demonstration program, participating hospitals are paid the reasonable costs of providing covered inpatient hospital services (other than services furnished by a psychiatric or rehabilitation unit of a hospital that is a distinct part), applicable for discharges occurring in the first cost reporting period beginning on or after the October 1, 2004 implementation date of the demonstration program. Payments to the participating hospitals will be the lesser amount of the PO 00000 Frm 00149 Fmt 4701 Sfmt 4702 23675 reasonable cost or a target amount in subsequent cost reporting periods. The target amount in the second cost reporting period is defined as the reasonable costs of providing covered inpatient hospital services in the first cost reporting period, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period. The target amount in subsequent cost reporting periods is defined as the preceding cost reporting period’s target amount, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period. Covered inpatient hospital services are inpatient hospital services (defined in section 1861(b) of the Act), and include extended care services furnished under an agreement under section 1883 of the Act. Section 410A of Pub. L. 108–173 requires that, ‘‘in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.’’ Generally, when CMS implements a demonstration program on a budget neutral basis, the demonstration program is budget neutral in its own terms; in other words, the aggregate payments to the participating providers do not exceed the amount that would be paid to those same providers in the absence of the demonstration program. This form of budget neutrality is viable when, by changing payments or aligning incentives to improve overall efficiency, or both, a demonstration program may reduce the use of some services or eliminate the need for others, resulting in reduced expenditures for the demonstration program’s participants. These reduced expenditures offset increased payments elsewhere under the demonstration program, thus ensuring that the demonstration program as a whole is budget neutral or yields savings. However, the small scale of this demonstration program, in conjunction with the payment methodology, makes it extremely unlikely that this demonstration program could be viable under the usual form of budget neutrality. Specifically, cost-based payments to participating small rural hospitals are likely to increase Medicare outlays without producing any offsetting reduction in Medicare expenditures elsewhere. Therefore, a rural community hospital’s E:\FR\FM\30APP2.SGM 30APP2 23676 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules participation in this demonstration program is unlikely to yield benefits to the participant if budget neutrality were to be implemented by reducing other payments for these providers. In order to achieve budget neutrality for this demonstration program for FY 2009, we are proposing to adjust the national inpatient PPS rates by an amount sufficient to account for the added costs of this demonstration program. We are proposing to apply budget neutrality across the payment system as a whole rather than merely across the participants in this demonstration program. As we discussed in the FY 2005, FY 2006, FY 2007 and FY 2008 IPPS final rules (69 FR 49183; 70 FR 47462; 71 FR 48100; and 72 FR 47392), we believe that the language of the statutory budget neutrality requirements permits the agency to implement the budget neutrality provision in this manner. For FY 2009, using data from the cost reports from each of the nine hospitals’ first year of participation in the demonstration program, that is, cost reports for years beginning in CY 2005, and estimating the cost of six additional hospitals based on these data, we estimate that the additional cost would be $32,011,849. (In the final rule, we should know the exact number of hospitals participating in the demonstration program and would revise our estimates accordingly.) This estimated adjusted amount reflects the estimated difference between the participating hospitals costs and the IPPS payment based on data from the hospitals’ cost reports. We discuss the payment rate adjustment that is required to ensure the budget neutrality of the demonstration program for FY 2009 in section II.A.4. of the Addendum to this proposed rule. jlentini on PROD1PC65 with PROPOSALS2 V. Proposed Changes to the IPPS for Capital-Related Costs A. Background Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient acute hospital services ‘‘in accordance with a prospective payment system established by the Secretary.’’ Under the statute, the Secretary has broad authority in establishing and implementing the IPPS for acute care hospital inpatient capitalrelated costs. We initially implemented the IPPS for capital-related costs in the Federal fiscal year (FY) 1992 IPPS final rule (56 FR 43358), in which we established a 10-year transition period to change the payment methodology for Medicare hospital inpatient capitalrelated costs from a reasonable cost- VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 based methodology to a prospective methodology (based fully on the Federal rate). FY 2001 was the last year of the 10year transition period established to phase in the IPPS for hospital inpatient capital-related costs. For cost reporting periods beginning in FY 2002, capital IPPS payments are based solely on the Federal rate for most acute care hospitals (other than hospitals receiving certain exception payments and certain new hospitals). The basic methodology for determining capital prospective payments using the Federal rate is set forth in § 412.312. For the purpose of calculating payments for each discharge, the standard Federal rate is adjusted as follows: (Standard Federal Rate) × (DRG Weight) × (Geographic Adjustment Factor (GAF)) × (Large Urban Add-on, if applicable) × (COLA for hospitals located in Alaska and Hawaii) × (1 + Capital DSH Adjustment Factor + Capital IME Adjustment Factor, if applicable). Hospitals also may receive outlier payments for those cases that qualify under the threshold established for each fiscal year as specified in § 412.312(c) of the regulations. 1. Exception Payments The regulations at § 412.348(f) provide that a hospital may request an additional payment if the hospital incurs unanticipated capital expenditures in excess of $5 million due to extraordinary circumstances beyond the hospital’s control. This policy was originally established for hospitals during the 10-year transition period, but as we discussed in the FY 2003 IPPS final rule (67 FR 50102), we revised the regulations at § 412.312 to specify that payments for extraordinary circumstances are also made for cost reporting periods after the transition period (that is, cost reporting periods beginning on or after October 1, 2001). Additional information on the exception payment for extraordinary circumstances in § 412.348(f) can be found in the FY 2005 IPPS final rule (69 FR 49185 and 49186). During the transition period, under §§ 412.348(b) through (e), eligible hospitals could receive regular exception payments. These exception payments guaranteed a hospital a minimum payment percentage of its Medicare allowable capital-related costs depending on the class of the hospital (§ 412.348(c)), but were available only during the 10-year transition period. After the end of the transition period, eligible hospitals can no longer receive this exception payment. However, even PO 00000 Frm 00150 Fmt 4701 Sfmt 4702 after the transition period, eligible hospitals receive additional payments under the special exceptions provisions at § 412.348(g), which guarantees all eligible hospitals a minimum payment of 70 percent of its Medicare allowable capital-related costs provided that special exceptions payments do not exceed 10 percent of total capital IPPS payments. Special exceptions payments may be made only for the 10 years from the cost reporting year in which the hospital completes its qualifying project, and the hospital must have completed the project no later than the hospital’s cost reporting period beginning before October 1, 2001. Thus, an eligible hospital may receive special exceptions payments for up to 10 years beyond the end of the capital IPPS transition period. Hospitals eligible for special exceptions payments are required to submit documentation to the intermediary indicating the completion date of their project. (For more detailed information regarding the special exceptions policy under § 412.348(g), we refer readers to the FY 2002 IPPS final rule (66 FR 39911 through 39914) and the FY 2003 IPPS final rule (67 FR 50102).) 2. New Hospitals Under the IPPS for capital-related costs, § 412.300(b) of the regulations defines a new hospital as a hospital that has operated (under current or previous ownership) for less than 2 years. (For more detailed information, we refer readers to the FY 1992 IPPS final rule (56 FR 43418).) During the 10-year transition period, a new hospital was exempt from the capital IPPS for its first 2 years of operation and was paid 85 percent of its reasonable costs during that period. Originally, this provision was effective only through the transition period and, therefore, ended with cost reporting periods beginning in FY 2002. Because, as discussed in the FY 2003 IPPS final rule (67 FR 50101), we believe that special protection to new hospitals is also appropriate even after the transition period, we revised the regulations at § 412.304(c)(2) to provide that, for cost reporting periods beginning on or after October 1, 2002, a new hospital (defined under § 412.300(b)) is paid 85 percent of its Medicare allowable capital-related costs through its first 2 years of operation, unless the new hospital elects to receive fully prospective payment based on 100 percent of the Federal rate. (We refer readers to the FY 2002 IPPS final rule (66 FR 39910) for a detailed discussion of the statutory basis for the system, the development and evolution of the system, the methodology used to E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules determine capital-related payments to hospitals both during and after the transition period, and the policy for providing exception payments.) jlentini on PROD1PC65 with PROPOSALS2 3. Hospitals Located in Puerto Rico Section 412.374 provides for the use of a blended payment amount for prospective payments for capital-related costs to hospitals located in Puerto Rico. Accordingly, under the capital IPPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capitalrelated costs. In general, hospitals located in Puerto Rico are paid a blend of the applicable capital IPPS Puerto Rico rate and the applicable capital IPPS Federal rate. Prior to FY 1998, hospitals in Puerto Rico were paid a blended capital IPPS rate that consisted of 75 percent of the capital IPPS Puerto Rico specific rate and 25 percent of the capital IPPS Federal rate. However, effective October 1, 1997 (FY 1998), in conjunction with the change to the operating IPPS blend percentage for hospitals located in Puerto Rico required by section 4406 of Pub. L. 105–33, we revised the methodology for computing capital IPPS payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the capital IPPS Puerto Rico rate and 50 percent of the capital IPPS Federal rate. Similarly, in conjunction with the change in operating IPPS payments to hospitals located in Puerto Rico for FY 2005 required by section 504 of Pub. L. 108–173, we again revised the methodology for computing capital IPPS payments to hospitals located in Puerto Rico to be based on a blend of 25 percent of the capital IPPS Puerto Rico rate and 75 percent of the capital IPPS Federal rate effective for discharges occurring on or after October 1, 2004. B. Revisions to the Capital IPPS Based on Data on Hospital Medicare Capital Margins As noted above, under the Secretary’s broad authority under the statute in establishing and implementing the IPPS for hospital inpatient capital-related costs, we have established a standard Federal payment rate for capital-related costs, as well as the mechanism for updating that rate each year. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the IPPS by updating the FY 1989 Medicare inpatient capital cost per case by an actuarial estimate of the increase in Medicare inpatient capital costs per case. Each year after FY 1992, we update the capital standard Federal rate, as provided at § 412.308(c)(1), to VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 account for capital input price increases and other factors. The regulations at § 412.308(c)(2) provide that the capital Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the capital Federal rate to total capital payments under the capital Federal rate. In addition, § 412.308(c)(3) requires that the capital Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for (regular and special) exceptions under § 412.348. Section 412.308(c)(4)(ii) requires that the capital standard Federal rate be adjusted so that the effects of the annual DRG reclassification and the recalibration of DRG weights, and changes in the geographic adjustment factor are budget neutral. In the FY 2008 IPPS final rule with comment period (72 FR 47398 through 47401), based on our analysis of data on inpatient hospital Medicare capital margins that we obtained through our monitoring and comprehensive review of the adequacy of the standard Federal payment rate for capital-related costs and the updates provided under the existing regulations, we made changes in the payment structure under the capital IPPS beginning with FY 2008. We summarize these changes below. We refer readers to section V.B. of the preamble of the FY 2008 final rule with comment period (72 FR 47393 through 47401) for a detailed discussion of the data used as a basis for these changes. These data showed that hospital inpatient Medicare capital margins were very high across all hospitals during the period from FY 1996 through FY 2004. In the FY 2008 IPPS final rule with comment period, as background, we noted that, in general, under a PPS, standard payment rates should reflect the costs that an average, efficient provider would bear to provide the services required for quality patient care. Payment rate updates should also account for the changes necessary to continue providing such services. Updates should reflect, for example, the increased costs that are necessary to provide for the introduction of new technology that improves patient care. Updates should also take into account the productivity gains that, over time, allow providers to realize the same, or even improved, quality outcomes with reduced inputs and lower costs. Hospital margins, the difference between the costs of actually providing services and the payments received under a particular system, thus provide some evidence concerning whether payment rates have been established and updated at an appropriate level over time for efficient providers to provide PO 00000 Frm 00151 Fmt 4701 Sfmt 4702 23677 necessary services. All other factors being equal, sustained substantial positive margins demonstrate that payment rates and updates have exceeded what is required to provide those services. It is to be expected, under a PPS, that highly efficient providers might regularly realize positive margins, while less efficient providers might regularly realize negative margins. However, a PPS that is correctly calibrated should not necessarily experience sustained periods in which providers generally realize substantial positive Medicare margins. Under the capital IPPS in particular, it seems especially appropriate that there should not be sustained significant positive margins across the system as a whole. Prior to the implementation of the capital IPPS, Congress mandated that the Medicare program pay only 85 percent of hospitals’ inpatient Medicare capital costs. During the first 5 years of the capital IPPS, Congress also mandated a budget neutrality adjustment, under which the standard Federal capital rate was set each year so that payments under the system as a whole equaled 90 percent of estimated hospitals’ inpatient Medicare capital costs for the year. Finally, Congress has twice adjusted the standard Federal capital rate (a 7.4 percent reduction beginning in FY 1994, followed by a 17.78 percent reduction beginning in FY 1998). On the second occasion in particular, the specific congressional mandate was ‘‘to apply the budget neutrality factor used to determine the Federal capital payment rate in effect on September 30, 1995 * * * to the unadjusted standard Federal capital payment rate’’ for FY 1998 and beyond. (The designated budget neutrality factor constituted a 17.78 percent reduction.) This statutory language indicates that Congress considered the payment levels in effect during FYs1992 through 1995, established under the budget neutrality provision to pay 90 percent of hospitals’ inpatient Medicare capital costs in the aggregate, appropriate for the capital IPPS. The statutory history of the capital IPPS thus suggests that the system in the aggregate should not provide for continuous, large positive margins. As we also discussed in the FY 2008 IPPS final rule with comment period, we believed that there could be a number of reasons for the relatively high margins that most IPPS hospitals have realized under the capital IPPS. One possibility is that the updates to the capital IPPS rates have been higher than the actual increases in Medicare inpatient capital costs that hospitals E:\FR\FM\30APP2.SGM 30APP2 23678 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules have experienced in recent years. Another possible reason for the relatively high margins of most capital IPPS hospitals may be that the payment adjustments provided under the system are too high, or perhaps even unnecessary. Specifically, the adjustments for teaching hospitals, disproportionate share hospitals, and large urban hospitals appear to be contributing to excessive payment levels for these classes of hospitals. Since the inception of the capital IPPS in FY 1992, the system has provided adjustments for teaching hospitals (the IME adjustment factor, under § 412.322 of the regulations), disproportionate share hospitals (the DSH adjustment factor, under § 412.320), and large urban hospitals (the large urban location adjustment factor, under § 412.316(b)). The classes of hospitals eligible for these adjustments have been realizing much higher margins than other hospitals under the system. Specifically, teaching hospitals (11.6 percent for FYs 1998 through 2004), disproportionate share hospitals (8.4 percent), and urban hospitals (8.3 percent) have had significant positive margins. Other classes of hospitals have experienced much lower margins, especially rural hospitals (0.3 percent for FYs 1998 through 2004) and nonteaching hospitals (1.3 percent). The three groups of hospitals that have been realizing especially high margins under the capital IPPS are, therefore, classes of hospitals that are eligible to receive one or more specific payment adjustment under the system. We believed that the evidence indicates that these adjustments have been contributing to the significantly large positive margins experienced by the classes of hospitals eligible for these adjustments. Therefore, in the FY 2008 IPPS final rule with comment period, we made two changes to the structure of payments under the capital IPPS, as discussed under items 1. and 2. below. 1. Elimination of the Large Add-On Payment Adjustment In the FY 2008 IPPS final rule with comment period, we determined that the data we had gathered on inpatient hospital Medicare capital margins provided sufficient evidence to warrant elimination of the large urban add-on payment adjustment starting in FY 2008 under the capital IPPS. Therefore, for FYs 2008 and beyond, we discontinued the 3.0 percent additional payment that had been provided to hospitals located in large urban areas (72 FR 24822). This decision was supported by comments from MedPAC. 2. Changes to the Capital IME Adjustment a. Background and Changes Made for FY 2008 In the FY 2008 IPPS proposed rule, we noted that margin analysis indicated that several classes of hospitals had experienced continuous, significant positive margins. The analysis indicated that the existing payment adjustments for teaching hospitals and disproportionate share hospitals were contributing to excessive payment levels for these classes of hospitals. Therefore, we stated that it may be appropriate to reduce these adjustments significantly, or even to eliminate them altogether, within the capital IPPS. These payment adjustments, unlike parallel adjustments under the operating IPPS, were not mandated by the Act. Rather, they were included within the original design of the capital IPPS under the Secretary’s broad authority in section 1886(g)(1) of the Act to include appropriate adjustments and exceptions within a capital IPPS. In the FY 2008 final rule with comment period, we also noted a MedPAC recommendation that we seriously reexamine the appropriateness of the existing capital IME adjustment, that the margin analysis indicated such adjustment may be too high, and that MedPAC’s previous analysis also suggested the adjustment may be too high. In light of MedPAC’s recommendation, we extended the margin analysis discussed in the FY 2008 IPPS proposed rule in order to distinguish the experience of teaching hospitals from the experience of urban and rural hospitals generally. Specifically, we isolated the margins of urban, large urban, and rural teaching hospitals, as opposed to urban, large urban, and rural nonteaching hospitals. In conducting this analysis, we employed updated cost report information, which allowed us to incorporate the margins for an additional year, FY 2005, into the analysis. The data on the experience of urban, large urban, and rural teaching hospitals as opposed to nonteaching hospitals provided significant new information. As the analysis demonstrated, teaching hospitals in each class (urban, large urban, and rural) performed significantly better than comparable nonteaching hospitals. For the period covering FYs 1998 through 2005, urban teaching hospitals realized aggregate positive margins of 11.9 percent, compared to a positive margin of 0.9 percent for urban nonteaching hospitals. Similarly, large urban teaching hospitals realized an aggregate positive margin of 12.8 percent during that period, while large urban nonteaching hospitals had an aggregate positive margin of only 2.9 percent. Finally, rural teaching hospitals experienced an aggregate positive margin of 4.5 percent, as compared to a negative 1.3 percent margin for nonteaching rural hospitals. We noted that the positive margins for teaching hospitals did not exhibit a decline to the same degree as the margins for all hospitals. For example, the positive margins for all IPPS hospitals declined from 8.7 percent in FY 2002 to 5.3 percent in FY 2004 and 3.7 percent in FY 2005. For urban hospitals, aggregate margins decreased from 10.3 percent in FY 2002 to 6.4 percent in FY 2004 and 4.8 percent in FY 2005. Rural hospitals experienced a decrease from 1.5 percent in FY 2001 to a negative margin of -4.2 percent in FY 2005. In comparison, the aggregate margin for teaching hospitals was 12.1 percent in FY 2001 and 10.6 percent in FY 2005. For urban teaching hospitals, margins were 12.5 percent in FY 2001, 14.0 percent in FY 2002, 13.6 percent in FY 2003, 11.9 percent in FY 2004, and 10.9 percent in FY 2005. Rural teaching hospital margins were more variable, but did not exhibit a pattern of significant decline. In FY 2001, rural teaching hospitals had a positive margin of 3.2 percent; in FY 2002, 8.2 percent; in FY 2003, 4.7 percent; in FY 2004, 5.7 percent; and in FY 2005, 4.0 percent. We are reprinting below the table found in the FY 2008 IPPS final rule with comment period showing our analysis (72 FR 47400). jlentini on PROD1PC65 with PROPOSALS2 HOSPITAL INPATIENT MEDICARE CAPITAL MARGINS 1996 U.S. ................................. URBAN ........................... RURAL ............................ No DSH Payments ......... Has DSH Payments ........ VerDate Aug<31>2005 17.6 17.7 16.8 16.2 18.5 19:42 Apr 29, 2008 1997 13.4 13.8 11.0 11.7 14.4 Jkt 214001 1998 7.0 7.8 2.1 4.2 8.6 PO 00000 1999 6.8 7.5 2.4 4.3 8.1 Frm 00152 2000 2001 7.3 8.4 1.0 5.6 8.2 8.1 9.2 1.5 5.5 9.0 Fmt 4701 Sfmt 4702 2002 8.7 10.3 ¥1.7 4.7 10.0 2003 7.6 9.0 ¥1.4 4.4 8.5 2004 2005 5.3 6.4 ¥2.3 ¥1.3 7.0 E:\FR\FM\30APP2.SGM 3.7 4.8 ¥4.2 ¥4.7 5.9 30APP2 Aggregate 1996–2005 8.5 9.4 2.6 5.9 9.5 Aggregate 1998–2005 6.8 7.9 ¥0.4 3.2 8.1 23679 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules HOSPITAL INPATIENT MEDICARE CAPITAL MARGINS—Continued 1996 $1–$249,999 ................... $250,000–$999,999 ........ $1,000,000–$2,999,999 .. $3,000,000 or more ........ TEACHING ..................... Urban .............................. Large Urban .................... Rural ............................... NONTEACHING ............. Urban .............................. Large Urban .................... Rural ............................... Census Division: New England (1) ...... Middle Atlantic (2) .... South Atlantic (3) ..... East North Central (4) ......................... East South Central (5) ......................... West North Central (6) ......................... West South Central (7) ......................... Mountain (8) ............ Pacific (9) ................. Code 99 ................... Bed Size: < 100 beds .............. 100–249 beds .......... 250–499 beds .......... 500–999 beds .......... >= 1000 beds .......... 1997 1998 1999 2000 2001 2002 2003 2004 2005 Aggregate 1996–2005 Aggregate 1998–2005 14.5 15.5 16.8 20.3 19.5 19.7 20.5 13.9 15.3 14.4 15.5 17.3 12.9 9.0 13.0 16.6 15.7 15.9 16.8 8.5 10.5 10.1 11.3 11.4 ¥0.4 2.3 8.7 10.4 9.8 10.2 11.0 1.0 3.4 3.8 6.2 2.3 3.1 1.6 9.0 9.3 9.7 10.0 10.1 2.9 2.8 3.0 6.1 2.4 1.6 2.8 8.7 9.7 11.2 11.4 12.5 5.8 2.2 3.0 5.7 0.2 4.1 2.7 7.0 12.1 12.1 12.5 13.9 3.2 2.6 3.1 5.2 1.2 3.2 ¥2.4 10.1 13.2 13.8 14.0 15.2 8.2 1.7 3.6 5.3 ¥3.7 1.4 ¥1.5 5.2 12.5 13.2 13.6 14.7 4.7 0.0 0.9 1.7 ¥2.6 ¥1.7 ¥4.3 3.2 10.6 11.7 11.9 12.0 5.7 ¥3.2 ¥2.9 ¥0.9 ¥3.9 ¥4.8 ¥7.3 2.0 9.5 10.6 10.9 11.9 4.0 ¥5.1 ¥4.9 ¥3.2 ¥6.0 3.2 1.5 8.2 12.2 12.7 13.0 13.9 5.7 2.8 3.1 5.1 2.0 1.9 ¥0.9 6.6 11.0 11.6 11.9 12.8 4.5 0.3 0.9 2.9 ¥1.3 27.9 19.1 18.1 25.9 15.5 13.9 17.1 11.1 5.9 15.1 11.6 4.0 18.2 14.1 6.0 20.7 16.5 5.0 21.3 18.7 6.6 21.1 18.0 6.9 20.5 14.7 5.8 20.3 16.0 2.8 21.0 15.6 7.4 19.5 15.2 5.4 18.2 12.7 6.4 7.1 8.8 8.5 6.1 7.1 6.6 3.2 8.4 6.7 14.9 11.1 3.3 4.1 3.8 3.8 3.8 ¥0.9 ¥3.4 ¥5.8 3.2 0.9 14.3 7.0 0.1 ¥-0.3 ¥1.5 2.0 1.9 3.4 1.6 ¥0.4 2.8 0.9 13.2 17.2 20.4 23.7 8.3 14.7 16.1 24.1 3.3 8.5 12.3 14.5 2.6 7.7 11.3 16.8 ¥0.7 7.2 11.9 19.8 0.0 6.4 13.3 20.7 1.2 2.9 14.7 20.5 ¥2.0 3.3 12.1 25.1 ¥4.0 0.8 9.8 21.6 ¥6.5 ¥4.7 8.8 24.8 1.2 5.8 13.0 21.4 ¥1.0 3.6 11.7 20.8 17.7 15.1 18.9 19.9 8.2 13.0 10.5 14.1 17.1 14.0 4.6 3.7 8.9 10.7 2.2 3.5 4.5 8.3 10.4 ¥1.3 2.7 4.3 10.6 11.3 ¥6.6 2.5 6.1 10.7 10.8 ¥3.6 ¥1.8 6.0 12.1 12.6 6.5 ¥1.2 4.2 11.6 10.1 8.1 ¥6.1 1.5 10.3 7.3 6.5 ¥9.6 0.8 7.7 7.8 2.1 2.0 5.6 11.4 11.6 3.5 ¥0.9 3.8 10.1 10.1 2.3 jlentini on PROD1PC65 with PROPOSALS2 Notes: Based on Medicare Cost Report hospital data updated as of the 1st quarter of 2007. Medicare payments are from Worksheet E, Part A, Lines 9 and 10. Expenses are from Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8. We apply the outlier trimming methodology developed with MedPAC. Code 99 applies when census division information was not specified in the Medicare Cost Report hospital data. As we indicated in the FY 2008 IPPS final rule with comment period (72 FR 47401), the statutory history of the capital IPPS suggests that the system in the aggregate should not provide for continuous, large positive margins. As we also indicated, a possible reason for the relatively high margins of many capital IPPS hospitals may be that the payment adjustments provided under the system are too high, or perhaps even unnecessary. We agreed with MedPAC’s recommendation and reexamined the appropriateness of the teaching adjustment. We concluded that the record of relatively high and persistent positive margins for teaching hospitals under the capital IPPS indicated that the teaching adjustment is unnecessary, and that it was therefore appropriate to exercise our discretion under the capital IPPS to eliminate this adjustment. At the same time, we believed that we should mitigate abrupt changes in payment policy and that we should provide time for hospitals to adjust to changes in the payments that they can expect under the program. Therefore, in the FY 2008 IPPS final rule with comment period, we adopted a policy to phase out the capital VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 teaching adjustment over a 3-year period beginning in FY 2008. Specifically, we maintained the adjustment for FY 2008, in order to give teaching hospitals an opportunity to plan and make adjustments to the change. During the second year of the transition, FY 2009, the formula for determining the amount of the teaching adjustment was revised so that adjustment amounts will be half of the amounts provided under the current formula. For FY 2010 and after, hospitals will no longer receive an adjustment for teaching activity under the capital IPPS. b. Public Comments Received on Phase Out of Capital IPPS Teaching Adjustment Provisions Included in the FY 2008 Final Rule With Comment Period and Further Solicitation of Public Comments As indicated above, in the FY 2008 IPPS final rule with comment period, we formally adopted as final policy a phase out of the capital IPPS teaching adjustment over a 3-year period, maintaining the current adjustment for FY 2008, making a 50-percent reduction in FY 2009, and eliminating the PO 00000 Frm 00153 Fmt 4701 Sfmt 4702 adjustment for FY 2010 and subsequent years. However, because we concluded that this change to the structure of payments under the capital IPPS was significant, we provided the public with an opportunity for further comment on these provisions through a 90-day comment period after publication of the FY 2008 IPPS final rule with comment period (72 FR 47401). In addition, as we indicated in that final rule with comment period, to provide a more than adequate opportunity for hospitals, associations, and other interested parties to raise issues and concerns related to our policy, we are providing additional opportunity for public comment during this FY 2009 proposed rulemaking cycle for the IPPS. We received numerous timely pieces of correspondence that commented on the policy of phasing out the capital IPPS teaching adjustment as described in the FY 2008 IPPS final rule with comment period. These comments are available on our e-rulemaking Web site, at https://www.cms.hhs.gov/ eRulemaking/ECCMSR/list.asp. We will also accept public comments on this policy during the comment period for this proposed rule. We will respond to E:\FR\FM\30APP2.SGM 30APP2 23680 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules both sets of public comments when we issue the FY 2009 IPPS final rule, which is scheduled for publication in August 2008. VI. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS jlentini on PROD1PC65 with PROPOSALS2 A. Proposed Payments to Excluded Hospitals and Hospital Units Historically, hospitals and hospital units excluded from the prospective payment system received payment for inpatient hospital services they furnished on the basis of reasonable costs, subject to a rate-of-increase ceiling. An annual per discharge limit (the target amount as defined in § 413.40(a)) was set for each hospital or hospital unit based on the hospital’s own cost experience in its base year. The target amount was multiplied by the Medicare discharges and applied as an aggregate upper limit (the ceiling as defined in § 413.40(a)) on total inpatient operating costs for a hospital’s cost reporting period. Prior to October 1, 1997, these payment provisions applied consistently to all categories of excluded providers, which include rehabilitation hospitals and units (now referred to as IRFs), psychiatric hospitals and units (now referred to as IPFs), LTCHs, children’s hospitals, and cancer hospitals. Payment for children’s hospitals and cancer hospitals that are excluded from the IPPS continues to be subject to the rate-of-increase ceiling based on the hospital’s own historical cost experience. (We note that, in accordance with § 403.752(a) of the regulations, RNHCIs are also subject to the rate-ofincrease limits established under § 413.40 of the regulations.) In this FY 2009 IPPS proposed rule, we are proposing that the percentage increase in the rate-of-increase limits for cancer and children’s hospitals and RNHCIs would be the proposed percentage increase in the FY 2009 IPPS operating market basket, which is estimated to be 3.0 percent. Consistent with our historical approach, we calculated the proposed IPPS operating market basket for FY 2009 using the most recent data available. However, if more recent data are available for the final rule, we will use them to calculate the IPPS operating market basket. For cancer and children’s hospitals and RNHCIs, the proposed FY 2009 rate-ofincrease percentage that is applied to FY 2008 target amounts in order to calculate FY 2009 target amounts is 3.0 percent, based on Global Insight, Inc.’s 2008 first quarter forecast of the IPPS operating market basket increase, in VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 accordance with the applicable regulations in 42 CFR 413.40. IRFs, IPFs, and LTCHs were paid previously under the reasonable cost methodology. However, the statute was amended to provide for the implementation of prospective payment systems for IRFs, IPFs, and LTCHs. In general, the prospective payment systems for IRFs, IPFs, and LTCHs provided transition periods of varying lengths during which time a portion of the prospective payment was based on cost-based reimbursement rules under Part 413 (certain providers do not receive a transition period or may elect to bypass the transition period as applicable under 42 CFR Part 412, Subparts N, O, and P). We note that the various transition periods provided for under the IRF PPS, the IPF PPS, and the LTCH PPS have ended. For cost reporting periods beginning on or after October 1, 2002, all IRFs are paid 100 percent of the adjusted Federal rate under the IRF PPS. Therefore, for cost reporting periods beginning on or after October 1, 2002, no portion of an IRF PPS payment is subject to 42 CFR Part 413. Similarly, for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal prospective payment rate under the LTCH PPS. Therefore, for cost reporting periods beginning on or after October 1, 2006, no portion of the LTCH PPS payment is subject to 42 CFR Part 413. (We note that, to the extent a portion of a LTCH’s PPS payment was subject to reasonable cost principles, the Secretary utilized his broad authority under section 123 of the BBRA, as amended by section 307 of the BIPA, to make such portion subject to 42 CFR Part 413 and various provisions in section 1886(b) of the Act.) Likewise, for cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the Federal per diem amount under the IPF PPS. Therefore, for cost reporting periods beginning on or after January 1, 2008, no portion of an IPF PPS payment is subject to 42 CFR Part 413. B. IRF PPS Section 1886(j) of the Act, as added by section 4421(a) of Pub. L. 105–33, provided for a phase-in of a case-mix adjusted PPS for inpatient hospital services furnished by IRFs for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2002, with payments based entirely on the adjusted Federal prospective payment for cost reporting periods beginning on or after October 1, 2002. Section 1886(j) of the Act was amended by section 125 of Pub. L. 106–113 to PO 00000 Frm 00154 Fmt 4701 Sfmt 4702 require the Secretary to use a discharge as the payment unit for services furnished under the PPS for inpatient rehabilitation hospitals and inpatient rehabilitation units of hospitals (referred to as IRFs), and to establish classes of patient discharges by functional-related groups. Section 305 of Pub. L. 106–554 further amended section 1886(j) of the Act to allow IRFs, subject to the blended methodology, to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act. On August 7, 2001, we issued a final rule in the Federal Register (66 FR 41316) establishing the PPS for IRFs, effective for cost reporting periods beginning on or after January 1, 2002. There was a transition period for cost reporting periods beginning on or after January 1, 2002, and ending before October 1, 2002. For cost reporting periods beginning on or after October 1, 2002, payments are based entirely on the adjusted Federal prospective payment rate determined under the IRF PPS. C. LTCH PPS On August 30, 2002, we issued a final rule in the Federal Register (67 FR 55954) establishing the PPS for LTCHs, effective for cost reporting periods beginning on or after October 1, 2002. Except for a LTCH that made an election under § 412.533(c) or a LTCH that is defined as new under § 412.23(e)(4), there was a transition period under § 412.533(a) for LTCHs. For cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal prospective payment rate. D. IPF PPS In accordance with section 124 of Pub. L. 106–113 and section 405(g)(2) of Pub. L. 108–173, we established a PPS for inpatient hospital services furnished in IPFs. On November 15, 2004, we issued in the Federal Register a final rule (69 FR 66922) that established the IPF PPS, effective for IPF cost reporting periods beginning on or after January 1, 2005. Under the requirements of that final rule, we computed a Federal per diem base rate to be paid to all IPFs for inpatient psychiatric services based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. The Federal per diem base rate is adjusted to reflect certain patient characteristics, including age, specified DRGs, selected high-cost comorbidities, days of the stay, and certain facility characteristics, including a wage index E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 adjustment, rural location, indirect teaching costs, the presence of a fullservice emergency department, and COLAs for IPFs located in Alaska and Hawaii. We established a 3-year transition period during which IPFs whose cost reporting periods began on or after January 1, 2005, and before January 1, 2008, would be paid a PPS payment, a portion of which was based on reasonable cost principles and a portion of which was the Federal per diem payment amount. For cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the Federal per diem payment amount. E. Determining Proposed LTCH Cost-toCharge Ratios (CCRs) Under the LTCH PPS In general, we use a LTCH’s overall CCR, which is computed based on either the most recently settled cost report or the most recent tentatively settled cost report, whichever is from the latest cost reporting period, in accordance with § 412.525(a)(4)(iv)(B) and § 412.529(c)(4)(iv)(B) for high cost outliers and short-stay outliers, respectively. (We note that, in some instances, we use an alternative CCR, such as the statewide average CCR in accordance with the regulations at § 412.525(a)(4)(iv)(C) and § 412.529(c)(4)(iv)(C), or a CCR that is specified by CMS or that is requested by the hospital under the provisions of the regulations at § 412.525(a)(4)(iv)(A) and § 412.529(c)(4)(iv)(A).) Under the LTCH PPS, a single prospective payment per discharge is made for both inpatient operating and capital-related costs. Therefore, we compute a single ‘‘overall’’ or ‘‘total’’ LTCH-specific CCR based on the sum of LTCH operating and capital costs (as described in Chapter 3, section 150.24, of the Medicare Claims Processing Manual (CMS Pub. 100–4)) as compared to total charges. Specifically, a LTCH’s CCR is calculated by dividing a LTCH’s total Medicare costs (that is, the sum of its operating and capital inpatient routine and ancillary costs) by its total Medicare charges (that is, the sum of its operating and capital inpatient routine and ancillary charges). Generally, a LTCH is assigned the applicable statewide average CCR if, among other things, a LTCH’s CCR is found to be in excess of the applicable maximum CCR threshold (that is, the LTCH CCR ceiling). This is because CCRs above this threshold are most likely due to faulty data reporting or entry, and, therefore, these CCRs should not be used to identify and make payments for outlier cases. Such data VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 are clearly errors and should not be relied upon. Thus, under our established policy, generally, if a LTCH’s calculated CCR is above the applicable ceiling, the applicable LTCH PPS statewide average CCR is assigned to the LTCH instead of the CCR computed from its most recent (settled or tentatively settled) cost report data. In the FY 2008 IPPS final rule with comment period, in accordance with § 412.525(a)(4)(iv)(C)(2) for high-cost outliers and § 412.529(c)(4)(iv)(C)(2) for short-stay outliers, using our established methodology for determining the LTCH total CCR ceiling, based on IPPS total CCR data from the March 2007 update to the Provider-Specific File (PSF), we established a total CCR ceiling of 1.284 under the LTCH PPS effective October 1, 2007, through September 30, 2008. (For further detail on our methodology for annually determining the LTCH total CCR ceiling, we refer readers to the FY 2007 IPPS final rule (71 FR 48117 through 48121) and the FY 2008 IPPS final rule with comment period (72 FR 47403 through 47404).) Our general methodology established for determining the statewide average CCRs used under the LTCH PPS is similar to our established methodology for determining the LTCH total CCR ceiling (described above) because it is based on ‘‘total’’ IPPS CCR data. Under the LTCH PPS high-cost outlier policy at § 412.525(a)(4)(iv)(C) and the short-stay outlier policy at § 412.529(c)(4)(iv)(C), the fiscal intermediary (or MAC) may use a statewide average CCR, which is established annually by CMS, if it is unable to determine an accurate CCR for a LTCH in one of the following circumstances: (1) A new LTCH that has not yet submitted its first Medicare cost report (for this purpose, a new LTCH is defined as an entity that has not accepted assignment of an existing hospital’s provider agreement in accordance with § 489.18); (2) a LTCH whose CCR is in excess of the LTCH CCR ceiling (as discussed above); and (3) any other LTCH for whom data with which to calculate a CCR are not available (for example, missing or faulty data). (Other sources of data that the fiscal intermediary (or MAC) may consider in determining a LTCH’s CCR include data from a different cost reporting period for the LTCH, data from the cost reporting period preceding the period in which the hospital began to be paid as a LTCH (that is, the period of at least 6 months that it was paid as a short-term acute care hospital), or data from other comparable LTCHs, such as LTCHs in the same chain or in the same region.) PO 00000 Frm 00155 Fmt 4701 Sfmt 4702 23681 In this proposed rule, in accordance with § 412.525(a)(4)(iv)(C)(2) for highcost outliers and § 412.529(c)(4)(iv)(C)(2) for short-stay outliers, using our established methodology for determining the LTCH total CCR ceiling (described above), based on IPPS total CCR data from the December 2007 update to the PSF), we are proposing a total CCR ceiling of 1.262 under the LTCH PPS, effective for discharges occurring on or after October 1, 2008, and before October 1, 2009. If more recent data become available before publication of the final rule, we will use such data to determine the final total CCR ceiling under the LTCH PPS for FY 2009. In this FY 2009 IPPS proposed rule, in accordance with § 412.525(a)(4)(iv)(C) for high-cost outliers and § 412.529(c)(4)(iv)(C) for short-stay outliers, using our established methodology for determining the LTCH statewide average CCRs (described above), based on the most recent complete IPPS total CCR data from the December 2007 update of the PSF, we are proposing LTCH PPS statewide average total CCRs for urban and rural hospitals that would be effective for discharges occurring on or after October 1, 2008, and before October 1, 2009, presented in Table 8C of the Addendum to this proposed rule. If more recent data become available before publication of the final rule, we will use such data to determine the final statewide average total CCRs for urban and rural hospitals under the LTCH PPS for FY 2009 using our established methodology described above. We note that, for this proposed rule, as we established when we revised our methodology for determining the applicable LTCH statewide average CCRs in the FY 2007 IPPS final rule (71 FR 48119 through 48121), and as is the case under the IPPS, all areas in the District of Columbia, New Jersey, Puerto Rico, and Rhode Island are classified as urban, and, therefore, there are no proposed rural statewide average total CCRs listed for those jurisdictions in Table 8C of the Addendum to this proposed rule. In addition, as we established when we revised our methodology for determining the applicable LTCH statewide average CCRs in that same final rule, and as is the case under the IPPS, although Massachusetts has areas that are designated as rural, there were no shortterm acute care IPPS hospitals or LTCHs located in those areas as of December 2007. Therefore, for this proposed rule, there is no proposed rural statewide average total CCR listed for rural Massachusetts in Table 8C of the E:\FR\FM\30APP2.SGM 30APP2 23682 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 Addendum of this proposed rule. As we also established when we revised our methodology for determining the applicable LTCH statewide average CCRs in the FY 2007 IPPS final rule (71 FR 48120 through 48121), in determining the urban and rural statewide average total CCRs for Maryland LTCHs paid under the LTCH PPS, we use, as a proxy, the national average total CCR for urban IPPS hospitals and the national average total CCR for rural IPPS hospitals, respectively. We use this proxy because we believe that the CCR data on the PSF for Maryland hospitals may not be accurate (as discussed in greater detail in that same final rule (71 FR 48120)). F. Proposed Change to the Regulations Governing Hospitals-Within-Hospitals On September 1, 1994, we published hospital-within-hospital (HwH) regulations for LTCHs to address inappropriate Medicare payments to entities that were effectively units of other hospitals (59 FR 45330). There was concern that the HwH model was being used by some acute care hospitals paid under the IPPS as a way of inappropriately receiving higher payments for a subset of their cases. Moreover, IPPS-exclusion of long-term care ‘‘units’’ was and remains inconsistent with the statutory scheme. Therefore, we established the HwH regulations at 42 CFR 412.23 (currently at § 412.22) for a LTCH HwH that is colocated with another hospital. A colocated hospital is a hospital that occupies space in the same building or on the same campus as another hospital. The regulations at § 412.23(e) required that, to be excluded from the IPPS, longterm care HwHs must have a separate governing body, chief medical officer, medical staff, and chief executive officer from that of the co-located hospital. In addition, the HwH must meet either of the following two criteria: The HwH must perform certain specified basic hospital functions on its own and not receive them from the host hospital or a third entity that controls both hospitals; or the HwH must receive at least 75 percent of its inpatients from sources other than the co-located hospital. A third option was added to the regulations on September 1, 1995 (60 FR 45778) that allowed HwHs to demonstrate their separateness by showing that the cost of the services that the hospital obtains under contracts or other agreements with the co-located hospital or a third entity that controls both hospitals is no more than 15 percent. In 1997, we extended application of the HwH rules at § 412.22 to all classes of IPPS excluded hospitals. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Therefore, effective for cost reporting periods beginning on or after October 1, 1997, psychiatric, rehabilitation, cancer, and children’s hospitals that are colocated with another hospital are also required to meet the ‘‘separateness’’ criteria at § 412.22(e). In addition, a ‘‘grandfathering’’ provision was added to the regulations at § 412.22(f), as provided for under section 4417 of the Balanced Budget Act (BBA) of 1997 (Pub. L. 105–33). This provision of the regulations allowed a LTCH that was excluded from the IPPS on or before September 30, 1995, and at that time occupied space in a building also used by another hospital, or in one or more buildings located on the same campus as buildings used by another hospital, to retain its IPPS-excluded status even if the HwH criteria at § 412.22(e) could not be met, as long as the hospital continued to operate under the same terms and conditions as were in effect on September 30, 1995. Consistent with the grandfathering provision under the BBA, which only applied to LTCHs, we extended the application of the grandfathering rule to the other classes of IPPS-excluded hospitals that are HwHs but did not meet the criteria at § 412.22(e). (We subsequently expanded this provision to allow for a grandfathered hospital to make specified changes during particular timeframes.) Despite our efforts to allow those HwHs for whom the IPPS-exclusion status is appropriate to meet the HwH criteria, it appears that there may be a gap in our regulations. There remain certain HwHs under current rules that may be unnecessarily restricted from expanding their bed size. These HwHs are State hospitals that are co-located with another State hospital and that are grandfathered under § 412.22(f). Where a State law defines the structure and authority of the State’s agencies and institutions, and the State hospital is colocated with another hospital that is under State governance, each hospital may have control over the day-to-day operations of its respective facility and have separate management, patient intake, and billing systems and medical staff, as well as a governing board. However, State law may require that the legal accountability for the budgets and activities of entities operating within a State-run institution rests with the State. Therefore, the co-located State hospitals may also be governed by a common governing body. Because of State law requirements, these HwHs are, therefore, precluded from meeting the HwH criteria at § 412.22(e)(1)(i) that requires the governing body of a colocated hospital to be separate from the PO 00000 Frm 00156 Fmt 4701 Sfmt 4702 governing body of the hospital with which it shares space. The excluded hospital’s governing body cannot be under the control of the hospital occupying space in the same building or on the same campus, or of any third entity that controls both hospitals. Currently, there are State HwHs in these types of arrangements that have been able to retain their IPPS-excluded status solely because of the grandfathering provision in § 412.22(f). These HwHs were IPPS-excluded even before the HwH criteria were implemented and only remain excluded HwHs under § 412.22(f) as long as they continue to meet the requirements specified under § 412.22(f)(1), (f)(2), and (f)(3). Because they are grandfathered, these HwHs cannot increase their bed size without losing their IPPS-excluded status under the grandfathering provisions (§ 412.22(f)). Furthermore, if a grandfathered State-run HwH increased its bed size, it would be unable to qualify as an IPPS-excluded HwH under § 412.22(e) because it cannot meet the HwH criteria at § 412.22(e)(1)(i) as a result of State law requirements regarding its organizational structure and governance. These HwHs are precluded from the flexibility to expand their bed size, which is available to other HwHs whose organizational structure is not bound by State law. As discussed in the previous paragraph, the organizational arrangements were in place for these State-operated HwHs before the HwH regulations were adopted. To the extent the arrangements are required by State law, we believe they do not reflect attempts by entities to establish a nominal hospital and, in turn, seek inappropriate exclusions. We also believe it may be unnecessary to prevent hospitals that were created before the HwH requirements, and that because of State statutory requirements cannot meet the subsequently issued separate governing body requirements, from being excluded from the IPPS. Accordingly, we are proposing to add a provision to the regulations that would apply only to State hospitals that were in existence when the HwH regulations were established. This proposed provision would not apply to other State hospitals that chose to open as a HwH subsequent to the establishment of the HwH regulations in FY 1994, under an organizational structure the same as or similar to the one described in this section. These hospitals knew, in advance of becoming a HwH, the requirements that had to be met in order to be an IPPS-excluded HwH, unlike E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 those hospitals that existed before the HwH regulations were established. Accordingly, we are proposing to add a new paragraph (e)(1)(vi) to § 412.22 to provide that if a hospital cannot meet the criteria in § 412.22(e)(1)(i) solely because it is a State hospital occupying space with another State hospital, the HwH can nevertheless qualify for an exclusion from the IPPS if that hospital meets the other applicable criteria in § 412.22(e) and— • Both State hospitals share the same building or same campus and have been continuously owned and operated by the State since October 1, 1995; • Is required by State law to be subject to the governing authority of the State hospital with which it shares space or the governing authority of a third entity that controls both hospitals; and • Was excluded from the inpatient prospective payment system before October 1, 1995, and continues to be excluded from the IPPS through September 30, 2008. We believe the proposed criteria capture the segment of grandfathered, State-operated HwHs that are unable to increase their bed size because of State law regarding governance. We emphasize that we intend to allow an exception to the criteria in § 412.22 (e)(1)(i) only if the hospital that meets the proposed criteria above cannot meet the separate governing body requirement because of State law. We do not intend to provide similar treatment for hospitals that are not subject to State statutory requirements regarding governance but have chosen not to organize in a manner that would allow them to be an IPPS-excluded hospital that meets the HwH criteria at § 412.22(e)(1)(i). VII. Disclosure Required of Certain Hospitals and Critical Access Hospitals Regarding Physician Ownership (§ 489.2(u) and (v)) Section 1866 of the Act states that any provider of services (except a fund designated for purposes of sections 1814(g) and 1835(e) of the Act) shall be qualified to participate in the Medicare program and shall be eligible for Medicare payments if it files with the Secretary a Medicare provider agreement and abides by the requirements applicable to Medicare provider agreements. These requirements are incorporated into our regulations in 42 CFR Part 489, Subparts A and B. Section 1861(e) of the Act defines the term ‘‘hospital.’’ Section 1861(e)(9) of the Act authorizes the Secretary to establish requirements for hospitals as he finds necessary in the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 interest of patient health and safety. Section 1820(e)(3) of the Act authorizes the Secretary to establish criteria necessary for an institution to be certified as a ‘‘critical access hospital.’’ In the FY 2008 IPPS final rule with comment period, we revised our regulations governing Medicare provider agreements, specifically § 489.20(u), to require a hospital to disclose to all patients whether it is physician-owned and, if so, the names of its physician owners (72 FR 47385 through 47387). In addition, we added a definition of physician-owned hospital at § 489.3. The disclosure requirement in current § 489.20(u) is applicable only to those hospitals with physician ownership. (For purposes of this proposal, the term ‘‘hospital’’ also includes ‘‘critical access hospital’’ (CAH).) We neglected to include those hospitals in which no physician held an ownership or investment interest, but in which an immediate family member of a physician held an ownership or investment interest. However, it was always our intent to have consistency between the disclosure requirements and the physician self-referral statute and regulations. The physician selfreferral statute and regulations, which recognize the potential for program and patient abuse where a financial relationship exists, are applicable to both a physician and the immediate family member of the physician. We believe that it is necessary to revise our definition of physician-owned hospital because a physician’s potential conflict of interest occurs not only in those instances where he or she has a financial relationship in the form of an ownership or investment interest, but also where his or her immediate family member has a similar interest, and patients should be informed of this as part of making an informed decision concerning treatment. Therefore, we are proposing to revise the language in § 489.3 to define a ‘‘physician-owned hospital’’ as a participating hospital in which a physician, or an immediate family member of a physician (as defined at § 411.351), has an ownership or investment interest in the hospital. To effectuate the changes made in the FY 2008 IPPS final rule with comment period, we relied on our authority in sections 1861(e)(9), 1820(e)(3) and 1866 of the Act, and on our general rulemaking authority in sections 1871 and 1102 of the Act. Following publication of the FY 2008 IPPS final rule with comment period, we became aware that some physician-owned hospitals have no physician owners who refer patients to the hospital (for example, in the case of a hospital whose PO 00000 Frm 00157 Fmt 4701 Sfmt 4702 23683 physician-owners have retired from the practice of medicine). We believe that requiring a hospital with no referring physician owners to disclose to all patients that it is physician-owned and to provide the patients with a list of the (nonreferring) physician owners would be an unnecessary burden on the hospital and of no value in assisting a patient in making an informed decision as to where to seek treatment. Similarly, we do not believe that it is useful to require a hospital to make such disclosures when no referring physician has an immediate family member who has an ownership or investment interest in the hospital. Accordingly, we are proposing to include in § 489.20(v) new language to provide for an exception to the disclosure requirements for a physician-owned hospital (as defined at § 489.3) that does not have any physician owners who refer patients to the hospital (and that has no referring physicians (as defined at § 411.351) who have an immediate family member with an ownership or investment interest in the hospital), provided that the hospital attests, in writing, to that effect and maintains such attestation in its files for review by State and Federal surveyors or other government officials. (We note that, as explained below, we are proposing to redesignate the existing paragraphs (v) and (w) of § 489.20 as paragraphs (w) and (x), respectively.) We are proposing to revise § 489.20(u) to specify that a hospital must furnish to patients the list of owners and investors who are physicians (or immediate family members of physicians) at the time the list is requested by or on behalf of the patient. In response to the FY 2008 IPPS proposed rule, we received public comments that noted that our proposal did not establish a timeframe within which the hospital must furnish to patients the required list of the hospital’s physician owners or investors. These commenters suggested that we require that the list be provided to the patient at the time the request for the list is made by or on behalf of the patient. We stated in the preamble of the FY 2008 IPPS final rule with comment period that we would not revise the provision to include any specific timeframe for making the list available because we believed that it was important to allow hospitals some degree of flexibility regarding the manner and form in which it notified patients of the identity of its physician owners and investors (72 FR 47386). However, we also stated later in the preamble that we were revising proposed § 489.20(u) to specify that the E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23684 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules hospital should furnish a list of physician owners to a patient at the beginning of his or her hospital stay or outpatient visit, but the regulation text did not reflect this change (72 FR 47387). We have reconsidered the issue and are proposing in § 489.20(u)(1) that the list of the hospital’s owners or investors who are physicians or immediate family members of physicians (as defined at § 411.351) must be furnished at the time the patient or someone on the patient’s behalf requests it. We are proposing this change for two reasons. First, in the FY 2008 IPPS final rule with comment period, in response to public comments received on the FY 2008 IPPS proposed rule, we stated that we believed that the physician ownership disclosure proposal would permit an individual to make more informed decisions regarding his or her treatment and to evaluate whether the existence of a financial relationship, in the form of an ownership interest, suggests a conflict of interest that is not in his or her best interest. However, we maintain that the provision of a generic notice that the hospital is owned by physicians or immediate family members of physicians is insufficient to permit an individual to make a truly informed decision. We believe that it is critical that the patient receives the list of names of the relevant owners or investors at the time the request is made by or on behalf of the patient so that the patient may make a determination as to whether his or her admitting or referring physician has a potential conflict of interest. Second, furnishing the list at the time the request is made by the patient or on behalf of the patient is crucial to affording the patient an opportunity to make an informed decision before treatment is furnished at the hospital. We are not specifying a form to be used for the list; rather, we are addressing the timeframe for the hospital to furnish the list to the patient. In addition, we are proposing to add new § 489.20(u)(2) to require a hospital to require all physicians who are members of the hospital’s medical staff to agree, as a condition of continued medical staff membership or admitting privileges, to disclose in writing to all patients who they refer to the hospital any ownership or investment interest in the hospital held by themselves or by an immediate family member. We would require that physicians agree to make such disclosures at the time they refer patients to the hospital. We proposed a similar requirement in the FY 2008 IPPS proposed rule, but decided not to adopt it as final. In response to a public comment, we stated that we would not VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 finalize the proposal because we believed that it would not provide any additional protections for patients that would not already be offered by the requirement for hospitals to disclose their physician ownership to patients. We have revisited this issue. In the FY 2008 IPPS final rule with comment period, we stated that the scheduling of most hospital inpatient or outpatient services is performed by a staff member in the physician’s office, often weeks, or even months, in advance of the furnishing of the service. As discussed previously, we believe that early notification of physician ownership or investment in the hospital is beneficial to the patient’s decisionmaking concerning his or her treatment. Currently, under § 489.20(u), scheduling of inpatient stays and outpatient visits at physician-owned hospitals would be permitted without notification to the patient of the referring physician’s ownership or investment interest in the hospital. If a patient were notified of the physician ownership or investment at the time of the referral, he or she would have an opportunity to discuss the physician’s ownership or investment in the hospital and make a more informed decision. We believe that it would be in the best interests of the patient and the physician owner or investor to disclose the physician’s (or his or her immediate family member’s) ownership in the hospital at the time the physician is referring the patient to the hospital. We are revising § 489.20(u) accordingly. We note that notification of physician ownership or investment in a hospital may not be viewed negatively by all interested parties. For instance, some physician owners or investors in hospitals believe that disclosing their ownership or investment interests in the hospital to their patients at the time of the referral is extremely beneficial for both the physician and the patient. They communicate to patients their belief that their ownership in the hospital permits them to have total control over scheduling, staffing, and quality mechanisms. Section 5006 of the Medicare, Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) required, among other things, that HHS study the quality of care and patient satisfaction with specialty hospitals. HHS concluded that specialty hospital patients have very favorable perceptions of the clinical quality of care they receive, and that overall patient satisfaction is very high. We are also proposing to revise § 489.53 to permit CMS to terminate the Medicare provider agreement if the hospital fails to comply with the PO 00000 Frm 00158 Fmt 4701 Sfmt 4702 provisions of proposed § 489.20(u)(1) or (u)(2). We believe that these revisions would be necessary to enforce the proposed disclosure requirements set forth in § 489.20. We are not inclined to make a corresponding change to the medical staff bylaws condition of participation (CoP) in § 482.22(c). We believe that the proposed disclosure requirement is appropriate for inclusion in the regulations governing Medicare provider agreements for the following reasons. As stated in the FY 2008 IPPS final rule with comment period, each participating provider must comply with all applicable provisions of the provider agreement regulations found in 42 CFR Part 489, and CMS may terminate a provider agreement if the provider is not in substantial compliance with these requirements (72 FR 47391). A provider’s compliance with applicable provider agreement regulations is reviewed through a variety of means, including onsite investigation of complaints. Thus, compliance with this proposed requirement could be easily monitored. We also note that any revisions to the medical staff bylaws concerning the requirement that the disclosure be given at the time of the referral would be difficult to enforce as a CoP because the required notification generally would be given outside of the hospital’s or CAH’s premises. However, we are considering whether these proposed changes would be better effectuated through changes to our regulations governing the CoPs applicable to hospitals and CAHs, which appear at 42 CFR Part 482 and 42 CFR Part 485, Subpart F, respectively, and, therefore, we are soliciting public comments on this issue. In the FY 2008 IPPS final rule with comment period, we added a new provision at § 489.20(v) to require that hospitals and CAHs: (1) Furnish all patients written notice at the beginning of their inpatient hospital stay or outpatient service if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week; and (2) describe how the hospital or CAH will meet the medical needs of any patient who develops an emergency medical condition at a time when no physician is present in the hospital (72 FR 47387). (We are proposing to redesignate existing § 489.20(v) and (w) as § 489.20(w) and (x), respectively, to accommodate the addition of the proposed exception to the requirements in § 489.20(v) discussed above.) We stated that it is important to ensure that consumers are provided accurate information on the availability of E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules physician services at the point when they are about to become patients of a hospital or CAH. In order to be fully informed, consumers should be made aware of whether a hospital or CAH has a physician on-site 24 hours per day, 7 days per week, and should be made aware of the hospital’s or CAH’s processes for addressing medical emergencies that may occur when a physician is not on site. Given the patient safety measures addressed by these provisions, we are proposing to set forth penalties for failure to comply with these requirements. Specifically, we are proposing to revise § 489.53 to permit CMS to terminate the provider agreement of any hospital or CAH that fails to comply with the requirements set forth in proposed redesignated § 489.20(w). We are also soliciting public comments on whether hospitals and CAHs should educate patients about the availability of information regarding physician ownership under the proposed disclosure requirements and, if so, by what means (for example, by a posting in the admissions office or in a patient brochure). VIII. Physician Self-Referral Provisions (§§ 411.351, 411.352 and 411.354) A. Stand in the Shoes Provisions 1. Physician ‘‘Stand in the Shoes’’ Provisions jlentini on PROD1PC65 with PROPOSALS2 a. Background Section 1877 of the Act, also known as the physician self-referral law: (1) Prohibits a physician from making referrals for certain designated health services (‘‘DHS’’) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment or compensation), unless an exception applies; and (2) prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third party payor) for those referred services. The statute establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that pose no risk of program or patient abuse. Determining whether DHS entities and referring physicians (or their immediate family members) have direct or indirect financial relationships is a key step in applying the statute. In the final rule entitled ‘‘Medicare Program; Physicians’ Referrals to Health Care Entities With Which They Have Financial Relationships (Phase III),’’ published in the Federal Register on September 5, 2007 (72 FR 51012) VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 (‘‘Phase III’’), we interpreted certain provisions of section 1877 of the Act, including provisions relating to direct and indirect compensation arrangements. Specifically, the Phase III final rule included provisions under which referring physicians are treated as standing in the shoes of their physician organizations for purposes of applying the rules that describe direct and indirect compensation arrangements in § 411.354 (72 FR 51026 through 51030). A ‘‘physician organization’’ is defined at § 411.351 as ‘‘a physician (including a professional corporation of which the physician is the sole owner), a physician practice, or a group practice that complies with the requirements of § 411.352.’’ Therefore, when determining whether a direct or indirect compensation arrangement exists between a physician and an entity to which the physician refers Medicare patients for DHS, the referring physician stands in the shoes of: (1) Another physician who employs the referring physician; (2) his or her wholly-owned professional corporation (‘‘PC’’); (3) a physician practice (that is, a medical practice) that employs or contracts with the referring physician or in which the physician has an ownership interest; or (4) a group practice of which the referring physician is a member or independent contractor. The referring physician is considered to have the same compensation arrangements (with the same parties and on the same terms) as the physician organization in whose shoes the referring physician stands. Subsequent to the publication of Phase III, industry stakeholders, including academic medical centers (‘‘AMCs’’), integrated tax-exempt health care delivery systems, and their representatives, expressed concern about the application of the Phase III ‘‘stand in the shoes’’ provisions to compensation arrangements involving ‘‘mission support payments’’ and ‘‘similar payments’’ (referred to in this proposed rule generally as ‘‘support payments’’). The stakeholders believed that certain payments did not previously trigger application of the physician self-referral law but, after Phase III, need to satisfy the requirements of an exception. One example offered was a DHS entity component (such as a hospital) of an AMC that transfers funds to the faculty practice plan component of the AMC. If a referring physician stands in the shoes of his or her faculty practice plan, the compensation arrangement between the hospital providing the support payment and the faculty practice plan will be considered to be a direct compensation PO 00000 Frm 00159 Fmt 4701 Sfmt 4702 23685 arrangement between the hospital and the physician and would need to satisfy the requirements of a direct compensation arrangement exception, if the physician is to continue referring Medicare patients to the component for DHS. According to the industry stakeholders, before Phase III, such arrangements would have been analyzed under the rules regarding indirect compensation arrangements and would, in their view, have been permitted. After Phase III, in their view, it is unlikely that the requirements of an available exception could be satisfied given the nature of support payments; that is, support payments usually are not tied to specific items or services provided by the faculty practice plan (or group practice within an integrated health care delivery system), but rather are intended to support the overall mission of the AMC or maintain operations in an integrated health care delivery system. For this reason, support payments likely do not satisfy the requirement, present in many exceptions, that the compensation be fair market value for items or services provided. Similarly, some stakeholders raised concerns about support payments made from faculty practice plans to AMC components. Although AMCs are free to use the exception for services provided by an AMC in § 411.355(e) (which would protect support payments made among AMC components if all of the conditions of the exception are met), industry stakeholders explained that many AMCs do not do so, preferring instead to rely on other available exceptions and the rules regarding indirect compensation arrangements (especially prior to Phase III). To provide CMS sufficient time to study the ‘‘stand in the shoes’’ provisions as they relate to compensation arrangements involving support payments, seek additional public comment, and develop an approach for addressing this issue, on November 15, 2007, we issued a final rule entitled ‘‘Medicare Program; Delay of the Date of Applicability for Certain Provisions of Physicians’ Referrals to Health Care Entities With Which They Have Financial Relationships (Phase III)’’ (72 FR 64164) that delayed the effective date of the provisions in § 411.354(c)(1)(ii), § 411.354(c)(2)(iv), and § 411.354(c)(3) for 12 months after the effective date of Phase III (that is, until December 4, 2008). That final rule was applicable to the following compensation arrangements between the following physician organizations and entities ONLY: • With respect to an AMC as described in § 411.355(e)(2), E:\FR\FM\30APP2.SGM 30APP2 23686 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 compensation arrangements between a faculty practice plan and another component of the same AMC; and • With respect to an integrated section 501(c)(3) health care system, compensation arrangements between an affiliated DHS entity and an affiliated physician practice in the same integrated section 501(c)(3) health care system. Following the publication of the November 15, 2007 final rule, other industry stakeholders asserted that, in addition to section 501(c)(3) health care systems, most integrated health care delivery systems, including ones involving for-profit entities, make support payments. The stakeholders further asserted that, although under the ‘‘stand in the shoes’’ provisions such payments must now satisfy a direct compensation arrangement exception, there is, in fact, no applicable exception. These stakeholders urged that any approach to addressing the impact of the Phase III ‘‘stand in the shoes’’ provisions on support payments and other monetary transfers within integrated health care delivery systems should have universal applicability that is not dependent on whether the system meets the definition of an AMC or has a particular status under the rules of the Internal Revenue Service. b. Proposals Given the potential widespread impact of the ‘‘stand in the shoes’’ provisions, as well as the considerable industry interest in their application, we are revisiting the ‘‘stand in the shoes’’ policy and regulations issued in Phase III. We believe that a more refined approach to the ‘‘stand in the shoes’’ provisions would accomplish our goals of simplifying the analysis of many financial arrangements and reducing program abuse by bringing more financial relationships within the scope of the physician self-referral law (such as certain potentially abusive arrangements between DHS entities and physician organizations that may not have met the definition of an ‘‘indirect compensation arrangement’’). We note that we are not suggesting that support payments and other similar compensation arrangements are without risk of program or patient abuse, nor are we endorsing such payments and arrangements. We are proposing here two alternative ways to address the ‘‘stand in the shoes’’ issues described above, and are seeking industry input on each proposal, as well as on other possible approaches. The first is a multi-faceted approach to revising the Phase III ‘‘stand in the shoes’’ provisions. The second proposal VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 would leave the Phase III ‘‘stand in the shoes’’ provisions as promulgated and would, instead, create a new exception using our authority under section 1877(b)(4) of the Act for nonabusive arrangements that warrant protection not available under existing exceptions. We are also interested in public comments on other approaches and on whether changes to the existing ‘‘stand in the shoes’’ provisions are needed at all. For the first proposal, we propose revising § 411.354(c)(2)(iv) to provide that a physician would be deemed not to stand in the shoes of his or physician organization if the compensation arrangement between the physician organization and the physician satisfies the requirements of the exception in § 411.357(c) (for bona fide employment relationships), the exception in § 411.357(d) (for personal service arrangements), or the exception in § 411.357(l) (for fair market value compensation). Currently, all physicians stand in the shoes of their physician organizations, regardless of the nature of the compensation they receive from the physician organization. Under our proposal, the first step in the analysis would be to look at the compensation a referring physician receives from his or her physician organization. A compensation arrangement between a physician organization and a physician that satisfies the requirements of § 411.357(c), (d), or (l) would be consistent with fair market value by design and not determined in a manner that takes into account (directly or indirectly) the volume or value of any referrals by the physician to the physician organization. Although such compensation could, in some circumstances, be determined in a manner that takes into account (directly or indirectly) the volume or value of the physician’s referrals to the DHS entity (see 66 FR 869), we believe that the risk of program or patient abuse will be addressed sufficiently by analyzing such arrangements between DHS entities and referring physicians who do not stand in the shoes of their physician organizations using the rules regarding indirect compensation arrangements. Therefore, under this proposal, if the compensation arrangement between a physician organization and one of its referring physicians satisfies the requirements of one of the exceptions noted above, the referring physician would be deemed not to stand in the shoes of the physician organization for purposes of applying the definitions of, and provisions related to, direct and indirect compensation arrangements in PO 00000 Frm 00160 Fmt 4701 Sfmt 4702 § 411.354(c). Arrangements between DHS entities and physician organizations whose physicians do not stand in their shoes may still create indirect compensation arrangements that would need to satisfy the requirements of the exception for indirect compensation arrangements in § 411.357(p). Under this first proposed approach, physician owners and investors would continue to stand in the shoes of their physician organizations. However, we are concerned that considering all physician owners of, or physician investors in, a physician organization to stand in the shoes of the physician organization, as they currently do under the Phase III ‘‘stand in the shoes’’ provisions, might be over-inclusive. For example, in a State that prohibits the corporate practice of medicine, a physician owner of a captive or ‘‘friendly’’ PC who has no right to the distribution of profits would stand in the shoes of his or her physician organization, even though his or her employment arrangement with the group satisfies the requirements of the exception for bona fide employment relationships in § 411.357(c). We are considering whether these and similarly situated physician owners should have to stand in the shoes of their physician organizations when their ownership interest is nominal in nature and their compensation arrangement with the physician organization satisfies the requirements of one of the exceptions in § 411.357(c), (d), or (l). We are soliciting public comments on this issue. As described above, a physicianemployee or contractor whose compensation arrangement with a physician organization does not satisfy the requirements of § 411.357(c), (d), or (l) would stand in the shoes of the physician organization. This is necessary to address our concern that an arrangement between a DHS entity and a physician organization that compensates its physicians in a manner that does not satisfy the requirements of an exception may be particularly prone to abuse. For example, where a physician-employee’s compensation arrangement with his or her group practice exceeds fair market value for services provided to the group practice employer (and, thus, does not satisfy the requirements of the exception in § 411.357(c)), and the physicianemployee’s DHS referrals to the group practice instead are protected under the exception for in-office ancillary services in § 411.355(b), there is risk that the physician-employee’s above-fair-marketvalue compensation may reflect the volume or value of referrals to the DHS E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules entity. This could be the result of a support or other payment between the DHS entity and the group practice that is designed to channel compensation to the physician-employee for referrals to the DHS entity. We are also considering, and solicit comments on, an approach under which only owners of a physician organization would stand in the shoes of that physician organization (in which case, a physician would not stand in the shoes of a physician organization unless he or she holds an ownership or investment interest, even if the physician’s compensation arrangement with that physician organization does not satisfy the requirements of § 411.357(c), (d), or (l)). In conjunction with this approach, we are interested in receiving comments on whether and under what circumstances the ‘‘stand in the shoes’’ provisions should apply to a physician organization that has no physician owners. In this first approach, we also propose to revise § 411.354(c)(3)(ii) to provide that the provisions of §§ 411.354(c)(1)(ii) and (c)(2)(iv) do not apply when the requirements of § 411.355(e) are satisfied. In other words, a physician would not stand in the shoes of his or her physician organization (for example, a faculty practice plan) when his or her referral for DHS is protected under the exception in § 411.355(e) for services provided by an AMC. We note that, if all of the requirements of the exception in § 411.355(e) are not satisfied, a physician would stand in the shoes of his or her physician organization unless, as discussed above with respect to proposed revised § 411.354(c)(2)(iv), the compensation from the physician organization to the physician satisfies the requirements of the exception for bona fide employment relationships, the exception for personal service arrangements, or the exception for fair market value compensation in § 411.357(c), (d), and (l), respectively. We are proposing to include a specific revision to the regulation in § 411.354(c)(2)(iv); however, we are seeking public comment as to whether this policy is better achieved by revising § 411.354(c)(3) to delete the reference to applying the exceptions in § 411.355, and thereby providing that the ‘‘stand in the shoes’’ provisions do not apply where the prohibition on referrals is not applicable because all of the requirements of any of the exceptions in § 411.355 are satisfied. In this first approach, we also propose to revise § 411.354(c)(3)(ii) to provide that the provisions of § 411.354(c)(1)(ii) and (c)(2)(iv) do not apply when compensation is provided by a VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 component of an AMC to a physician organization affiliated with that AMC through a written contract to provide services required to satisfy the AMC’s obligations under the Medicare graduate medical education (GME) rules where the contract is limited to only services necessary to fulfill the GME obligations as set forth in 42 CFR, Part 413, Subpart F. We have in mind certain arrangements between a hospital component of an AMC and a community physician group to serve as a teaching site for the AMC’s residents, as required by the GME rules. If adopted, this proposal would not mean that such arrangements necessarily are lawful, but rather that they would be analyzed by applying the rules regarding indirect compensation arrangements. Under this first proposal, if adopted, some referring physicians would no longer stand in the shoes of their physician organizations as they currently do under the Phase III ‘‘stand in the shoes’’ provisions. In such circumstances, the rules regarding direct and indirect compensation arrangements would still apply, and financial relationships would still need to be analyzed for compliance with the statute and regulations. We are concerned that, where physicians do not stand in the shoes of their physician organizations, some potentially abusive arrangements between DHS entities and physician organizations might be viewed incorrectly as falling outside the definition of an ‘‘indirect compensation arrangement’’ at § 411.354(c)(2) and, therefore, as not within the scope of the physician self-referral law. The definition of ‘‘indirect compensation arrangement’’ generally requires that three elements be present: (1) An unbroken chain of financial relationships between the DHS entity and the referring physician; (2) aggregate compensation to the referring physician (from the entity in the chain closest to the physician) that varies with or takes into account in any manner the volume or value of referrals to, or other business generated for, the DHS entity; and (3) knowledge by the DHS entity that the referring physician receives such compensation. (We refer readers to 66 FR 864 through 870, 69 FR 16057 through 16063, and 72 FR 51026 through 51031 for further explanation.) We believe that some parties may be construing these elements (particularly the second and the third) too narrowly. For example, we believe that aggregate compensation can vary with or take into account the volume or value of referrals to, or business generated for, DHS PO 00000 Frm 00161 Fmt 4701 Sfmt 4702 23687 entities in a wide range of circumstances, including, without limitation, arrangements involving: variable, per-click, or percentage-based compensation; exclusive contracts; inflated fixed payments; or explicit or implicit tying of compensation to other referrals. To address this issue, we may provide additional guidance on the application of the three elements of the definition of ‘‘indirect compensation arrangement’’ in the FY 2009 IPPS final rule. We are interested in public comments regarding ways in which we can ensure that the full range of potentially abusive arrangements between DHS entities and physician organizations are appropriately addressed in situations where physicians do not stand in the shoes of their physician organizations. As discussed above, we are proposing an alternative approach to addressing the Phase III ‘‘stand in the shoes’’ provisions. (However, we are proposing regulation text for the first proposal only.) Our alternative proposal is to make no revisions to the Phase III ‘‘stand in the shoes’’ provisions in §§ 411.354(c)(1)(ii), (c)(2)(iv), and, (c)(3) and, to the extent necessary to protect nonabusive arrangements, promulgate a separate exception using our authority under section 1877(b)(4) of the Act to create exceptions for arrangements that do not pose a risk of program or patient abuse. The new exception would apply to specific types of nonabusive payments or arrangements that are not otherwise covered by existing exceptions (for example, certain support payments, as described above), subject to conditions necessary to protect against program and patient abuse, similar to those conditions incorporated into the existing exception for services provided by an AMC in § 411.355(e). Specifically, we are considering establishing a new exception, using our authority under section 1877(b)(4) of the Act, for compensation arrangements between DHS entities and physician organizations and physicians for ‘‘mission support’’ payments (or similar compensation arrangements) and, if so, how we should define those payments (or similar compensation arrangements), and what criteria such an exception should include to protect against program or patient abuse. We are soliciting comments about this proposal, including whether an exception should be limited to ‘‘mission support’’ payments, whether other specific types of payments or compensation arrangements should be eligible for such an exception, the types of parties that should be permitted to use the E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23688 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules exception (for example, AMC components, physician practices), and the conditions that should apply to such an exception to ensure that a protected compensation arrangement poses no risk of program or patient abuse. We are concerned that some ‘‘mission support’’ payments or similar payments are subject to fraud and abuse. We are interested in public comments that identify with specificity the types of compensation agreements that should be permitted under an applicable exception. Under this approach, the proposed exception might address compensation arrangements between components of certain well-defined integrated delivery systems, perhaps with tightly-crafted conditions similar to those in the existing exception for services provided by an AMC in § 411.355(e). For example, some industry stakeholders have recommended that we establish an exception for compensation arrangements between a DHS entity component of an integrated health care delivery system and a physician organization component of the same integrated health care delivery system. We are concerned that the term ‘‘integrated health care delivery system’’ is loosely used in the industry to describe a wide variety of systems, with varying degrees of actual integration, and that it may prove infeasible to craft a sufficiently circumscribed definition. In many circumstances, payment arrangements between components of ‘‘integrated health care delivery systems,’’ as well as payments from ‘‘integrated health care delivery systems’’ to physicians affiliated with those systems are susceptible to fraud and abuse. However, we are soliciting public comments defining a fully integrated health care delivery system, what types of compensation arrangements should be protected (for example, support payments), and what conditions should be included in an exception that would ensure no risk of program or patient abuse. We note that any exception established using our authority under section 1877(b)(4) of the Act would include documentation requirements and a requirement that the arrangement not violate the antikickback statute or any Federal or State law or regulation governing billing or claims submission, consistent with the existing exceptions created under this authority. According to some industry stakeholders, an ‘‘integrated health care delivery system’’ could be defined, for example, as a health care delivery system comprised of two or more entities that are related and VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 substantially integrated by common ownership or control, and which includes at least one hospital and one physician organization that has no physician owners or investors who make referrals for DHS to any component of the health care delivery system. Entities that file consolidated financial statements could be deemed to be substantially integrated for purposes of this definition. For purposes of this approach, ownership could exist if an individual or individuals possess 50 percent ownership or equity in the component of the integrated health care delivery system, and control would exist if an individual or an organization has the power, directly or indirectly, significantly to influence or direct the actions or policies of the component of the integrated health care delivery system. As noted above, it would be necessary to define ‘‘integrated health care delivery system,’’ as well as ‘‘ownership’’ and ‘‘control,’’ and to determine whether to permit integrated health care delivery systems to include entities related through written contractual affiliation agreements and, if so, what limitations (if any) should be placed on the types of contractually affiliated entities we would permit to be included as components of an integrated health care delivery system. We would need also to determine what characteristics indicate substantial integration and identify the types of compensation arrangements that exist between components of integrated health care delivery systems. We are seeking public comments regarding this possible approach (including the specific issues noted), as well as public comments on other alternative approaches to addressing the concerns regarding support payments and similar monetary transfers noted by industry stakeholders and described above. 2. DHS Entity ‘‘Stand in the Shoes’’ Provisions On July 12, 2007, we published in the Federal Register a proposed rule entitled ‘‘Medicare Program; Proposed Revisions to Payment Policies Under the Physician Fee Schedule, and Other Part B Payment Policies for CY 2008; Proposed Revisions to the Payment Policies of Ambulance Services Under the Ambulance Fee Schedule for CY 2008; and the Proposed Elimination of the E-Prescribing Exemption for Computer-Generated Facsimile Transmissions; Proposed Rule’’ (the ‘‘CY 2008 PFS proposed rule’’) (72 FR 38122). In that rule, we proposed a corollary provision to the Phase III ‘‘stand in the shoes’’ provisions that addressed the DHS entity side of PO 00000 Frm 00162 Fmt 4701 Sfmt 4702 physician—DHS entity financial relationships. Specifically, we proposed to amend § 411.354(c) to provide that, where a DHS entity owns or controls an entity to which a physician refers Medicare patients for DHS, the DHS entity would stand in the shoes of the entity that it owns or controls and would be deemed to have the same compensation arrangements with the same parties and on the same terms as does the entity that it owns or controls. For example, a hospital would stand in the shoes of a medical foundation that it owns or controls (such as where the hospital is the sole member of a nonprofit corporation). Thus, under the CY 2008 PFS proposed rule proposal, if a hospital owns or controls a medical foundation that contracts with a physician to provide physician services at a clinic owned by the medical foundation, the hospital would stand in the shoes of the medical foundation and would be deemed to have a direct compensation relationship with the contractor physician. We solicited public comments as to whether and how we would employ a ‘‘stand in the shoes’’ approach for these types of relationships, as well as for other types of financial relationships. In response to the CY 2008 PFS proposed rule, we received comments from a variety of industry stakeholders, including physicians, medical associations, and their representatives. Although several commenters supported the proposed entity ‘‘stand in the shoes’’ provisions because they share our concerns regarding parties ability to avoid application of the physician selfreferral law by simply inserting an entity in the chain of financial relationships linking a DHS entity and a referring physician, many commenters expressed concern that the proposal was unclear and potentially overly broad. Commenters requested guidance regarding the level of ownership or control that would trigger the application of the entity ‘‘stand in the shoes’’ provisions. One commenter recommended that, instead of finalizing the entity ‘‘stand in the shoes’’ provisions, we issue, through a notice of proposed rulemaking, a more detailed proposal that would give industry stakeholders the opportunity to provide more meaningful comments. We did not finalize the DHS entity ‘‘stand in the shoes’’ provisions in the CY 2008 PFS final rule published in the Federal Register on November 27, 2007 (72 FR 66222, 66306). Because the DHS entity ‘‘stand in the shoes’’ provisions are integrally related to the physician ‘‘stand in the shoes’’ provisions that we finalized in Phase III and for which we E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules are proposing the regulatory revisions described above, we are re-proposing here the DHS entity ‘‘stand in the shoes’’ provisions, with some modification. We believe that a comprehensive approach to the ‘‘stand in the shoes’’ provisions that addresses both physicians and physician organizations, as well as DHS entities and other entities that they own or control, is the best vehicle to address the goals outlined in the Phase III final rule, namely: (1) Simplifying the analysis of many financial arrangements; and (2) reducing program abuse by bringing more financial relationships within the ambit of the physician self-referral law. We are proposing to revise § 411.354(a) to provide that an entity that furnishes DHS would be deemed to stand in the shoes of an organization in which it has a 100 percent ownership interest and would be deemed to have the same compensation arrangements with the same parties and on the same terms as does the organization that it owns. We believe this approach is straightforward and can be readily applied. We note that, under this approach (as compared to our CY 2008 PFS proposal), a DHS entity would stand in the shoes of any wholly-owned organization, not merely a whollyowned DHS entity. An organization may be in any legal form (for example, a limited liability company, partnership, or corporation, regardless of status as nonprofit or exempt from taxation). We are seeking public comments specifically as to whether we should consider a DHS entity to stand in the shoes of another organization in which the DHS entity holds less than a 100 percent ownership interest and, if so, what amount of ownership should trigger application of the entity ‘‘stand in the shoes’’ provisions. In addition, we are seeking public comments as to whether we should deem a DHS entity to stand in the shoes of an organization that it controls (for example, an entity would stand in the shoes of a nonprofit organization of which it is the sole member); we would consider a DHS entity to control an organization if the DHS entity has the power, directly or indirectly, significantly to influence or direct the actions or policies of the organization. We are seeking public comments as to what level of control should trigger the application of the entity ‘‘stand in the shoes’’ provisions. 3. Application of the Physician ‘‘Stand in the Shoes’’ and the Entity ‘‘Stand in the Shoes’’ Provisions In order to protect against program and patient abuse when multiple links VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 involving various corporate and other entities exist in a chain of financial relationships between a DHS entity and a referring physician, we are proposing that, when applying the physician ‘‘stand in the shoes’’ provisions and the entity ‘‘stand in the shoes’’ provisions to a chain of financial relationships between a physician and a DHS entity, the following conventions would apply: • First, parties would apply the physician ‘‘stand in the shoes’’ provisions and deem the physician to stand in the shoes of his or her physician organization (in those instances where the physician ‘‘stand in the shoes’’ provisions apply to the particular physician and physician organization). • However, if applying the physician ‘‘stand in the shoes’’ provisions would result in only one financial relationship remaining between the DHS entity and the ‘‘collapsed’’ physician/physician organization and that relationship is an ownership interest, the physician ‘‘stand in the shoes’’ provisions would not be applied, and the entity ‘‘stand in the shoes’’ provisions instead would be applied first. • If more than two organizations remain after first ‘‘collapsing’’ the physician and the physician organization (that is, if at least two links remain in the chain of financial relationships between the physician who is standing in the shoes of his or her physician organization and the DHS entity), the next step would be to apply the entity ‘‘stand in the shoes’’ provisions. These conventions ensure that at least one compensation arrangement remains between the DHS entity and the referring physician for purposes of analyzing the chain of relationships under the physician-self referral rules. For example, if a chain of financial relationships runs: hospital—whollyowned home health agency—group practice—physician owner of the group practice, the first step would be to apply the physician ‘‘stand in the shoes provisions’’ such that the physician owner would stand in the shoes of the group practice. The next step would be to apply the entity ‘‘stand in the shoes’’ provisions and deem the hospital to stand in the shoes of its wholly-owned home health agency. Assuming that the financial relationship between the home health agency and the group practice is a compensation arrangement, the remaining financial relationship would be deemed to be a direct compensation arrangement between the hospital (standing in the shoes of the home health agency) and the physician (standing in the shoes of the group PO 00000 Frm 00163 Fmt 4701 Sfmt 4702 23689 practice). By contrast, the example of a chain of financial relationships that runs: hospital—group practice whollyowned by the hospital—employed physician of the group practice (whose compensation does not satisfy the requirements of the exception in § 411.357(c)), is illustrative. If the relationship between the hospital and the group practice is solely an ownership interest (that is, there is no separate compensation arrangement between them), applying the physician ‘‘stand in the shoes’’ provisions first, so that the physician-employee stands in the shoes of the group practice, would result in one remaining financial link between the group practice and the hospital, and that relationship would be an ownership interest. In those circumstances, the entity ‘‘stand in the shoes’’ provisions would be applied first and the hospital would stand in the shoes of its wholly-owned group practice. The physician would not stand in the shoes of the group practice. The remaining financial relationship would be deemed to be a direct compensation arrangement between the hospital (standing in the shoes of the group practice) and the physician. (We note that, in this example, the physician’s compensation from the group practice does not satisfy the requirements of the exception for bona fide employment relationships in § 411.357(c) and, thus, no direct exception would apply to that compensation arrangement.) Using the same chain of financial relationships, but assuming instead that the hospital has a compensation arrangement with (in addition to being the sole owner of) the group practice (for example, an office space rental agreement), under the proposals described above, the physician would stand in the shoes of the group practice, but the hospital would not stand in the shoes of the group practice because, after first applying the physician ‘‘stand in the shoes’’ provisions, only two organizations would remain (that is, only one link in the chain of financial relationships remains). The remaining financial relationship created by the rental agreement would be deemed to be a direct compensation arrangement between the hospital and the physician, which would need to satisfy the requirements of an exception. We are not proposing regulation text at this time with respect to the application of the physician and entity ‘‘stand in the shoes’’ provisions. At such time as these provisions are finalized, we would amend the regulation text, as appropriate, to codify requirements E:\FR\FM\30APP2.SGM 30APP2 23690 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 related to the application of the provisions. 4. Definitions: ‘‘Physician’’ and ‘‘Physician Organization’’ In an interim final rule with comment period entitled ‘‘Medicare Program; Physicians’ Referrals to Health Care Entities With Which They Have Financial Relationships (Phase II); Interim Final Rule,’’ published in the Federal Register on March 26, 2004 (72 FR 16054) (‘‘Phase II’’), we revised the definition of ‘‘referring physician’’ at § 411.351 to provide that a referring physician is deemed to stand in the shoes of his or her wholly-owned PC (69 FR 16060). In that rule, we stated that it is not necessary to treat a referring physician as separate from his or her wholly-owned PC. In the Phase III final rule, for purposes of implementing the physician ‘‘stand in the shoes’’ provisions, the term ‘‘physician organization’’ was newly defined at § 411.351 as ‘‘a physician (including a professional corporation of which the physician is the sole owner), a physician practice, or a group practice that complies with the requirements of § 411.352.’’ Our intent was that, when applying the physician ‘‘stand in the shoes’’ provisions in § 411.354, a physician would stand in the shoes of: (1) Another physician who employs the physician; (2) his or her wholly-owned PC; (3) a physician practice that employs or contracts with the physician or in which the physician has an ownership interest; or (4) a group practice of which the physician is a member or independent contractor. Essentially, we intended this definition to incorporate the Phase II policy that a physician stands in the shoes of, or is considered the same as, the PC of which he or she is the sole owner. In determining whether a direct or indirect compensation arrangement exists between a DHS entity and a referring physician, we intended that parties should first ‘‘collapse’’ the physician into his or her wholly-owned PC, and then deem that ‘‘collapsed’’ physician/PC unit to stand in the shoes of the physician organization (if one exists). However, we are concerned that parties may interpret the rules, using the definition of ‘‘physician organization’’ exclusive of the definition of ‘‘referring physician,’’ as requiring only that they deem a physician to stand in the shoes of his or her wholly-owned PC without further deeming the ‘‘collapsed’’ physician/PC unit to stand in the shoes of the physician organization. That is, with respect to a chain of financial relationships that runs: hospital—group practice—PC—physician, parties might VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 interpret our rules as requiring only that the physician stand in the shoes of the PC and not in the shoes of the group practice, so that the resulting chain of financial relationships (after the application of the ‘‘stand in the shoes’’ provisions) would run: hospital—group practice—PC/physician. However, our intention was that, after application of the ‘‘stand in the shoes’’ provisions, the chain of financial relationships would run: hospital—group practice/PC/ physician. Therefore, we are proposing revisions to the definitions of ‘‘physician’’ and ‘‘physician organization’’ to clarify that: (1) A physician and the PC of which he or she is the sole owner are always treated the same for purposes of applying the physician self-referral rules; and (2) a physician who stands in the shoes of his or her wholly-owned PC also stands in the shoes of his or her physician organization in accordance with § 411.354(c)(1)(ii) and (c)(2)(iv). B. Period of Disallowance In response to the Phase II interim final rule with comment period, several commenters questioned what the time period would be for which the physician could not refer patients for DHS to an entity and for which the entity could not bill Medicare (the ‘‘period of disallowance’’) where a financial relationship between a referring physician and an entity failed to satisfy the requirements of an exception to the general prohibition on self-referral. (See 72 FR 51024 through 51025; and 72 FR 38183.) In the Phase III final rule, in response to these inquiries, we stated that the statute provides no explicit limitation on the billing and claims submission prohibition (72 FR 51025). In the CY 2008 PFS proposed rule, we stated that the statute contemplates that the period of disallowance begins with the date that a financial relationship failed to comply with the statute and the regulations, and ends with the date that the arrangement came into compliance or ended (72 FR 38183). We noted that, in some cases, it may not be clear when a financial relationship has ended. We provided the example of an entity leasing space to a physician at a rental price that is substantially below fair market value. We stated that such an arrangement may raise the inference that the below-market rent was in exchange for future referrals, including referrals made beyond the expiration of the lease. We solicited comments with respect to: (1) The types of noncompliance for which it is not clear when a financial relationship ended; and (2) whether we should always PO 00000 Frm 00164 Fmt 4701 Sfmt 4702 employ a case-by-case approach or deem certain types of financial relationships to continue for a prescribed period of time. We also solicited public comments as to whether we should allow a prescribed period of disallowance to terminate where the parties have returned (or paid back the value of) any excess compensation. For example, if we were to impose a period of disallowance for a prescribed period of time because it would not be clear when a noncompliant compensation arrangement ended, we stated that we might allow the parties to terminate the period of disallowance sooner than the prescribed period if the prohibited compensation were returned. In the CY 2008 PFS proposed rule, we cautioned that we did not envision allowing such an option where the parties knew or, in our judgment, reasonably should have known, that the arrangement did not satisfy the requirements of an exception. Finally, we sought public comments as to whether we should impose a period of disqualification, prohibiting the parties from using an exception where an arrangement has failed to satisfy the requirements of that exception. We gave the example of nonmonetary compensation provided by an entity to a physician that greatly exceeded the permissible limit prescribed in § 411.357(k), and questioned whether, in addition to whatever period of disallowance would apply, the parties should be disqualified, for some period of time, from using this exception. We received few public comments in response to the CY 2008 PFS proposed rule solicitation of comments; however, with respect to the length of the period of disallowance, one commenter asserted that the appropriate period of disallowance should match the period that the financial relationship did not satisfy the requirements of an exception, but that the period should be limited to a maximum term. In addition, commenters asserted that, if the parties unwind the relationship and return the prohibited compensation, the period of disallowance should end. Another commenter suggested that the period of disallowance should end once the hospital corrects or terminates the arrangement and the physician repays to the hospital any compensation in excess of what is permitted. Alternatively, according to the commenter, if the physician does not repay the excess compensation, the period of disallowance should end once the hospital repays to Medicare the excess compensation, and the hospital should be prohibited from paying any further compensation to the physician until the E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules physician reimburses the hospital for the excess compensation. One commenter asserted that certain circumstances warrant no period of disallowance. For instance, according to the commenter, if parties to an arrangement were unaware that the arrangement violates the physician selfreferral law but later were notified by CMS or its contractor of the possible violation, they should be able to amend the arrangement so that it satisfies the requirements of an exception without any period of disallowance. The commenter also asserted that there should be no period of disqualification preventing the parties from using an exception in light of the onerous penalties under the physician selfreferral law. At this time, we are proposing to amend § 411.353(c) to provide that, where the reason(s) a financial relationship does not meet any applicable exception is not related to compensation (for example, a signature is missing or an agreement is not in writing as required by the applicable exception), the period of disallowance would begin on the date the arrangement first was out of compliance and end no later than the date the arrangement was brought into compliance (for example, by obtaining a missing signature on an agreement or executing a written agreement as required by the applicable exception). For example, where a hospital and a physician enter into a personal service arrangement for medical director services and begin performing under the arrangement on January 1, but do not execute a written agreement until January 31, provided that all of the requirements of § 411.357(d) (the exception for personal service arrangements) are satisfied as of January 31, the period of disallowance would begin on January 1 and end no later than January 31. As discussed below, we believe that it is possible that a financial arrangement may end prior to the arrangement being brought into compliance. In such circumstances, a determination as to the duration of the period of disallowance necessarily would be made on a case-by-case basis considering the facts and circumstances, and we are not proposing a prescribed period of disallowance for such a situation. We are also proposing that, where the reason a financial relationship does not meet any applicable exception is related to the payment or receipt of excess compensation (for example, the compensation paid to a physician is greater than fair market value or exceeds the limits in § 411.357(k) or (m)), the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 period of disallowance would begin on the date the arrangement first was out of compliance and end no later than the date the excess compensation (including interest, as appropriate) was returned by the party receiving it to the party that provided it and all other requirements of the applicable exception are met. For example, if a hospital provided nonmonetary compensation totaling $100 in excess of the limits in § 411.357(k) on February 1 and the parties did not discover the noncompliance until October 1 (and, therefore, could not avail themselves of the provisions in § 411.357(k)(3) permitting parties to remain in compliance with the exception if excess nonmonetary compensation (within certain limits) provided inadvertently is discovered and returned with 180 days of its receipt), the period of disallowance would begin on February 1 and end no later than the date that the physician returned the excess nonmonetary compensation or its value ($100 plus interest, as appropriate) to the hospital. Assuming that the physician paid the hospital $100 (plus interest, as appropriate) on October 15, the period of disallowance would run from February 1 through no later than October 15. Our proposal would also prescribe a period of disallowance where the reason a financial relationship does not meet any applicable exception is related to the payment or receipt of compensation that is insufficient to satisfy the requirements of an exception (for example, office space or equipment rental payments that are below fair market value). We are proposing that the period of disallowance would begin on the date the arrangement first was out of compliance and end no later than the date the shortfall was paid to the party to which it is owed and all other requirements of the applicable exception are met. The ‘‘shortfall’’ would be that amount (including interest, as appropriate) necessary to bring the arrangement into compliance from the date of its inception. For example, assume a hospital and physician entered into a 2-year office space rental agreement on January 1 (of Year 1) which specified rental charges (consistent with fair market value) of $20 per square foot during Year 1 and automatically adjusted upward each January 1 by any increase in the CPI–U. If, on January 1 of Year 2 of the agreement, the rental charges increased to $21 per square foot based on the amount of increase in the CPI–U, but the physician continued to pay $20 per square foot until the compliance failure PO 00000 Frm 00165 Fmt 4701 Sfmt 4702 23691 was identified on June 30 of Year 2, the period of disallowance would run from January 1 of Year 2 until no later than June 30 of Year 2, provided that the physician paid the hospital on June 30 of Year 2 the shortfall of $1 per square foot for the 6-month shortfall period (plus interest, as appropriate) and, as of July 1 through the term of the agreement, the physician paid $21 per square foot for the office space, and the arrangement otherwise satisfied the requirements of the exception in § 411.357(d). As discussed below, we believe that it is possible that an arrangement may end prior to excess compensation being returned or a shortfall being paid; however, such a determination as to the duration of the period of disallowance necessarily would be made on a case-by-case basis considering the facts and circumstances, and we are not proposing a prescribed period of disallowance for such a situation. We also note that an arrangement may be noncompliant for reasons that are related to compensation, but which do not involve the payment or receipt of excess compensation or a shortfall in compensation paid or received. For example, many of our exceptions require that the compensation not take into account the volume or value of referrals or other business generated between the parties and that the compensation be commercially reasonable, even if no referrals were made between the parties. It is possible that the amount of compensation provided under an arrangement is fair market value or is consistent with a prescribed limit in one of the exceptions (such as in § 411.357(k)), but, for example, takes into account the volume or value of referrals and this results in a noncompliant arrangement. We are not proposing a prescribed period of disallowance for arrangements that are noncompliant for reasons that are related to compensation but which do not involve only the payment or receipt of excess compensation or a shortfall in compensation paid or received. Rather, the appropriate period of disallowance for such arrangements would need to be determined on a case-by-case basis. Essentially, our proposals place an outside limit on the period of disallowance in certain circumstances. That is, where the reason(s) for noncompliance does not relate to compensation, the latest the period of disallowance would end would be the date the arrangement was brought into compliance. Where the reason for noncompliance is the fact that excess compensation was provided or too little compensation was paid, the latest the E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23692 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules period of disallowance would end would be the date that the party receiving the excess compensation returned it to the party that provided it or the party owing the shortfall in compensation paid it to the party to which it was owed (assuming the arrangement otherwise satisfies the requirements of an applicable exception). We recognize, of course, that parties to a financial relationship that is noncompliant may never bring the relationship into compliance with an applicable exception. The financial relationship may expire according to the terms of the underlying agreement (such as the date of expiration of a personal service contract), or it may end earlier or later than the expiration date provided in the underlying agreement. However, we do not propose to prescribe with specificity when such a noncompliant financial relationship (and, thus, the period of disallowance) might end. Likewise, if a party that receives excess compensation never repays the excess compensation, or a party who owes additional compensation (the shortfall) never pays it, the question arises as to when the financial relationship ends. To return to the example that we gave in the CY 2008 PFS proposed rule and that we reference above, if an entity leases space to a physician at a rental price that is substantially below fair market value, the inference may be raised that the below-market rent was in exchange for future referrals, including referrals made beyond the expiration of the lease agreement. Therefore, in such a situation, if the physician does not pay the rental charges shortfall, the financial relationship may not end at the expiration of the written lease agreement, but rather could extend for some period beyond the expiration of the written lease agreement. We are not proposing to establish any specific time period or even guidelines for when the financial relationship in the above example would be deemed to end (so that future referrals would not be tainted); rather the determination of when the financial relationship ends must depend on the facts and circumstances. We note that our proposals pertain only to placing an outside limit on the period of disallowance for making referrals and billing the Medicare program in the case of certain noncompliant financial relationships; they do not address whether the anti-kickback statute is implicated and/or whether civil monetary penalties under the physician self-referral statute are potentially VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 applicable due to noncompliant financial relationships. We are not proposing, as one commenter suggested, that, in a situation involving noncompliance due to excess compensation paid by an entity to a physician (or the physician’s immediate relative), the period of disallowance would end no later than the date the entity repays the excess compensation to the Medicare program, should the physician not repay the excess compensation to the entity. This approach is not consistent with the statute. We are also not proposing, as another commenter suggested, to impose no period of disallowance for the situation in which parties allegedly were unaware of the noncompliant nature of a financial relationship. We do not have the authority under section 1877 of the Act to waive violations of the physician self-referral law. We note also that there would be practical problems in determining whether parties were unaware of the noncompliant nature of the arrangement and that we would be discouraging parties from carefully structuring arrangements and monitoring them. In the CY 2008 PFS proposed rule, we proposed an alternative method of compliance that may address some of the commenter’s concerns, and that proposal is still under consideration for final rulemaking. Finally, we are not proposing to impose a period of disqualification during which the parties to a noncompliant financial relationship would be prohibited from using a particular exception due to that relationship. We may propose rulemaking on this subject in the future. C. Gainsharing Arrangements 1. Background The term ‘‘gainsharing’’ typically refers to an arrangement under which a hospital gives physicians a share of the reduction in the hospital’s costs (that is, the hospital’s cost savings) attributable in part to the physicians’ efforts. Gainsharing may take several forms. Some arrangements are narrowly targeted, giving the physician a financial incentive to select specific medical devices and products that are less expensive or to adopt specific clinical practices or protocols that reduce costs. Other, more problematic arrangements are not targeted at utilization of specific supplies or specific clinical practices, but instead offer the physician payments to reduce total average costs per case below target amounts. Gainsharing arrangements seek to align physician incentives with those of hospitals by offering physicians a share PO 00000 Frm 00166 Fmt 4701 Sfmt 4702 of the hospital’s variable cost savings attributable to the physicians’ efforts in controlling the cost of providing patient care. Following the institution of the Medicare Part A DRG system of hospital reimbursement and with the growth of managed care, hospitals have experienced significant financial pressure to reduce costs. However, because physicians are paid separately under Medicare Part B and Medicaid, physicians do not share necessarily a hospital’s incentive to control the hospital’s patient care costs. Gainsharing arrangements are designed to align hospital and physician incentives by offering physicians a portion of the hospital’s cost savings in exchange for identifying and implementing cost-saving strategies. 2. Statutory Impediments to Gainsharing Arrangements Whereas gainsharing promotes hospital cost reductions by aligning physician incentives with those of the hospital, these arrangements also implicate the physician self-referral statute (section 1877 of the Act). Section 1877(a)(1) of the Act states that, except as provided in section 1877(b) of the Act, if a physician (or an immediate family member of such physician) has a financial relationship with an entity, the physician may not make a referral to the entity for the furnishing of DHS for which payment otherwise may be made under title XVIII of the Act. The provision of monetary or nonmonetary remuneration by a hospital to a physician through a gainsharing arrangement would constitute a financial relationship with an entity for purposes of the physician self-referral statute. Gainsharing arrangements also implicate two specific fraud and abuse statutes. First, sections 1128A(b)(1) and (b)(2) of the Act, commonly referred to as the Civil Monetary Penalty, or CMP, statute, prohibit a hospital from knowingly making a payment directly or indirectly to a physician as an inducement to reduce or limit items or services furnished to Medicare or Medicaid beneficiaries, and a physician from knowingly accepting such payment. Second, gainsharing arrangements implicate section 1128B(b) of the Act (the ‘‘anti-kickback statute’’) if one purpose of the cost savings payment is to influence referrals of Federal health care program business. 3. Office of Inspector General (OIG) Approach Towards Gainsharing Arrangements The HHS Office of Inspector General (‘‘OIG’’) historically has been wary of E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules gainsharing arrangements. In July 1999, OIG issued a Special Advisory Bulletin that addressed the application of sections 1128A(b)(1) and (2) of the Act to gainsharing arrangements. Although OIG recognized that appropriately structured gainsharing arrangements may offer significant benefits where there is no adverse impact on the quality of care received by patients, section 1128A(b) of the Act clearly prohibits arrangements that are intended as an inducement to limit or reduce services to Medicare or Medicaid patients. In addition, OIG stated that regulatory relief from the CMP prohibition would require statutory authorization. OIG has issued several favorable advisory opinions regarding individual gainsharing arrangements, although the opinions (like all OIG advisory opinions) do not have general applicability. When evaluating the risks posed by a gainsharing arrangement, OIG has generally looked for three types of safeguards, namely: (1) Measures that promote accountability and transparency; (2) adequate quality controls; and (3) controls on payments related to referrals. Properly structured, gainsharing arrangements may offer opportunities for hospitals to reduce costs without causing inappropriate reductions in medical services or rewarding referrals of Federal health care program patients. In a number of specific cases involving limited proposed arrangements, OIG has issued advisory opinions in which it concluded that the proposed arrangement presents a low risk of abuse and, therefore, it would exercise its prosecutorial discretion not to impose sanctions. In these cases, OIG has concluded, based on the totality of facts and circumstances and the presence of adequate safeguards, that: (1) The proposed arrangement would constitute an improper payment to induce the reduction or limitation of services as prohibited by sections 1128A(b)(1) and (2) of the Act, but that OIG would not impose sanctions on the requestors of the advisory opinion; and (2) the proposed arrangement would potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent to induce or reward referrals of Federal health care program business were present, but that OIG would not impose administrative sanctions on the requestors under section 1128A(a), or under section 1128(b)(7) or section 1128A(a)(7), as those sections relate to the commission of acts described in the anti-kickback statute. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 4. MedPAC Recommendation MedPAC, in its March 2005 Report to Congress, ‘‘Physician-owned Specialty Hospitals,’’ recommended that gainsharing arrangements between physicians and hospitals be permitted. Specifically, MedPAC stated that, ‘‘[t]he Congress should grant the Secretary the authority to allow gainsharing arrangements between physicians and hospitals and to regulate those arrangements to protect the quality of care and minimize financial incentives that could affect physician referrals.’’ (See https://www.medpac.gov/ publications/congressional repots/ Mar05EntireReport.pdf, at page 47). In addition, MedPAC stated that, drawing on OIG’s work, the Secretary could require that gainsharing arrangements: • Identify specific actions that would produce savings, such as limiting the inappropriate use of supplies; • Are transparent and disclosed to patients; • Include periodic reviews of quality of care by an independent organization; • Limit the amount of time during which physicians can share cost savings in order to prevent hospitals from using these agreements as a mechanism to induce physician referrals; • Avoid rewarding physicians for increasing referrals to the hospitals, such as capping potential savings based on the number of prior year admissions; and • Monitor changes in the severity, age, and insurance coverage of patients affected by the gainsharing arrangement. 5. Demonstration Programs CMS has long been interested in evaluating the association between payments and the quality of care. In 1991, CMS initiated a demonstration program entitled the ‘‘Medicare Participating Heart Bypass Center Demonstration.’’ This demonstration was conducted to assess the feasibility and cost effectiveness of a negotiated all-inclusive bundled payment arrangement for coronary artery bypass graft (CABG) surgery while maintaining high quality care. CMS originally negotiated contracts with four applicants. In 1993, the demonstration was expanded to include three more participants. The results of the demonstration showed that an allinclusive bundled payment arrangement can provide an incentive to physicians and hospitals to work together to provide services more efficiently, improve quality, and reduce costs. The bundling of the physician and hospital payments did not have a negative impact on the post-discharge health PO 00000 Frm 00167 Fmt 4701 Sfmt 4702 23693 improvements of the demonstration patients. Three of the four original hospitals were able to make major changes in physician practice patterns and operations that generated significant cost savings. A hospital’s participation in the demonstration appeared to have little or no effect on physician referral patterns. A second demonstration project that involves gainsharing arrangements is authorized by section 646 of the MMA, which added a new section 1866C of the Act and established the Medicare Health Care Quality MHCQ Demonstration Program. MHCQ demonstration projects are intended to ‘‘* * * examine health delivery factors that encourage the delivery of improved quality in patient care.’’ Using the authority provided by section 1866C of the Act, CMS decided to implement a 3-year demonstration that would test gainsharing models involving physicians and collaborations between hospitals working with physicians in a single geographic area to improve the quality of inpatient hospital care. In contrast to traditional models of gainsharing, the proposed demonstration approaches must be across single or multiple organizations and involve long-term followup to ensure both documented improvements in quality and reductions in the overall costs of care. CMS is particularly interested in demonstration designs that: (1) Track patients well beyond a hospital episode to determine the impact of hospital-physician collaborations on preventing short and longer-term complications, duplication of services, and coordination of care across settings; and (2) offer other quality improvements for eliminating preventable complications and unnecessary costs. A third series of demonstration projects was authorized by section 5007 of the Deficit Reduction Act of 2005 (the ‘‘DRA’’) (Pub. L. 109–171). This provision requires the Secretary to establish a qualified gainsharing demonstration under which the Secretary shall approve up to six demonstration projects. Section 5007 demonstration projects would involve arrangements between a hospital and physicians and practitioners under which the hospital provides for remuneration (that is, gainsharing payments) to certain physicians and to certain practitioners (as defined in 1842(b)(18)(C) of the Act) that represents solely a share of the savings incurred directly as a result of collaborative efforts between the hospital and a particular physician (or practitioner) to improve overall quality and efficiency. Each demonstration E:\FR\FM\30APP2.SGM 30APP2 23694 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules D. Physician-Owned Implant and Other Medical Device Companies project must also provide measures to monitor quality and efficiency in the participating project hospital(s). 1. Background jlentini on PROD1PC65 with PROPOSALS2 6. Solicitation of Comments In the CY 2008 PFS proposed rule, we noted that we are concerned about compensation arrangements between entities and physicians under which compensation is determined on a percentage basis (for example, rental charges for office space that are determined based on a percentage of a group practice’s revenues) (72 FR 38184). We proposed to clarify that percentage-based compensation arrangements may be used only for paying for personally performed physician services and that such arrangements must be based on the revenues directly resulting from the physician services rather than based on some other factor such as a percentage of the savings by the hospital department. The proposed changes, if finalized, might prevent typical gainsharing arrangements between physicians and hospitals to which they refer for DHS. We have not yet finalized our proposal in the CY 2008 PFS final rule; however, it remains under active consideration. Notwithstanding our general concern with arrangements that involve the use of a percentage-based compensation formula (other than payment to a physician for work personally performed by the physician), we recognize the value to the Medicare program and its beneficiaries where the alignment of hospital and physician incentives results in improvements in quality of care. Therefore, we are considering whether to issue an exception specific to gainsharing arrangements. Under section 1877(b)(4) of the Act, we may issue additional exceptions (that is, exceptions not specified in the statute) only where doing so would create no risk of program or patient abuse. At this time, we decline to issue a specific proposal concerning an exception for gainsharing arrangements, but rather are soliciting comments as to whether we should establish an exception for gainsharing arrangements, and, if so, what safeguards should be included in the exception. Specifically, we are interested in receiving comments on: (1) What types of requirements and safeguards should be included in any exception for gainsharing arrangements; and (2) whether certain services, clinical protocols, or other arrangements should not qualify for the exception. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 We have recently become aware of an increase in physician investment in implant and other medical device manufacturing, distribution, and purchasing companies. We recognize that physician involvement often adds value to device manufacturing companies and that many physicians may have legitimate investment interests in these companies. Physicians participate in the research, development, and testing involved in creating and producing many lifesaving and quality-of-life enhancing medical devices. The added value of physician involvement in distribution and purchasing companies, essentially middlemen companies, is less clear. When physicians profit from the referrals they make to hospitals through physician-owned implant and medical device companies (‘‘POCs’’), we are concerned about possible program or patient abuse. POCs exist in three primary forms: manufacturers, distributors, and group purchasing organizations (‘‘GPOs’’). Our understanding, however, is that many POCs are not manufacturers, but rather are companies that profit from the purchase and resale of products made by another organization (that is, they act as distributors) or from GPO fees paid by device vendors. In many cases, the physician investors bear little, if any, economic risk with respect to the medical devices. It is also our understanding that some physicians are offered investment interests in ‘‘private label’’ or similar manufacturing entities when the physicians have provided little, if any, necessary research, design, or testing services. We are concerned that some physician-owned organizations may serve little purpose other than providing physicians the opportunity to earn economic benefits in exchange for nothing more than ordering medical devices or other products that the physician-investors use on their own patients. The financial incentives paid to the physicians may foster an anti-competitive climate, raise quality of care concerns, and lead to overutilization of the device or other product to which the physician is linked. Physicians are responsible for selecting or recommending the devices ordered for the hospital’s patients. It is reasonable to believe that medical device or implant companies without physician investment will have difficulty finding referral sources in areas where many physicians are PO 00000 Frm 00168 Fmt 4701 Sfmt 4702 invested in a POC that offers competing products. In response to our proposed change to the definition of ‘‘entity’’ at § 411.351 in the CY 2008 PFS proposed rule, we received public comments regarding whether a physician-owned implant or other medical device company should or should not be considered to be an ‘‘entity.’’ One commenter noted that orthopedic surgeons may have an ownership interest in a manufacturer of spinal implants that sells its implants to the hospital where the surgeon performs his or her surgeries. According to the commenter, because the proposed definition of ‘‘entity’’ would extend to an entity that ‘‘performs the DHS,’’ the manufacturer arguably could be considered to be an ‘‘entity’’ under § 411.351. This commenter urged us to exclude such manufacturers from the definition of ‘‘entity.’’ The commenter stated that indirect arrangements involving spinal implants would trigger the self-referral prohibition if they are not at fair market value. Comments submitted on behalf of a manufacturer of spinal implants asserted that, despite superficial similarities, joint ventures involving medical devices differ in many material ways from the types of arrangements about which we expressed concern. This commenter also asserted that the meaning of ‘‘has performed the DHS’’ is unclear and that we should clarify that the proposal applied only to ‘‘true’’ ‘‘under arrangement’’ relationships with hospitals, but that, in any event, implantable devices are not DHS. According to the commenter, even if implantable devices were deemed to be DHS, the rigorous physician selfreferral exceptions (for example, the exception for indirect compensation arrangements in § 411.357(p)) are still available to protect the arrangement and against program or patient abuse. In an October 6, 2006 letter response to a request for guidance regarding certain physician investments in the medical device industry, OIG stated that it was aware of an apparent proliferation of physician investments in medical device and distribution companies, including GPOs, and that, given the strong potential for improper inducements between and among the physician investors, the companies, device vendors, and medical device purchasers, it believed that all of these ventures should be closely scrutinized under the fraud and abuse laws. OIG also clarified that its 1989 Special Fraud Alert on Joint Ventures applies to all physician joint ventures and would, therefore, apply to physician investments in medical device manufacturing and distribution E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules companies, as well as GPOs. OIG confirmed that the fact that a substantial portion of a venture’s gross revenues is derived from participant-driven referrals is a potential indicator of a problematic joint venture. The October 6, 2006 letter response is available at https:// oig.hhs.gov/fraud/docs/ alertsandbulletins/ GuidanceMedicalDevice%20(2).pdf. See also https://oig.hhs.gov/testimony/docs/ 2008/demske_testimony022708.pdf. A medical device company requested that we take a closer look at the current prevalence of POCs and the impact that these companies may have on program or patient abuse, as well as the negative impact on competition among POCs and nonphysician owned medical device companies. This company noted that, in the CY2008 PFS proposed rule, we proposed revising the definition of ‘‘entity’’ to include, among other things, an entity that causes a claim to be submitted to Medicare. It suggested that we finalize our proposal and that we deem POCs to be DHS entities under certain circumstances. It also suggested that, in certain circumstances, physician investors in POCs should be deemed to have a direct compensation relationship with the hospitals that order and use implantable devices furnished by the POCs. The company suggested that a POC should not be considered to have caused a claim to be presented where the referring physician is named as an inventor on an issued patent for the implantable item, provided that the physician does not receive any remuneration from the POC based on the volume or value of his or her referrals, or where the physician’s investment interest satisfies the requirements of the exception in § 411.356(a) for large, publicly traded entities. We note that it is not clear to us under what circumstances a patent holder physician, who presumably receives royalty payments from the POC, would receive remuneration that does not relate to the volume or value of referrals or other business generated by the physician. In the Phase II final rule with comment period, we noted that we received a comment that questioned whether the payment of a royalty by an equipment manufacturer to a physician inventor for a device implanted during surgeries performed by the physician inventor is permitted or whether that arrangement would create an indirect compensation relationship with the hospital that purchased the device. We stated, in response, that the physician inventor would have an indirect compensation arrangement with the hospital in which VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 the surgeries are performed but, provided the royalty payment was fair market value, the relationship should satisfy the exception for indirect compensation arrangements in § 411.357(p) (69FR 16060). 2. Solicitation of Comments At this time, we are not issuing a specific proposal regarding POCs. The statute and our existing regulations, specifically those related to indirect compensation arrangements, address many POCs. In some problematic circumstances, an unbroken chain of financial relationships will connect the physician owner of a POC to a DHS entity to which the physician makes referrals, and the other elements of an indirect compensation arrangement contained in § 411.354(c)(2) will also be present, including the requisite knowledge by the DHS entity of the physician’s interest in the POC. In many instances, the arrangement would not satisfy the requirements of the exception for indirect compensation arrangements in § 411.357(p), and would, therefore, run afoul of the physician self-referral statute. However, we are soliciting public comments as to whether our physician self-referral rules should address POCs and similar physician owned companies more specifically, or whether the concerns surrounding POCs and similar organizations, to the extent that they are not addressed by the statute and our current rules, are better addressed through enforcement of the False Claims Act, the anti-kickback statute and similar fraud and abuse laws, other public laws, and through other applicable Federal, State, and local regulations. In this regard, we are seeking comments as to whether, and to what degree, physician investment in POCs and similar organizations presents risks of overutilization, substandard care, and increased costs to the Medicare program and its beneficiaries, or whether the risk is confined to possible anti-competitive behavior. To the extent that commenters believe that certain physician investment in POCs and similar organizations should be addressed more specifically under our physician self-referral rules, commenters are encouraged to provide us with suggestions as to specific actions we should take (for example, considering POCs to be DHS entities under certain circumstances, considering physician investors in POCs who influence hospitals as to the ordering of medical devices to have direct compensation relationships with the hospitals, excepting certain investment interests from coverage under our rules, etc.). PO 00000 Frm 00169 Fmt 4701 Sfmt 4702 23695 IX. Financial Relationships Between Hospitals and Physicians A. Background As stated earlier, under section 1877 of the Act, a physician is prohibited from referring a Medicare patient for DHS to an entity (including an individual) with which the physician (or an immediate family member of the physician) has a financial relationship, unless an exception applies. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a claim or bill to Medicare or any individual, third party payor, or other entity for DHS furnished as a result of a prohibited referral. Also, section 1877 of the Act prohibits us from making payment for DHS furnished pursuant to a prohibited referral. The statute contains several exceptions for certain types of compensation arrangements and ownership or investment interests, including the exception in section 1877(d)(3) of the Act for ownership or investment by a physician in the hospital itself and not merely in a subdivision of the hospital (that is, the ‘‘whole’’ hospital). Section 1877(b)(4) of the Act authorizes us to create additional exceptions, provided that they do not create a risk of program or patient abuse. As a result of the statutory exceptions in section 1877 of the Act, and the exceptions we have created using our authority under section 1877(b)(4) of the Act, our regulations contain approximately 40 exceptions to the prohibition on physician self-referrals. (We refer readers to 42 CFR 411.351 through 411.357 of our regulations and the September 5, 2007 ‘‘Phase III’’ final rule (72 FR 51012).) Section 1877(f) of the Act provides that: ‘‘Each entity providing covered items or services for which payment may be made under this title [42 USCS 1395 et seq.] shall provide the Secretary with the information concerning the entity’s ownership, investment, and compensation arrangements, including: (1) The covered items and services provided by the entity, and (2) the names and unique physician identification numbers of all physicians with an ownership or investment interest (as described in subsection (a)(2)(A)), or with a compensation arrangement (as described in subsection (a)(2)(B)), in the entity, or whose immediate relatives have such an ownership or investment interest or who have a compensation relationship with the entity. Such information shall be provided in such form, manner, and E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23696 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules at such times as the Secretary shall specify.’’ (Emphasis added) Some industry representatives have argued that the reference to financial relationships as described in section 1877(a)(2)(A) and (a)(2)(B) of the Act limits our ability to obtain information on financial relationships that do not satisfy one of the statutory or regulatory exceptions. We disagree. The statute clearly contains a broad authorization for the Secretary to obtain information concerning an entity’s financial relationships, ‘‘including,’’ but not limited to, financial relationships that satisfy an exception. We believe that there would have been little point to the Congress providing us with the authority to compel information on excepted arrangements only, because, as we have noted previously, ‘‘an entity could decide that one or more of its financial relationships falls within an exception, fail to retain data concerning those financial relationships, and thereby prevent the government from reviewing the arrangements to determine if they qualify for an exception.’’ (72 FR 51069.) Accordingly, our regulation in § 411.361 requires entities to report ‘‘any ownership or investment interest, as defined at § 411.354(b), or any compensation arrangement, as defined at § 411.354(c), except for ownership or investment interests that satisfy the exceptions set forth in § 411.356(a) and § 411.356(b) regarding publicly-traded securities and mutual funds’’ (emphasis added). The statute provides that an ownership or investment interest in the entity may be through equity, debt, or other means, and includes an interest in an entity that holds an ownership or investment interest in any entity that furnishes DHS. Our regulations have been drafted to reflect clearly our commonsense interpretation of the statutory reporting requirements. In the proposed rule entitled ‘‘Medicare and Medicaid Programs; Physicians’’ Referrals to Health Care Entities With Which They Have Financial Relationships,’’ published in the Federal Register on January 9, 1998 (63 FR 1703), we proposed to modify § 411.361 to require that entities report information concerning their reportable financial relationships to us on a prescribed form and thereafter report annually all changes to the submitted information that occurred in the previous 12 months. In addition, we revisited the statute and interpreted the opening paragraph of section 1877(f) of the Act to permit us to gather any data on financial relationships, including, but not necessarily limited to, financial VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 relationships for which there are no exceptions under section 1877(a)(2)(A) or (a)(2)(B) of the Act. Therefore, we proposed to amend § 411.361 to reflect explicitly our authority to ask for a broader scope of information than the regulation permitted at that time. In the Phase II final rule with comment period (69 FR 16121), we modified the reporting requirement in § 411.361 to remove all references to the use of a prescribed form, to require entities to make information available only upon request, and to maintain the information only for the length of time specified by the applicable regulatory requirements for the information (that is, the rules of the Internal Revenue Service, Securities and Exchange Commission, Medicare, Medicaid, or other programs). In addition, we modified § 411.361 to provide that entities need not report ownership or investment interests that satisfy the exceptions in § 411.356(a) and (b) for publicly-traded securities and mutual funds. Most, if not all, hospitals have financial relationships with referring physicians. These financial relationships may involve ownership or investment interests, compensation arrangements, or both. The financial relationships can be direct or they may be indirect (such as through a physician group practice or limited liability company). The physician self-referral statute was first enacted in 1989, and the reporting requirements in the regulations in § 411.361 were first implemented in our December 3, 1991 interim final rule with comment period, published in the Federal Register at 56 FR 61374. Since that time, CMS has not engaged in a comprehensive reporting initiative to examine financial relationships between hospitals and physicians. Consistent with congressional intent in enacting the physician self-referral statute, we believe it is important to query hospitals concerning their financial relationships with physicians. B. Section 5006 of the Deficit Reduction Act (DRA) of 2005 Section 5006 of the DRA required the Secretary to develop a strategic and implementing plan to address certain issues relating to physician-owned specialty hospitals. The specific issues the Secretary was required to address were: (1) Proportionality of investment return; (2) bona fide investment; (3) annual disclosure of investment information; (4) the provision by specialty hospitals of (i) care to patients who are eligible for Medicaid (or who are not eligible for Medicaid but who PO 00000 Frm 00170 Fmt 4701 Sfmt 4702 are regarded as such because they receive benefits under a section 1115 waiver) and (ii) charity care; and (5) appropriate enforcement. In order to assist us in preparing the report and implementing plan required by section 5006 of the DRA, we sent a voluntary survey to 130 specialty hospitals and 220 competitor hospitals, which sought information regarding, among other things, the hospitals’ ownership and investment relationships, and their compensation arrangements with physicians. In the enforcement section of the strategic and implementing plan that was included in our ‘‘Final Report to the Congress and Strategic and Implementing Plan Required under Section 5006 of the Deficit Reduction Act of 2005’’ issued on August 8, 2006, available on our Web site at https:// www.cms.hhs.gov/ PhysicianSelfReferral/ 06a_DRA_Reports.asp (hereinafter referred to as the ‘‘DRA Report to Congress’’), we stated that we would require all hospitals (that is, not just specialty hospitals) to provide us information on a periodic basis concerning the investment interests in the hospital of physicians and the hospital’s compensation arrangements with physicians (DRA Report to Congress 69). We stated that we would not limit our requirement to information concerning physician investments in specialty hospitals for two reasons. First, physician investments in any type of hospital raise potential issues concerning compensation arrangements that can be associated with the investment. For example, a disproportionate return on investment or non-bona fide investment (through, for example, a sham loan), creates a prohibited compensation arrangement under the physician self-referral law and raises the possibility of an illegal kickback scheme. Second, other types of compensation arrangements (that is, those that are not associated with an investment interest), implicate the physician self-referral law, such as leasing, employment, and personal service arangements. It is also important to note that, although a physician may be highly motivated to refer patients to a hospital in which he or she has an ownership interest, the physician may be just as likely to refer patients to a hospital with which he or she has a compensation relationship, given that the physician may see a more direct and immediate financial benefit from the compensation arrangement. In the DRA Report to Congress, we stated that we would implement a regular disclosure process, but that we had not designed E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 the process at that point, and that we would consider such issues as whether we should: (1) Survey all hospitals annually; (2) stagger our survey so that all hospitals are queried but not all in the same year; and/or (3) focus our inquiry on certain types of relationships or certain hospitals. We stated that we would also consider whether, having once provided information, hospitals need only submit updated information on a yearly or other periodic basis. C. Disclosure of Financial Relationships Report (DFRR) Following up on our commitment to capture information concerning financial relationships between all types of hospitals and physicians, and to assist in enforcement of the physician self-referral statute and implementing regulations, we created an information collection instrument, referred to as the Disclosure of Financial Relationships Report (‘‘DFRR’’). The DFRR is designed to collect information concerning the ownership and investment interests and compensation arrangements between hospitals and physicians. (Appendix C of this proposed rule contains the DFRR instrument and instructions for public comment.) We believe information submitted by hospitals would permit us to analyze the types of financial relationships involving hospitals and physicians, the structure of various compensation arrangements and trends therein, and potentially whether the hospitals are in compliance with the physician self-referral law and implementing regulations. Using our authority under section 1877(f) of the Act and 42 CFR 411.361, we are proposing to send the DFRR to 500 hospitals, a number that we believe is necessary to provide us with sufficient information: (1) To determine compliance; and (2) to assist us in any future rulemaking concerning the reporting requirements and other physician self-referral provisions. We intend for our sample size to be a significant percentage of the total number of Medicare-participating hospitals. The 2007 CMS Statistics Handbook determined that, as of December 2006, there were approximately 6,200 Medicareparticipating hospitals. Our goal is to begin by sending the DFRR to 8 to 10 percent of the Medicare-participating hospitals (496 to 620 hospitals). We reviewed our available funding and determined that our resources would permit us to review data from 500 hospitals (both general acute care hospitals and specialty hospitals). As discussed further below, the DFRR also may assist us in making an VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 informed decision as to whether to propose rulemaking for an annual (or other periodic) disclosure requirement for all hospitals. By posing a comprehensive set of questions to a significant number of hospitals, we believe that we will be informed not only as to whether we should engage in such rulemaking, but also as to what the design of the proposed information collection should look like. Originally, we had planned to pilot this information collection request in advance of rulemaking. Thus, we prepared a proposed information collection request in accordance with the Paperwork Reduction Act. We announced and sought public comment on the information collection request in a 60-day Federal Register notice (CMS– 10236) that was published on May 18, 2007 (72 FR 28056). On September 14, 2007, we published in the Federal Register a revised information collection request in which we increased the time estimate for completing the DFRR and increased the time for submission of the DFRR from 45 days to 60 days (72 FR 52568). (For additional information, we refer the reader to 72 FR 28056 and 72 FR 52568.) In this proposed rule, we are providing a discussion of the potential burden associated with completing the DFRR, including an analysis that provides estimates of the burden for small, medium, and large hospitals. To better understand the potential burden for completing the DFRR collection, we reviewed the bed size of Medicareparticipating hospitals and developed three categories of hospitals (small, medium, and large hospitals). We randomly selected 20 hospitals from each category and requested that these 60 hospitals estimate the aggregate number of hours it would take them to complete and submit the entire DFRR collection. The 33 hospitals that responded included 11 small, 11 medium, and 11 large hospitals. We reviewed the responses from the 33 hospitals and determined that the average number of hours to complete the DFRR was 31 hours. This figure represents a significant increase from our most recent time and burden estimate. Therefore, we believe it would be beneficial to seek further comments on the accuracy of the time and burden estimates associated with this information collection instrument. Because the information that we seek is that which hospitals should already be keeping in the normal course of their business activities (even apart from the need to document compliance with the physician self-referral law), we anticipate that the majority of the time PO 00000 Frm 00171 Fmt 4701 Sfmt 4702 23697 spent completing the DFRR will be spent by administrative staff. We believe that the tasks involved would include retrieving the information and printing it from electronic files or copy it from hard files, which largely should involve administrative personnel. In addition, the review and organization of the materials would also impose burden on the respondent. Nevertheless, in order to err on the side of more potential burden rather than less, we have calculated costs using an hourly rate for accountants. D. Civil Monetary Penalties We are proposing that the DFRR be completed, certified by the appropriate officer of the hospital, and received by CMS within 60 days of the date that appears on the cover letter or e-mail transmission of the DFRR. We are soliciting comment on the proposed 60day timeframe for completing the DFRR. Section 411.361(f) provides that failure to timely submit the requested information concerning an entity’s ownership, investment, and compensation arrangements may result in civil monetary penalties of up to $10,000 for each day beyond the deadline established for disclosure. Although we have the authority to impose civil monetary penalties, we seek not to invoke this authority and will work with entities to comply with the reporting requirements. Prior to imposing a civil monetary penalty in any amount, we would issue a letter to any hospital that does not return the completed DFRR, inquiring as to why the hospital did not return timely the completed DFRR. In addition, a hospital may, upon a demonstration of good cause, receive an extension of time to submit the requested information. E. Uses of Information Captured by the DFRR As noted above, we anticipate that the DFRR will be useful in determining whether the financial relationships between 500 hospitals and the physicians associated with those hospitals are in compliance with the physician self-referral statute and regulations. In addition, the results of the DFRR may assist us in other rulemaking efforts. In the CY 2008 PFS proposed rule, we proposed certain changes to our physician self-referral rules (72 FR 38179 through 38187). With the exception of the anti-markup provisions, however, we have not yet finalized any of the proposals. We are actively working on the proposals, and although we expect to finalize the proposals before receiving and E:\FR\FM\30APP2.SGM 30APP2 23698 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules analyzing the completed DFRRs, information gleaned from the completed DFRRs may shape our final rulemaking if that rulemaking is delayed. Our analysis of the DFRRs may affect subsequent proposals on these and other related issues. jlentini on PROD1PC65 with PROPOSALS2 F. Solicitation of Comments We are soliciting comments on the DFRR information collection instrument through this proposed rule as follows: • Whether the collection effort should be recurring, and, if so, whether it should be implemented on an annual or some other periodic basis. • Whether we are collecting too much or not enough information, and whether we are collecting the correct (or incorrect) type of information. • The amount of time it will take hospitals to complete the DFRR and the costs associated with completing the DFRR; the amount of time we should give hospitals to complete and return their responses to us. • Whether we should direct the collection instrument to all hospitals, and, if so, whether we should stagger the collection so that only a certain number of hospitals are subject to it in any given year. • Whether hospitals, once having completed the DFRR, should have to send in yearly updates and report only changed information. X. MedPAC Recommendations We are required by section 1886(e)(4)(B) of the Act to respond to MedPAC’s recommendations regarding hospital inpatient payments in our annual proposed and final IPPS rules. We have reviewed MedPAC’s March 2008 ‘‘Report to the Congress: Medicare Payment Policy’’ and have given it careful consideration in conjunction with the proposed policies set forth in this document. MedPAC’s Recommendation 2A–1 states that ‘‘The Congress should increase payment rates for the acute inpatient and outpatient prospective payment systems in 2009 by the projected rate of increase in the hospital market basket index, concurrent with implementation of a quality incentive payment program.’’ This recommendation is discussed in Appendix B to this proposed rule. Recommendation 2A–2: MedPAC recommended that ‘‘The Congress should reduce the indirect medical education adjustment in 2009 by 1 percentage point to 4.5 percent per 10 percent increment in the resident-to-bed ratio. The funds obtained by reducing the indirect medical education adjustment should be used to fund a quality incentive payment program.’’ VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Response: Redirecting funds obtained by reducing the IME adjustment to fund a quality incentive payment program is consistent with the VBP initiatives to improve the quality of care and, therefore, merits consideration. However, section 502(a) of Pub. L. 108– 173 modified the formula multiplier (c) to be used in the calculation of the IME adjustment beginning midway through FY 2004 and provided for a new schedule of formula multipliers for FYs 2005 and thereafter. Consequently, CMS could not implement MedPAC’s recommendation to reduce the IME adjustment in 2009 without a statutory change. We note that included in the President’s FY 2009 budget proposal was a proposal to reduce the IME adjustment from 5.5 percent to 2.2 percent over 3 years, starting in FY 2009, in order to better align IME payments with the estimated costs per case that teaching hospitals may face. In its June 2007 ‘‘Report to Congress: Promoting Greater Efficiency in Medicare,’’ MedPAC made recommendations concerning the Medicare hospital wage index. Section 106(b)(1) of the MIEA–TRHCA (Pub. L. 109–432) required MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare hospital wage index classification system applied under the Medicare IPPS, including any alternatives that MedPAC recommended to the method to compute the wage index under section 1886(d)(3)(E) of the Act. In addition, section 106(b)(2) of the MIEA–TRHCA instructed the Secretary taking into account MedPAC’s recommendations on the Medicare hospital wage index classification system, to include in this FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS. The MedPAC recommendations and our proposals concerning the Medicare hospital wage index are discussed in section III.B. of the preamble of this proposed rule. For further information relating specifically to the MedPAC reports or to obtain a copy of the reports, contact MedPAC at (202) 653–7220, or visit MedPAC’s Web site at: https:// www.medpac.gov. data are available in computer tape or cartridge format. However, some files are available on diskette as well as on the Internet at: https://www.cms.hhs.gov/ providers/hipps. Data files and the cost for each file, if applicable, are listed below. Anyone wishing to purchase data tapes, cartridges, or diskettes should submit a written request along with a company check or money order (payable to CMS-PUF) to cover the cost to the following address: Centers for Medicare & Medicaid Services, Public Use Files, Accounting Division, P.O. Box 7520, Baltimore, MD 21207–0520, (410)–786–3691. Files on the Internet may be downloaded without charge. 1. CMS Wage Data This file contains the hospital hours and salaries for FY 2005 used to create the proposed FY 2009 prospective payment system wage index. The file is currently available for the NPRM and will be available by the beginning of May for the final rule. Processing year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. .................. Wage data year 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 PPS fiscal year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 These files support the following: • Notice of proposed rulemaking published in the Federal Register. • Final rule published in the Federal Register. Media: Diskette/most recent year on the Internet. File Cost: $165.00 per year. Periods Available: FY 2009 PPS Update. XI. Other Required Information 2. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index Values Only) A. Requests for Data From the Public In order to respond promptly to public requests for data related to the prospective payment system, we have established a process under which commenters can gain access to raw data on an expedited basis. Generally, the This file contains a history of all wage indices since October 1, 1983. Media: Diskette/most recent year on the Internet. File Cost: $165.00 per year. Periods Available: FY 2009 PPS Update. PO 00000 Frm 00172 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 3. FY 2009 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW by Provider This file includes each hospital’s adjusted and unadjusted average hourly wage. Media: Internet. Periods Available: FY 2009 PPS Update. 4. FY 2009 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW and Pre-Reclassified Wage Index by CBSA This file includes each CBSA’s adjusted and unadjusted average hourly wage. Media: Internet. Periods Available: FY 2009 PPS Update. 5. Provider Occupational Mix Adjustment Factors for Each Occupational Category This file contains each hospital’s occupational mix adjustment factors by occupational category. Media: Internet. Periods Available: FY 2009 PPS Update. 6. PPS SSA/FIPS MSA State and County Crosswalk This file contains a crosswalk of State and county codes used by the Social Security Administration (SSA) and the Federal Information Processing Standards (FIPS), county name, and a historical list of Metropolitan Statistical Areas (MSAs). Media: Diskette/Internet. File Cost: $165.00 per year. Periods Available: FY 2009 PPS Update. 7. Reclassified Hospitals New Wage Index (Formerly: Reclassified Hospitals by Provider Only) jlentini on PROD1PC65 with PROPOSALS2 This file contains a list of hospitals that were reclassified for the purpose of assigning a new wage index. Two versions of these files are created each year. They support the following: • Notice of proposed rulemaking published in the Federal Register. • Final rule published in the Federal Register. Media: Diskette/Internet. File Cost: $165.00 per year. Periods Available: FY 2009 PPS Update. 8. PPS–IV to PPS–XII Minimum Data Set The Minimum Data Set contains cost, statistical, financial, and other information from Medicare hospital cost reports. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 a Medicare participating hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. Media: Tape/Cartridge. File Cost: $770.00 per year. Periods beginning on or after PPS–IV ............. PPS–V .............. PPS–VI ............. PPS–VII ............ PPS–VIII ........... PPS–IX ............. PPS–X .............. PPS–XI ............. PPS–XII ............ 10/01/86 10/01/87 10/01/88 10/01/89 10/01/90 10/01/91 10/01/92 10/01/93 10/01/94 and before 10/01/87 10/01/88 10/01/89 10/01/90 10/01/91 10/01/92 10/01/93 10/01/94 10/01/95 (NOTE: The PPS–XIII, PPS–XIV, PPS–XV, PPS–XVI, PPS–XVII, PPS–XVIII, PPS–XIX PPS–XX, PPS–XXI, PPS–XXII, and PPS– XXIII Minimum Data Sets are part of the PPS– XIII, PPS–XIV, PPS–XV, PPS–XVI, PPS–XVII, PPS–XVIII, PPS–XIX, PPS–XX, PPS–XXI, PPS–XXII, and PPS–XXIII Hospital Data Set Files (refer to item 10 below).) 9. PPS–IX to PPS–XII Capital Data Set The Capital Data Set contains selected data for capital-related costs, interest expense and related information and complete balance sheet data from the Medicare hospital cost report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for a Medicare certified hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month. Media: Tape/Cartridge. File Cost: $770.00 per year. Periods beginning on or after PPS–IX ............. PPS–X .............. PPS–XI ............. PPS–XII ............ 10/01/91 10/01/92 10/01/93 10/01/94 and before 10/01/92 10/01/93 10/01/94 10/01/95 (Note: The PPS–XIII, PPS–XIV, PPS– XV, PPS–XVI, PPS–XVII, PPS–XVIII, PPS–XIX PPS–XX, PPS–XXI, PPS–XXII, and PPS–XXIII Capital Data Sets are part of the PPS–XIII, PPS–XIV, PPS–XV, PPS–XVI, PPS–XVII, PPS–XVIII, PPS– XIX, PPS–XX, PPS–XXI, PPS–XXII, and PPS–XXIII Hospital Data Set Files (refer to item 10 below).) 10. PPS–XIII to PPS–XXIII Hospital Data Set The file contains cost, statistical, financial, and other data from the Medicare Hospital Cost Report. The data set includes only the most current cost PO 00000 Frm 00173 Fmt 4701 Sfmt 4702 23699 report (as submitted, final settled, or reopened) submitted for a Medicarecertified hospital by the Medicare fiscal intermediary to CMS. The data set is updated at the end of each calendar quarter and is available on the last day of the following month. Media: Diskette/Internet. File Cost: $2,500.00. Periods beginning on or after PPS–XIII ........... PPS–XIV ........... PPS–XV ............ PPS–XVI ........... PPS–XVII .......... PPS–XVIII ......... PPS–XIX ........... PPS–XX ............ PPS–XXI ........... PPS–XXII .......... PPS–XXIII ......... 10/01/95 10/01/96 10/01/97 10/01/98 10/01/99 10/01/00 10/01/01 10/01/02 10/01/03 10/01/04 10/01/05 and before 10/01/96 10/01/97 10/01/98 10/01/99 10/01/00 10/01/01 10/01/02 10/01/03 10/01/04 10/01/05 10/01/06 11. Provider-Specific File This file is a component of the PRICER program used in the fiscal intermediary’s or the MAC’s system to compute DRG payments for individual bills. The file contains records for all prospective payment system eligible hospitals, including hospitals in waiver States, and data elements used in the prospective payment system recalibration processes and related activities. Beginning with December 1988, the individual records were enlarged to include pass-through per diems and other elements. Media: Diskette/Internet. File Cost: $265.00. Periods Available: FY 2009 PPS Update. 12. CMS Medicare Case-Mix Index File This file contains the Medicare casemix index by provider number as published in each year’s update of the Medicare hospital inpatient prospective payment system. The case-mix index is a measure of the costliness of cases treated by a hospital relative to the cost of the national average of all Medicare hospital cases, using DRG weights as a measure of relative costliness of cases. Two versions of this file are created each year. They support the following: • Notice of proposed rulemaking published in the Federal Register. • Final rule published in the Federal Register. Media: Diskette/most recent year on Internet. Price: $165.00 per year/per file. Periods Available: FY 1985 through FY 2009. E:\FR\FM\30APP2.SGM 30APP2 23700 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 13. MS–DRG Relative Weights (Formerly Table 5 DRG) This file contains a listing of MS– DRGs, MS–DRG narrative descriptions, relative weights, and geometric and arithmetic mean lengths of stay as published in the Federal Register. The hard copy image has been copied to diskette. There are two versions of this file as published in the Federal Register: • Notice of proposed rulemaking. • Final rule. Media: Diskette/Internet. File Cost: $165.00. Periods Available: FY 2009 PPS Update. 14. PPS Payment Impact File This file contains data used to estimate payments under Medicare’s hospital inpatient prospective payment systems for operating and capital-related costs. The data are taken from various sources, including the Provider-Specific File, Minimum Data Sets, and prior impact files. The data set is abstracted from an internal file used for the impact analysis of the changes to the prospective payment systems published in the Federal Register. This file is available for release 1 month after the proposed and final rules are published in the Federal Register. Media: Diskette/Internet. File Cost: $165.00. Periods Available: FY 2009 PPS Update. jlentini on PROD1PC65 with PROPOSALS2 15. AOR/BOR Tables This file contains data used to develop the MS–DRG relative weights. It contains mean, maximum, minimum, standard deviation, and coefficient of variation statistics by MS–DRG for length of stay and standardized charges. The BOR tables are ‘‘Before Outliers Removed’’ and the AOR is ‘‘After Outliers Removed.’’ (Outliers refer to statistical outliers, not payment outliers.) Two versions of this file are created each year. They support the following: • Notice of proposed rulemaking published in the Federal Register. • Final rule published in the Federal Register. Media: Diskette/Internet. File Cost: $165.00. Periods Available: FY 2009 PPS Update. 16. Prospective Payment System (PPS) Standardizing File This file contains information that standardizes the charges used to calculate relative weights to determine payments under the prospective payment system. Variables include wage VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 index, cost-of-living adjustment (COLA), case-mix index, disproportionate share, and the Metropolitan Statistical Area (MSA). The file supports the following: • Notice of proposed rulemaking published in the Federal Register. • Final rule published in the Federal Register. Media: Internet. File Cost: No charge. Periods Available: FY 2009 PPS Update. For further information concerning these data tapes, contact the CMS Public Use Files Hotline at (410) 786–3691. Commenters interested in discussing any data used in constructing this proposed rule should contact Nisha Bhat at (410) 786–5320. B. Collection of Information Requirements 1. Legislative Requirement for Solicitation of Comments Under the Paperwork Reduction Act of 1995, we are required to provide 60day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: • The need for the information collection and its usefulness in carrying out the proper functions of our agency. • The accuracy of our estimate of the information collection burden. • The quality, utility, and clarity of the information to be collected. • Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. 2. Solicitation of Comments on Proposed Requirements in Regulatory Text We are soliciting public comment on each of the issues listed under section XI.B.1. of this preamble for the following sections of this document that contain information collection requirements (ICRs): a. ICRs Regarding Physician Reporting Requirements (§ 411.361) Section 411.361(a) of the regulations states that except for entities that furnish 20 or fewer Part A and Part B services during a calendar year or for Medicare covered services furnished outside the United States, all entities furnishing services for which payment PO 00000 Frm 00174 Fmt 4701 Sfmt 4702 may be made under Medicare must submit information to CMS or to the Office of the Inspector General (OIG) concerning their reportable financial relationships (any ownership or investment interest, or compensation arrangement) in the form, manner, and at times that CMS or OIG specifies. As described in section IX. of the preamble of this proposed rule, and in accordance with its authority under 42 CFR 411.361(e), CMS is requiring that hospitals provide information concerning their ownership, investment and compensation arrangements with physicians by completing the DFRR instrument. An information collection request concerning the DFRR was previously submitted to OMB for approval. We announced and sought public comment on the information collection request in both 60-day and 30-day Federal Register notices that published on May 18, 2007 (72 FR 28056), and September 14, 2007 (72 FR 52568), respectively. As further discussed in section IX. of this preamble, we have decided to obtain additional input from the public concerning the time and cost burden associated with completing and submitting the DFRR instrument. (The instrument is included as Appendix C to this proposed rule.) We believe that hospital accounting personnel would be responsible for: (1) Ensuring that the appropriate data or supporting documentation is retrieved; (2) completing the DFRR; and (3) submitting the DFRR to the Chief Executive Officer, Chief Financial Officer, or comparable officer of the hospital for his or her signature on the certification statement. Initially, CMS would require 500 hospitals to complete and submit the DFRR instrument. We estimate that these tasks would require 31 hours for each of the 500 hospitals to complete the DFRR. Thus, the total number of burden hours required for 500 hospitals to complete the DFRR instrument is 15,500 hours. b. ICRs Regarding Risk Adjustment Data (§ 422.310) As discussed in section IV.H. of the preamble of this proposed rule, § 422.310(b) states that each MA organization must submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. In addition, § 422.310(b) states that CMS may collect data necessary to characterize the functional limitations of enrollees of E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 each MA organization. Section 422.310(c) lists the nature of the data elements to be submitted to CMS. The burden associated with these requirements is the time and effort necessary for the MA organization to submit the necessary data to CMS. These requirements are subject to the PRA and the associated burden is currently approved under OMB control number 0938–0878. However, under notice and comment periods separate from this proposed rule, we intend to revise the currently approved information collection to include burden estimates as they pertain to § 422.310. The preliminary burden estimate for this proposed rule is as follows: Currently, there are 676 MA organizations. Assuming that 99 percent of encounter data claims are submitted electronically and 1 percent are submitted manually, we estimate that it will take 1,089 hours annually for submission of electronic claims and 73,335 hours annually for submission of manual claims. The estimated annual burden associated with these requirements is an annual average of 110 hours per MA organization. c. ICRs Regarding Basic Commitments of Providers (§ 489.20) As discussed in section IV.I. of the preamble of this proposed rule, proposed § 489.20(r)(2) states that a hospital, as defined in § 489.24(b), must maintain an on-call list of physicians on its medical staff to provide treatment necessary to stabilize patients who are receiving services required under § 489.24 in accordance with the resources available to the hospital. The burden associated with this requirement is the time and effort necessary to draft, maintain, and periodically update the list of on-call physicians. We estimate that it will take 3 hours for each of the 100 Medicare-participating hospitals to comply with this recordkeeping requirement. The estimated annual burden associated with this requirement is 300 hours. As discussed in section VII. of the preamble of this proposed rule, proposed § 489.20(u)(1) states that, in the case of a physician-owned hospital as defined in § 489.3, the hospital must furnish written notice to all patients at the beginning of their hospital stay or outpatient visit that the hospital is a physician-owned facility. In addition, patients must be advised that a list of the hospital’s owners or investors who are physicians (or immediate family members of physicians) is available upon request. Upon receiving the request of the patient or an individual on behalf of the patient, a hospital must VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 immediately disseminate the list to the requesting patient. The burden associated with the requirements in this section is the time and effort necessary for a hospital to furnish written notice to all patients that the hospital is a physician-owned hospital. Whereas this requirement is subject to the PRA, the associated burden is currently approved under OMB control number 0938–1034, with an expiration date of February 28, 2011. In addition, there is burden associated with furnishing a patient with the list of the hospital’s owners or investors who are physicians (or immediate family members of physicians) at the time of the patient request. However, CMS has no way to accurately quantify the burden because we cannot estimate the number of this type of request that a hospital may receive. We are soliciting public comments on the annual number of requests a hospital may receive for lists of physician-owners and investors, and will reevaluate this issue in the final rule stage of rulemaking. Proposed § 489.20(u)(2) would require disclosure of physician ownership as a condition of continued medical staff membership or admitting privileges. The burden associated with this requirement is the time and effort required for a hospital to develop, draft, and implement changes to its medical staff bylaws and other policies governing admitting privileges. Approximately 175 physician-owned hospitals would be required to comply with this requirement. We estimate that it will require a hospital’s general counsel 4 hours to revise a hospital’s medical staff bylaws and policies governing admitting privileges. Therefore, the total annual hospital burden would be 700 hours. In addition, the proposed § 489.20(u)(2) imposes a burden on physicians. As stated earlier, all physicians who are also members of the hospital’s medical staff must agree, as a condition of continued medical staff membership or admitting privileges, to disclose, in writing, to all patients they refer to the hospital any ownership or investment interest in the hospital held by themselves or by an immediate family member. The disclosure must be made at the time the referral is made. The burden associated with this requirement is the time and effort necessary for a physician to draft a disclosure and to provide it to the patient at the time the referral is made to the physician-owned hospital. We estimate that it will take each physician, or designated office staff member, 1 hour to develop a disclosure notice and make copies that will be distributed to PO 00000 Frm 00175 Fmt 4701 Sfmt 4702 23701 patients. In addition, we estimate 30 seconds to provide the disclosure to each patient and an additional 30 seconds to record the proof of disclosure into each patient’s medical record. Although we can estimate the number of physician-owned hospitals, we are unable to quantify the number of physicians that possess an ownership or investment interest in hospitals. There is limited data available concerning physician ownership in hospitals. The studies to date, including those by CMS and the Government Accountability Office, pertain to physician ownership in specialty hospitals (cardiac, orthopedic, and surgical hospitals). These specialty hospital studies published data concerning the average percentage of shares of direct ownership by physicians (less than 2 percent), indirect ownership through group practices, and the aggregate percentage of physician ownership, but did not publish the number of physician owners in these types of hospitals. More importantly, proposed § 489.20(u)(2) would apply to physician ownership in any type of hospital. Our other research involved a review of enrollment data. However, the CMS enrollment application (CMS–855) requires the reporting of ownership interests that exceed 5 percent or greater, and, thus, most physician ownership is not captured. In summary, because we are unable to estimate the total physician burden associated with this reporting requirement, we are seeking public comment pertaining to this burden and will reevaluate this issue in the final rule stage of rulemaking. Proposed § 489.20(v) states that the aforementioned requirements in § 489.20(u)(1) and (u)(2) do not apply to a physician-owned hospital that does not have at least one referring physician who has an ownership or investment interest in the hospital or who has an immediate family member who has an ownership or investment interest in the hospital. To comply with this exception, an eligible hospital must sign an attestation to that effect and maintain the document in its records. Therefore, the number of hospitals that are now subject to the disclosure requirement would be slightly reduced. However, there may be a minimal burden attributable to the proposed requirement that the hospital maintain an attestation statement in its records. The burden associated with this requirement will be limited to those physician-owned hospitals that do not have at least one referring physician who has an ownership or investment interest in the hospital or who has an immediate family member who has an E:\FR\FM\30APP2.SGM 30APP2 23702 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules ownership or investment interest in the hospital. The burden would include the time and effort for these hospitals to develop, sign, and maintain the attestations in their records. We estimate that 10 percent, or approximately 18, of the estimated 175 physician-owned hospitals would be subject to this requirement. We estimate that it would take each of these physician-owned hospitals an average of 1 hour to develop, sign, and maintain the attestation in its records. The estimated annual burden associated with this requirement is 18 hours. However, because we have no way of knowing for certain the number of physician-owned hospitals that do not have at least one referring physician who has an ownership or investment interest in the hospital or who has an immediate family member who has an ownership or investment interest in the hospital, we are requesting public comment regarding the accuracy of our estimate and the associated burden with the attestation requirement. Section 489.20(w) requires all hospitals, as defined in § 489.24(b), to furnish all patients notice, in accordance with § 482.13(b)(2), at the beginning of their hospital stay or outpatient visit if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week. The notice must indicate how the hospital will meet the medical needs of any inpatient who develops an emergency medical condition, as defined in § 489.24(b), at a time when there is no physician present in the hospital. The burden associated with this requirement is the time and effort necessary for each hospital to develop a standard notice to furnish to its patients. Whereas this requirement is subject to the PRA, the associated burden is approved under OMB control number 0938–1034 with a current expiration date of February 28, 2011. ESTIMATED ANNUAL REPORTING AND RECORDKEEPING BURDEN OMB control No. Regulation section(s) § 411.361 ........................................... § 422.310(b) ...................................... § 489.20(r) ......................................... § 489.20(u)(1) and (w) ...................... § 489.20(u)(2) .................................... § 489.20(v) ........................................ Total ........................................... 0938–New 0938–0878 0938–New 0938–1034 0938–New 0938–New Respondents Responses Burden per response (hours) Total annual burden (hours) ........................................ ....................................... ........................................ ....................................... ........................................ ........................................ 500 676 100 2,679 175 18 500 676 100 49,735,635 175 18 31 110 3 ** 4 1 15,500 * 74,424 300 839,599 700 18 ........................................................... ........................ ........................ ........................ 930,541 * Burden estimate is based on proposed revisions to the currently approved OMB control number. ** There are multiple requirements associated with the regulation section approved under this OMB control number. There is no uniform estimate of the burden per response. 3. Associated Information Collections Not Specified in Regulatory Text This proposed rule imposes collection of information requirements as outlined in the regulation text and specified above. However, this proposed rule also makes reference to several associated information collections that are not discussed in the regulation text. The following is a discussion of these collections, which have already received OMB approval. jlentini on PROD1PC65 with PROPOSALS2 a. Present on Admission (POA) Indicator Reporting Section II.F.8 of the preamble of this proposed rule discusses the present on admission indicator (POA) reporting requirements. As stated earlier, POA indicator information is necessary to identify which conditions were acquired during hospitalization for the hospital-acquired condition (HAC) payment provision and for broader public health uses of Medicare data. Through Change Request No. 5499 (released May 11, 2007), CMS issued instructions requiring IPPS hospitals to submit the POA indicator data for all diagnosis codes on Medicare claims. The burden associated with this requirement is the time and effort VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 necessary to place the appropriate POA codes on Medicare claims. While the requirement is subject to the PRA; the associated burden is approved under 0938–0997 with an expiration date of August 31, 2009. b. Proposed Add-On Payments for New Services and Technologies Section II.J. of the preamble of this proposed rule discusses proposed addon payments for new services and technologies. Specifically, this section states that applicants for add-on payments for new medical services or technologies for FY 2010 must submit a formal request. A formal request includes a full description of the clinical applications of the medical service or technology and the results of any clinical evaluations demonstrating that the new medical service or technology represents a substantial clinical improvement. In addition, the request must contain a significant sample of the data to demonstrate that the medical service or technology meets the high-cost threshold. We detailed the burden associated with this requirement in a final rule published in the Federal Register on September 7, 2001 (66 FR 46902). As PO 00000 Frm 00176 Fmt 4701 Sfmt 4702 stated in that final rule, we believe the associated burden is exempt from the PRA as stipulated under 5 CFR 1320.3(h)(6). Collection of the information for this requirement will be conducted on an individual case-bycase basis. c. Reporting of Hospital Quality Data for Annual Hospital Payment Update As noted in section IV.B. of the preamble of this proposed rule, the RHQDAPU program was originally established to implement section 501(b) of Pub. L. 108–173, thereby expanding our voluntary Hospital Quality Initiative. The RHQDAPU program originally consisted of a ‘‘starter set’’ of 10 quality measures. OMB approved the collection of data associated with the original starter set of quality measures under OMB control number 0938–0918, with a current expiration date of January 31, 2010. We added additional quality measures to the RHQDAPU program and submitted the information collection request to OMB for approval. This expansion of the RHQDAPU measures was part of our implementation of section 5001(a) of the DRA. Section 1886(b)(3)(B)(viii)(III) of the Act, added E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules by section 5001(a) of the DRA, requires that the Secretary expand the ‘‘starter set’’ of 10 quality measures that were established by the Secretary as of November 1, 2003, to include measures ‘‘that the Secretary determines to be appropriate for the measurement of the quality of care furnished by hospitals in inpatient settings.’’ The burden associated with these reporting requirements is currently approved under OMB control number 0938–1022 with a current expiration date of December 31, 2008. However, for FY 2009, we submitted to OMB for approval a revised information collection request using the same OMB control number (0938–1022). In the revised request, we proposed to add three new RHQDAPU quality measures that we adopted for the FY 2009 RHADAPU program to the PRA process. These three measures are as follows: • Pneumonia 30-day Mortality (Medicare patients); • SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose; and • SCIP Infection 6: Surgery Patients with Appropriate Hair Removal. The revised information collection request was announced in the Federal Register via an emergency notice on January 28, 2008 (73 FR 4868). The information collection request is currently under review by OMB. Once approved, we will submit another revision of the information collection request to obtain approval for the new measures contained in this proposed rule. Section IV.B.5. of the preamble of this proposed rule also discusses the requirements for the continuous collection of HCAHPS quality data. The HCAHPS survey is designed to produce comparable data on the patient’s perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers. We also added the HCAHPS survey to the PRA process in the information collection request currently approved under OMB control number 0938–1022 with a current expiration date of December 31, 2008. Section IV.B.9. of the preamble of this proposed rule addresses the reconsideration and appeal procedures for a hospital that we believe did not meet the RHQDAPU program requirements. If a hospital disagrees with our determination, it may submit a written request to us requesting that we reconsider our decision. The hospital’s letter must explain the reasons it believes it did meet the RHQDAPU program requirements. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 While this is a reporting requirement, the burden associated with it is not subject to the PRA under 5 CFR 1320.4(a)(2). The burden associated with information collection requirements imposed subsequent to an administrative action is not subject to the PRA. d. Occupational Mix Adjustment to the FY 2009 Index (Hospital Wage Index Occupational Mix Survey) Section III. of the preamble of this proposed rule details the proposed changes to the hospital wage index. Specifically, section III.D. addresses the proposed occupational mix adjustment to the proposed FY 2009 index. While the preamble does not contain any new information collection requirements, it is important to note that there is an OMB approved collection associated with the hospital wage index. Section 304(c) of Pub. L. 106–554 amended section 1886(d)(3)(E) of the Act to require CMS to collect data at least once every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. We collect the data via the occupational mix survey. The burden associated with this information collection request is the time and effort required to collect and submit the data in the Hospital Wage Index Occupational Mix Survey to CMS. While this burden is subject to the PRA, it is already approved under OMB control number 0938–0907, with an expiration date of February 28, 2011. 4. Addresses for Submittal of Comments on Information Collection Requirements If you comment on these information collection and recordkeeping requirements, please do either of the following: 1. Submit your comments electronically as specified in the ADDRESSES section of this proposed rule; or 2. Mail copies to the address specified in the ADDRESSES section of this proposed rule and to— Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Carolyn L. Raffaelli, CMS Desk Officer, CMS–1390–P; E-mail: Carolyn_L._Raffaelli@omb.eop.gov. Fax (202) 395–6974. C. Response to Comments Because of the large number of public comments we normally receive on PO 00000 Frm 00177 Fmt 4701 Sfmt 4702 23703 Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document. List of Subjects 42 CFR Part 411 Kidney diseases, Medicare, Physician referral, Reporting and recordkeeping requirements. 42 CFR Part 412 Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 42 CFR Part 413 Health facilities, Kidney diseases, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 42 CFR Part 422 Administrative practice and procedure, Grant programs—health, Health care, Health insurance, Health maintenance organizations (HMO), Loan programs—health, Medicare, Reporting and recordkeeping requirements. 42 CFR Part 489 Health facilities, Medicare, Reporting and recordkeeping requirements. For the reasons stated in the preamble of this proposed rule, the Centers for Medicare & Medicaid Services is proposing to amend 42 CFR Chapter IV as follows: PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT 1. The authority citation for part 411 continues to read as follows: Authority: Secs. 1102, 1860D–1 through 1860D–42, 1871, and 1877 of the Social Security Act (42 U.S.C. 1302, 1395w–101 through 1395w–152, 1395hh, and 1395nn). 2. Section 411.351 is amended by— a. Revising the definition of ‘‘physician’’. b. Revising the definition of ‘‘physician organization’’. The revisions read as follows: § 411.351 Definitions. * * * * * Physician means a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor, as defined in section 1861(r) of the Act. A physician and the E:\FR\FM\30APP2.SGM 30APP2 23704 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules professional corporation of which he or she is a sole owner are the same for purposes of this subpart. * * * * * Physician organization means a physician, a physician practice, or a group practice that complies with the requirements of § 411.352. * * * * * 3. Section 411.353 is amended by revising paragraph (c) to read as follows: § 411.353 Prohibition on certain referrals by physicians and limitations on billing. * * * * (c) Denial of payment. Except as provided in paragraph (e) of this section, no Medicare payment may be made for a designated health service that is furnished pursuant to a prohibited referral. The period during which referrals are prohibited is the period of disallowance. For purposes of this section, with respect to the following types of noncompliance, the period of disallowance begins at the time the financial relationship fails to satisfy the requirements of an applicable exception and ends no later than— (1) Where the noncompliance is unrelated to compensation, the date that the financial relationship satisfies all of the requirements of an applicable exception; (2) Where the noncompliance is due to the payment of excess compensation, the date on which the excess compensation is returned to the party that paid it and the financial relationship satisfies all of the requirements of an applicable exception; or (3) Where the noncompliance is due to the payment of compensation that is of an amount insufficient to satisfy the requirements of an applicable exception, the date on which the additional required compensation is paid to the party to which it is owed such that the financial relationship would satisfy all of the requirements of the exception as of its date of inception. * * * * * 4. Section 411.354 is amended by— a. Adding a new paragraph (a)(1)(iii). b. Revising paragraph (c)(2)(iv). c. Revising paragraph (c)(3)(ii). The addition and revisions read as follows: jlentini on PROD1PC65 with PROPOSALS2 * § 411.354 Financial relationship, compensation, and ownership or investment interest. (a) * * * (1) * * * (iii) For purposes of paragraph (c) of this section, an entity that furnishes DHS is deemed to stand in the shoes of VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 an organization in which it has a 100 percent ownership interest. * * * * * (c) * * * (2) * * * (iv) For purposes of paragraph (c)(2)(i) of this section, a physician is deemed to ‘‘stand in the shoes’’ of his or her physician organization unless the total compensation from the physician organization to the physician satisfies the requirements of § 411.357(c), (d), or (l). (3) * * * (ii) The provisions of paragraphs (c)(1)(ii) and (c)(2)(iv) of this section— (A) Need not apply during the original term or current renewal term of an arrangement that satisfied the requirements of § 411.357(p) as of September 5, 2007 (42 CFR parts 400– 413, revised as of October 1, 2007); (B) Do not apply to an arrangement that satisfies the requirements of § 411.355(e); and (C) Do not apply with respect to an arrangement between a physician organization and a component of an academic medical center listed in § 411.355(e)(2) for the provision to that academic medical center of only services required to satisfy the academic medical center’s obligations under the Medicare graduate medical education (GME) rules in part 413, subpart F of this chapter. * * * * * PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES 5. The authority citation for part 412 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh), and sec. 124 of Pub. L. 106–113 (113 Stat. 1501A–332). 6. Section 412.4 is amended by revising paragraph (c)(3) to read as follows: § 412.4 Discharges and transfers. * * * * * (c) * * * (3) To home under a written plan of care for the provision of home health services from a home health agency and those services begin— (i) Effective for fiscal years prior to FY 2009, within 3 days after the date of discharge; and (ii) Effective FY 2009, within 7 days after the date of discharge. * * * * * 7. Section 412.22 is amended by— a. In the introductory text of paragraph (e), removing the phrase PO 00000 Frm 00178 Fmt 4701 Sfmt 4702 ‘‘paragraph (f) of this section’’ and adding in its place ‘‘paragraphs (e)(1) (vi) and (f) of this section’’. b. Adding a new paragraph (e)(1)(vi). The addition reads as follows: § 412.22 Excluded hospitals and hospital units: General rules. * * * * * (e) * * * (1) * * * (vi) Effective October 1, 2008, if a State hospital that is occupying space in the same building or on the same campus as another State hospital cannot meet the criterion under paragraph (e)(1)(i) of this section solely because its governing body is under the control of the State hospital with which it shares a building or a campus, or is under the control of a third entity that also controls the State hospital with which it shares a building or a campus, the State hospital can nevertheless qualify for an exclusion if it meets the other applicable criteria in this section and— (A) Both State hospitals occupy space in the same building or on the same campus and have been continuously owned and operated by the State since October 1, 1995; (B) Is required by State law to be subject to the governing authority of the State hospital with which it shares space or the governing authority of a third entity that controls both hospitals; and (C) Was excluded from the inpatient prospective payment system before October 1, 1995, and continues to be excluded from the inpatient prospective payment system through September 30, 2008. * * * * * 8. Section 412.64 is amended by— a. Republishing the introductory text of paragraph (b)(1)(ii) and revising paragraph (b)(1)(ii)(A). b. In the introductory text of paragraph (h)(4), removing the date ‘‘September 30, 2008’’ and adding in its place ‘‘September 30, 2011’’. The revision reads as follows: § 412.64 Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years. * * * * * (b) * * * (1) * * * (ii) The term urban area means— (A) A Metropolitan Statistical Area or a Metropolitan division (in the case where a Metropolitan Statistical Area is divided into Metropolitan Divisions), as defined by the Executive Office of Management and Budget; or * * * * * 9. Section 412.87 is amended by— E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules § 412.232 Criteria for all hospitals in a rural county seeking urban redesignation. a. Revising paragraph (b)(1). b. Adding a new paragraph (c). The revision and addition read as follows: * § 412.87 Additional payment for new medical services and technologies: General provisions. * * * * * (b) * * * (1) A new medical service or technology represents an advance that substantially improves, relating to technologies previously available, the diagnosis or treatment of Medicare beneficiaries. * * * * * (c) Announcement of determinations and deadline for consideration of new medical service or technology applications. CMS will consider whether a new medical service or technology meets the eligibility criteria specified in paragraph (b) of this section and announce the results in the Federal Register as part of its annual updates and changes to the IPPS. CMS will only consider, for add-on payments for a particular fiscal year, an application for which the new medical service or technology has received FDA approval or clearance by July 1 prior to the particular fiscal year. 10. Section 412.230 is amended by— a. Revising paragraph (d)(1)(iv)(C). b. Adding a new paragraph (d)(1)(iv)(D). The addition and revision read as follows: § 412.230 Criteria for an individual hospital seeking redesignation to another rural area or an urban area. jlentini on PROD1PC65 with PROPOSALS2 * * * * * (d) * * * (1) * * * (iv) * * * (C) With respect to redesignations for fiscal years 2002 through 2009, the hospital’s average hourly wage is equal to, in the case of a hospital located in a rural area, at least 82 percent, and in the case of a hospital located in an urban area, at least 84 percent of the average hourly wage of hospitals in the area to which it seeks redesignation. (D) With respect to redesignations for fiscal year 2010 and later fiscal years, the hospital’s average hourly wage is equal to, in the case of a hospital located in a rural area, at least 86 percent, and in the case of a hospital located in an urban area, at least 88 percent of the average hourly wage of hospitals in the area to which it seeks redesignation. * * * * * 11. Section 412.232 is amended by revising paragraphs (c)(1) and (c)(2) to read as follows: VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 * * * * (c) * * * (1) Aggregate hourly wage for fiscal years before fiscal year 2010—(i) Aggregate hourly wage. With respect to redesignations effective beginning fiscal year 1999 and before fiscal year 2010, the aggregate average hourly wage for all hospitals in the rural county must be equal to at least 85 percent of the average hourly wage in the adjacent urban area. (ii) Aggregate hourly wage weighted for occupational mix. For redesignations effective before fiscal year 1999, the aggregate hourly wage for all hospitals in the rural county, weighed for occupational categories, is at least 90 percent of the average hourly wage in the adjacent urban area. (2) Aggregate hourly wage for fiscal year 2010 and later fiscal years. With respect to redesignations effective for fiscal year 2010 and later fiscal years, the aggregate average hourly wage for all hospitals in the rural county must be equal to at least 88 percent of the average hourly wage in the adjacent urban area. * * * * * 12. Section 412.234 is amended by revising paragraphs (b)(1) and (b)(2) to read as follows: § 412.234 Criteria for all hospitals in an urban county seeking redesignation to another urban area. * * * * * (b) * * * (1) Aggregate hourly wage for fiscal years before fiscal year 2010—(i) Aggregate hourly wage. With respect to redesignations effective beginning fiscal year 1999 and before fiscal year 2010, the aggregate average hourly wage for all hospitals in the urban county must be at least 85 percent of the average hourly wage in the urban area to which the hospitals in the county seek reclassification. (ii) Aggregate hourly wage weighted for occupational mix. For redesignations effective before fiscal year 1999, the aggregate hourly wage for all hospitals in the county, weighed for occupational categories, is at least 90 percent of the average hourly wage in the adjacent urban area. (2) Aggregate hourly wage for fiscal year 2010 and later fiscal years. With respect to redesignations effective for fiscal year 2010 and later fiscal years, the aggregate average hourly wage for all hospitals in the urban county must be at least 88 percent of the average hourly wage in the urban area to which the PO 00000 Frm 00179 Fmt 4701 Sfmt 4702 23705 hospitals in the county seek reclassification. * * * * * PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES 13. The authority citation for Part 413 continues to read as follows: Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Pub. L. 106–133 (113 Stat. 1501A– 332). § 413.79 [Amended] 14. In § 413.79(f)(6)(iv), remove the cross-reference ‘‘§ 413.75(d)’’ and add the cross-reference ‘‘paragraph (d) of this section’’ in its place. PART 422—MEDICARE ADVANTAGE PROGRAM 15. The authority citation for Part 422 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). 16. Section 422.310 is revised to read as follows: § 422.310 Risk adjustment data. (a) Definition of risk adjustment data. Risk adjustment data are all data that are used in the development and application of a risk adjustment payment model. (b) Data collection: Basic rule. Each MA organization must submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. CMS may also collect data necessary to characterize the functional limitations of enrollees of each MA organization. (c) Sources and extent of data. (1) To the extent required by CMS, risk adjustment data must account for the following: (i) Items and services covered under the original Medicare program. (ii) Medicare-covered items and services for which Medicare is not the primary payer. (iii) Other additional or supplemental benefits that the MA organization may provide. (2) The data must account separately for each provider, supplier, physician, E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23706 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules or other practitioner that would be permitted to bill separately under the original Medicare program, even if they participate jointly in the same service. (d) Other data requirements. (1) MA organizations must submit data that conform to CMS’ requirements for data equivalent to Medicare fee-for-service data, when appropriate, and to all relevant national standards. CMS may specify abbreviated formats for data submission required of MA organizations. (2) The data must be submitted electronically to the appropriate CMS contractor. (3) MA organizations must obtain the risk adjustment data required by CMS from the provider, supplier, physician, or other practitioner that furnished the item or service. (4) MA organizations may include in their contracts with providers, suppliers, physicians, and other practitioners, provisions that require submission of complete and accurate risk adjustment data as required by CMS. These provisions may include financial penalties for failure to submit complete data. (e) Validation of risk adjustment data. MA organizations and their providers and practitioners will be required to submit a sample of medical records for the validation of risk adjustment data, as required by CMS. There may be penalties for submission of false data. (f) Use of data. CMS uses the data obtained under this section to determine the risk adjustment factors used to adjust payments, as required under §§ 422.304(a) and (c). CMS may also use the data for other purposes, including updating of risk adjustment models. (g) Deadlines for submission of risk adjustment data. Risk adjustment factors for each payment year are based on risk adjustment data submitted for items and services furnished during the 12-month period before the payment year that is specified by CMS. As determined by CMS, this 12-month period may include a 6-month data lag that may be changed or eliminated as appropriate. CMS may adjust these deadlines, as appropriate. (1) The annual deadline for risk adjustment data submission is the first Friday in September for risk adjustment data reflecting items and services furnished during the 12-month period ending the prior June 30, and the first Friday in March for data reflecting services furnished during the 12-month period ending the prior December 31. (2) CMS allows a reconciliation process to account for late data submissions. CMS continues to accept risk adjustment data submitted after the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 March deadline until January 31 of the year following the payment year. After the payment year is completed, CMS recalculates the risk factors for affected individuals to determine if adjustments to payments are necessary. Risk adjustment data that are received after the annual January 31 late data submission deadline will not be accepted for the purposes of reconciliation. PART 489—PROVIDER AGREEMENTS AND SUPPLIER APPROVAL 17. The authority citation for part 489 continues to read as follows: Authority: Secs. 1102, 1819, 1820(e), 1861, 1864(m), 1866, 1869, and 1871 of the Social Security Act (42 U.S.C. 1302, 1395i–3, 1395x, 1395aa(m), 1395cc, 1395ff, and 1395hh). 18. Section 489.3 is amended by revising the definition of ‘‘physicianowned hospital’’ to read as follows: § 489.3 Definitions. * * * * * Physician-owned hospital means any participating hospital (as defined in § 489.24) in which a physician, or an immediate family member of a physician (as defined in § 411.351 of this chapter), has an ownership or investment interest. The ownership or investment interest may be through equity, debt, or other means, and includes an interest in an entity that holds an ownership or investment interest in the hospital. This definition does not include a hospital with physician ownership or investment interests that satisfy the requirements at § 411.356(a) or (b) of this chapter. * * * * * 19. Section 489.20 is amended by— a. Revising paragraph (r)(2). b. Revising paragraph (u). c. Redesignating paragraphs (v) and (w) as paragraphs (w) and (x), respectively. d. Adding a new paragraph (v). The revisions and addition read as follows: § 489.20 Basic commitments. * * * * * (r) * * * (2) An on-call list of physicians on its medical staff available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services required under § 489.24 in accordance with the resources available to the hospital; and * * * * * (u) Except as provided in paragraph (v) of this section, in the case of a physician-owned hospital as defined in § 489.3— PO 00000 Frm 00180 Fmt 4701 Sfmt 4702 (1) To furnish written notice to all patients at the beginning of their hospital stay or outpatient visit that the hospital is a physician-owned hospital, in order to assist the patients in making an informed decision regarding their care, in accordance with § 482.13(b)(2) of this subchapter. The notice should disclose, in a manner reasonably designed to be understood by all patients, the fact that the hospital meets the Federal definition of a physicianowned hospital specified in § 489.3 and that the list of the hospital’s owners or investors who are physicians or immediate family members of physicians (as defined at § 411.351 of this chapter) must be provided to the patients at the time the request for the list is made by or on behalf of the patient. For purposes of this paragraph (u)(1), the hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service. (2) To require all physicians who are members of the hospital’s medical staff to agree, as a condition of continued medical staff membership or admitting privileges, to disclose, in writing, to all patients they refer to the hospital any ownership or investment interest in the hospital that is held by themselves or by an immediate family member (as defined in § 411.351 of this chapter). Disclosure must be required at the time the referral is made. (v) The requirements of paragraph (u) of this section do not apply to any physician-owned hospital that does not have at least one referring physician (as defined at § 411.351 of this chapter) who has an ownership or investment interest in the hospital or who has an immediate family member who has an ownership or investment interest in the hospital, provided that such hospital signs an attestation statement to that effect and maintain such a notice in its records. * * * * * 20. Section 489.24 is amended by— a. Revising paragraph (a)(2). b. Revising paragraph (f). c. Revising paragraph (j). The revisions read as follows: § 489.24 Special responsibilities of Medicare hospitals in emergency cases. (a) * * * (2) Nonapplicability of provisions of this section. Sanctions under this section for an inappropriate transfer during a national emergency or for the direction or relocation of an individual to receive medical screening at an E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules alternate location pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan do not apply to a hospital with a dedicated emergency department located in an emergency area during an emergency period, as specified in section 1135(g)(1) of the Act. A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided for by section 135(e)(1)(B) of the Act. * * * * * (f) Recipient hospital responsibilities. A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive case units, or, with respect to rural areas, regional referral centers (which, for purposes of this subpart, mean hospitals meeting the requirements of referral centers found at § 412.96 of this chapter)) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This provision applies to— (1) Any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department; and (2) An individual who has been admitted under paragraph (d)(2)(i) of this section and who has not been stabilized. * * * * * (j) Availability of on-call physicians. In accordance with the on-call list requirements specified in § 489.20(r)(2), a hospital must have written policies and procedures in place— (1) To respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control; and (2) To provide that emergency services are available to meet the needs of individuals with emergency medical conditions if a hospital elects to— (i) Permit on-call physicians to schedule elective surgery during the time that they are on call; VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 (ii) Permit on-call physicians to have simultaneous on-call duties; and (iii) Participate in a formal community call plan. Notwithstanding participation in a community call plan, hospitals are still required to perform medical screening examinations on individuals who present seeking treatment and to conduct appropriate transfers. The formal community plan must include the following elements: (A) A clear delineation of on-call coverage responsibilities; that is, when each hospital participating in the plan is responsible for on-call coverage. (B) A description of the specific geographic area to which the plan applies. (C) A signature by an appropriate representative of each hospital participating in the plan. (D) Assurances that any local and regional EMS system protocol formally includes information on community oncall arrangements. (E) Evidence of engagement of the hospitals participating in the community call plan in an analysis of the specialty on-call needs of the community for which the plan is effective. (F) A statement specifying that even if an individual arrives at a hospital that is not designated as the on-call hospital, that hospital still has an obligation under § 489.24 to provide a medical screening examination and stabilizing treatment within its capability, and that hospitals participating in the community call plan must abide by the regulations under § 489.24 governing appropriate transfers. (G) An annual assessment of the community call plan by the participating hospitals. 21. Section 489.53 is amended by revising paragraph (c) to read as follows: § 489.53 Termination by CMS. * * * * * (c) Termination of agreements with physician-owned hospitals. In the case of a physician-owned hospital, as defined at § 489.3, CMS may terminate the provider agreement if the hospital failed to comply with the requirements of § 489.20(u) or (w). * * * * * (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program) PO 00000 Frm 00181 Fmt 4701 Sfmt 4702 23707 Dated: April 1, 2008. Kerry Weems, Acting Administrator, Centers for Medicare & Medicaid Services. Dated: April 10, 2008. Michael O. Leavitt, Secretary. [Editorial Note: The following Addendum and appendixes will not appear in the Code of Federal Regulations.] Addendum—Proposed Schedule of Standardized Amounts, Update Factors, and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2008 I. Summary and Background In this Addendum, we are setting forth the methods and data we used to determine the proposed prospective payment rates for Medicare hospital inpatient operating costs and Medicare hospital inpatient capitalrelated costs. We are also setting forth the proposed rate-of-increase percentages for updating the target amounts for certain hospitals and hospital units excluded from the IPPS. In general, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital’s payment per discharge under the IPPS is based on 100 percent of the Federal national rate, also known as the national adjusted standardized amount. This amount reflects the national average hospital cost per case from a base year, updated for inflation. SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: The Federal national rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospitalspecific rate based on FY 1996 costs per discharge. Under section 1886(d)(5)(G) of the Act, MDHs historically have been paid based on the Federal national rate or, if higher, the Federal national rate plus 50 percent of the difference between the Federal national rate and the updated hospital-specific rate based on FY 1982 or FY 1987 costs per discharge, whichever was higher. (MDHs did not have the option to use their FY 1996 hospitalspecific rate.) However, section 5003(a)(1) of Pub. L. 109–171 extended and modified the MDH special payment provision that was previously set to expire on October 1, 2006, to include discharges occurring on or after October 1, 2006, but before October 1, 2011. Under section 5003(b) of Pub. L. 109–171, if the change results in an increase to an MDH’s target amount, an MDH must rebase its hospital-specific rates to its FY 2002 cost report. Section 5003(c) of Pub. L. 109–171 further required that MDHs be paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent of the difference between the Federal national rate and the updated hospital-specific rate. Further, based on the provisions of section 5003(d) of Pub. L. 109–171, MDHs are no longer subject to the 12-percent cap on their DSH payment adjustment factor. E:\FR\FM\30APP2.SGM 30APP2 23708 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 For hospitals located in Puerto Rico, the payment per discharge is based on the sum of 25 percent of an updated Puerto Ricospecific rate based on average costs per case of Puerto Rico hospitals for the base year and 75 percent of the Federal national rate. (We refer readers to section II.D.3. of this Addendum for a complete description.) As discussed below in section II. of this Addendum, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs for FY 2009. In section III. of this Addendum, we discuss our proposed policy changes for determining the prospective payment rates for Medicare inpatient capital-related costs for FY 2009. Section IV. of this Addendum sets forth our proposed changes for determining the rate-ofincrease limits for certain hospitals excluded from the IPPS for FY 2009. The tables to which we refer in the preamble of this proposed rule are presented in section V. of this Addendum of this proposed rule. II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2009 The basic methodology for determining prospective payment rates for hospital inpatient operating costs for FY 2005 and subsequent fiscal years is set forth at § 412.64. The basic methodology for determining the prospective payment rates for hospital inpatient operating costs for hospitals located in Puerto Rico for FY 2005 and subsequent fiscal years is set forth at §§ 412.211 and 412.212. Below we discuss the factors used for determining the prospective payment rates. In summary, the proposed standardized amounts set forth in Tables 1A, 1B, and 1C, of section VI. of this Addendum reflect— • Equalization of the standardized amounts for urban and other areas at the level computed for large urban hospitals during FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) of the Act, updated by the applicable percentage increase required under sections 1886(b)(3)(B)(i)(XX) and 1886(b)(3)(B)(viii) of the Act. • The labor-related share that is applied to the standardized amounts and Puerto Ricospecific standardized amounts to give the hospital the highest payment, as provided for under sections 1886(d)(3)(E), and 1886(d)(9)(C)(iv) of the Act. • Proposed updates of 3.0 percent for all areas (that is, the estimated full market basket percentage increase of 3.0 percent), as required by section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a)(1) of Pub. L. 109–171, and reflecting the requirements of section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109–171, to reduce the applicable percentage increase by 2.0 percentage points for a hospital that fails to submit data, in a form and manner specified by the Secretary, relating to the quality of inpatient care furnished by the hospital. • A proposed update of 3.0 percent to the Puerto Rico-specific standardized amount (that is, the full estimated rate-of-increase in the hospital market basket for IPPS VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 hospitals), as provided for under § 412.211(c), which states that we update the Puerto Rico-specific standardized amount using the percentage increase specified in § 412.64(d)(1), or the percentage increase in the market basket index for prospective payment hospitals for all areas. • An adjustment to the standardized amount to ensure budget neutrality for DRG recalibration and reclassification, as provided for under section 1886(d)(4)(C)(iii) of the Act. • An adjustment to ensure the wage index update and changes are budget neutral, as provided for under section 1886(d)(3)(E) of the Act. • An adjustment to ensure the effects of geographic reclassification are budget neutral, as provided for in section 1886(d)(8)(D) of the Act, by removing the FY 2008 budget neutrality factor and applying a revised factor. • An adjustment to remove the FY 2008 outlier offset and apply an offset for FY 2009. • An adjustment to ensure the effects of the rural community hospital demonstration required under section 410A of Pub. L. 108– 173 are budget neutral, as required under section 410A(c)(2) of Pub. L. 108–173. • An adjustment to eliminate the effect of coding or classification changes that do not reflect real changes in case-mix, as discussed below and in section II.D. of the preamble to this proposed rule. We note that, beginning in FY 2008, we applied the budget neutrality adjustment for the rural floor to the hospital wage indices rather than the standardized amount. For FY 2009, we are proposing to continue to apply the rural floor budget neutrality adjustment to hospital wage indices rather than the standardized amount. In addition, instead of applying the budget neutrality adjustment for the imputed rural floor adopted under section 1886(d)(3)(E) of the Act to the standardized amounts, beginning with FY 2009, we are proposing to apply the imputed rural floor budget neutrality adjustment to the wage indices. Beginning in FY 2009, we are also proposing to apply the budget neutrality adjustments for the rural floor and imputed rural floor at the State level rather than the national level. For a complete discussion of the budget neutrality proposals concerning the rural floor and the imputed rural floor, including the proposal for a within-State budget neutrality adjustment, we refer readers to section III.B.2.b. of the preamble to this proposed rule. A. Calculation of the Adjusted Standardized Amount 1. Standardization of Base-Year Costs or Target Amounts In general, the national standardized amount is based on per discharge averages of adjusted hospital costs from a base period (section 1886(d)(2)(A) of the Act) or, for Puerto Rico, adjusted target amounts from a base period (section 1886(d)(9)(B)(i) of the Act), updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. The September 1, 1983 interim final rule (48 FR 39763) contained a detailed explanation of how base-year cost data (from cost reporting periods ending during FY 1981) were established for urban PO 00000 Frm 00182 Fmt 4701 Sfmt 4702 and rural hospitals in the initial development of standardized amounts for the IPPS. The September 1, 1987 final rule (52 FR 33043 and 33066) contains a detailed explanation of how the target amounts were determined and how they are used in computing the Puerto Rico rates. Sections 1886(d)(2)(B) and (d)(2)(C) of the Act require us to update base-year per discharge costs for FY 1984 and then standardize the cost data in order to remove the effects of certain sources of cost variations among hospitals. These effects include case-mix, differences in area wage levels, cost-of-living adjustments for Alaska and Hawaii, indirect medical education costs, and costs to hospitals serving a disproportionate share of low-income patients. In accordance with section 1886(d)(3)(E) of the Act, the Secretary estimates, from timeto-time, the proportion of hospitals’ costs that are attributable to wages and wage-related costs. In general, the standardized amount is divided into labor-related and nonlaborrelated amounts; only the proportion considered to be the labor-related amount is adjusted by the wage index. Section 1886(d)(3)(E) of the Act requires that 62 percent of the standardized amount be adjusted by the wage index, unless doing so would result in lower payments to a hospital than would otherwise be made. (Section 1886(d)(9)(C)(iv)(II) of the Act extends this provision to the labor-related share for hospitals located in Puerto Rico.) For FY 2009, we are not proposing to change the national and Puerto Rico-specific labor-related and nonlabor-related shares from the percentages established for FY 2008. Therefore, the labor-related share continues to be 69.7 percent for the national standardized amounts and 58.7 percent for the Puerto Rico-specific standardized amount. Consistent with section 1886(d)(3)(E) of the Act, we are applying the wage index to a labor-related share of 62 percent for all non-Puerto Rico hospitals whose wage indexes are less than or equal to 1.0000. For all non-Puerto Rico hospitals whose wage indices are greater than 1.0000, we are applying the wage index to a laborrelated share of 69.7 percent of the national standardized amount. For hospitals located in Puerto Rico, we are applying a laborrelated share of 58.7 percent if its Puerto Rico-specific wage index is less than or equal to 1.0000. For hospitals located in Puerto Rico whose Puerto Rico-specific wage index values are greater than 1.0000, we are applying a labor share of 62 percent. The standardized amounts for operating costs appear in Table 1A, 1B, and 1C of the Addendum to this proposed rule. 2. Computing the Average Standardized Amount Section 1886(d)(3)(A)(iv)(II) of the Act requires that, beginning with FY–2004 and thereafter, an equal standardized amount be computed for all hospitals at the level computed for large urban hospitals during FY 2003, updated by the applicable percentage update. Section 1886(d)(9)(A)(ii)(II) of the Act equalizes the Puerto Rico-specific urban and rural area rates. Accordingly, we are calculating FY 2009 national and Puerto Rico E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules standardized amounts irrespective of whether a hospital is located in an urban or rural location. 3. Updating the Average Standardized Amount In accordance with section 1886(d)(3)(A)(iv)(II) of the Act, we are updating the equalized standardized amount for FY 2008 by the full estimated market basket percentage increase for hospitals in all areas, as specified in section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a)(1) of Pub. L. 109–171. The percentage change in the market basket reflects the average change in the price of goods and services purchased by hospitals to furnish inpatient care. The most recent forecast of the hospital market basket increase for FY 2009 is 3.0 percent. Thus, for FY 2009, the proposed update to the average standardized amount is 3.0 percent for hospitals in all areas. The estimated market basket increase of 3.0 percent is based on the 2008 first quarter forecast of the hospital market basket increase (as discussed in Appendix B of this proposed rule). Section 1886(b)(3)(B) of the Act specifies the mechanism to be used to update the standardized amount for payment for inpatient hospital operating costs. Section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109–171, provides for a reduction of 2.0 percentage points from the update percentage increase (also known as the market basket update) for FY 2007 and each subsequent fiscal year for any ‘‘subsection (d) hospital’’ that does not submit quality data, as discussed in section IV.A. of the preamble of this proposed rule. The standardized amounts in Tables 1A through 1C of section V. of the Addendum to this proposed rule reflect these differential amounts. Section 412.211(c) states that we update the Puerto Rico-specific standardized amount using the percentage increase specified in § 412.64(d)(1) or the percentage increase in the market basket index for prospective payment hospitals for all areas. We are proposing to apply the full rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Rico-specific standardized amount. Therefore, the proposed update to the Puerto Rico-specific standardized amount is estimated to be 3.0 percent. Although the update factors for FY 2009 are set by law, we are required by section 1886(e)(4) of the Act to recommend, taking into account MedPAC’s recommendations, appropriate update factors for FY 2009 for both IPPS hospitals and hospitals and hospital units excluded from the IPPS. Our recommendation on the update factors (which is required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set forth in Appendix B of this proposed rule. 4. Other Adjustments to the Average Standardized Amount As in the past, we are adjusting the FY 2009 standardized amount to remove the effects of the FY 2008 geographic reclassifications and outlier payments before applying the FY 2009 updates. We then applied budget neutrality offsets for outliers and geographic reclassifications to the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 standardized amount based on proposed FY 2009 payment policies. We do not remove the prior year’s budget neutrality adjustments for reclassification and recalibration of the DRG weights and for updated wage data because, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act, estimated aggregate payments after updates in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year’s adjustment, we would not have satisfied these conditions. Budget neutrality is determined by comparing aggregate IPPS payments before and after making changes that are required to be budget neutral (for example, changes to DRG classifications, recalibration of the DRG relative weights, updates to the wage index, and different geographic reclassifications). We included outlier payments in the simulations because they may be affected by changes in these parameters. We are also proposing to adjust the standardized amount this year by an estimated amount to ensure that aggregate IPPS payments did not exceed the amount of payments that would have been made in the absence of the rural community hospital demonstration program, as required under section 410A of Pub. L. 108–173. This demonstration is required to be budget neutral under section 410A(c)(2) of Pub. L. 108–173. For FY 2009, we are proposing to no longer apply budget neutrality for the imputed rural floor to the standardized amount, and to apply it instead to the wage index, as discussed in section of II.B.2. of the preamble to this proposed rule. For FY 2009, we are also proposing an adjustment to eliminate the effect of coding or classification changes that did not reflect real changes in case-mix using the Secretary’s authority under section 1886(d)(3)(A)(vi) of the Act, by the percentage specified in section 7 of Pub. L. 110–90. a. Proposed Recalibration of DRG Weights and Updated Wage Index—Budget Neutrality Adjustment Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning in FY 1991, the annual DRG reclassification and recalibration of the relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. As discussed in section II. of the preamble of this proposed rule, we normalized the recalibrated DRG weights by an adjustment factor so that the average case weight after recalibration is equal to the average case weight prior to recalibration. However, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payments to hospitals are affected by factors other than average case weight. Therefore, as we have done in past years, we made a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met. Section 1886(d)(3)(E) of the Act requires us to update the hospital wage index on an annual basis beginning October 1, 1993. This provision also requires us to make any PO 00000 Frm 00183 Fmt 4701 Sfmt 4702 23709 updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. Consistent with current policy, for FY 2009, we are adjusting 100 percent of the wage index factor for occupational mix. We describe the occupational mix adjustment in section III.D. of the preamble to this proposed rule. To comply with the requirement that DRG reclassification and recalibration of the relative weights and the updated wage index be budget neutral, we used FY 2007 discharge data to simulate payments and compared aggregate payments using the FY 2008 relative weights and wage indices to aggregate payments using the proposed FY 2009 relative weights and wage indices. The same methodology was used for the FY 2008 budget neutrality adjustment. Based on this comparison, we computed a proposed budget neutrality adjustment factor equal to 0.999525 to be applied to the national standardized amount. We are also adjusting the Puerto Rico-specific standardized amount for the effect of DRG reclassification and recalibration. We computed a proposed budget neutrality adjustment factor of 0.998700 to be applied to the Puerto Ricospecific standardized amount. These proposed budget neutrality adjustment factors are applied to the standardized amounts for FY 2008 without removing the prior year’s budget neutrality adjustments. In addition, as discussed in section IV. of this Addendum, we are applying the same proposed DRG reclassification and recalibration budget neutrality factor of 0.998700 to the hospital-specific rates that would be effective for cost reporting periods beginning on or after October 1, 2008. b. Reclassified Hospitals—Budget Neutrality Adjustment Section 1886(d)(8)(B) of the Act provides that, effective with discharges occurring on or after October 1, 1988, certain rural hospitals are deemed urban. In addition, section 1886(d)(10) of the Act provides for the reclassification of hospitals based on determinations by the MGCRB. Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the wage index. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amount to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. We note that the wage index adjustments provided under section 1886(d)(13) of the Act are not budget neutral. Section 1886(d)(13)(H) of the Act provides that any increase in a wage index under section 1886(d)(13) shall not be taken into account ‘‘in applying any budget neutrality adjustment with respect to such index’’ under section 1886(d)(8)(D) of the Act. To calculate the proposed budget neutrality factor for FY 2009, we used FY 2007 discharge data to simulate payments, and compared total IPPS payments prior to any reclassifications under sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act to total IPPS payments after such reclassifications. E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23710 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Based on these simulations, we calculated a proposed adjustment factor of 0.992333 to ensure that the effects of these provisions are budget neutral, consistent with the statute. The proposed adjustment factor is applied to the standardized amount after removing the effects of the FY 2008 budget neutrality adjustment factor. We note that the FY 2009 adjustment reflects FY 2009 wage index reclassifications approved by the MGCRB or the Administrator. (Section 1886(d)(10)(D)(v) of the Act makes wage index reclassifications effective for 3 years. Therefore, the FY 2009 geographic reclassification could either be the continuation of a 3-year reclassification that began in FY 2007 or FY 2008, or a new one beginning in FY 2009.) c. Case-Mix Budget Neutrality Adjustment As stated earlier, beginning in FY 2008, we adopted the new MS–DRG patient classification system for the IPPS to better recognize severity of illness in Medicare payment rates. In the FY 2008 IPPS final rule with comment period, we indicated that we believe the adoption of the MS–DRGs had the potential to lead to increases in aggregate payments without a corresponding increase in actual patient severity of illness due to the incentives for improved documentation and coding. In that final rule, using the Secretary’s authority under section 1886(d)(3)(A)(vi) of the Act to maintain budget neutrality by adjusting the national standardized amounts to eliminate the effect of changes in coding or classification that do not reflect real change in case-mix, we established prospective documentation and coding adjustments of ¥1.2 percent for FY 2008, ¥1.8 percent for FY 2009, and ¥1.8 percent for FY 2010. On September 29, 2007, Pub. L. 110–90 was enacted. Section 7 of Pub. L. 110–90 included a provision that reduces the documentation and coding adjustment for the MS–DRG system that we adopted in the FY 2008 IPPS final rule with comment period to ¥0.6 percent for FY 2008 and ¥0.9 percent for FY 2009. To comply with the provision of section 7 of Pub. L. 110–90, in a final rule that appeared in the Federal Register on November 27, 2007 (72 FR 66886), we changed the IPPS documentation and coding adjustment for FY 2008 to ¥0.6 percent, and revised the FY 2008 national standardized amounts (as well as other payment factors and thresholds) accordingly, with these revisions effective October 1, 2007. For FY 2009, section 7 of Pub. L. 110–90 requires a documentation and coding adjustment of ¥0.9 percent instead of the ¥1.8 percent adjustment specified in the FY 2008 IPPS final rule with comment period. As required by statute, we are applying a documentation and coding adjustment of ¥0.9 percent to the FY 2009 IPPS national standardized amounts. The documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period are cumulative. As a result, the ¥0.9 percent documentation and coding adjustment in FY 2009 is in addition to the ¥0.6 percent adjustment in FY 2008, yielding a combined effect of ¥1.5 percent. As discussed in more detail in section II.D. of the preamble of this proposed rule, in calculating the FY 2008 Puerto Rico standardized amount, we made an VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 inadvertent error and applied the documentation and coding adjustment established using our authority in section 1886(d)(3)(A)(vi) of the Act (which only applies to the national standardized amounts) to the Puerto Rico-specific standardized amount. We are currently in the process of developing a Federal Register notice to remove the ¥0.6 percent documentation and coding adjustment from the FY 2008 Puerto Rico-specific standardized amount retroactive to October 1, 2007. As discussed in section II.D. of the preamble of this proposed rule, we are not applying the documentation and coding adjustment to the Puerto Rico-specific standardized amount for FY 2009, but we may consider doing so for the FY 2010 Puerto Rico-specific standardized amount in the FY 2010 rulemaking. In calculating the FY 2009 Puerto Rico-specific standardized amount for this proposed rule, we have removed the ¥0.6 percent documentation and coding adjustment that was inadvertently applied to the FY 2008 Puerto Rico-specific standardized amount. d. Outliers Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for ‘‘outlier’’ cases involving extraordinarily high costs. To qualify for outlier payments, a case must have costs greater than the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the ‘‘outlier threshold’’ or ‘‘fixed loss’’ amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for an outlier payment). We refer to the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the outlier threshold as the outlier ‘‘fixed-loss cost threshold.’’ To determine whether the costs of a case exceed the fixed-loss cost threshold, a hospital’s CCR is applied to the total covered charges for the case to convert the charges to estimated costs. Payments for eligible cases are then made based on a marginal cost factor, which is a percentage of the estimated costs above the fixed-loss cost threshold. The marginal cost factor for FY 2009 is 80 percent, the same marginal cost factor we have used since FY 1995 (59 FR 45367). In accordance with section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year are projected to be not less than 5 percent nor more than 6 percent of total operating DRG payments plus outlier payments. Section 1886(d)(3)(B) of the Act requires the Secretary to reduce the average standardized amount by a factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to reduce the average standardized amount applicable to hospitals located in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. More information on outlier payments may be found on the CMS Web site at https://www.cms.hhs.gov/ AcuteInpatientPPS/ 04_outlier.asp#TopOfPage. PO 00000 Frm 00184 Fmt 4701 Sfmt 4702 (1) Proposed FY 2009 Outlier Fixed-Loss Cost Threshold For FY 2009, we are proposing to use the same methodology used for FY 2008 (72 FR 47417) to calculate the outlier threshold. Similar to the methodology used in the FY 2008 final rule with comment period, for FY 2009, we are applying an adjustment factor to the CCRs to account for cost and charge inflation (as explained below). As we have done in the past, to calculate the proposed FY 2009 outlier threshold, we simulated payments by applying FY 2009 rates and policies using cases from the FY 2007 MedPAR files. Therefore, in order to determine the proposed FY 2009 outlier threshold, we inflate the charges on the MedPAR claims by 2 years, from FY 2007 to FY 2009. We are proposing to continue using a refined methodology that takes into account the lower inflation in hospital charges that are occurring as a result of the outlier final rule (68 FR 34494), which changed our methodology for determining outlier payments by implementing the use of more current CCRs. Our refined methodology uses more recent data that reflect the rate-ofchange in hospital charges under the new outlier policy. Using the most recent data available, we calculated the 1-year average annualized rateof-change in charges-per-case from the last quarter of FY 2006 in combination with the first quarter of FY 2007 (July 1, 2006 through December 31, 2006) to the last quarter of FY 2007 in combination with the first quarter of FY 2008 (July 1, 2007 through December 31, 2007). This rate of change was 5.84 percent (1.0585) or 12.03 percent (1.1204) over 2 years. As we have done in the past, we are proposing to establish the proposed FY 2009 outlier threshold using hospital CCRs from the December 2007 update to the ProviderSpecific File (PSF)—the most recent available data at the time of this proposed rule. This file includes CCRs that reflected implementation of the changes to the policy for determining the applicable CCRs that became effective August 8, 2003 (68 FR 34494). As discussed in the FY 2007 final rule (71 FR 48150), we worked with the Office of Actuary to derive the methodology described below to develop the CCR adjustment factor. For FY 2009, we are proposing to use the same methodology to calculate the CCR adjustment by using the FY 2007 operating cost per discharge increase in combination with the actual FY 2007 operating market basket increase determined by Global Insight, Inc., as well as the charge inflation factor described above to estimate the adjustment to the CCRs. (We note that the FY 2007 actual (otherwise referred to as ‘‘final’’) operating market basket increase reflects historical data whereas the published FY 2007 operating market basket update factor was based on Global Insight, Inc.’s 2006 second quarter forecast with historical data through the first quarter of 2007.) By using the operating market basket rate-of-increase and the increase in the average cost per discharge from hospital cost reports, we are using two different measures of cost inflation. For FY E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 2009, we determined the adjustment by taking the percentage increase in the operating costs per discharge from FY 2005 to FY 2006 (1.0538) from the cost report and dividing it by the final operating market basket increase from FY 2006 (1.0420). We repeated this calculation for 2 prior years to determine the 3-year average of the rate of adjusted change in costs between the operating market basket rate-of-increase and the increase in cost per case from the cost report (FY 2003 to FY 2004 percentage increase of operating costs per discharge of 1.0629 divided by FY 2004 final operating market basket increase of 1.0400, FY 2004 to FY 2005 percentage increase of operating costs per discharge of 1.0565 divided by FY 2005 final operating market basket increase of 1.0430). For FY 2009, we averaged the differentials calculated for FY 2004, FY 2005, and FY 2006, which resulted in a mean ratio of 1.0154. We multiplied the 3-year average of 1.0154 by the 2007 operating market basket percentage increase of 1.0340, which resulted in an operating cost inflation factor of 5.0 percent or 1.05. We then divided the operating cost inflation factor by the 1-year average change in charges (1.058474) and applied an adjustment factor of 0.9920 to the operating CCRs from the PSF. As stated in the FY 2008 final rule with comment period, we continue to believe it is appropriate to apply only a 1-year adjustment factor to the CCRs. On average, it takes approximately 9 months for fiscal intermediaries (or, if applicable, the MAC) to tentatively settle a cost report from the fiscal year end of a hospital’s cost reporting period. The average ‘‘age’’ of hospitals’ CCRs from the time the fiscal intermediary or the MAC inserts the CCR in the PSF until the beginning of FY 2008 is approximately 1 year. Therefore, as stated above, we believe a 1-year adjustment factor to the CCRs is appropriate. We used the same methodology for the capital CCRs and determined the adjustment by taking the percentage increase in the capital costs per discharge from FY 2005 to FY 2006 (1.0462) from the cost report and dividing it by the final capital market basket increase from FY 2006 (1.0090). We repeated this calculation for 2 prior years to determine the 3-year average of the rate of adjusted change in costs between the capital market basket rate-of-increase and the increase in cost per case from the cost report (FY 2003 to FY 2004 percentage increase of capital costs per discharge of 1.0315 divided by FY 2004 final capital market basket increase of 1.0050, FY 2004 to FY 2005 percentage increase of capital costs per discharge of 1.0311 divided by FY 2005 final capital market basket increase of 1.0060). For FY 2009, we averaged the differentials calculated for FY 2004, FY 2005, and FY 2006, which resulted in a mean ratio of 1.0294. We multiplied the 3-year average of 1.0294 by the 2007 capital market basket percentage increase of 1.0120, which resulted in a capital cost inflation factor of 4.17 percent or 1.0417. We then divided the capital cost inflation factor by the 1-year average change in charges (1.058474) and applied an adjustment factor of 0.9842 to the capital CCRs from the PSF. We are using the same VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 charge inflation factor for the capital CCRs that was used for the operating CCRs. The charge inflation factor is based on the overall billed charges. Therefore, we believe it is appropriate to apply the charge factor to both the operating and capital CCRs. For purposes of estimating the proposed outlier threshold for FY 2009, we assume 3.0 percent case-mix growth in FY 2009 compared with our FY 2007 claims data (that is, a 1.2 percent increase in FY 2008 and an additional 1.8 percent increase in FY 2009). The 3 percent case-mix growth was projected by the Office of the Actuary as the amount case-mix is expected to increase in response to adoption of the MS–DRGs as a result of improvements in documentation and coding that do not reflect real changes in patient severity of illness. It is necessary to take the 3 percent expected case-mix growth into account when calculating the outlier threshold that results in outlier payments being 5.1 percent of total payments for FY 2009. If we did not take this 3 percent projected case-mix growth into account, our estimate of total payments would be too low, and as a result, our estimate of the outlier threshold would be too high. While we assume 3 percent case-mix growth for all hospitals in our outlier threshold calculations, the FY 2009 national standardized amounts used to calculate the outlier threshold reflect the statutorily mandated documentation and coding adjustment of ¥0.9 percent for FY 2009, on top of the ¥0.6 percent adjustment for FY 2008. Using this methodology, we are proposing an outlier fixed-loss cost threshold for FY 2009 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $21,025. As we did in establishing the FY 2008 outlier threshold (72 FR 47417), in our projection of FY 2009 outlier payments, we are not making any adjustments for the possibility that hospitals’ CCRs and outlier payments may be reconciled upon cost report settlement. We continue to believe that, due to the policy implemented in the outlier final rule (68 FR 34494, June 9, 2003), CCRs will no longer fluctuate significantly and, therefore, few hospitals will actually have these ratios reconciled upon cost report settlement. In addition, it is difficult to predict the specific hospitals that will have CCRs and outlier payments reconciled in any given year. We also noted that reconciliation occurs because hospitals’ actual CCRs for the cost reporting period are different than the interim CCRs used to calculate outlier payments when a bill is processed. Our simulations assume that CCRs accurately measure hospital costs based on information available to us at the time we set the outlier threshold. For these reasons, we are not making any assumptions about the effects of reconciliation on the outlier threshold calculation. We also note that there are some factors that contributed to a proposed lower fixed loss outlier threshold for FY 2009 compared to FY 2008. First, the case-weighted national average operating CCR declined by approximately an additional 1 percentage PO 00000 Frm 00185 Fmt 4701 Sfmt 4702 23711 point from the March 2007 update (used to calculate the FY 2008 outlier threshold) to the December 2007 update of the PSF (used to calculate the proposed FY 2009 outlier threshold). In addition, as discussed in sections II.C. and II.H. of the preamble of this proposed rule, we began a 2-year phase-in of the MS–DRGs in FY 2008, with the DRG relative weights based on a 50 percent blend of the CMS DRGs and MS–DRGs in FY 2008 and based on 100 percent of the MS–DRGs beginning in FY 2009. Better recognition of severity of illnesses with the MS–DRGs means that nonoutlier payments will compensate hospitals for the higher costs of some cases that previously received outlier payments. As cases are paid more accurately, in order to meet the 5.1 percent target, we need to decrease the fixed-loss outlier threshold so that more cases qualify for outlier payments. In addition, as noted previously, in our modeling of the outlier threshold, we included a 3-percent adjustment for expected case-mix growth between FY 2007 and FY 2009. Together, we believe that the above factors cumulatively contributed to a lower proposed fixed-loss outlier threshold in FY 2009 compared to FY 2008. (2) Other Proposed Changes Concerning Outliers As stated in the FY 1994 IPPS final rule (58 FR 46348), we establish an outlier threshold that is applicable to both hospital inpatient operating costs and hospital inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common threshold resulted in a lower percentage of outlier payments for capital-related costs than for operating costs. We are projecting that the proposed thresholds for FY 2009 will result in outlier payments that will equal 5.1 percent of operating DRG payments and 5.73 percent of capital payments based on the Federal rate. In accordance with section 1886(d)(3)(B) of the Act, we are reducing the FY 2009 standardized amount by the same percentage to account for the projected proportion of payments paid as outliers. The outlier adjustment factors that are applied to the standardized amount for the proposed FY 2009 outlier threshold are as follows: Operating standardized amounts National ......... Puerto Rico ... 0.948928 0.955988 Capital federal rate 0.942711 0.925627 Consistent with current policy, we are applying the outlier adjustment factors to FY 2009 rates after removing the effects of the FY 2008 outlier adjustment factors on the standardized amount. To determine whether a case qualifies for outlier payments, we apply hospital-specific CCRs to the total covered charges for the case. Estimated operating and capital costs for the case are calculated separately by applying separate operating and capital CCRs. These costs are then combined and E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23712 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules compared with the outlier fixed-loss cost threshold. The outlier final rule (68 FR 34494) eliminated the application of the statewide average CCRs for hospitals with CCRs that fell below 3 standard deviations from the national mean CCR. However, for those hospitals for which the fiscal intermediary or MAC computes operating CCRs greater than 1.213 or capital CCRs greater than 0.148, or hospitals for whom the fiscal intermediary or MAC is unable to calculate a CCR (as described at § 412.84(i)(3) of our regulations), we still use statewide average CCRs to determine whether a hospital qualifies for outlier payments.27 Table 8A in this Addendum contains the statewide average operating CCRs for urban hospitals and for rural hospitals for which the fiscal intermediary or MAC is unable to compute a hospital-specific CCR within the above range. Effective for discharges occurring on or after October 1, 2008, these statewide average ratios would replace the ratios published in the IPPS final rule for FY 2008 (72 FR 48126–48127). Table 8B in this Addendum contains the comparable statewide average capital CCRs. Again, the CCRs in Tables 8A and 8B would be used during FY 2009 when hospital-specific CCRs based on the latest settled cost report are either not available or are outside the range noted above. For an explanation of Table 8C, we refer readers to section V. of this Addendum. We finally note that we published a manual update (Change Request 3966) to our outlier policy on October 12, 2005, which updated Chapter 3, Section 20.1.2 of the Medicare Claims Processing Manual. The manual update covered an array of topics, including CCRs, reconciliation, and the time value of money. We encourage hospitals that are assigned the statewide average operating and/or capital CCRs to work with their fiscal intermediaries (or MAC if applicable) on a possible alternative operating and/or capital CCR as explained in Change Request 3966. Use of an alternative CCR developed by the hospital in conjunction with the fiscal intermediary or MAC can avoid possible overpayments or underpayments at cost report settlement, thus ensuring better accuracy when making outlier payments and negating the need for outlier reconciliation. We also note that a hospital may request an alternative operating or capital CCR ratio at any time as long as the guidelines of Change Request 3966 are followed. To download and view the manual instructions on outlier and cost-to-charge ratios, visit the Web site: https://www.cms.hhs.gov/manuals/ downloads/clm104c03.pdf. (3) FY 2007 and FY 2008 Outlier Payments In the FY 2008 IPPS final rule (72 FR 47420), we stated that, based on available data, we estimated that actual FY 2007 outlier payments would be approximately 4.6 percent of actual total DRG payments. This estimate was computed based on simulations using the FY 2006 MedPAR file (discharge data for FY 2006 bills). That is, the estimate 27 These figures represent 3.0 standard deviations from the mean of the log distribution of CCRs for all hospitals. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 of actual outlier payments did not reflect actual FY 2007 bills, but instead reflected the application of FY 2007 rates and policies to available FY 2006 bills. Our current estimate, using available FY 2007 bills, is that actual outlier payments for FY 2007 were approximately 4.64 percent of actual total DRG payments. Thus, the data indicate that, for FY 2007, the percentage of actual outlier payments relative to actual total payments is lower than we projected before FY 2007. Consistent with the policy and statutory interpretation we have maintained since the inception of the IPPS, we do not plan to make retroactive adjustments to outlier payments to ensure that total outlier payments for FY 2007 are equal to 5.1 percent of total DRG payments. We currently estimate that actual outlier payments for FY 2008 will be approximately 4.8 percent of actual total DRG payments, 0.3 percentage points lower than the 5.1 percent we projected in setting the outlier policies for FY 2008. This estimate is based on simulations using the FY 2007 MedPAR file (discharge data for FY 2007 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2008 by applying FY 2008 rates and policies, including an outlier threshold of $22,185 to available FY 2007 bills. e. Proposed Rural Community Hospital Demonstration Program Adjustment (Section 410A of Pub. L. 108–173) Section 410A of Pub. L. 108–173 requires the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) of Pub. L. 108–173 requires that ‘‘in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.’’ As discussed in section IV.K. of the preamble to this proposed rule, we have satisfied this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. There are currently nine hospitals participating in the demonstration program. CMS is currently conducting a solicitation for up to six additional hospitals to participate in the demonstration program. For this proposed rule, we used data from the cost reports of the 9 currently participating hospitals to estimate a total cost number for 15 hospitals that could potentially participate in the demonstration program in FY 2009. (In the final rule, we will know the exact number of hospitals participating in the demonstration program, and we will revise our estimates accordingly.) We estimate that the average additional annual payment that will be made to each participating hospital under the demonstration will be approximately $2,134,123. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration program. As an estimate of the cost for a total of 15 hospitals that may participate, the total annual impact of the demonstration program for FY 2009 is PO 00000 Frm 00186 Fmt 4701 Sfmt 4702 projected to be $32,011,849. The required adjustment to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999666. In order to achieve budget neutrality, we are adjusting the national IPPS rates by an amount sufficient to account for the added costs of this demonstration. In other words, we are applying budget neutrality across the payment system as a whole rather than merely across the participants of this demonstration, consistent with past practice. We believe that the language of the statutory budget neutrality requirement permits the agency to implement the budget neutrality provision in this manner. The statutory language requires that ‘‘aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration * * * was not implemented,’’ but does not identify the range across which aggregate payments must be held equal. 5. Proposed FY 2009 Standardized Amount The adjusted proposed standardized amount is divided into labor-related and nonlabor-related portions. Tables 1A and 1B of this Addendum contain the national standardized amounts that we are proposing to apply to all hospitals, except hospitals located in Puerto Rico, for FY 2009. The proposed Puerto Rico-specific amounts are shown in Table 1C of this Addendum. The proposed amounts shown in Tables 1A and 1B differ only in that the labor-related share applied to the standardized amounts in Table 1A is 69.7 percent, and Table 1B is 62 percent. In accordance with sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act, we are applying a labor-related share of 62 percent, unless application of that percentage would result in lower payments to a hospital than would otherwise be made. In effect, the statutory provision means that we apply a labor-related share of 62 percent for all hospitals (other than those in Puerto Rico) whose wage indexes are less than or equal to 1.0000. In addition, Tables 1A and 1B include proposed standardized amounts reflecting the full 3.0 percent update for FY 2009, and proposed standardized amounts reflecting the 2.0 percentage point reduction to the update (a 1.0 percent update) applicable for hospitals that fail to submit quality data consistent with section 1886(b)(3)(B)(viii) of the Act. Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the dischargeweighted average of the national large urban standardized amount (this proposed amount is set forth in Table 1A). The proposed laborrelated and nonlabor-related portions of the national average standardized amounts for Puerto Rico hospitals for FY 2009 are set forth in Table 1C of this Addendum. This table also includes the proposed Puerto Rico standardized amounts. The labor-related share applied to the Puerto Rico specific standardized amount is 58.7 percent, or 62 percent, depending on which provides higher payments to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108–173, provides E:\FR\FM\30APP2.SGM 30APP2 23713 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules that the labor-related share for hospitals located in Puerto Rico be 62 percent, unless the application of that percentage would result in lower payments to the hospital.) The following table illustrates the proposed changes from the FY 2008 national average standardized amount. The second and third columns show the proposed changes from the FY 2008 standardized amounts for hospitals that satisfy the quality data submission requirement for receiving the full update (3.0 percent) with the different labor-related shares that apply to hospitals. The fourth and fifth columns show the proposed changes for hospitals receiving the reduced update (1.0 percent) with the different labor-related shares that apply to hospitals. The first row of the table shows the updated (through FY 2008) average standardized amount after restoring the FY 2008 offsets for outlier payments, demonstration budget neutrality, the New Jersey imputed floor budget neutrality, and the geographic reclassification budget neutrality. The DRG reclassification and recalibration and wage index budget neutrality factor is cumulative. Therefore, the FY 2008 factor is not removed from this table. Also, in order to properly apply the documentation and coding adjustment, it was necessary to first remove the FY 2008 adjustment from the FY 2008 rate in the first row of the table and then later in the table to cumulatively apply the sum of the FY 2008 and FY 2009 adjustments (that is, 1¥(.006 + .009)) to the FY 2009 rate. (For a complete discussion on the documentation and coding adjustment, we refer readers to section II.D of the preamble to this proposed rule.) COMPARISON OF FY 2008 STANDARDIZED AMOUNTS TO THE PROPOSED FY 2009 SINGLE STANDARDIZED AMOUNT WITH FULL UPDATE AND REDUCED UPDATE Full update (3.0 percent); wage index is greater than 1.0000 FY 2008 Base Rate, after removing geographic reclassification budget neutrality, demonstration budget neutrality, documentation and coding adjustment, NJ imputed floor budget neutrality and outlier offset (based on the labor and market share percentage for FY 2009). FY 2009 Update Factor ................................. FY 2009 DRG Recalibrations and Wage Index Budget Neutrality Factor. FY 2009 Reclassification Budget Neutrality Factor. FY 2009 Outlier Factor .................................. Rural Demonstration Budget Neutrality Factor. FY 2009 Documentation and Coding Adjustment and Actual FY 2008 Adjustment. Proposed Rate for FY 2009 ........................... Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the national average standardized amounts. The labor-related and nonlabor-related portions of the national average standardized amounts for hospitals located in Puerto Rico are set forth in Table 1C of this Addendum. This table also includes the Puerto Rico standardized amounts. The labor-related share applied to the Puerto Rico standardized amount is 58.7 percent, or 62 percent, depending on which results in higher payments to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108– 173, provides that the labor-related share for hospitals located in Puerto Rico be 62 percent, unless the application of that percentage would result in lower payments to the hospital.) Full update (3.0 percent); wage index is less than 1.0000 Reduced update (1.0 percent); wage index is greater than 1.0000 Reduced update (1.0 percent); wage index is less than 1.0000 Labor: $3,723.07 ........ Nonlabor: $1,618.50 .. Labor: $3,311.77 ........ Nonlabor: $2,029.80 .. Labor: $3,723.07 ........ Nonlabor: $1,618.50 .. Labor: $3,311.77 Nonlabor: $2,029.80 1.030 .......................... 0.999525 .................... 1.030 .......................... 0.999525 .................... 1.010 .......................... 0.999525 .................... 1.010 0.999525 0.992333 .................... 0.992333 .................... 0.992333 .................... 0.992333 0.948928 .................... 0.999666 .................... 0.948928 .................... 0.999666 .................... 0.948928 .................... 0.999666 .................... 0.948928 0.999666 0.985 .......................... 0.985 .......................... 0.985 .......................... 0.985 Labor: $3,553.98 ........ Nonlabor: $1,544.98 .. Labor: $3,161.36 ........ Nonlabor: $1,937.60 .. Labor: $3,484.97 ........ Nonlabor: $1,514.98 .. Labor: $3,099.97 Nonlabor: $1,899.98 B. Proposed Adjustments for Area Wage Levels and Cost-of-Living Tables 1A through 1C, as set forth in this Addendum, contain the proposed laborrelated and nonlabor-related shares that we are using to calculate the proposed prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico for FY 2009. This section addresses two types of adjustments to the standardized amounts that were made in determining the prospective payment rates as described in this Addendum. 1. Proposed Adjustment for Area Wage Levels Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require that we make an adjustment to the labor-related portion of the national and Puerto Rico prospective payment rates, respectively, to account for area differences in hospital wage levels. This adjustment is made by multiplying the labor-related portion of the adjusted standardized amounts by the appropriate wage index for the area in which the hospital is located. In section III. of the preamble to this proposed rule, we discuss the data and methodology for the FY 2009 wage index. 2. Proposed Adjustment for Cost-of-Living in Alaska and Hawaii Section 1886(d)(5)(H) of the Act authorizes the Secretary to make an adjustment to take into account the unique circumstances of hospitals in Alaska and Hawaii. Higher laborrelated costs for these two States are taken into account in the adjustment for area wages described above. For FY 2009, we are proposing to adjust the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor-related portion of the standardized amount by the applicable adjustment factor contained in the table below. jlentini on PROD1PC65 with PROPOSALS2 TABLE OF COST-OF-LIVING ADJUSTMENT FACTORS: ALASKA AND HAWAII HOSPITALS Cost of living adjustment factor Area Alaska: City of Anchorage and 80-kilometer (50-mile) radius by road ..................................................................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00187 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 1.24 23714 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE OF COST-OF-LIVING ADJUSTMENT FACTORS: ALASKA AND HAWAII HOSPITALS—Continued Cost of living adjustment factor Area City of Fairbanks and 80-kilometer (50-mile) radius by road ...................................................................................................... City of Juneau and 80-kilometer (50-mile) radius by road .......................................................................................................... Rest of Alaska .............................................................................................................................................................................. Hawaii: City and County of Honolulu ........................................................................................................................................................ County of Hawaii .......................................................................................................................................................................... County of Kauai ............................................................................................................................................................................ County of Maui and County of Kalawao ...................................................................................................................................... 1.24 1.24 1.25 1.25 1.17 1.25 1.25 (The above factors are based on data obtained from the U.S. Office of Personnel Management.) jlentini on PROD1PC65 with PROPOSALS2 C. Proposed MS–DRG Relative Weights As discussed in section II.H. of the preamble of this proposed rule, we have developed proposed relative weights for each MS–DRG that reflect the resource utilization of cases in each MS–DRG relative to Medicare cases in other MS–DRGs. Table 5 of this Addendum contains the proposed relative weights that we will apply to discharges occurring in FY 2009. These factors have been recalibrated as explained in section II. of the preamble of this proposed rule. D. Calculation of the Proposed Prospective Payment Rates General Formula for Calculation of the Proposed Prospective Payment Rates for FY 2009 In general, the operating prospective payment rate for all hospitals paid under the IPPS located outside of Puerto Rico, except SCHs and MDHs, for FY 2009 equals the Federal rate. The prospective payment rate for SCHs for FY 2009 equals the higher of the applicable Federal rate, or the hospital-specific rate as described below. The prospective payment rate for MDHs for FY 2009 equals the higher of the Federal rate, or the Federal rate plus 75 percent of the difference between the Federal rate and the hospital-specific rate as described below. The prospective payment rate for hospitals located in Puerto Rico for FY 2009 equals 25 percent of the Puerto Rico rate plus 75 percent of the applicable national rate. 1. Federal Rate The Federal rate is determined as follows: Step 1—Select the applicable average standardized amount depending on whether the hospital submitted qualifying quality data (full update for qualifying hospitals, update minus 2.0 percentage points for nonqualifying hospitals). Step 2—Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified. Step 3—For hospitals in Alaska and Hawaii, multiply the nonlabor-related portion of the standardized amount by the applicable cost-of-living adjustment factor. Step 4—Add the amount from Step 2 and the nonlabor-related portion of the standardized amount (adjusted, if applicable, under Step 3). VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Step 5—Multiply the final amount from Step 4 by the relative weight corresponding to the applicable MS–DRG (see Table 5 of this Addendum). The Federal rate as determined in Step 5 is then further adjusted if the hospital qualifies for either the IME or DSH adjustment. In addition, for hospitals that qualify for a low-volume payment adjustment under section 1886(d)(12) of the Act and 42 CFR 412.101(b), the payment in Step 5 is increased by 25 percent. 2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs) a. Calculation of Hospital-Specific Rate Section 1886(b)(3)(C) of the Act provides that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge. As discussed previously, MDHs are required to rebase their hospital-specific rates to their FY 2002 cost reports if doing so results in higher payments. In addition, effective for discharges occurring on or after October 1, 2006, MDHs are to be paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent (changed from 50 percent) of the difference between the Federal national rate and the greater of the updated hospital-specific rates based on either FY 1982, FY 1987 or FY 2002 costs per discharge. Further, MDHs are no longer subject to the 12-percent cap on their DSH payment adjustment factor. Hospital-specific rates have been determined for each of these hospitals based on the FY 1982 costs per discharge, the FY 1987 costs per discharge, or, for SCHs, the FY 1996 costs per discharge and for MDHs, the FY 2002 cost per discharge. For a more detailed discussion of the calculation of the hospital-specific rates, we refer the reader to the FY 1984 IPPS interim final rule (48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); the FY 1991 IPPS final rule (55 FR 35994); and the FY 2001 IPPS final rule (65 FR 47082). In addition, for both SCHs and MDHs, the hospital-specific rate is adjusted by the budget neutrality adjustment factor as discussed in section III. of this Addendum. The resulting rate will be used in determining the payment rate an SCH PO 00000 Frm 00188 Fmt 4701 Sfmt 4702 or MDH will receive for its discharges beginning on or after October 1, 2007. b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital-Specific Rates for FY 2009 We are proposing to increase the hospitalspecific rates by 3.0 percent (the proposed estimated hospital market basket percentage increase) for FY 2009 for those SCHs and MDHs that submit qualifying quality data and by 1.0 percent for SCHs and MDHs that fail to submit qualifying quality data. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospitalspecific rates for SCHs is equal to the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2008, is the market basket rate-ofincrease for hospitals that submit qualifying quality data and the market basket rate-ofincrease minus 2 percent for hospitals that fail to submit qualifying quality data. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospitalspecific rates for MDHs also equals the update factor provided for under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2009, is the market basket rate-of-increase for hospitals that submit qualifying quality data and the market basket rate-of-increase minus 2 percent for hospitals that fail to submit qualifying quality data. 3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2008, and Before October 1, 2009 Section 1886(d)(9)(E)(iv) of the Act provides that, effective for discharges occurring on or after October 1, 2004, hospitals located in Puerto Rico are paid based on a blend of 75 percent of the national prospective payment rate and 25 percent of the Puerto Rico-specific rate. a. Puerto Rico Rate The Puerto Rico prospective payment rate is determined as follows: Step 1—Select the applicable average standardized amount considering the applicable wage index (Table 1C of this Addendum). Step 2—Multiply the labor-related portion of the standardized amount by the applicable Puerto Rico-specific wage index. Step 3—Add the amount from Step 2 and the nonlabor-related portion of the standardized amount. E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 Step 4—Multiply the amount from Step 3 by the applicable MS–DRG relative weight (Table 5 of this Addendum). Step 5—Multiply the result in Step 4 by 25 percent. b. National Rate The national prospective payment rate is determined as follows: Step 1—Select the applicable average standardized amount. Step 2—Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified. Step 3—Add the amount from Step 2 and the nonlabor-related portion of the national average standardized amount. Step 4—Multiply the amount from Step 3 by the applicable MS–DRG relative weight (Table 5 of this Addendum). Step 5—Multiply the result in Step 4 by 75 percent. The sum of the Puerto Rico rate and the national rate computed above equals the prospective payment for a given discharge for a hospital located in Puerto Rico. This rate is then further adjusted if the hospital qualifies for either the IME or DSH adjustment. III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient CapitalRelated Costs for FY 2009 The PPS for acute care hospital inpatient capital-related costs was implemented for cost reporting periods beginning on or after October 1, 1991. Effective with that cost reporting period, hospitals were paid during a 10-year transition period (which extended through FY 2001) to change the payment methodology for Medicare acute care hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate). The basic methodology for determining Federal capital prospective rates is set forth in the regulations at 42 CFR 412.308 through 412.352. Below we discuss the factors that we are proposing to use to determine the capital Federal rate for FY 2009, which would be effective for discharges occurring on or after October 1, 2008. The 10-year transition period ended with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002). Therefore, for cost reporting periods beginning in FY 2002, all hospitals (except ‘‘new’’ hospitals under § 412.304(c)(2)) are paid based on the capital Federal rate. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the IPPS by updating the FY 1989 Medicare inpatient capital cost per case by an actuarial estimate of the increase in Medicare inpatient capital costs per case. Each year after FY 1992, we update the capital standard Federal rate, as provided at § 412.308(c)(1), to account for capital input price increases and other factors. The regulations at § 412.308(c)(2) provide that the capital Federal rate be adjusted annually by a factor equal to the estimated proportion of outlier payments under the capital Federal rate to total capital payments under the capital Federal rate. In VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 addition, § 412.308(c)(3) requires that the capital Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for (regular and special) exceptions under § 412.348. Section 412.308(c)(4)(ii) requires that the capital standard Federal rate be adjusted so that the effects of the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor (GAF) are budget neutral. For FYs 1992 through 1995, § 412.352 required that the capital Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the respective fiscal year. That provision expired in FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to the capital Federal rate that was made in FY 1994, and § 412.308(b)(3) describes the 0.28 percent reduction to the capital Federal rate made in FY 1996 as a result of the revised policy for paying for transfers. In FY 1998, we implemented section 4402 of Pub. L. 105–33, which required that, for discharges occurring on or after October 1, 1997, the budget neutrality adjustment factor in effect as of September 30, 1995, be applied to the unadjusted capital standard Federal rate and the unadjusted hospital-specific rate. That factor was 0.8432, which was equivalent to a 15.68 percent reduction to the unadjusted capital payment rates. An additional 2.1 percent reduction to the rates was effective from October 1, 1997 through September 30, 2002, making the total reduction 17.78 percent. As we discussed in the FY 2003 IPPS final rule (67 FR 50102) and implemented in § 412.308(b)(6), the 2.1 percent reduction was restored to the unadjusted capital payment rates effective October 1, 2002. To determine the appropriate budget neutrality adjustment factor and the regular exceptions payment adjustment during the 10-year transition period, we developed a dynamic model of Medicare inpatient capital-related costs; that is, a model that projected changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the capital cost model was only used to estimate the regular exceptions payment adjustment and other factors during the transition period. As we explained in the FY 2002 IPPS final rule (66 FR 39911), beginning in FY 2002, an adjustment for regular exception payments is no longer necessary because regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991, and before October 1, 2001 (see § 412.348(b)). Because payments are no longer made under the regular exception policy effective with cost reporting periods beginning in FY 2002, we discontinued use of the capital cost model. The capital cost model and its application during the transition period are described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099). Section 412.374 provides for the use of a blended payment system for payments to PO 00000 Frm 00189 Fmt 4701 Sfmt 4702 23715 hospitals located in Puerto Rico under the IPPS for acute care hospital inpatient capitalrelated costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to hospitals located in Puerto Rico using the same methodology used to compute the national Federal rate for capital-related costs. In accordance with section 1886(d)(9)(A) of the Act, under the IPPS for acute care hospital operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals located in Puerto Rico were paid a blended operating rate that consisted of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. Similarly, prior to FY 1998, hospitals located in Puerto Rico were paid a blended capital rate that consisted of 75 percent of the applicable capital Puerto Rico-specific rate and 25 percent of the applicable capital Federal rate. However, effective October 1, 1997, in accordance with section 4406 of Pub. L. 105–33, the methodology for operating payments made to hospitals located in Puerto Rico under the IPPS was revised to make payments based on a blend of 50 percent of the applicable standardized amount specific to Puerto Rico hospitals and 50 percent of the applicable national average standardized amount. In conjunction with this change to the operating blend percentage, effective with discharges occurring on or after October 1, 1997, we also revised the methodology for computing capital payments to hospitals located in Puerto Rico to be based on a blend of 50 percent of the Puerto Rico capital rate and 50 percent of the capital Federal rate. As we discussed in the FY 2005 IPPS final rule (69 FR 49185), section 504 of Pub. L. 108–173 increased the national portion of the operating IPPS payments for hospitals located in Puerto Rico from 50 percent to 62.5 percent and decreased the Puerto Rico portion of the operating IPPS payments from 50 percent to 37.5 percent for discharges occurring on or after April 1, 2004 through September 30, 2004 (see the March 26, 2004 One-Time Notification (Change Request 3158)). In addition, section 504 of Pub. L. 108–173 provided that the national portion of operating IPPS payments for hospitals located in Puerto Rico is equal to 75 percent and the Puerto Rico portion of operating IPPS payments is equal to 25 percent for discharges occurring on or after October 1, 2004. Consistent with that change in operating IPPS payments to hospitals located in Puerto Rico, for FY 2005 (as we discussed in the FY 2005 IPPS final rule), we revised the methodology for computing capital payments to hospitals located in Puerto Rico to be based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate for discharges occurring on or after October 1, 2004. A. Determination of Proposed Federal Hospital Inpatient Capital-Related Prospective Payment Rate Update In the FY 2008 IPPS final rule with comment period (72 FR 66886 through 66888), we established a capital Federal rate E:\FR\FM\30APP2.SGM 30APP2 23716 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 of $426.14 for FY 2008. In the discussion that follows, we explain the factors that we are proposing to use to determine the proposed FY 2009 capital Federal rate. In particular, we explain why the proposed FY 2009 capital Federal rate would decrease approximately 1.14 percent, compared to the FY 2008 capital Federal rate. However, taking into account an estimated increase in Medicare fee-for-service discharges in FY 2009 as compared to FY 2008, as well as the estimated increase in payments due to documentation and coding (discussed in section VIII. of Appendix A to this proposed rule), we estimate that the increase in aggregate capital payments would be negligible during this same period (approximately $6 million). Total payments to hospitals under the IPPS are relatively unaffected by changes in the capital prospective payments. Because capital payments constitute about 10 percent of hospital payments, a 1-percent change in the capital Federal rate yields only about a 0.1 percent change in actual payments to hospitals. As noted above, aggregate payments under the capital IPPS are projected to increase in FY 2009 compared to FY 2008. 1. Projected Capital Standard Federal Rate Update a. Description of the Update Framework Under § 412.308(c)(1), the capital standard Federal rate is updated on the basis of an analytical framework that takes into account changes in a capital input price index (CIPI) and several other policy adjustment factors. Specifically, we have adjusted the projected CIPI rate-of-increase as appropriate each year for case-mix index-related changes, for intensity, and for errors in previous CIPI forecasts. The proposed update factor for FY 2009 under that framework is 0.7 percent based on the best data available at this time. The proposed update factor under that framework is based on a projected 1.2 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a ¥0.5 percent adjustment for the FY 2007 DRG reclassification and recalibration, and a forecast error correction of 0.0 percent. As discussed below in section III.C. of the Addendum to this proposed rule, we continue to believe that the CIPI is the most appropriate input price index for capital costs to measure capital price changes in a given year. We also explain the basis for the FY 2009 CIPI projection in that same section of this Addendum. In addition, as also noted below, the proposed capital rates would be further adjusted to account for documentation and coding improvements under the MS–DRGs discussed in section II.D. of the preamble of this proposed rule. Below we describe the policy adjustments that we are proposing to apply in the update framework for FY 2009. The case-mix index is the measure of the average MS–DRG weight for cases paid under the IPPS. Because the MS–DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 The case-mix index can change for any of several reasons: • The average resource use of Medicare patients changes (‘‘real’’ case-mix change); • Changes in hospital coding of patient records result in higher weight MS–DRG assignments (‘‘coding effects’’); and • The annual MS–DRG reclassification and recalibration changes may not be budget neutral (‘‘reclassification effect’’). We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted MS-DRGs but do not reflect higher resource requirements. The capital update framework includes the same case-mix index adjustment used in the former operating IPPS update framework (as discussed in the May 18, 2004 IPPS proposed rule for FY 2005 (69 FR 28816)). (We no longer use an update framework to make a recommendation for updating the operating IPPS standardized amounts as discussed in section II. of Appendix B in the FY 2006 IPPS final rule (70 FR 47707).) Absent the projected increase in case-mix resulting from documentation and coding improvements under the recently adopted MS-DRGs, for FY 2009, we are projecting a 1.0 percent total increase in the case-mix index. We estimate that the real case-mix increase will also equal 1.0 percent for FY 2009. The net adjustment for change in casemix is the difference between the projected real increase in case-mix and the projected total increase in case-mix. Therefore, the net adjustment for case-mix change in FY 2009 is 0.0 percentage points. The capital update framework also contains an adjustment for the effects of DRG reclassification and recalibration. This adjustment is intended to remove the effect on total payments of prior year’s changes to the DRG classifications and relative weights, in order to retain budget neutrality for all case-mix index-related changes other than those due to patient severity. Due to the lag time in the availability of data, there is a 2year lag in data used to determine the adjustment for the effects of DRG reclassification and recalibration. For example, we are adjusting for the effects of the FY 2007 DRG reclassification and recalibration as part of our proposed update for FY 2009. We estimate that FY 2007 DRG reclassification and recalibration resulted in a 0.5 percent change in the case-mix when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the DRGs. Therefore, we are proposing to make a ¥0.5 percent adjustment for DRG reclassification in the proposed update for FY 2009 to maintain budget neutrality. The capital update framework also contains an adjustment for forecast error. The input price index forecast is based on historical trends and relationships ascertainable at the time the update factor is established for the upcoming year. In any given year, there may be unanticipated price fluctuations that may result in differences between the actual increase in prices and the forecast used in calculating the update PO 00000 Frm 00190 Fmt 4701 Sfmt 4702 factors. In setting a prospective payment rate under the framework, we make an adjustment for forecast error only if our estimate of the change in the capital input price index for any year is off by 0.25 percentage points or more. There is a 2-year lag between the forecast and the availability of data to develop a measurement of the forecast error. A forecast error of 0.10 percentage point was calculated for the FY 2007 update. That is, current historical data indicate that the forecasted FY 2007 CIPI (1.1 percent) used in calculating the FY 2007 update factor slightly understated the actual realized price increases (1.2 percent) by 0.10 percentage point. This slight underprediction was mostly due to the incorporation of newly available source data for fixed asset prices and moveable asset prices into the market basket. However, because this estimation of the change in the CIPI is less than 0.25 percentage points, it is not reflected in the update recommended under this framework. Therefore, we are proposing to make a 0.0 percent adjustment for forecast error in the update for FY 2009. Under the capital IPPS update framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data that were used in the past under the framework for operating IPPS. The intensity factor for the operating update framework reflects how hospital services are utilized to produce the final product, that is, the discharge. This component accounts for changes in the use of quality-enhancing services, for changes within DRG severity, and for expected modification of practice patterns to remove noncost-effective services. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services) and changes in real case-mix. The use of total charges in the calculation of the intensity factor makes it a total intensity factor; that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and the combination of quality-enhancing new technologies and complexity within the DRG system, we assume that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one-half of the estimated annual increase in intensity, to allow for increases within DRG severity and the adoption of quality-enhancing technology. We have developed a Medicare-specific intensity measure based on a 5-year average. Past studies of case-mix change by the RAND Corporation (Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988 by G. M. Carter, J. P. Newhouse, and D. A. Relles, R–4098– HCFA/ProPAC (1991)) suggest that real casemix change was not dependent on total change, but was usually a fairly steady increase of 1.0 to 1.5 percent per year. E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules However, we used 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment. We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix. As we noted above, in accordance with § 412.308(c)(1)(ii), we began updating the capital standard Federal rate in FY 1996 using an update framework that takes into account, among other things, allowable changes in the intensity of hospital services. For FYs 1996 through 2001, we found that case-mix constant intensity was declining, and we established a 0.0 percent adjustment for intensity in each of those years. For FYs 2002 and 2003, we found that case-mix constant intensity was increasing, and we established a 0.3 percent adjustment and 1.0 percent adjustment for intensity, respectively. For FYs 2004 and 2005, we found that the charge data appeared to be skewed (as discussed in greater detail below), and we established a 0.0 percent adjustment in each of those years. Furthermore, we stated that we would continue to apply a 0.0 percent adjustment for intensity until any increase in charges can be tied to intensity rather than attempts to maximize outlier payments. As noted above, our intensity measure is based on a 5-year average, and therefore, the intensity adjustment for FY 2009 is based on data from the 5-year period beginning with FY 2003 and extending through FY 2007. There continues to be a substantial increase in hospital charges for three of those 5 years without a corresponding increase in the hospital case-mix index. Most dramatically, for FY 2003, the change in hospitals’ charges is over 16 percent, which is reflective of the large increases in charges that we found in the 4 years prior to FY 2003 and before our revisions to the outlier policy in 2003 (discussed below). For FY 2004 and FY 2005, the change in hospitals’ charges is somewhat lower in comparison to FY 2003, but is still significantly large. For FY 2006 and FY 2007, the change in hospitals’ charges appears to be slightly moderating. However, the change in hospitals’ charges for FYs 2003 and 2004 and to a somewhat lesser extent FY 2005 remains similar to the considerable increase in hospitals’ charges that we found when examining hospitals’ charge data in determining the intensity factor in the update recommendations for the past few years, as discussed in the FY 2004 IPPS final rule (68 FR 45482), the FY 2005 IPPS final rule (69 FR 49285), the FY 2006 IPPS final rule (70 FR 47500), the FY 2007 IPPS final rule (72 FR 47500), and the FY 2008 IPPS final rule with comment period (72 FR 47426). If hospitals were treating new or different types of cases, which would result in an appropriate increase in charges per discharge, then we would expect hospitals’ case-mix to increase proportionally. As we discussed most recently in the FY 2008 IPPS final rule with comment period (72 FR 47426), because our intensity calculation relies heavily upon charge data and we believe that these charge data may be inappropriately skewed, we established a 0.0 percent adjustment for intensity for FY 2008 just as we did for FYs 2004 through 2007. On June 9, 2003, we published in the Federal Register revisions to our outlier policy for determining the additional payment for extraordinarily high-cost cases (68 FR 34494 through 34515). These revised policies were effective on August 8, 2003, and October 1, 2003. While it does appear that a response to these policy changes is beginning to occur, that is, the increase in charges for FYs 2004 and 2005 are somewhat less than the previous 4 years, they still show a significant annual increase in charges without a corresponding increase in hospital case-mix. Specifically, the increases in charges in FY 2004 and FY 2005 23717 (approximately 12 percent and 8 percent, respectively), for example, which, while less than the increase in the previous 3 years, are still much higher than increases in years prior to FY 2001. In addition, these increases in charges for FYs 2003, FY 2004, and FY 2005 significantly exceed the respective casemix increases for the same period. Based on the significant increases in charges for FYs 2003 through 2005 that remain in the 5-year average used for the intensity adjustment, we believe residual effects of hospitals’ charge practices prior to the implementation of the outlier policy revisions established in the June 9, 2003 final rule continue to appear in the data, because it may have taken hospitals some time to adopt changes in their behavior in response to the new outlier policy. Thus, we believe that the FY 2003, FY 2004, FY 2005 charge data may still be skewed. Although it appears that the change in hospitals’ charges is more reasonable because the intensity adjustment is based on a 5-year average, and although the new outlier policy was generally effective in FY 2004, we believe the effects of hospitals attempting to maximize outlier payments, while lessening costs, continue to skew the charge data. Therefore, we are proposing to make a 0.0 percent adjustment for intensity for FY 2009. In the past (FYs 1996 through 2001) when we found intensity to be declining, we believed a zero (rather than negative) intensity adjustment was appropriate. Similarly, we believe that it is appropriate to apply a zero intensity adjustment for FY 2009 until any increase in charges during the 5-year period upon which the intensity adjustment is based can be tied to intensity rather than to attempts to maximize outlier payments. Above, we described the basis of the components used to develop the proposed 0.7 percent capital update factor for all hospitals under the capital update framework for FY 2009 as shown in the table below. CMS PROPOSED FY 2009 UPDATE FACTOR TO THE CAPITAL FEDERAL RATE Capital Input Price Index ............................................................................................................................................................................. Intensity ........................................................................................................................................................................................................ Case-Mix Adjustment Factors: Real Across DRG Change ................................................................................................................................................................... Projected Case-Mix Change ................................................................................................................................................................ ¥1.0 1.0 Subtotal ......................................................................................................................................................................................... Effect of FY 2007 Reclassification and Recalibration ................................................................................................................................. Forecast Error Correction ............................................................................................................................................................................ 1.2 ¥0.5 0.0 Total Update for Hospitals .................................................................................................................................................................... 0.7 jlentini on PROD1PC65 with PROPOSALS2 b. Comparison of CMS and MedPAC Update Recommendation (MedPAC’s Report to the Congress: Medicare Payment Policy, March 2008, Section 2A.) In its March 2008 Report to Congress, MedPAC did not make a specific update recommendation for capital IPPS payments for FY 2009. However, in that same report, in assessing the adequacy of current payments and costs, MedPAC recommended an update to the hospital inpatient and outpatient PPS rates equal to the increase in the hospital market basket in FY 2009, concurrent with a quality incentive program. 2. Proposed Outlier Payment Adjustment Factor VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Section 412.312(c) establishes a unified outlier payment methodology for inpatient operating and inpatient capital-related costs. A single set of thresholds is used to identify outlier cases for both inpatient operating and inpatient capital-related payments. Section 412.308(c)(2) provides that the standard Federal rate for inpatient capital-related costs PO 00000 Frm 00191 Fmt 4701 Sfmt 4702 1.2 0.0 be reduced by an adjustment factor equal to the estimated proportion of capital-related outlier payments to total inpatient capitalrelated PPS payments. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments. In the FY 2008 IPPS final rule with comment (72 FR 66887), we estimated that outlier payments for capital would equal 4.77 percent of inpatient capital-related payments based on the capital Federal rate in FY 2008. Based on the proposed thresholds as set forth E:\FR\FM\30APP2.SGM 30APP2 23718 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 in section II.A. of this Addendum, we estimate that proposed outlier payments for capital-related costs would equal 5.73 percent for inpatient capital-related payments based on the proposed capital Federal rate in FY 2009. Therefore, we are proposing to apply an outlier adjustment factor of 0.9427 to the capital Federal rate. Thus, we estimate that the percentage of capital outlier payments to total capital standard payments for FY 2009 will be higher than the percentages for FY 2008. This increase is primarily due to the proposed decrease to the fixed-loss amount, which is discussed section II.A. of this Addendum. The outlier reduction factors are not built permanently into the capital rates; that is, they are not applied cumulatively in determining the capital Federal rate. The proposed FY 2009 outlier adjustment of 0.9427 is a ¥1.01percent change from the FY 2008 outlier adjustment of 0.9523. Therefore, the net change in the proposed outlier adjustment to the capital Federal rate for FY 2009 is 0.9899 (0.9427/0.9523). Thus, the proposed outlier adjustment decreases the FY 2009 capital Federal rate by 1.01 percent compared with the FY 2008 outlier adjustment. 3. Proposed Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the GAF Section 412.308(c)(4)(ii) requires that the capital Federal rate be adjusted so that aggregate payments for the fiscal year based on the capital Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the GAF are projected to equal aggregate payments that would have been made on the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 basis of the capital Federal rate without such changes. Because we implemented a separate GAF for Puerto Rico, we apply separate budget neutrality adjustments for the national GAF and the Puerto Rico GAF. We apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. Separate adjustments were unnecessary for FY 1998 and earlier because the GAF for Puerto Rico was implemented in FY 1998. In the past, we used the actuarial capital cost model (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of the capital Federal rate with and without changes in the DRG classifications and weights and in the GAF to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the GAF. During the transition period, the capital cost model was also used to estimate the regular exception payment adjustment factor. As we explain in section III.A. of this Addendum, beginning in FY 2002, an adjustment for regular exception payments is no longer necessary. Therefore, we will no longer use the capital cost model. Instead, we are using historical data based on hospitals’ actual cost experiences to determine the exceptions payment adjustment factor for special exceptions payments. To determine the proposed factors for FY 2009, we compared (separately for the national capital rate and the Puerto Rico capital rate) estimated aggregate capital Federal rate payments based on the FY 2008 DRG relative weights and the FY 2008 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2009 PO 00000 Frm 00192 Fmt 4701 Sfmt 4702 relative weights and the proposed FY 2009 GAFs. We established the final FY 2008 budget neutrality factors of 0.9902 for the national capital rate and 0.9955 for the Puerto Rico capital rate. In making the comparison, we set the exceptions reduction factor to 1.00. To achieve budget neutrality for the changes in the national GAFs, based on calculations using updated data, we are proposing to apply an incremental budget neutrality adjustment of 1.0013 for FY 2009 to the previous cumulative FY 2008 adjustments of 0.9902, yielding a proposed adjustment of 0.9915, through FY 2009. For the Puerto Rico GAFs, we are proposing to apply a proposed incremental budget neutrality adjustment of 1.0009 for FY 2009 to the previous cumulative FY 2008 adjustment of 0.9955, yielding a proposed cumulative adjustment of 0.9965 (calculated with unrounded numbers) through FY 2009. We then compared estimated aggregate capital Federal rate payments based on the FY 2008 DRG relative weights and the proposed FY 2009 GAFs to estimated aggregate capital Federal rate payments based on the cumulative effects of the proposed FY 2009 DRG relative weights and the proposed FY 2009 GAFs. The proposed incremental adjustment for proposed DRG classifications and proposed changes in relative weights is 0.9994 both nationally and for Puerto Rico. The proposed cumulative adjustments for DRG classifications and changes in relative weights and for proposed changes in the GAFs through FY 2009 are 0.9909 nationally and 0.9959 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year: BILLING CODE 4120–01–P E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 BILLING CODE 4120–01–C The methodology used to determine the recalibration and geographic (DRG/GAF) budget neutrality adjustment factor is similar to the methodology used in establishing budget neutrality adjustments under the PPS for operating costs. One difference is that, under the operating PPS, the budget neutrality adjustments for the effect of geographic reclassifications are determined VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 separately from the effects of other changes in the hospital wage index and the DRG relative weights. Under the capital PPS, there is a single DRG/GAF budget neutrality adjustment factor (the national capital rate and the Puerto Rico capital rate are determined separately) for changes in the GAF (including geographic reclassification) and the DRG relative weights. In addition, there is no adjustment for the effects that PO 00000 Frm 00193 Fmt 4701 Sfmt 4702 23719 geographic reclassification has on the other payment parameters, such as the payments for serving low-income patients or indirect medical education payments. In the FY 2008 IPPS correction notice (72 FR 57636), we calculated a GAF/DRG budget neutrality factor of 0.9996 for FY 2008. For FY 2009, we are proposing to establish a GAF/DRG budget neutrality factor of 1.0007. The GAF/DRG budget neutrality factors are E:\FR\FM\30APP2.SGM 30APP2 ep30ap08.021</GPH> Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 23720 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules built permanently into the capital rates; that is, they are applied cumulatively in determining the capital Federal rate. This follows the requirement that estimated aggregate payments each year be no more or less than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAFs. The incremental change in the proposed adjustment from FY 2008 to FY 2009 is 1.0007. The cumulative change in the proposed capital Federal rate due to this proposed adjustment is 0.9909 (the product of the incremental factors for FYs 1994 though 2008 and the proposed incremental factor of 1.0007 for FY 2009). (We note that averages of the incremental factors that were in effect during FYs 2004 and 2005, respectively, were used in the calculation of the proposed cumulative adjustment of 0.9909 for FY 2009.) The proposed factor accounts for DRG reclassifications and recalibration and for changes in the GAFs. It also incorporates the effects on the proposed GAFs of FY 2009 geographic reclassification decisions made by the MGCRB compared to FY 2008 decisions. However, it does not account for changes in payments due to changes in the DSH and IME adjustment factors. 4. Exceptions Payment Adjustment Factor Section 412.308(c)(3) of our regulations requires that the capital standard Federal rate be reduced by an adjustment factor equal to the estimated proportion of additional payments for both regular exceptions and special exceptions under § 412.348 relative to total capital PPS payments. In estimating the proportion of regular exception payments to total capital PPS payments during the transition period, we used the actuarial capital cost model originally developed for determining budget neutrality (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to determine the exceptions payment adjustment factor, which was applied to both the Federal and hospitalspecific capital rates. An adjustment for regular exception payments is no longer necessary in determining the FY 2009 capital Federal rate because, in accordance with § 412.348(b), regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991 and before October 1, 2001. Accordingly, as we explained in the FY 2002 IPPS final rule (66 FR 39949), in FY 2002 and subsequent fiscal years, no payments are made under the regular exceptions provision. However, in accordance with § 412.308(c), we still need to compute a budget neutrality adjustment for special exception payments under § 412.348(g). We describe our methodology for determining the exceptions adjustment used in calculating the FY 2008 capital Federal rate below. Under the special exceptions provision specified at § 412.348(g)(1), eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a disproportionate share percentage of at least 20.2 percent or qualify for DSH payments under § 412.106(c)(2), and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent. An eligible hospital may receive VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 special exceptions payments if it meets the following criteria: (1) A project need requirement as described at § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test as described at § 412.348(g)(4); (2) an age of assets test as described at § 412.348(g)(3); and (3) a project size requirement as described at § 412.348(g)(5). Based on information compiled from our fiscal intermediaries, six hospitals have qualified for special exceptions payments under § 412.348(g). Because we have cost reports ending in FY 2005 for all of these hospitals, we calculated the adjustment based on actual cost experience. Using data from cost reports ending in FY 2005 from the December 2007 update of the HCRIS data, we divided the capital special exceptions payment amounts for the six hospitals that qualified for special exceptions by the total capital PPS payment amounts (including special exception payments) for all hospitals. Based on the data from cost reports ending in FY 2005, this ratio is rounded to 0.0002. We also computed the ratios for FY 2004 and FY 2003, which both round to 0.0003. Since the ratios are trending downward, we are proposing an adjustment of 0.0002. Because special exceptions are budget neutral, we are proposing to offset the proposed capital Federal rate by 0.02 percent for special exceptions payments for FY 2009. Therefore, the proposed exceptions adjustment factor is equal to 0.9998 (1¥0.0002) to account for special exceptions payments in FY 2009. In the FY 2008 IPPS final rule with comment period (72 FR 47430), we estimated that total (special) exceptions payments for FY 2008 would equal 0.03 percent of aggregate payments based on the capital Federal rate. Therefore, we applied an exceptions adjustment factor of 0.9997 (1 ¥ 0.0003) to determine the FY 2008 capital Federal rate. As we stated above, we estimate that exceptions payments in FY 2009 would equal 0.02 percent of aggregate payments based on the proposed FY 2009 capital Federal rate. Therefore, we are proposing to apply an exceptions payment adjustment factor of 0.9998 to the proposed capital Federal rate for FY 2009. The proposed exceptions adjustment factor for FY 2009 is slightly lower than the factor used in determining the FY 2008 capital Federal rate in the FY 2008 IPPS final rule. The exceptions reduction factors are not built permanently into the capital rates; that is, the factors are not applied cumulatively in determining the capital Federal rate. Therefore, the net change in the proposed exceptions adjustment factor used in determining the proposed FY 2009 capital Federal rate is 1.0001 (0.9998/0.9997). 5. Proposed Capital Standard Federal Rate for FY 2009 In the FY 2008 IPPS final rule with comment period (72 FR 66888), we established a capital Federal rate of $426.14 for all hospitals for FY 2008. We are proposing to establish an update of 0.7 percent in determining the proposed FY 2009 capital Federal rate for all hospitals. However, under the statutory authority at section 1886(d)(3)(A)(vi) of the Act, and as specified in section 7 of Pub. L. 110–90, we PO 00000 Frm 00194 Fmt 4701 Sfmt 4702 are proposing an additional 0.9 percent reduction to the proposed standardized amounts for both capital and operating Federal payment rates in FY 2009. The proposed 0.9 percent reduction is based on our Actuary’s analysis of the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix in light of the adoption of the MS–DRGs. Although the proposed 0.9 percent reduction is outside the established process for developing the proposed capital Federal payment rate, it nevertheless is a factor in the final prospective payment rate to hospitals for capital-related costs. For that reason, the proposed national capital Federal payment rate proposed in this proposed rule was determined by applying the proposed 0.9 percent reduction. (As discussed below in section II.A.6. of this Addendum, we are not proposing to apply the proposed 0.9 percent reduction in developing the proposed FY 2009 Puerto Rico-specific capital rate.) As a result of the proposed 0.70 percent update and other proposed budget neutrality factors discussed above, we are proposing to establish a capital Federal rate of $421.29 for FY 2009. The proposed capital Federal rate for FY 2009 was calculated as follows: • The proposed FY 2009 update factor is 1.0070, that is, the update is 0.70 percent. • The proposed FY 2009 budget neutrality adjustment factor that is applied to the capital standard Federal payment rate for changes in the DRG relative weights and in the GAFs is 1.0007. • The proposed FY 2009 outlier adjustment factor is 0.9427. • The proposed FY 2009 (special) exceptions payment adjustment factor is 0.9998. • The proposed FY 2009 reduction for improvements in documentation and coding under the MS–DRGs is 0.9 percent. Because the proposed capital Federal rate has already been adjusted for differences in case-mix, wages, cost-of-living, indirect medical education costs, and payments to hospitals serving a disproportionate share of low-income patients, we are not proposing to make additional adjustments in the proposed capital standard Federal rate for these factors, other than the budget neutrality factor for changes in the DRG relative weights and the GAFs. We are providing the following chart that shows how each of the proposed factors and adjustments for FY 2009 affected the computation of the proposed FY 2009 capital Federal rate in comparison to the FY 2008 capital Federal rate. The proposed FY 2009 update factor has the effect of increasing the proposed capital Federal rate by 0.70 percent compared to the FY 2008 capital Federal rate. The proposed GAF/DRG budget neutrality factor has the effect of increasing the proposed capital Federal rate by 0.07 percent. The proposed FY 2009 outlier adjustment factor has the effect of decreasing the proposed capital Federal rate by 1.01 percent compared to the FY 2008 capital Federal rate. The proposed FY 2009 exceptions payment adjustment factor has the effect of increasing the proposed capital Federal rate by 0.01 percent. The proposed adjustment for improvements in documentation and coding E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules under the MS–DRGs has the effect of decreasing the proposed FY 2009 capital Federal rate by 0.9 percent as compared to the FY 2008 capital Federal rate. The combined effect of all the proposed changes decreases the proposed capital Federal rate 23721 by 1.14 percent compared to the FY 2008 capital Federal rate. COMPARISON OF FACTORS AND ADJUSTMENTS: FY 2008 CAPITAL FEDERAL RATE AND PROPOSED FY 2009 CAPITAL FEDERAL RATE FY 2008 Update Factor 1 ................................................................................................ GAF/DRG Adjustment Factor 1 ........................................................................ Outlier Adjustment Factor 2 .............................................................................. Exceptions Adjustment Factor 2 ....................................................................... MS–DRG Coding and Documentation Improvements Adjustment Factor 3 .... Capital Federal Rate ........................................................................................ 1.0090 0.9996 0.9523 0.9997 0.9940 $426.14 Proposed FY 2009 4 1.0070 1.0007 0.9427 0.9998 0.9910 $421.29 Change 1.0070 1.0007 0.9899 1.0001 0.9910 0.9886 Percent change 5 0.70 0.07 ¥1.01 0.01 ¥0.90 ¥1.14 1 The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental change from FY 2008 to FY 2009 resulting from the application of the proposed 1.0007 GAF/DRG budget neutrality factor for FY 2009 is 1.0007. 2 The outlier reduction factor and the exceptions adjustment factor are not built permanently into the capital rates; that is, these factors are not applied cumulatively in determining the capital rates. Thus, for example, the net change resulting from the application of the proposed FY 2009 outlier adjustment factor is 0.9427/0.9523, or 0.9899. 3 Proposed adjustment to FY 2009 IPPS rates to account for documentation and coding improvements expected to result from the adoption of the MS–DRGs, as discussed above in section III.D. of the Addendum to this proposed rule. 4 Proposed factors for FY 2009, as discussed above in section III. of this Addendum. 5 Percent change of individual factors may not sum due to rounding. jlentini on PROD1PC65 with PROPOSALS2 6. Proposed Special Capital Rate for Puerto Rico Hospitals Section 412.374 provides for the use of a blended payment system for payments to hospitals located in Puerto Rico under the PPS for acute care hospital inpatient capitalrelated costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to hospitals located in Puerto Rico using the same methodology used to compute the national Federal rate for capital-related costs. Under the broad authority of section 1886(g) of the Act, as discussed in section V. of the preamble of this proposed rule, beginning with discharges occurring on or after October 1, 2004, capital payments to hospitals located in Puerto Rico are based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate. The Puerto Rico capital rate is derived from the costs of Puerto Rico hospitals only, while the capital Federal rate is derived from the costs of all acute care hospitals participating in the IPPS (including Puerto Rico). To adjust hospitals’ capital payments for geographic variations in capital costs, we apply a GAF to both portions of the blended capital rate. The GAF is calculated using the operating IPPS wage index, and varies depending on the labor market area or rural area in which the hospital is located. We use the Puerto Rico wage index to determine the GAF for the Puerto Rico part of the capitalblended rate and the national wage index to determine the GAF for the national part of the blended capital rate. Because we implemented a separate GAF for Puerto Rico in FY 1998, we also apply separate budget neutrality adjustments for the national GAF and for the Puerto Rico GAF. However, we apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. As we stated above in section III.A.4. of this Addendum, for Puerto Rico, the proposed GAF budget neutrality factor is 1.0009, while the DRG adjustment is 0.9994, for a VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 combined proposed cumulative adjustment of 1.0004. In computing the payment for a particular Puerto Rico hospital, the Puerto Rico portion of the capital rate (25 percent) is multiplied by the Puerto Rico-specific GAF for the labor market area in which the hospital is located, and the national portion of the capital rate (75 percent) is multiplied by the national GAF for the labor market area in which the hospital is located (which is computed from national data for all hospitals in the United States and Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to the Puerto Rico capital rate as a result of Pub. L. 105–33. In FY 2003, a small part of that reduction was restored. For FY 2008, before application of the GAF, the special capital rate for hospitals located in Puerto Rico was $201.67 for discharges occurring on or after October 1, 2007, through September 30, 2008 (72 FR 66888). However, as discussed in greater detail in section II.D. of the preamble of this proposed rule, we are revising this rate in a forthcoming correction notice that will be retroactive to October 1, 2007, to remove the application of the 0.6 percent documentation and coding adjustment for FY 2008, consistent with the correction to the Puerto Rico specific standardized amount for FY 2008. The statute gives broad authority to the Secretary under section 1886(g) of the Act, with respect to the development of and adjustments to a capital PPS. Although we would not be outside the authority of section 1886(g) of the Act in applying the documentation and coding adjustment to the Puerto Rico-specific portion of the capital payment rate, we have historically made changes to the capital PPS consistent with those changes made to the IPPS. Thus, we are removing the documentation and coding adjustment from the FY 2008 Puerto Ricospecific portion of the blended capital payment rate, consistent with its removal from the Puerto Rico-specific standardized amount under the IPPS for operating costs. Furthermore, we are not proposing to apply PO 00000 Frm 00195 Fmt 4701 Sfmt 4702 the 0.9 percent documentation and coding adjustment to the proposed FY 2009 Puerto Rico-specific portion of the blended capital payment. However, as also discussed in section II.D. of the preamble of this proposed rule, we may propose to apply such an adjustment to the Puerto Rico operating and capital rates in the future. With the changes we are proposing to make to the other factors used to determine the capital rate, the proposed FY 2009 special capital rate for hospitals in Puerto Rico is $197.19. B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2009 Because the 10-year capital PPS transition period ended in FY 2001, all hospitals (except ‘‘new’’ hospitals under § 412.324(b) and under § 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate in FY 2007. The applicable capital Federal rate was determined by making the following adjustments: • For outliers, by dividing the capital standard Federal rate by the outlier reduction factor for that fiscal year; and • For the payment adjustments applicable to the hospital, by multiplying the hospital’s GAF, disproportionate share adjustment factor, and IME adjustment factor, when appropriate. For purposes of calculating payments for each discharge during FY 2009, the capital standard Federal rate would be adjusted as follows: (Standard Federal Rate) × (DRG weight) × (GAF) × (COLA for hospitals located in Alaska and Hawaii) × (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). The result is the adjusted capital Federal rate. (As discussed above and in section V. of the preamble of this proposed rule, we eliminated the large urban add-on adjustment in existing regulations at § 412.316, beginning in FY 2008.) Hospitals also may receive outlier payments for those cases that qualify under the thresholds established for each fiscal year. Section 412.312(c) provides for a single E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23722 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments. The proposed outlier thresholds for FY 2009 are in section II.A. of this Addendum. For FY 2009, a case qualifies as a cost outlier if the cost for the case plus the IME and DSH payments is greater than the prospective payment rate for the DRG plus the proposed fixed-loss amount of $21,025. An eligible hospital may also qualify for a special exceptions payment under § 412.348(g) up through the 10th year beyond the end of the capital transition period if it meets the following criteria: (1) A project need requirement described at § 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test as described at § 412.348(g)(4); and (2) a project size requirement as described at § 412.348(g)(5). Eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a DSH patient percentage of at least 20.2 percent or qualify for DSH payments under § 412.106(c)(2), and hospitals that have a combined Medicare and Medicaid inpatient utilization of at least 70 percent. Under § 412.348(g)(8), the amount of a special exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital PPS to the cumulative minimum payment level. This amount is offset by: (1) Any amount by which a hospital’s cumulative capital payments exceed its cumulative minimum payment levels applicable under the regular exceptions process for cost reporting periods beginning during which the hospital has been subject to the capital PPS; and (2) any amount by which a hospital’s current year operating and capital payments (excluding 75 percent of operating DSH payments) exceed its operating and capital costs. Under § 412.348(g)(6), the minimum payment level is 70 percent for all eligible hospitals. During the transition period, new hospitals (as defined under § 412.300) were exempt from the capital IPPS for their first 2 years of operation and were paid 85 percent of their reasonable costs during that period. Effective with the third year of operation through the remainder of the transition period, under § 412.324(b), we paid the hospitals under the appropriate transition methodology (if the hold-harmless methodology were applicable, the holdharmless payment for assets in use during the base period would extend for 8 years, even if the hold-harmless payments extend beyond the normal transition period). Under § 412.304(c)(2), for cost reporting periods beginning on or after October 1, 2002, we pay a new hospital 85 percent of its reasonable costs during the first 2 years of operation unless it elects to receive payment based on 100 percent of the capital Federal rate. Effective with the third year of operation, we pay the hospital based on 100 percent of the capital Federal rate (that is, the same methodology used to pay all other hospitals subject to the capital PPS). C. Capital Input Price Index 1. Background Like the operating input price index, the capital input price index (CIPI) is a fixed- VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 weight price index that measures the price changes associated with capital costs during a given year. The CIPI differs from the operating input price index in one important aspect—the CIPI reflects the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted-average of past capital purchase prices up to and including the current year. We periodically update the base year for the operating and capital input prices to reflect the changing composition of inputs for operating and capital expenses. The CIPI was last rebased to FY 2002 in the FY 2006 IPPS final rule (70 FR 47387). 2. Forecast of the CIPI for FY 2009 Based on the latest forecast by Global Insight, Inc. (first quarter of 2008), we are forecasting the CIPI to increase 1.2 percent in FY 2009. This reflects a projected 1.9 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment), and a 2.9 percent increase in other capital expense prices in FY 2009, partially offset by 2.8 percent decline in vintage-weighted interest expenses in FY 2009. The weighted average of these three factors produces the 1.2 percent increase for the CIPI as a whole in FY 2009. IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages Historically, hospitals and hospital units excluded from the prospective payment system received payment for inpatient hospital services they furnished on the basis of reasonable costs, subject to a rate-ofincrease ceiling. An annual per discharge limit (the target amount as defined in § 413.40(a)) was set for each hospital or hospital unit based on the hospital’s own cost experience in its base year. The target amount was multiplied by the Medicare discharges and applied as an aggregate upper limit (the ceiling as defined in § 413.40(a)) on total inpatient operating costs for a hospital’s cost reporting period. Prior to October 1, 1997, these payment provisions applied consistently to all categories of excluded providers (rehabilitation hospitals and units (now referred to as IRFs), psychiatric hospitals and units (now referred to as IPFs), LTCHs, children’s hospitals, and cancer hospitals). Payment for services furnished in children’s hospitals and cancer hospitals that are excluded from the IPPS continues to be subject to the rate-of-increase ceiling based on the hospital’s own historical cost experience. (We note that, in accordance with § 403.752(a), RNHCIs are also subject to the rate-of-increase limits established under § 413.40 of the regulations.) We are proposing that the FY 2009 rate-ofincrease percentage for cancer and children’s hospitals and RNHCIs is the percentage increase in the FY 2009 IPPS operating PO 00000 Frm 00196 Fmt 4701 Sfmt 4702 market basket, estimated to be 3.0 percent. Consistent with our historical approach, if more recent data are available for the final rule, we will use those data to calculate the IPPS operating market basket. For this proposed rule, we are proposing to calculate the IPPS operating market basket for FY 2009 using the most recent data available. For cancer and children’s hospitals and RNHCIs, the proposed FY 2009 rate-of-increase percentage that is applied to FY 2008 target amounts in order to calculate the proposed FY 2009 target amounts is based on Global Insight, Inc.’s 2008 forecast of the IPPS operating market basket increase, in accordance with the applicable regulations at 42 CFR 413.40. IRFs, IPFs, and LTCHs were previously paid under the reasonable cost methodology. However, the statute was amended to provide for the implementation of prospective payment systems for IRFs, IPFs, and LTCHs. In general, the prospective payment systems for IRFs, IPFs, and LTCHs provide transitioning periods of varying lengths of time during which a portion of the prospective payment is based on cost-based reimbursement rules under 42 CFR Part 413 (certain providers do not receive a transitioning period or may elect to bypass the transition as applicable under 42 CFR part 412, subparts N, O, and P.) We note that the various transitioning periods provided for under the IRF PPS, the IPF PPS, and the LTCH PPS have ended. For cost reporting periods beginning on or after October 1, 2002, all IRFs are paid 100 percent of the adjusted Federal rate under the IRF PPS. Therefore, for cost reporting periods beginning on or after October 1, 2002, no portion of an IRF PPS payment is subject to 42 CFR part 413. Similarly, for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal prospective payment rate under the LTCH PPS. Therefore, for cost reporting periods beginning on or after October 1, 2006, no portion of the LTCH PPS payment is subject to 42 CFR part 413. Likewise, for cost reporting periods beginning on or after January 1, 2008, all IPFs are paid 100 percent of the Federal per diem amount under the IPF PPS. Therefore, for cost reporting periods beginning on or after January 1, 2008, no portion of an IPF PPS payment is subject to 42 CFR part 413. V. Tables This section contains the tables referred to throughout the preamble to this proposed rule and in this Addendum. Tables 1A, 1B, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4D, 4D–1, 4D– 2, 4E, 4F, 4G, 4H, 4J, 5, 6A, 6B, 6C, 6D, 6E, 6F, 7A, 7B, 8A, 8B, 8C, 9A, 9C, 10, and 11 are presented below. The following tables discussed in section II. of the preamble of this proposed rule are available only through the Internet on the CMS Web site at: https:// www.cms.hhs.gov/AcuteInpatientPPS/: Table 6G.—Additions to the CC Exclusions List; Table 6H.—Deletions from the CC Exclusions List; Table 6I.—Complete List of Complication and Comorbidity (CC) Exclusions; Table 6J.—Major Complication and Comorbidity (MCC) List; and Table 6K.— Complication and Comorbidity (CC). E:\FR\FM\30APP2.SGM 30APP2 23723 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules The tables presented in this section of the Addendum are as follows: Table 1A.—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1) Table 1B.—National Adjusted Operating Standardized Amounts, Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal To 1) Table 1C.—Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D.—Capital Standard Federal Payment Rate Table 2.—Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2007; Hospital Wage Indexes for Federal Fiscal Year 2009; Hospital Average Hourly Wages for Federal Fiscal Years 2007 (2003 Wage Data), 2008 (2004 Wage Data), and 2009 (2005 Wage Data); and 3Year Average of Hospital Average Hourly Wages Table 3A.—FY 2009 and 3-Year Average Hourly Wage for Urban Areas by CBSA Table 3B.—FY 2009 and 3-Year Average Hourly Wage for Rural Areas by CBSA Table 4A.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA and by State—FY 2009 Table 4B.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA and by State—FY 2009 Table 4C.—Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA and by State—FY 2009 Table 4D–1.—Rural Floor Budget Neutrality Factors—FY 2009 Table 4D–2.—Urban Areas with Hospitals Receiving the Statewide Rural Floor or Imputed Floor Wage Index—FY 2009 Table 4E.—Urban CBSAs and Constituent Counties—FY 2009 Table 4F.—Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA—FY 2009 Table 4J.—Out-Migration Adjustment—FY 2009 Table 5.—List of Medicare Severity Diagnosis-Related Groups (MS–DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay Table 6A.—New Diagnosis Codes Table 6B.—New Procedure Codes Table 6C.—Invalid Diagnosis Codes Table 6D.—Invalid Procedure Codes Table 6E.—Revised Diagnosis Code Titles Table 6F.—Revised Procedure Code Titles Table 7A.—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2007 MedPAR Update—December 2007 GROUPER V25.0 MS–DRGs Table 7B.—Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2007 MedPAR Update—December 2007 GROUPER V26.0 MS–DRGs Table 8A.—Proposed Statewide Average Operating Cost-to-Charge Ratios— March 2008 Table 8B.—Proposed Statewide Average Capital Cost-to-Charge Ratios—March 2008 Table 8C.—Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs— March 2008 Table 9A.—Hospital Reclassifications and Redesignations—FY 2009 Table 9C.—Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act—FY 2009 Table 10.—Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Medicare Severity Diagnosis-Related Group (MS–DRG)— March 2008 Table 11.—Proposed FY 2009 MS–LTC– DRGs, Proposed Relative Weights, Proposed Geometric Average Length of Stay, and Proposed Short-Stay Outlier Threshold TABLE 1A.—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR [69.7 Percent Labor Share/30.3 Percent Nonlabor Share if Wage Index Greater Than 1] Full update (3.0 percent) Reduced update (1.0 percent) Labor-related Nonlabor-related Labor-related Nonlabor-related $3,553.98 $1,544.98 $3,484.97 $1,514.98 TABLE 1B.—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR [62 Percent Labor Share/38 Percent Nonlabor Share if Wage Index Less Than or Equal to 1] Full update (3.0 percent) Reduced update (1.0 percent) Labor-related Nonlabor-related Labor-related Nonlabor-related $3,161.36 $1,937.60 $3,099.97 $1,899.98 TABLE 1C.—ADJUSTED OPERATING STANDARDIZED AMOUNTS FOR PUERTO RICO, LABOR/NONLABOR Rates if wage index greater than 1 Labor National ............................................................................................................................ Puerto Rico ...................................................................................................................... TABLE 1D.—CAPITAL STANDARD FEDERAL PAYMENT RATE jlentini on PROD1PC65 with PROPOSALS2 VerDate Aug<31>2005 19:42 Apr 29, 2008 Rate $421.29 Jkt 214001 $1,544.98 920.46 TABLE 1D.—CAPITAL STANDARD FEDERAL PAYMENT RATE—Continued Rate National ....................................... $3,553.98 1,501.82 Nonlabor Puerto Rico ................................. PO 00000 Frm 00197 Fmt 4701 Sfmt 4702 197.19 E:\FR\FM\30APP2.SGM 30APP2 Rates if wage index less than or equal to 1 Labor $3,161.36 1,421.88 Nonlabor $1,937.60 1,000.40 23724 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 010001 010005 010006 010007 010008 010009 010010 010011 010012 010015 010016 010018 010019 010021 010022 010023 010024 010025 010027 010029 010032 010033 010034 010035 010036 010038 010039 010040 010043 010044 010045 010046 010047 010049 010050 010051 010052 010054 010055 010056 010058 010059 010061 010062 010064 010065 010066 010068 010069 010072 010073 010078 010079 010083 010084 010085 010086 010087 010089 010090 010091 010092 010095 010097 010099 010100 010101 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.5513 1.1192 1.4819 1.0611 1.0242 0.9973 1.0945 1.6762 1.1633 1.0453 1.5794 1.4886 1.2556 1.2285 0.9940 1.7665 1.5997 1.2929 0.7391 1.5947 0.8805 2.1342 1.0166 1.2478 1.1526 1.3336 1.6454 1.6515 1.0854 1.0626 1.1529 1.5241 0.8836 1.1411 1.0831 0.8989 0.8813 1.1310 1.5957 1.5856 1.0206 1.0080 0.9842 1.0319 1.7124 1.5119 0.8885 *** 0.9721 *** 0.9451 1.6130 1.2409 1.1817 *** 1.3040 1.0270 2.2105 1.2944 1.7257 0.9075 1.4953 0.8389 0.7528 0.9928 1.7251 1.1737 PO 00000 Frm 00198 Average hourly wage FY 2007 0.8397 0.8636 0.7883 0.7647 0.7821 0.8636 0.8786 0.8786 0.9524 0.7693 0.8786 0.8786 0.7883 0.7677 0.9760 0.8192 0.8192 0.8495 0.7662 0.8495 0.7972 0.8786 0.8192 0.8786 0.7647 0.8054 0.8987 0.8052 0.8786 0.7647 0.7869 0.8052 0.7774 0.7662 0.8786 0.8695 0.8192 0.8636 0.8322 0.8786 0.8786 0.8636 0.8740 0.7718 0.8786 0.8786 0.7647 * 0.7647 * 0.7647 0.8054 0.8987 0.8115 * 0.8636 0.7647 0.7809 0.8786 0.8030 0.7693 0.8695 0.8695 0.8192 0.7647 0.8115 0.8786 Fmt 4701 Sfmt 4702 22.1989 23.6022 23.4975 19.9329 17.9533 23.5626 27.0385 27.6658 24.4059 22.3383 24.6488 23.7048 22.8766 19.7367 25.8404 25.4272 22.0819 22.7635 16.4682 23.9007 19.3311 27.4181 17.7457 24.2425 21.5796 23.7039 26.9919 24.3207 21.9774 22.5009 20.4927 23.4219 26.4851 21.7888 22.9620 18.7701 25.9233 23.3624 22.5396 23.7398 19.5092 23.0012 24.1185 21.4805 24.8155 23.0477 19.8692 22.7156 23.1243 24.4989 18.3963 23.5279 22.7337 22.4279 26.3238 24.2609 22.2096 22.4318 25.0811 26.0494 23.1310 26.6796 16.5250 19.4511 20.8383 23.8919 24.2575 Average hourly wage FY 2008 23.2195 23.0203 23.7502 21.3492 22.0793 25.9011 22.8602 27.4668 25.5767 27.0806 26.8611 24.8974 23.3460 21.0624 27.4318 26.1739 25.0715 23.6186 17.0513 25.0468 18.5545 29.1471 19.1549 24.2746 24.2887 27.0752 28.6462 24.7657 23.9121 24.4276 23.1695 25.9105 19.7542 22.4248 24.4060 18.0305 36.3638 24.4810 22.4145 24.5754 17.0150 24.8199 25.2454 21.7112 27.6149 24.3346 25.4612 24.4145 23.6272 * 19.0046 24.3828 22.3034 24.0036 26.5079 23.6280 21.5584 24.8320 26.2628 26.3957 22.5272 26.9959 17.0024 19.2481 20.6736 25.1460 25.0974 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 24.7672 25.7755 25.0258 22.0185 23.2562 25.8405 24.8375 27.1978 26.4968 23.6811 28.9705 26.9498 25.0154 21.7592 28.7520 27.0693 26.6617 23.8602 18.2507 24.3605 20.8446 29.2005 21.2713 26.5285 23.7923 28.9624 29.8012 25.9851 25.3624 23.4009 23.5160 25.4444 21.7347 23.1186 25.3663 20.0755 23.4990 25.4189 25.3295 25.7272 31.1856 27.8607 25.5878 22.9481 26.6313 24.5833 25.6055 * 27.3424 * 20.7832 25.2879 23.1015 25.0403 27.5054 24.0460 26.8993 26.2401 25.9704 25.6095 23.6554 28.5598 17.8242 18.4215 22.3677 25.4338 26.2731 Average hourly wage** (3 years) 23.3821 24.1406 24.0951 21.1334 20.8430 25.1048 24.7458 27.4380 25.4682 24.1695 26.8024 25.1709 23.7418 20.8458 27.3475 26.2901 24.5911 23.4229 17.2827 24.4407 19.6445 28.6046 19.3572 25.0065 23.2285 26.4786 28.4927 25.0414 23.7097 23.4233 22.3334 24.8777 22.0981 22.4564 24.2272 18.9088 28.7904 24.4485 23.4244 24.7305 21.2663 25.3457 24.9798 22.0341 26.3101 24.0058 23.6384 23.5620 24.6217 24.4989 19.3949 24.4148 22.7293 23.8754 26.7172 23.9691 23.3292 24.3812 25.7574 26.0158 23.1156 27.4270 17.1161 18.9973 21.2837 24.8850 25.2372 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23725 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 010102 010103 010104 010108 010109 010110 010112 010113 010114 010118 010120 010125 010126 010128 010129 010130 010131 010137 010138 010139 010143 010144 010145 010146 010148 010149 010150 010152 010157 010158 010162 010163 010164 010165 010166 010167 010168 020001 020004 020006 020008 020012 020014 020017 020018 020019 020024 020026 020027 030001 030002 030006 030007 030009 030010 030011 030012 030013 030014 030016 030017 030018 030019 030022 030023 030024 030030 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.9506 1.8628 1.8548 1.0595 0.9572 0.7382 0.9794 1.6320 1.4032 1.2125 1.0320 1.0385 1.1498 0.9062 1.0676 1.0051 1.3760 1.2318 0.6210 1.5846 1.2041 1.7285 1.4494 1.1251 0.8893 1.2271 0.9968 1.2632 1.1630 1.2536 *** *** 1.2261 *** *** 1.6912 1.3124 1.7281 *** 1.2847 1.2046 1.3619 1.0617 2.0201 0.9475 0.9038 1.1768 1.5400 0.9585 1.5351 2.1087 1.7187 1.4597 *** 1.4417 1.5335 1.4301 1.5318 1.5815 1.2770 2.0581 1.3639 1.3016 1.8063 1.8138 2.1440 1.6952 PO 00000 Frm 00199 Average hourly wage FY 2007 0.8192 0.8786 0.8786 0.8192 0.8098 0.7862 0.7647 0.7809 0.8786 0.8192 0.7647 0.8123 0.8192 0.7693 0.7781 0.8786 0.8987 0.8786 0.7713 0.8786 0.8636 0.7809 0.8695 0.8054 0.7647 0.8192 0.8192 0.7809 0.7883 0.7883 * * 0.8786 * * 0.8786 0.9061 1.1884 * 1.1884 1.1884 1.1884 1.1884 1.1884 1.9292 * 1.1884 1.9292 1.9292 1.0271 1.0271 0.9442 1.1305 * 0.9442 0.9442 1.0198 0.9903 1.0271 1.0271 1.0271 1.0271 1.0271 1.0271 1.1652 1.0271 1.0271 Fmt 4701 Sfmt 4702 25.6158 27.8272 27.6471 24.6740 17.6733 26.0038 17.1833 22.3282 25.6152 21.4630 20.9019 21.5123 23.9327 23.6647 22.1574 23.7528 26.4297 27.5782 16.7602 26.8726 26.2762 22.5133 24.5092 22.6586 23.9246 24.4805 23.6080 22.4075 23.3828 23.5533 33.8777 * * * * * * 35.4232 31.8004 34.3752 36.1250 32.5975 29.4472 35.4119 * * 29.5195 * * 32.4791 30.2200 27.0599 31.1928 26.5408 28.5684 28.1423 27.3895 27.0111 29.6582 29.1980 30.6007 29.4566 29.5921 30.5710 34.2142 31.9247 32.0994 Average hourly wage FY 2008 26.9859 28.9636 28.3126 25.4325 21.0449 19.8738 20.4027 24.7170 25.7090 22.7191 22.1868 22.8911 24.4957 24.9881 21.8502 24.5644 27.2707 28.5843 14.5551 28.1473 24.0674 22.3916 25.8293 22.6879 23.5714 25.4354 24.4098 23.7803 24.2206 25.5905 * 34.0325 23.2447 28.8040 29.7256 * * 36.5298 * 37.0211 39.3432 33.9375 30.9722 35.8804 * * 38.6934 * * 33.4178 31.0818 27.7421 33.7213 * 30.6261 28.8203 29.1042 31.2815 29.8296 30.7896 34.4852 31.8056 30.1934 30.3746 35.8287 33.1797 34.4166 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 26.6935 30.4015 30.4938 26.8882 21.9296 22.1164 21.3150 25.0689 25.3646 25.3678 22.8170 23.6542 25.7234 25.9417 24.4806 25.2775 28.0468 30.4347 15.0814 29.3543 25.0859 23.8581 27.3277 23.7803 25.0949 26.8895 25.0060 26.0777 27.1156 26.2350 * * 25.6659 * * * * 38.1754 * 37.2838 40.6758 36.1891 30.6325 38.2137 * * 39.9916 * * 35.9045 32.9061 29.1218 35.5193 * 31.8606 30.2062 31.3041 31.9135 30.6276 31.1854 34.8458 31.7220 33.6528 35.0728 37.5481 35.6078 36.4747 Average hourly wage** (3 years) 26.4289 29.0796 28.7438 25.7625 20.0804 22.5113 19.6839 24.0138 25.5596 23.1085 21.9915 22.7013 24.7205 24.9328 22.8945 24.5383 27.2971 28.8905 15.4264 28.1531 25.0921 22.9469 25.8981 23.0525 24.1955 25.7355 24.3378 24.1152 24.7415 25.0899 33.8777 34.0325 24.4751 28.8040 29.7256 * * 36.7192 31.8004 36.2129 38.7262 34.2975 30.3727 36.5154 * * 35.5845 * * 33.8225 31.4265 28.0025 33.5056 26.5408 30.4135 29.0981 29.3702 30.1305 30.0779 30.4653 33.3763 31.0137 31.0565 31.9469 35.8798 33.6344 34.2670 23726 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 030033 030036 030037 030038 030040 030043 030055 030060 030061 030062 030064 030065 030067 030068 030069 030071 030073 030074 030077 030078 030080 030083 030084 030085 030087 030088 030089 030092 030093 030094 030099 030100 030101 030102 030103 030105 030106 030107 030108 030109 030110 030111 030112 030113 030114 030115 030117 030118 030119 030120 030121 040001 040002 040004 040007 040010 040011 040014 040015 040016 040017 040018 040019 040020 040021 040022 040026 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.3116 1.5415 1.9894 1.6433 *** 1.2301 1.4731 1.1614 1.6370 1.2360 2.0334 1.6347 1.0057 1.1245 1.4761 1.0045 1.1300 0.9181 0.8053 1.1355 *** 1.3493 1.0175 1.6306 1.7040 1.3727 1.5952 1.5055 1.3209 1.5460 0.9137 2.0982 1.4909 2.4535 1.7698 2.3493 1.5634 1.9107 2.0613 *** 1.6838 1.0463 2.0028 0.9099 1.4838 1.4714 1.2494 1.1423 1.2774 0.8689 1.0784 1.0747 1.1735 1.6814 1.7434 1.4746 1.0296 1.3517 1.1207 1.7125 1.1221 1.1123 1.0410 1.6290 1.5502 1.4648 1.5430 PO 00000 Frm 00200 Average hourly wage FY 2007 1.1305 1.0271 1.0271 1.0271 * 0.8857 1.0011 * 1.0271 0.8857 0.9442 1.0271 0.9155 0.8857 1.1254 1.4448 1.4448 1.4448 1.4448 1.4448 * 1.0271 1.4448 0.9442 1.0271 1.0271 1.0271 1.0271 1.0271 1.0271 0.8857 0.9442 1.1388 1.0271 1.0271 1.0271 1.0271 1.0271 1.0271 * 1.0271 0.9442 1.0271 1.4448 0.9442 1.0271 0.9817 1.0198 1.0271 1.0271 1.0271 0.9131 0.7641 0.9131 0.8754 0.9131 0.7641 0.8650 0.7641 0.8754 0.8952 0.7843 0.8909 0.8909 0.8754 0.9131 0.9146 Fmt 4701 Sfmt 4702 28.7508 30.9834 31.2877 29.9314 27.5322 26.5834 27.1473 24.8373 28.0696 26.6880 28.3853 29.5883 20.7591 23.1394 30.2224 * * * * * 27.1360 27.4983 * 26.8364 29.5962 27.8604 28.9068 31.7512 26.4430 31.5422 27.1402 31.5628 27.8302 31.6285 31.7322 31.2970 32.9840 35.6197 * 16.5906 31.4852 * * * * * * * * * * 22.9327 21.2020 27.1741 40.1291 24.2315 21.0967 26.4777 20.4279 25.8056 21.9147 24.0026 23.8706 22.6497 25.4046 29.5000 27.7931 Average hourly wage FY 2008 29.9383 33.0523 34.1079 31.7238 * 27.3856 27.1621 * 28.1337 28.9587 29.8226 31.0817 27.4497 23.8792 29.7802 * * * * * 28.6568 33.5302 * 28.1388 31.2331 29.9758 30.1591 30.6343 27.8821 33.4050 26.9227 34.7532 30.6764 33.6247 32.2833 32.7449 36.4667 35.5386 29.9395 * 29.7949 33.3711 36.6601 * * * * * * * * 22.9948 25.0000 28.1117 29.1941 26.5287 22.2431 28.9855 20.1061 26.5911 23.8768 25.6751 24.9113 23.9470 26.1853 27.9902 29.5299 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 32.0342 36.2020 35.1314 31.2906 * 28.3147 30.9311 * 33.0826 29.9331 31.6603 31.4568 27.0766 26.0276 30.7696 * * * * * 30.7660 35.8488 * 29.0750 31.1070 30.5716 31.3148 30.4361 33.0699 34.2007 24.9115 35.0944 33.2110 36.9492 33.9387 33.9846 40.1625 35.4524 34.8483 * 36.2124 28.5133 33.4776 * 28.8439 32.5857 * * * * * 24.4950 24.0479 29.2695 27.4839 28.2363 22.6320 34.8259 22.3145 26.4787 24.3768 26.2511 26.4915 26.1519 27.6779 30.0234 31.8579 Average hourly wage** (3 years) 30.2702 33.6063 33.3937 31.0104 27.5322 27.4531 28.4812 24.8373 29.7496 28.5898 30.0071 30.7651 25.0396 24.3896 30.2553 * * * * * 28.9576 32.0946 * 28.0469 30.6895 29.5054 30.1497 30.8516 29.2816 33.1194 26.3285 33.8057 30.6802 34.0941 32.6963 32.7833 36.8304 35.5298 32.9293 16.5906 32.4772 30.2230 34.6249 * 28.8439 32.5857 * * * * * 23.4592 23.3250 28.2056 32.0643 26.3909 22.0004 29.4945 20.9794 26.3029 23.3605 25.2931 25.0680 24.2422 26.3611 29.1589 29.7126 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23727 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 040027 040029 040036 040039 040041 040042 040047 040050 040051 040054 040055 040062 040067 040069 040071 040072 040074 040076 040078 040080 040081 040084 040085 040088 040091 040100 040114 040118 040119 040126 040132 040134 040137 040138 040141 040142 040143 040144 040145 040146 040147 040148 050002 050006 050007 050008 050009 050013 050014 050015 050016 050017 050018 050022 050024 050025 050026 050028 050030 050036 050038 050039 050040 050042 050043 050045 050046 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.5239 1.4258 1.6268 1.2296 1.1562 1.2893 1.0408 1.1948 0.9470 *** 1.5598 1.6247 1.1145 1.0608 1.5798 1.1274 1.2633 0.9952 1.6712 1.0467 0.8888 1.2389 1.0085 1.6650 1.1951 *** 1.8332 1.5334 1.3884 *** *** 2.3449 1.3582 1.5085 0.7864 1.5543 *** *** 1.7933 *** 1.7491 1.3585 1.4597 1.5912 1.4363 1.4460 1.6477 1.8267 1.2659 1.6268 1.3208 2.0225 1.2702 1.5850 1.1169 1.7936 1.5921 1.2946 1.2276 1.6000 1.6319 1.6727 1.3922 1.4804 1.6147 1.3307 1.1963 PO 00000 Frm 00201 Average hourly wage FY 2007 0.8477 0.8754 0.8754 0.8291 0.8650 0.9329 0.7758 0.7641 0.7641 * 0.7843 0.7843 0.7648 0.8909 0.8650 0.7641 0.8754 0.8650 0.8650 0.8291 0.7998 0.8754 0.8909 0.7789 0.8093 * 0.8754 0.8291 0.8650 * * 0.8754 0.8754 0.9131 0.9131 0.9146 * * 0.8291 * 0.8754 0.8754 1.5288 1.2730 1.5025 1.4905 1.3974 1.3974 1.2710 * 1.1925 1.2827 1.1916 1.1822 1.1822 1.1822 1.1822 1.1822 1.1822 1.1822 1.5766 1.1822 1.1916 1.2730 1.5288 1.1822 1.1822 Fmt 4701 Sfmt 4702 21.4252 24.8409 27.6234 21.2712 23.7787 21.1716 22.4249 17.6906 21.3342 18.0509 23.0448 23.8994 19.0471 24.8060 25.4680 22.4741 25.2699 23.5742 23.5915 24.1921 16.8437 27.7626 22.9916 22.4860 24.2398 21.3051 26.7581 26.0388 24.3680 15.6985 * 31.9325 25.9979 27.8584 26.1041 21.4222 37.1976 21.4008 * * * * 35.5184 33.5751 43.4440 49.3167 43.0584 35.7591 36.0305 32.2188 24.5768 39.6653 23.3204 31.6467 29.4062 33.5466 31.5250 27.3826 27.2945 33.8000 44.2265 35.2630 35.8322 37.3760 45.4887 25.0150 26.1926 Average hourly wage FY 2008 23.8220 25.1479 29.7150 21.4819 26.4964 19.8709 23.0358 18.5119 22.0394 19.5353 24.9164 25.2303 18.9872 24.9996 25.2840 22.1058 26.2661 23.0954 26.1937 24.8760 17.2536 26.6449 25.7215 23.6276 23.1913 22.6131 27.7928 26.8908 24.2419 17.3715 22.0054 32.2832 27.7360 28.3342 30.3475 23.8620 * * 24.4367 33.7876 * * 41.7336 37.1639 45.8773 46.8706 46.2186 43.5623 37.4135 * 31.0653 42.2200 31.8310 33.0592 33.4334 32.7476 33.1277 28.5736 30.9014 36.0905 48.7483 36.6943 35.7054 40.3326 48.2283 27.0676 29.1125 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 25.7922 27.8865 30.4885 22.9798 26.4417 23.1648 23.3547 19.6944 22.1983 * 26.0132 25.6541 20.9688 23.3108 26.6629 22.9668 27.3878 24.7891 25.6870 26.5895 18.4756 28.1552 26.6972 24.7107 22.3295 24.5448 28.5682 26.5770 25.6769 * 21.8131 34.9636 27.7619 33.0048 33.8758 23.1293 * * 20.3865 * 35.7643 * 43.1732 41.7694 46.3257 50.9532 49.7145 43.4884 39.4733 * 34.4877 44.3892 43.5594 36.6332 33.5179 36.4068 35.0276 28.1194 33.5634 37.8493 55.2150 34.9232 38.1639 40.4361 50.5011 28.5930 31.8120 Average hourly wage** (3 years) 23.6373 25.9688 29.2730 21.9027 25.5529 21.3821 22.9631 18.6284 21.8575 18.7591 24.6243 24.9287 19.6151 24.3661 25.8031 22.5262 26.2955 23.8273 25.0529 25.2945 17.5296 27.5095 25.1591 23.6212 23.2265 22.8466 27.7154 26.5251 24.7942 16.4167 21.8928 33.0707 27.1679 29.8698 29.9321 22.9022 37.1976 21.4008 22.2702 33.7876 35.7643 * 40.2432 37.1459 45.2428 49.0479 46.4654 40.8362 37.6850 32.2188 30.1759 42.1245 30.7984 33.8292 32.1616 34.2656 33.2678 28.0466 30.5981 35.9795 49.5117 35.5973 36.6252 39.4000 48.0790 26.9305 29.0132 23728 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050047 050054 050055 050056 050057 050058 050060 050063 050065 050067 050069 050070 050071 050072 050073 050075 050076 050077 050078 050079 050082 050084 050089 050090 050091 050093 050095 050096 050099 050100 050101 050102 050103 050104 050107 050108 050110 050111 050112 050113 050114 050115 050116 050117 050118 050121 050122 050124 050125 050126 050127 050128 050129 050131 050132 050133 050135 050136 050137 050138 050139 050140 050144 050145 050146 050148 050149 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.7553 1.1791 1.3418 1.4226 1.6897 1.6320 1.5084 1.4482 *** 1.2075 1.7361 1.3124 1.4512 1.4096 1.2488 1.3747 1.8168 1.5379 1.2512 1.5736 1.6600 1.5667 1.3670 1.2562 1.0354 1.5575 *** 1.2641 1.5398 1.8205 1.3210 1.3903 1.5437 1.4136 1.5287 1.8628 1.2335 1.1657 1.5363 1.1706 *** 1.4716 1.6387 *** 1.2470 1.2657 1.6278 1.2976 1.4819 1.5255 1.2888 1.4865 1.8869 1.4641 1.4120 1.5874 1.0174 1.3870 1.5096 1.4788 1.3979 1.3188 *** 1.5409 1.8140 1.0935 1.5423 PO 00000 Frm 00202 Average hourly wage FY 2007 1.4905 1.1822 1.4905 1.1916 1.1822 1.1916 1.1822 1.1916 * 1.1963 1.1822 1.5025 1.5766 1.5278 1.5278 1.5288 1.5278 1.1822 1.1916 1.5278 1.1822 1.1954 1.1822 1.4879 1.1916 1.1822 * 1.1916 1.1822 1.1822 1.5278 1.1822 1.1916 1.1916 1.1822 1.2827 1.1822 1.1916 1.1916 1.5025 * 1.1822 1.1916 * 1.1963 1.1822 1.1954 1.1916 1.5766 1.1916 1.2827 1.1822 1.1822 1.5278 1.1916 1.2710 1.1916 1.4879 1.1916 1.1916 1.1916 1.1822 * 1.4671 * * 1.1916 Fmt 4701 Sfmt 4702 55.9367 21.3650 42.9516 30.6126 30.0236 33.1409 29.9762 34.0906 34.9110 38.8070 34.6353 47.4099 50.7602 49.4344 49.9730 54.4089 52.3788 34.8660 32.0133 47.3449 38.2878 35.5196 33.9593 33.8953 32.1301 36.9481 * 34.9237 33.4174 31.4404 42.4589 32.0617 34.0935 32.3043 32.5846 38.8672 26.8408 28.7875 37.7281 39.4882 34.0309 28.8051 36.8825 34.2020 39.9683 30.6105 33.9812 30.2522 44.9523 31.7619 32.0355 31.1308 34.7359 45.3152 35.9199 31.9527 25.1813 43.3747 39.1496 45.3727 37.8986 40.9725 33.6662 42.2921 * 28.2305 35.8821 Average hourly wage FY 2008 45.1675 24.0338 44.2926 32.7693 31.7467 37.2538 32.0196 36.3085 38.2421 40.1393 35.3850 46.4009 49.6495 50.0343 49.0069 49.8290 50.2039 36.5384 30.4274 48.8994 37.8905 39.5748 36.4018 37.7421 37.1223 36.8486 * 33.1322 32.0650 33.3959 47.9327 32.8434 35.6773 33.6204 33.5687 42.0131 28.0670 31.8766 38.9483 42.8884 35.7274 32.5257 37.6018 35.0531 41.6701 34.6244 34.0259 29.9944 47.7578 32.6686 40.7610 33.4233 36.9887 47.5257 39.6807 33.1814 25.3209 46.6619 40.2457 40.6343 38.7385 39.4954 38.2424 48.0796 * * 37.3616 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 48.5921 27.1306 48.2759 34.7937 33.7545 39.1657 34.1151 36.6271 42.0052 41.8949 38.1313 49.3910 52.5202 51.9174 50.6478 51.5366 51.0338 37.4961 37.1909 48.2983 42.1694 41.0288 39.2412 41.5994 40.1032 37.7213 44.2364 33.3800 34.3480 34.2814 48.7447 33.2811 37.5528 37.1418 36.6966 43.0409 30.9036 31.9371 39.9904 46.3447 37.5895 33.8575 39.1213 * 41.8166 35.1123 36.8803 31.7666 53.6251 30.6587 42.5307 34.2327 40.7010 50.5592 39.5311 34.7446 25.4416 52.9752 45.3315 46.7946 44.3290 44.5658 40.4728 49.2634 * * 43.3419 Average hourly wage** (3 years) 49.7760 24.3249 45.1972 32.7247 31.8592 36.5431 31.9978 35.6915 38.4607 40.2601 36.1111 47.8284 51.0422 50.5640 49.8748 51.6907 51.1894 36.4378 33.1204 48.1333 39.4148 38.7442 36.5180 37.7203 36.4125 37.1762 44.2364 33.8096 33.2470 33.0478 46.4291 32.8150 35.8192 34.4090 34.2821 41.3295 28.6069 30.8306 38.9358 42.8008 35.8060 31.7873 37.9136 34.3889 41.1955 33.4898 34.9559 30.6975 49.3187 31.6279 37.9357 32.9837 37.4287 48.0185 38.3266 33.5182 25.3286 47.9218 41.8810 44.1215 40.6568 41.7792 37.3677 46.7040 * 28.2305 39.0535 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23729 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050150 050152 050153 050155 050158 050159 050167 050168 050169 050173 050174 050175 050177 050179 050180 050188 050189 050191 050192 050193 050194 050195 050196 050197 050204 050205 050207 050211 050214 050215 050219 050222 050224 050225 050226 050228 050230 050231 050232 050234 050235 050236 050238 050239 050240 050242 050243 050245 050248 050251 050253 050254 050256 050257 050261 050262 050264 050270 050272 050276 050277 050278 050279 050280 050281 050283 050289 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2344 1.4480 1.4515 *** 1.3682 1.2951 1.4830 1.5682 1.5146 1.3454 1.5492 *** *** 1.1909 1.5822 1.5411 1.0400 1.5029 0.9799 1.2329 1.3496 1.5733 1.0787 1.9800 1.4038 1.3872 *** 1.3077 *** *** 1.3346 1.6635 1.6644 1.3992 1.5964 1.3082 1.5485 1.7120 1.7085 1.2780 1.4885 1.4514 1.5286 1.6781 *** 1.3854 1.5755 1.3731 1.1239 *** *** 1.2803 *** 0.9389 1.2967 2.2067 1.3674 *** 1.4019 1.1193 1.1820 1.5456 1.1978 1.7360 1.4053 1.6153 1.6158 PO 00000 Frm 00203 Average hourly wage FY 2007 1.2710 1.4905 1.5766 * 1.1916 1.1822 1.1954 1.1822 1.1916 1.1822 1.4879 * * 1.1963 1.5278 1.5766 1.4671 1.1916 1.1822 1.1822 1.5758 1.5288 1.1822 1.5758 1.1916 1.1916 * 1.5288 * * 1.1916 1.1822 1.1822 1.1822 1.1822 1.4905 1.1822 1.1916 1.1925 1.1822 1.1916 1.1822 1.1916 1.1916 * 1.5758 1.1822 1.1822 1.4671 * * 1.2827 * 1.1822 1.1822 1.1916 1.5288 * 1.1822 1.5278 1.1916 1.1916 1.1822 1.2730 1.1916 1.5288 1.5025 Fmt 4701 Sfmt 4702 33.6583 46.1553 42.8955 16.9516 35.7805 32.5704 31.4798 37.9784 29.4693 29.0576 44.4199 33.3061 24.0717 30.4973 42.0358 41.0943 30.1155 37.7805 27.1400 33.9520 44.7107 48.8595 34.0956 50.0728 32.0121 29.3334 30.0062 35.0515 25.4647 48.8112 26.4143 32.3882 32.5010 34.0836 32.4411 43.7939 34.0600 32.1813 26.3004 32.3726 30.5405 33.0686 33.3346 33.1148 36.1154 46.4844 32.9385 27.3866 * 27.8452 23.5381 31.2386 29.6793 20.1829 29.2150 39.9946 47.7024 33.6855 29.4671 41.1406 35.4443 31.8712 29.7118 38.8341 29.4882 44.3122 44.2814 Average hourly wage FY 2008 37.9946 51.6567 47.6374 16.7756 39.9160 34.6915 34.0418 40.5973 31.4115 31.6717 48.1740 35.0152 * 31.6651 45.7099 43.7381 28.7580 37.8756 27.8386 29.0623 49.0030 53.5583 32.8293 52.9998 35.3954 30.6322 31.3431 35.0289 * 50.7578 25.8378 33.7510 35.7280 35.1227 35.4597 47.1430 35.8490 33.7139 34.3242 34.8308 37.0858 32.6462 34.0823 35.9041 40.7427 50.9882 36.1209 33.2556 40.4941 * * 33.0865 32.7159 24.0737 30.8704 41.4835 43.4181 36.0111 30.9290 43.7943 35.0079 34.3798 31.6738 41.3912 31.6639 43.6855 50.1762 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 43.5908 54.7138 50.4838 * 42.7838 35.0123 38.0704 40.8318 33.1105 32.3240 53.7062 * * 34.6529 48.7392 45.8470 31.5787 42.0018 27.4599 36.7215 49.8490 57.6511 41.1280 55.2982 38.8654 30.6087 * 42.9220 * * 26.7043 35.4673 37.2306 37.5227 36.5328 49.9023 38.8880 37.0216 35.5078 37.7096 39.1708 34.4239 35.1235 36.3232 * 53.7118 37.8510 34.5668 46.0285 * * 33.5043 32.6816 29.2635 33.7180 43.7672 48.0876 * 31.5894 47.2414 * 38.5649 32.1678 43.5214 31.0678 44.8602 52.0875 Average hourly wage** (3 years) 38.2550 50.9486 47.2422 16.8520 39.6127 34.1437 34.4888 39.8615 31.4624 30.9921 48.9658 34.1608 24.0717 32.3080 45.6253 43.4416 30.2839 39.2858 27.4784 32.9051 47.9003 53.3853 35.9355 52.8587 35.4348 30.1774 30.6661 37.8234 25.4647 49.8014 26.3093 33.9374 35.2444 35.6603 34.8249 46.9935 36.2981 34.3576 32.2261 34.9915 35.6922 33.3573 34.2447 35.1511 38.4427 50.5362 35.6823 31.8473 43.3497 27.8452 23.5381 32.6688 31.5748 24.4838 31.3396 41.7544 46.3588 34.8609 30.7391 44.0832 35.2189 35.0167 31.1945 41.2937 30.7699 44.2950 49.0216 23730 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050290 050291 050292 050295 050296 050298 050299 050300 050301 050305 050308 050309 050312 050313 050315 050320 050324 050325 050327 050329 050333 050334 050335 050336 050342 050348 050349 050350 050351 050352 050353 050357 050359 050360 050366 050367 050369 050373 050376 050378 050380 050382 050385 050390 050391 050393 050394 050396 050397 050407 050411 050414 050417 050420 050423 050424 050425 050426 050430 050432 050433 050434 050435 050438 050441 050444 050447 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.7575 1.9821 1.0615 1.4386 1.1373 1.2078 *** 1.4161 1.2490 1.4137 1.5368 1.4523 *** 1.2021 1.3141 1.2624 1.7781 1.1860 1.6676 1.2676 1.0488 1.5881 1.3834 1.2384 1.2489 1.7714 0.9688 1.4256 1.5307 1.3551 1.5204 1.5056 1.1869 1.5234 1.1511 1.4838 1.4765 1.4477 1.7774 1.0502 1.6776 1.4478 1.2993 1.1220 *** 1.3848 1.6185 1.5625 0.8787 1.1900 1.3207 1.3194 1.3093 *** 1.0114 1.9524 1.3696 1.4616 0.9394 *** *** 0.9988 1.1984 1.5503 1.9553 1.4083 2.2656 PO 00000 Frm 00204 Average hourly wage FY 2007 1.1916 1.4879 1.1822 1.1822 1.5758 1.1839 * 1.1822 1.4497 1.5288 1.5766 1.2827 * 1.1954 1.1822 1.5288 1.1822 1.1855 1.1822 1.1822 1.1822 1.4671 1.1963 1.1954 1.1822 1.1822 1.1822 1.1916 1.1916 1.2827 1.1916 1.1822 1.1822 1.5278 1.1837 1.5278 1.1916 1.1916 1.1916 1.1916 1.5766 1.1916 1.4879 1.1822 * 1.1916 1.1822 1.1822 1.1822 1.4905 1.1916 1.2827 1.1822 * 1.1822 1.1822 1.2827 1.1822 1.1822 * * 1.1822 1.1822 1.1916 1.5766 1.2202 1.1822 Fmt 4701 Sfmt 4702 37.3563 38.4365 26.9786 34.7382 39.9842 30.2022 35.1249 30.2874 35.9491 44.9681 43.7413 38.2659 36.8498 35.0478 33.2038 45.7686 34.5503 31.3730 33.9507 23.2927 19.6352 43.9656 30.9928 30.4664 29.2244 31.5156 24.4863 31.0136 30.6599 36.7673 29.4215 32.6763 29.8345 47.4497 33.6714 38.6330 30.6439 35.1380 34.3539 37.9904 46.0276 30.4014 36.8107 27.3183 17.2141 34.1743 27.4861 32.4918 28.3671 42.2748 38.8294 38.7585 32.9341 35.2869 28.3768 34.5680 49.2245 33.2031 23.9045 33.1876 21.3573 32.6255 30.6530 36.3026 44.5694 34.6313 26.7960 Average hourly wage FY 2008 40.6192 41.2100 27.3365 38.4256 42.5405 33.7864 32.3707 33.6821 37.1103 48.5339 46.4180 40.1499 * 37.5024 32.5538 46.2071 36.3474 37.0441 35.9349 33.0390 18.6534 47.2968 34.7192 31.5480 30.4226 32.7107 25.4266 31.7908 33.3064 37.0807 30.4206 36.2089 31.3391 52.3811 37.1527 40.1904 32.2467 34.3737 35.2837 40.1923 49.4258 32.6683 36.4188 27.9359 * 35.6356 32.1894 37.3972 29.6825 44.6839 38.6328 41.8688 36.1222 39.9237 31.9751 36.6091 46.6628 34.9855 24.5327 35.2416 21.1287 33.7794 33.0372 36.2044 46.6160 37.6821 29.0780 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 42.0066 43.2395 30.9112 39.5132 44.8105 33.6925 * 37.1244 36.3661 52.8531 49.0086 41.1612 * 37.8834 37.3526 50.6670 37.1854 34.0333 36.9523 36.7650 32.2010 50.9796 37.2324 33.0304 29.8368 33.5253 23.1089 34.0896 35.0010 38.6234 37.1683 38.9202 30.3963 53.4113 41.8302 40.0423 33.3330 37.6802 36.6487 42.0465 52.5752 32.9220 36.5610 33.0438 * 35.1855 32.1720 38.9901 31.1603 47.5560 44.7079 45.0472 37.0117 * 32.4104 37.5218 45.7794 37.6483 25.9363 * 23.0629 35.4799 35.7401 38.2823 49.2095 39.3915 27.1252 Average hourly wage** (3 years) 39.9556 41.1200 28.4996 37.7732 42.4568 32.5818 33.6024 33.7458 36.4668 48.7916 46.4303 39.8863 36.8498 36.8450 34.4352 47.5834 36.0605 34.2474 35.6196 31.1927 21.9629 47.4795 34.3853 31.7345 29.8437 32.6280 24.2535 32.2951 33.0083 37.4921 32.2253 35.9956 30.5262 51.1213 37.3699 39.6594 32.1001 35.7093 35.4753 40.0787 49.4098 31.9903 36.5948 29.3100 17.2141 35.0078 30.6682 36.2041 29.8101 44.8602 40.9918 42.0484 35.4225 37.6935 31.1452 36.2762 47.0234 35.2291 24.7203 34.2247 21.6609 33.9524 33.2043 36.9424 46.8421 37.5291 27.7351 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23731 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050448 050454 050455 050456 050457 050464 050468 050469 050470 050471 050476 050477 050478 050481 050485 050488 050491 050492 050494 050496 050498 050502 050503 050506 050510 050512 050515 050516 050517 050523 050526 050528 050531 050534 050535 050537 050541 050543 050545 050546 050547 050548 050549 050550 050551 050552 050557 050561 050567 050568 050569 050570 050571 050573 050575 050577 050578 050579 050580 050581 050583 050584 050585 050586 050588 050589 050590 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2948 1.9380 1.5610 *** 1.5970 1.7391 1.7714 *** *** 1.7119 1.4110 *** 1.0325 1.5130 1.6505 1.4378 *** 1.3241 1.4344 1.6970 1.3475 1.6482 1.5152 1.5249 1.3370 1.4990 1.3185 1.5093 1.2967 1.2869 1.1843 1.1507 1.0520 1.4315 *** 1.4828 1.4378 0.7526 0.7226 0.6945 1.0205 0.6180 1.6510 *** 1.3452 0.9428 1.5993 1.4093 1.5110 1.2464 1.3207 1.5519 *** 1.5662 1.3192 *** 1.4310 *** 1.1517 1.4139 1.6442 1.4508 *** 1.3101 1.3759 1.2424 1.2814 PO 00000 Frm 00205 Average hourly wage FY 2007 1.1822 1.4905 1.1822 * 1.4905 1.1963 1.1916 * * 1.1916 1.4497 * 1.1822 1.1916 1.1916 1.5288 * 1.1822 1.2710 1.5278 1.2827 1.1916 1.1822 1.1925 1.5278 1.5288 1.1822 1.2827 1.1822 1.5278 1.1822 1.1822 1.1916 1.1822 * 1.2827 1.5758 1.1822 1.1916 1.1822 1.4879 1.1822 1.1822 * 1.1822 1.1916 1.1963 1.1916 1.1822 1.1822 * 1.1822 * 1.1822 1.1916 * 1.1916 * 1.1822 1.1916 1.1822 1.1839 * 1.1822 1.1916 1.1822 1.2827 Fmt 4701 Sfmt 4702 30.6201 38.5833 30.4606 21.6261 47.8947 38.3058 31.1111 30.6502 27.8678 35.4768 38.7856 37.7668 40.2558 36.1394 36.1488 42.6854 34.3598 28.0826 38.1177 48.2468 37.1667 28.7046 34.0994 37.7420 52.5376 50.9264 38.9542 39.8161 20.0213 40.6535 28.1997 31.4941 27.1974 33.1666 34.6143 34.9931 52.5908 29.4443 31.3080 33.2245 34.8401 39.2234 35.2792 30.9612 34.0467 33.0711 33.3654 38.0196 35.7063 25.2337 31.6785 34.5161 34.7627 34.7279 25.1457 32.3744 35.2390 42.5081 31.5806 34.0136 34.5747 30.3434 22.2521 26.4782 32.7556 34.5100 38.4971 Average hourly wage FY 2008 32.7748 40.2811 34.5445 27.7659 50.0282 41.6235 35.7409 * 31.0466 36.8680 41.1042 40.1566 41.1668 38.8650 34.6219 45.0630 * 30.7718 40.6384 51.6363 41.0350 31.8872 37.3605 39.8586 49.4533 48.8057 40.2957 43.0249 22.4096 43.4579 33.3964 36.2908 28.3348 36.6447 37.8174 38.2145 48.0867 24.4913 35.3209 36.5099 33.8036 41.1075 38.3927 34.9476 37.2506 33.9810 35.7023 38.2543 37.6384 26.0908 * 38.4373 39.0649 35.2842 23.7990 * 31.3639 * 34.1531 37.7567 37.4450 30.7839 * 31.3513 37.7387 37.6886 41.7519 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 32.6666 43.3674 35.0200 27.9693 53.3144 42.6660 37.3361 * 32.5012 36.4887 40.5395 * 41.5592 42.8499 34.7050 47.1937 * 32.6577 42.3086 51.1433 42.2469 32.9773 37.7183 40.6497 51.3691 50.1599 41.0328 45.5247 29.3674 46.9830 35.5437 38.3022 28.4865 38.1859 * 40.1908 51.5270 32.8347 * * * * 40.6759 39.2133 37.6198 35.3466 38.6871 39.1298 39.0084 26.7719 * 40.6719 * 36.8535 22.1000 * 43.4883 * 35.0950 40.0883 40.5818 31.9887 * 31.1898 39.4229 37.2032 44.2900 Average hourly wage** (3 years) 31.9996 40.8320 33.3430 25.0702 50.4334 40.8465 34.8277 30.6502 30.5202 36.2903 40.1623 39.0877 41.0379 39.2898 35.1967 45.0874 34.3598 30.4668 40.3782 50.4172 40.1486 31.1609 36.4438 39.4417 51.0324 49.9366 40.1925 42.8485 23.6394 43.8643 32.2787 35.4339 28.0127 36.0367 36.2328 37.8814 50.6366 28.6007 33.2475 34.9356 34.2850 40.1570 38.1001 34.7849 36.3778 34.1389 35.9147 38.5223 37.5231 26.0576 31.6785 37.8603 36.9575 35.6371 23.5654 32.3744 36.9415 42.5081 33.6230 37.3040 37.4769 31.0588 22.2521 29.6927 36.6367 36.5093 41.5361 23732 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050591 050592 050594 050597 050599 050601 050603 050604 050608 050609 050613 050615 050616 050618 050624 050625 050633 050636 050641 050644 050660 050662 050663 050667 050668 050674 050677 050678 050680 050682 050684 050686 050688 050689 050690 050693 050694 050695 050696 050697 050699 050701 050704 050707 050708 050709 050710 050713 050714 050717 050718 050720 050722 050723 050724 050725 050726 050727 050728 050729 050730 050732 050733 050734 050735 050736 050737 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index *** *** *** 1.2983 1.8547 1.5329 1.4506 1.3664 1.2665 1.2511 *** *** 1.4930 1.0232 1.3457 1.7610 1.2411 1.2748 1.3434 1.0499 1.7555 0.7264 1.4166 0.9359 1.2668 1.2833 1.3833 1.3254 1.2900 0.8353 1.1150 1.5945 1.2103 1.5822 1.3422 1.3899 1.0517 *** 2.2640 1.1055 *** 1.3490 1.0435 *** 1.4932 1.4478 1.2058 *** 1.4054 1.5439 *** 0.9656 0.9138 1.3255 2.0000 0.8736 1.5371 1.3473 *** *** *** 2.3278 1.5906 *** 1.3963 1.2104 1.4996 PO 00000 Frm 00206 Average hourly wage FY 2007 * * * 1.1916 1.2827 1.1916 1.1822 1.5766 1.1822 1.1822 * * 1.1822 1.1822 1.1916 1.1916 1.1925 1.1822 1.1916 1.1916 * 1.5766 1.1916 1.3974 1.4905 1.2827 1.1916 1.1822 1.5278 1.1822 1.1822 1.1822 1.5766 1.5278 1.4879 1.1822 1.1822 * 1.1916 1.2730 * 1.1822 1.1916 * 1.1822 1.1822 1.1822 * 1.5818 1.1916 * 1.1822 1.1822 1.1916 1.1822 1.1916 1.1963 1.1916 * * * 1.1822 1.2730 * 1.1916 1.1916 1.1916 Fmt 4701 Sfmt 4702 30.6106 27.3606 36.5256 28.8294 32.7835 36.0572 34.0275 55.0821 30.4169 41.7208 42.8108 35.9547 37.7284 31.3182 33.9594 38.6591 36.8302 32.5576 39.6921 28.8237 * 33.2446 27.7334 24.2771 56.6555 48.0893 38.5770 32.4473 38.2871 17.9077 27.5256 41.0188 44.1510 45.0951 50.9094 34.5797 30.7858 39.6004 37.3837 16.6605 28.9083 31.9529 29.7740 35.7311 30.5860 26.8549 45.8022 21.1273 31.9527 39.3227 25.5140 29.4726 31.4867 38.5446 31.6910 24.3100 30.6479 33.9118 39.3581 36.5432 37.0629 * * * * * * Average hourly wage FY 2008 34.7133 31.8053 42.0788 31.5625 34.7187 39.7717 35.0279 49.4446 31.2909 39.7397 42.9930 39.1299 37.1200 33.1472 35.9346 41.0439 38.4916 33.0718 32.3586 30.7981 * 38.3017 17.7035 25.9161 51.6049 47.0720 39.2161 33.7633 37.9856 22.2193 28.8378 39.7757 49.4062 48.8533 49.0226 39.6838 32.1065 49.0340 39.8963 22.1441 21.5725 34.9876 31.6097 43.5555 31.8442 24.5621 44.2482 21.4825 34.1542 38.8773 31.9622 30.3595 33.7991 38.7140 35.2344 30.0580 28.6361 32.7783 41.8263 38.1882 39.2046 33.6831 40.1517 31.2883 * * * E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 * 32.2351 * 32.8964 36.6122 43.2367 35.4778 49.6225 30.7266 42.4128 * * 40.8621 34.9156 39.2531 44.8446 40.7347 35.4525 32.0483 33.2746 * * 17.8180 25.8444 52.6968 48.6658 40.7889 35.8378 39.0346 22.3883 33.5883 41.3815 53.2703 48.9898 51.7590 42.8232 34.8458 * 39.4330 26.7588 28.8973 37.2811 32.1995 44.0218 28.3051 29.5339 46.2957 * 42.9756 37.0867 * 32.1156 35.6698 41.1633 35.0980 28.8366 30.6054 33.0915 * * * 34.3456 40.6287 * 36.6052 41.8905 38.0395 Average hourly wage** (3 years) 32.5892 30.0884 39.2148 31.1668 34.7394 39.7359 34.9101 50.8907 30.8122 41.2383 42.8892 37.5269 38.5549 33.1400 36.4371 41.6090 38.7394 33.7338 34.3171 30.9581 * 35.5809 19.8971 25.2820 53.2587 47.9616 39.6370 34.1139 38.4541 20.9013 30.1544 40.7110 49.0705 47.6626 50.5850 38.9551 32.6630 44.6756 38.9118 21.2675 26.4337 34.8704 31.2008 40.8918 30.2199 27.1486 45.4488 21.2886 36.5738 38.4090 28.5587 30.5944 33.7766 39.6081 34.1972 27.6830 29.9355 33.2499 40.4993 37.4033 38.1210 34.0196 40.3877 31.2883 36.6052 41.8905 38.0395 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23733 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050738 050739 050740 050741 050742 050744 050745 050746 050747 050748 050749 050750 050751 050752 050753 050754 050755 050757 050758 050759 060001 060003 060004 060006 060008 060009 060010 060011 060012 060013 060014 060015 060016 060018 060020 060022 060023 060024 060027 060028 060030 060031 060032 060034 060036 060041 060043 060044 060049 060054 060064 060065 060071 060075 060076 060096 060100 060103 060104 060107 060112 060113 060114 060115 060116 060117 060118 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.5052 1.6284 1.4538 1.4520 1.4454 1.7412 1.3450 1.8196 1.5410 1.1344 1.3856 *** 2.9380 1.4092 1.6850 1.1933 1.3602 1.5947 1.3399 2.1683 1.5186 1.4098 1.1053 1.3131 1.2609 1.4736 1.5411 1.5219 1.5548 1.5942 1.8805 1.8679 1.1848 1.2897 1.5516 1.6011 1.6260 1.8688 1.5941 1.4266 1.4302 1.5357 1.4900 1.7145 1.0946 0.9254 0.9724 1.1929 1.4157 1.4812 1.7013 1.4081 1.1347 1.3842 1.2641 1.6188 1.7198 1.3654 1.4279 1.5071 1.6339 1.4241 1.3878 0.8560 1.2796 1.4396 1.4247 PO 00000 Frm 00207 Average hourly wage FY 2007 1.1916 1.1916 1.1916 1.1916 1.1916 1.1822 1.1822 1.1822 1.1822 1.1954 1.1822 * 1.1916 1.1916 1.1916 1.5025 1.1916 1.1822 1.1822 1.1822 1.0070 1.0409 1.0561 0.9303 0.9303 1.0561 0.9734 1.0561 0.9738 0.9303 1.0561 1.0561 0.9303 0.9303 0.9303 0.9738 1.0409 1.0561 1.0409 1.0561 0.9734 1.0409 1.0561 1.0561 0.9303 0.9303 0.9303 0.9303 0.9581 0.9925 1.0561 1.0561 0.9303 0.9925 0.9303 1.0409 1.0561 1.0409 1.0561 1.0561 1.0561 1.0561 1.0561 0.9303 1.0409 0.9303 0.9303 Fmt 4701 Sfmt 4702 * * * * * * * * * * * * * * * * * * * * 29.6191 29.4809 32.4609 25.2139 23.0947 31.5210 27.1916 35.1573 27.3885 26.8675 31.0542 32.5285 26.5427 24.1086 24.5992 28.2944 29.5760 30.0279 29.6121 31.6900 27.8642 27.8345 31.0686 30.9359 20.3226 24.6142 18.2143 26.5611 29.3724 24.3389 32.3681 32.4735 27.6657 32.2545 26.5631 32.1310 32.6104 31.6314 32.4232 26.8388 34.9272 * * * * * * Average hourly wage FY 2008 * * * * * * * * * * * * * * * * * * * * 31.0018 31.3616 32.0095 27.2057 26.5175 32.4208 29.5304 32.1001 28.7724 27.9145 31.9389 32.2927 27.1430 25.3897 25.9147 29.3379 31.1556 31.5411 30.9212 32.1656 29.9513 29.3907 32.7383 32.1252 22.8256 25.9710 21.9955 24.8352 30.2192 25.0980 33.2428 33.8538 28.1762 37.6023 30.7808 37.8243 33.2145 32.9690 35.4409 28.0660 34.7116 32.6073 34.8536 * * * * E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 43.9225 57.2436 54.0328 51.1485 39.0793 48.4913 42.5490 43.1981 44.5852 42.9957 28.1978 33.9880 29.5465 39.8004 * * * * * * 32.4200 31.8621 34.8408 26.8067 27.2059 34.0129 30.6402 34.4158 29.4348 28.0786 33.0340 36.3270 28.3040 26.5770 26.7340 31.9353 32.7901 32.8183 31.6117 33.4942 31.2907 30.8385 34.6417 33.3625 20.9359 31.4722 23.3899 29.4060 32.1570 24.6714 37.2384 34.9177 31.5370 35.8069 31.6033 38.2230 33.5326 33.7519 37.1405 30.3986 35.1275 35.2074 35.3035 * 33.1528 28.3098 * Average hourly wage** (3 years) 43.9225 57.2436 54.0328 51.1485 39.0793 48.4913 42.5490 43.1981 44.5852 42.9957 28.1978 33.9880 29.5465 39.8004 * * * * * * 30.9988 30.9372 33.1185 26.4045 25.5276 32.6683 29.1093 33.8458 28.5090 27.6090 32.0056 33.6071 27.3080 25.3463 25.7382 29.8727 31.1705 31.5099 30.7134 32.4479 29.7046 29.3398 32.7827 32.1070 21.3443 27.2226 21.1620 26.8390 30.6358 24.6993 33.8162 33.7649 29.2648 35.2179 29.6210 36.0395 33.1192 32.8044 34.8954 28.4350 34.9373 33.9039 35.0938 * 33.1528 28.3098 * 23734 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 060119 070001 070002 070003 070004 070005 070006 070007 070008 070009 070010 070011 070012 070015 070016 070017 070018 070019 070020 070021 070022 070024 070025 070027 070028 070029 070031 070033 070034 070035 070036 070038 070039 070040 080001 080002 080003 080004 080006 080007 090001 090003 090004 090005 090006 090008 090011 100001 100002 100006 100007 100008 100009 100012 100014 100015 100017 100018 100019 100020 100022 100023 100024 100025 100026 100027 100028 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 2.0319 1.5932 1.8116 1.1297 1.1791 1.4770 1.3529 1.2875 1.2515 1.3430 1.6851 1.4127 1.4106 1.4333 1.4989 1.3644 1.3783 1.3857 1.2985 1.1854 1.6626 1.3628 1.7385 1.4463 1.5690 1.2883 1.2891 1.4498 1.4240 1.2479 1.6115 0.8866 0.9487 1.0777 1.6391 *** 1.6226 1.5578 1.3096 1.4835 1.7487 1.2254 1.9209 1.4073 1.3917 1.2958 2.0065 1.4956 1.4292 1.6260 1.5846 1.6979 1.3613 1.6154 1.4551 1.2730 1.6234 1.6116 1.6071 *** 1.6470 1.5384 1.2924 1.7145 1.5761 *** 1.3554 PO 00000 Frm 00208 Average hourly wage FY 2007 0.9734 1.2038 1.1897 1.1897 1.1897 1.2038 1.2391 1.1897 1.1897 1.1897 1.2391 1.1897 1.1897 1.2391 1.2038 1.2038 1.2391 1.2038 1.1897 1.1897 1.2038 1.1897 1.1897 1.1897 1.2391 1.1897 1.2038 1.2391 1.2391 1.1897 1.1897 1.2038 1.2038 1.1897 1.0799 * 1.0799 1.0645 1.0304 1.0909 1.1018 1.0670 1.1018 1.0670 1.0670 1.0670 1.1018 0.9092 1.0025 0.9189 0.9189 0.9865 0.9865 0.9502 0.9073 0.8993 0.9073 0.9820 0.9401 * 1.0025 0.9073 0.9865 0.8633 0.8633 * 0.9401 Fmt 4701 Sfmt 4702 * 35.8958 33.4398 34.1352 29.4448 33.7813 37.9148 35.9617 28.5506 32.9299 35.3730 31.8987 29.4216 35.3385 31.4930 34.0490 39.7515 34.5125 33.6453 36.9241 39.0462 35.2323 32.4085 29.8513 35.1966 30.9299 30.1915 40.1594 38.3965 30.7440 38.3413 25.7914 36.1369 * 32.0105 29.6800 30.7697 30.1094 27.4749 30.1100 36.6577 31.0419 35.6964 33.0178 29.4912 32.0745 36.7579 26.4631 27.2350 29.1505 28.5702 29.1705 27.4424 28.4600 25.1524 26.0916 27.9654 30.2423 28.6630 27.1257 32.8088 25.2652 29.1894 23.3843 23.4730 18.9432 27.7497 Average hourly wage FY 2008 * 37.0403 34.7636 35.6320 29.9557 34.9404 39.3935 36.2914 30.7305 35.5670 36.7227 31.6843 31.9345 37.3454 33.2391 35.6456 41.8460 33.7246 32.9714 38.5623 40.2283 34.7419 34.5887 30.4433 38.0855 31.0662 30.4054 41.7955 40.1685 32.2766 42.3391 35.8053 34.7219 * 33.5310 31.3391 34.3048 32.2443 28.8862 31.1645 38.3043 32.1960 37.3798 33.7448 31.3562 33.7471 38.0654 27.2809 28.7068 28.3673 29.0472 30.3392 27.8618 29.8353 27.4019 27.2483 28.2402 30.6545 30.3008 * 36.7912 25.4270 29.5423 26.7013 26.0147 * 27.5664 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 * 37.9403 36.4240 36.0505 31.2093 36.5469 41.2133 36.8054 35.4942 36.6355 38.6086 34.1325 33.2459 39.9225 34.1238 37.5821 42.4745 35.8591 35.6515 39.7761 41.4692 36.8976 36.1293 33.5960 43.1846 32.8478 30.5906 44.6692 42.4078 33.4024 43.6345 29.9492 32.7121 * 34.9490 33.0378 30.5113 34.3823 31.0299 33.4764 40.1629 32.8939 38.5646 35.2850 32.3448 36.6606 39.0086 27.8509 30.6650 28.9654 30.3800 32.1650 30.0468 30.8602 27.4048 28.6813 29.8685 32.8609 31.4521 * 36.3330 27.1008 29.8902 27.1652 27.3027 * 28.7776 Average hourly wage** (3 years) * 36.9862 34.8862 35.2926 30.2307 35.0801 39.5140 36.3570 31.5216 34.9997 36.9439 32.5714 31.5134 37.5863 32.9404 35.7978 41.4021 34.6869 34.1183 38.4026 40.2883 35.6415 34.3741 31.3085 38.7150 31.6076 30.4009 42.2677 40.3330 32.1114 41.4903 29.4507 34.7190 * 33.5152 31.3601 31.8516 32.3013 29.2083 31.6259 38.3535 31.9877 37.2403 34.0306 31.0266 34.0292 37.9688 27.2111 28.8632 28.8205 29.3589 30.5829 28.3830 29.7781 26.6903 27.3086 28.7071 31.2755 30.1350 27.1257 35.3146 26.0111 29.5369 25.7513 25.6436 18.9432 28.0281 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23735 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 100029 100030 100032 100034 100035 100038 100039 100040 100043 100044 100045 100046 100047 100048 100049 100050 100051 100052 100053 100054 100055 100057 100061 100062 100063 100067 100068 100069 100070 100071 100072 100073 100075 100076 100077 100079 100080 100081 100084 100086 100087 100088 100090 100092 100093 100099 100102 100105 100106 100107 100108 100109 100110 100113 100114 100117 100118 100121 100122 100124 100125 100126 100127 100128 100130 100131 100132 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2121 1.3539 1.6723 1.7942 1.6017 1.7177 1.5743 1.7008 1.4134 1.5389 1.3128 1.4584 1.6986 0.9293 1.2227 1.1486 1.3882 1.4592 1.3335 1.4058 1.4682 1.4366 1.5221 1.6289 1.2914 1.4240 1.6629 1.5199 1.6948 1.3016 1.3899 1.7604 1.5137 1.2093 1.3908 1.4454 1.6170 0.9435 1.7063 1.3909 1.8447 1.5784 1.4708 1.5273 1.7183 1.0283 1.1035 1.5837 1.0497 1.1889 0.8653 1.2509 1.5739 1.9724 1.7025 1.2439 1.3879 1.1178 1.2316 1.1998 1.2235 1.3212 1.5761 2.1341 1.1458 1.4707 1.2889 PO 00000 Frm 00209 Average hourly wage FY 2007 0.9865 0.9189 0.8993 0.9865 0.9757 1.0025 1.0025 0.9092 0.8993 0.9905 0.9073 0.8993 0.9648 0.8633 0.8715 0.9865 0.9189 0.8715 0.9865 0.8703 0.8993 0.9189 0.9865 0.8633 0.8993 0.8993 0.9073 0.8993 0.9757 0.8993 0.9073 1.0025 0.8993 0.9865 0.9648 * 1.0025 0.8633 0.9189 1.0025 0.9757 0.9092 0.9092 0.9401 0.8633 0.8715 0.8758 0.9741 0.8633 0.9502 0.8633 0.9073 0.9189 0.9427 0.9865 0.9092 0.8633 0.8715 0.8703 0.8633 0.9865 0.8993 0.8993 0.8993 1.0025 0.9865 0.8993 Fmt 4701 Sfmt 4702 28.8842 24.6314 26.8162 28.1280 29.4803 31.3403 28.2531 26.2429 26.4221 30.3659 29.7375 26.9469 26.7674 19.3226 24.0385 21.5101 28.0946 23.6796 28.5118 28.7646 25.6243 24.8010 31.4413 25.1280 25.5097 26.8628 26.1341 25.7450 26.8461 26.3768 25.7962 30.5845 25.7612 23.4551 30.6925 * 28.2188 16.9756 27.4947 28.5971 29.5823 26.7574 26.5703 27.8341 21.6438 25.8454 26.1015 29.9745 24.7650 27.4760 21.3540 25.5669 29.4788 28.0440 29.2862 27.7198 27.6438 26.2990 24.6285 24.0333 29.7750 29.6247 26.0923 29.2566 26.0268 27.8164 26.0526 Average hourly wage FY 2008 30.5382 25.3513 26.9275 27.2915 30.2382 31.6657 29.3699 27.2835 27.0054 33.1141 26.5413 26.7702 29.9729 20.2657 24.5571 25.3354 28.6225 23.4036 31.7415 30.5515 27.3826 26.3134 30.4528 25.9597 26.4139 27.4762 27.6576 27.2108 29.2005 25.3667 27.1889 29.4165 27.6534 24.0412 30.7564 * 29.5346 19.5711 32.7503 29.9072 30.5938 28.2825 27.6175 26.6315 22.5555 26.2395 27.8551 30.9915 24.8098 30.5764 22.6270 26.2446 29.5985 29.2429 30.2544 28.4928 27.0981 27.9353 26.7175 24.8880 31.7749 28.3213 27.4632 30.0324 28.3651 29.7647 27.8180 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 31.5979 26.3096 27.8918 28.9362 32.5568 32.8363 29.0221 28.3342 26.8400 34.3895 25.5601 27.7856 31.4038 21.7684 27.6295 23.5194 30.1464 25.1096 31.9242 30.9825 29.6999 27.7025 31.9154 26.3043 27.0754 27.5486 27.6975 29.0462 29.1098 25.1867 27.6927 31.0379 26.7551 24.0262 27.9764 * 31.0487 19.7407 30.6285 31.3169 32.1290 29.5464 28.9548 28.6765 23.4836 28.0669 29.0373 30.8907 25.6284 31.2927 22.8139 26.7361 30.3729 30.5837 32.3934 30.0549 28.3179 24.9371 27.6162 26.2310 33.3469 28.9151 27.0669 30.3690 30.9735 30.9586 27.6613 Average hourly wage** (3 years) 30.3873 25.4476 27.2236 28.1268 30.7182 31.9625 28.8790 27.2945 26.7591 32.6318 27.1971 27.1801 29.3525 20.4248 25.3718 23.4888 29.0839 24.0877 30.6741 30.1173 27.4746 26.3249 31.2647 25.8131 26.3647 27.3159 27.1712 27.3031 28.3496 25.6298 26.8986 30.3564 26.7473 23.8474 29.8150 * 29.6112 18.7147 30.2189 29.9261 30.7622 28.3236 27.7918 27.7162 22.5921 26.7407 27.7069 30.6081 25.0615 29.8950 22.2176 26.2234 29.8429 29.3004 30.6145 28.8365 27.7197 26.3668 26.3632 25.0380 31.6838 28.9566 26.8835 29.9099 28.5262 29.6460 27.2139 23736 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 100134 100135 100137 100139 100140 100142 100150 100151 100154 100156 100157 100160 100161 100166 100167 100168 100172 100173 100175 100176 100177 100179 100180 100181 100183 100187 100189 100191 100200 100204 100206 100209 100210 100211 100212 100213 100217 100220 100223 100224 100225 100226 100228 100230 100231 100232 100234 100236 100237 100238 100239 100240 100242 100243 100244 100246 100248 100249 100252 100253 100254 100255 100256 100258 100259 100260 100264 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.8985 1.6390 1.3328 0.8641 1.1161 1.1395 1.2603 1.7355 1.6098 1.1428 1.5705 1.2508 1.5295 1.5059 1.2272 1.5608 *** 1.6082 0.9474 1.8223 1.3295 1.7392 1.5114 1.1566 1.2816 1.3637 1.3348 1.3365 1.3715 1.5799 1.2774 1.5193 1.5671 1.2490 1.4634 1.5367 1.3065 1.6181 1.5286 1.2624 1.3079 1.3028 1.3954 1.3499 1.7092 1.2640 1.3320 1.4357 1.8545 1.5484 1.3821 0.9591 1.5092 1.4703 1.4338 1.5457 1.5452 1.2896 1.1632 1.3893 1.4934 1.3025 1.7382 1.5591 1.2682 1.3830 1.4156 PO 00000 Frm 00210 Average hourly wage FY 2007 0.8633 0.8981 0.8715 0.9427 0.9092 0.8633 0.9865 0.9092 0.9865 0.9427 0.8993 0.9865 0.9189 0.9757 1.0025 1.0025 * 0.8993 0.8633 1.0025 0.9401 0.9092 0.8993 0.9865 0.9865 0.9865 1.0025 0.8993 1.0025 0.9427 0.8993 0.9865 1.0025 0.8993 0.8633 0.9757 0.9741 0.9502 0.8703 1.0025 1.0025 0.9092 1.0025 1.0025 0.8633 0.9092 1.0025 0.9648 1.0025 0.8993 0.8993 0.9865 0.8633 0.8993 0.9502 0.9905 0.8993 0.8993 0.9741 1.0025 0.8981 0.8993 0.8993 1.0025 0.8993 0.9905 0.8993 Fmt 4701 Sfmt 4702 20.7367 26.7030 24.8519 18.2197 26.1352 24.8853 26.8492 30.6447 28.2506 27.5706 29.7455 30.7454 28.0545 28.8685 30.2166 27.6739 20.7857 26.5436 23.9665 30.7087 28.0089 29.1111 29.9238 24.3708 29.0270 27.8144 28.8320 28.3710 28.7694 27.4763 27.0295 26.8473 29.8515 24.7533 26.1846 27.9283 27.3989 28.3868 25.0332 26.6446 28.5259 28.8165 28.1396 29.8493 25.7037 28.5537 27.4456 28.9955 31.7848 30.1094 28.6893 27.3523 25.6083 27.4534 26.6876 29.3310 28.8082 24.9876 27.8256 27.4927 26.1406 26.5571 30.3081 31.2203 27.4809 26.7129 26.8216 Average hourly wage FY 2008 21.6544 29.1856 26.8391 21.1310 27.8352 25.6999 27.7740 29.7267 29.7332 28.3927 30.3086 30.6902 29.5673 30.1811 31.7813 27.0938 22.2183 28.6402 25.0913 33.3181 29.6284 29.2795 31.0099 23.9656 30.5042 30.7705 29.9376 29.4533 29.6400 27.2819 27.7551 28.5336 32.0830 26.2859 27.7960 29.5218 27.7683 29.3601 26.1115 28.0455 30.8782 28.8791 30.1635 31.9448 26.6773 28.3892 28.8835 28.3017 33.1536 31.4198 29.0650 29.7000 26.1988 28.3894 28.2881 30.1061 30.2133 26.4676 27.1639 28.7770 27.4900 27.3866 30.2093 33.8630 29.0612 28.2301 28.0370 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 22.9624 29.8423 28.2969 21.4420 28.5466 26.8978 29.3690 31.3820 31.3618 28.3041 30.3339 32.3113 30.8955 31.9053 32.4711 28.0517 20.5502 30.2470 26.1711 35.5821 31.0063 30.5213 31.5463 26.0656 32.9863 31.6639 30.5491 30.9183 29.0719 29.9311 28.8609 29.0435 32.4538 28.8303 29.2475 30.2251 30.3301 30.8265 27.6756 29.1992 32.6890 30.2828 31.0195 34.6099 28.3633 29.3783 29.7800 30.5701 33.9606 31.6331 30.3212 31.0943 27.8149 29.8294 29.8266 30.0261 32.4702 28.5107 29.1429 28.5597 28.5240 29.5157 33.3907 35.2197 29.9274 29.4885 30.1956 Average hourly wage** (3 years) 21.8248 28.5445 26.7255 20.1386 27.5007 25.8482 27.9646 30.5873 29.8234 28.1071 30.1497 31.2761 29.5189 30.2720 31.5289 27.6177 21.2381 28.5123 25.0707 33.1514 29.5570 29.6480 30.8513 24.7884 30.7987 30.0560 29.8033 29.5986 29.1618 28.2769 27.8936 28.1481 31.4634 26.5619 27.7618 29.2000 28.4907 29.5174 26.3160 27.9615 30.6971 29.3578 29.7490 32.1778 26.9108 28.7734 28.7289 29.2818 32.9295 31.0862 29.3632 29.4319 26.5486 28.5415 28.3031 29.8298 30.5161 26.7077 28.0419 28.3018 27.3995 27.8451 31.2430 33.4797 28.8444 28.1387 28.3177 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23737 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 100265 100266 100267 100268 100269 100271 100275 100276 100277 100279 100281 100284 100285 100286 100287 100288 100289 100290 100291 100292 100293 100294 100295 100296 100297 100298 100299 100300 100302 110001 110002 110003 110004 110005 110006 110007 110008 110010 110011 110015 110016 110018 110020 110023 110024 110025 110026 110027 110028 110029 110030 110031 110032 110033 110034 110035 110036 110038 110039 110040 110041 110042 110043 110044 110045 110046 110050 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.3296 1.3896 1.2811 1.1771 1.3742 2.0607 1.3310 1.2874 1.5574 1.4040 1.3929 1.0632 1.2639 1.5465 1.3877 1.7404 1.6231 1.2302 1.3483 1.3753 *** *** *** 1.3271 *** 0.8450 1.2918 *** 1.1546 1.3724 1.3136 1.3119 1.3686 1.2944 1.5596 1.5907 1.3589 2.1741 1.2809 1.0815 1.2537 1.1989 1.2987 1.3269 1.4712 1.4799 1.0963 1.0459 1.7426 1.7563 1.3857 1.2793 1.2564 1.7263 1.7739 1.7859 1.8235 1.5488 1.3716 1.1123 1.2061 1.0795 1.7560 1.2146 1.0279 1.1453 1.0857 PO 00000 Frm 00211 Average hourly wage FY 2007 0.8993 0.8633 0.9757 1.0025 1.0025 * 1.0025 1.0025 0.9865 0.9502 1.0025 0.9865 1.0025 0.9820 1.0025 1.0025 1.0025 0.9215 0.9401 0.8633 * * * 0.9865 * 0.8981 0.9757 * 0.9189 0.8740 0.9760 0.7840 0.8880 0.9760 0.9589 0.8770 0.9760 0.9760 0.9760 0.9760 0.8495 0.9760 0.9760 0.9760 0.8943 1.0139 0.7840 0.7840 0.9604 0.9760 0.9760 0.9760 0.7840 0.9760 0.9604 0.9760 0.8943 0.8397 0.9604 0.9760 0.9760 0.9760 0.8943 0.7840 0.9760 0.9760 0.8499 Fmt 4701 Sfmt 4702 25.7432 23.0208 28.7259 29.0668 26.6047 * 26.8943 29.7606 20.4791 28.6383 29.6698 22.3134 * 28.3645 28.1051 28.7902 29.6376 27.1011 28.4722 26.7063 32.7963 30.7557 26.1983 * * * * * * 26.4338 26.4715 22.7066 24.9978 28.1209 28.3839 26.6396 29.2947 31.7185 28.0598 28.1274 22.7263 26.8016 28.3822 29.8061 27.0225 31.0703 21.8018 22.6058 30.4641 27.3618 29.6841 27.1989 23.2586 30.3415 27.2338 28.9408 26.6664 22.2720 26.3503 20.9487 24.8864 34.9954 27.8477 23.3039 24.4275 26.7464 27.5985 Average hourly wage FY 2008 26.3326 24.2517 28.9674 30.5750 27.8407 * 28.7797 30.5720 24.1122 29.2257 30.9131 25.2637 41.9481 25.8085 29.7536 31.0506 31.9011 28.7111 28.1515 27.7644 * * * 29.3870 32.1536 19.0297 34.3697 * * 26.5640 26.2228 24.2097 25.1846 27.2826 * 26.3133 30.9757 33.2396 28.5892 28.8796 24.3563 30.1849 27.5559 29.3282 27.3357 30.2845 22.8820 25.5291 31.4568 29.2134 29.9531 29.5533 25.1896 32.4178 28.7915 30.1852 27.2280 22.9685 26.2485 23.9526 26.1948 33.4391 28.8551 24.3772 27.7619 * 27.0651 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 26.6920 25.6366 30.6033 33.6114 28.3722 * 31.0459 31.7050 25.5878 31.1921 32.8807 21.4401 34.7963 26.5795 30.3059 32.9558 31.4701 29.7566 28.3762 28.5799 * * * 31.1449 * 21.9226 31.6820 33.1669 * 27.4189 28.9001 25.0083 27.2513 29.5994 32.3714 28.0665 31.8366 33.9818 30.3526 30.5004 25.9193 30.9429 29.4629 29.2001 28.5637 32.6731 24.3858 25.6536 32.8679 30.0367 32.0250 30.7447 24.4949 32.7019 29.6801 31.5705 28.4022 23.3659 28.4347 21.5761 27.6593 34.5117 30.3702 27.0418 28.2217 28.6264 27.1525 Average hourly wage** (3 years) 26.2976 24.3555 29.4523 31.0650 27.6319 * 28.9926 30.6750 23.9890 29.7250 31.2127 22.7441 39.4585 26.8126 29.3361 30.8729 31.0127 28.5282 28.3296 27.7205 32.7963 30.7557 26.1983 30.2840 32.1536 20.3569 33.1821 33.1669 * 26.8009 27.2273 23.9366 25.7796 28.4189 30.3778 27.0191 30.6980 32.9905 29.0303 29.2479 24.3226 29.3022 28.5809 29.4297 27.6412 31.3350 23.0082 24.4936 31.5933 28.8932 30.6320 29.1990 24.3026 31.8557 28.5541 30.2749 27.4638 22.8669 26.8945 22.1590 26.2845 34.3025 28.9989 24.8928 26.7950 27.6790 27.2626 23738 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 110051 110054 110059 110064 110069 110071 110073 110074 110075 110076 110078 110079 110080 110082 110083 110086 110087 110089 110091 110092 110095 110100 110101 110104 110105 110107 110109 110111 110112 110113 110115 110121 110122 110124 110125 110128 110129 110130 110132 110135 110136 110142 110143 110146 110149 110150 110153 110161 110163 110164 110165 110168 110172 110177 110183 110184 110186 110187 110189 110190 110191 110192 110193 110194 110198 110200 110201 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.1244 1.4223 1.1567 1.5836 1.3437 1.1205 1.0228 1.4894 1.3134 1.4843 1.9462 1.5678 *** 1.9672 1.9525 1.2641 1.4285 1.1392 1.2915 1.1137 1.4622 0.9787 0.9836 1.2036 1.3643 1.9504 1.0213 1.1524 1.0413 0.9563 1.7706 1.0024 1.5445 1.0887 1.2577 1.2891 1.5763 0.9171 1.0348 1.2731 *** 0.9807 1.4253 1.0832 *** 1.2994 1.1210 1.5555 1.4520 1.7038 1.4333 1.7664 1.4736 1.9238 1.2868 1.2634 1.3171 1.2029 1.1025 1.0867 1.3278 1.4139 *** 0.8957 1.3546 2.0256 1.4532 PO 00000 Frm 00212 Average hourly wage FY 2007 0.7840 0.9760 0.7840 0.9061 0.9618 0.7840 0.7840 0.9589 0.8841 0.9760 0.9760 0.9760 * 0.9760 0.9760 0.7840 0.9760 0.7840 0.9760 0.7840 0.8397 0.8630 0.7907 0.7840 0.7840 0.9815 0.7840 0.9604 0.8397 0.9604 0.9760 0.8397 0.8397 0.7840 0.9618 0.8841 0.9061 0.7840 0.7840 0.7840 * 0.8025 0.9760 0.9112 * 0.9760 0.9618 0.9760 0.8770 0.9815 0.9760 0.9760 0.9760 0.9604 0.9760 0.9760 0.9061 0.9760 0.9760 0.8081 0.9760 0.9760 * 0.7840 0.9760 0.9061 0.9815 Fmt 4701 Sfmt 4702 20.1756 28.9254 23.2137 24.1219 26.2085 21.3963 18.5753 27.9190 23.7585 28.7871 29.9625 26.8412 18.4714 30.8320 30.4287 21.6898 28.1633 23.9026 29.5337 20.8911 26.3075 16.2575 19.4257 20.3777 23.1405 28.9352 23.0376 25.1270 22.7672 21.3417 31.5074 26.2336 25.1934 22.9212 23.7834 25.7839 25.9625 19.1284 20.2502 22.5346 18.8212 21.3935 28.6583 27.0987 28.4040 25.3742 25.7467 30.4885 28.2169 28.8946 27.0977 28.5700 31.1234 28.8356 28.6208 28.3545 27.4925 25.2139 26.1418 23.3204 27.7760 28.8267 27.9161 19.1920 31.0557 24.9236 31.0841 Average hourly wage FY 2008 21.4898 29.4691 24.7838 26.9363 29.9098 21.2041 23.3571 31.0062 24.8244 29.4344 30.5196 27.3274 * 30.1072 34.0610 22.9959 31.0403 24.3327 27.0994 21.4168 28.0526 20.8201 21.0983 21.8966 23.4010 30.1027 21.6023 25.7084 26.4089 22.0793 32.7927 23.4571 25.4439 22.9571 24.7347 25.4190 30.0444 20.4349 21.2642 24.0945 * 21.6286 29.9139 29.0193 * 26.9884 29.3305 31.5001 27.7679 30.0145 28.7902 29.7774 31.3999 29.7079 28.3505 29.4071 28.2880 26.9638 26.2799 24.5224 30.9481 30.0843 * 21.0826 32.8171 27.2974 32.0967 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 22.1488 31.5780 24.9265 28.7283 30.6443 23.6494 23.0067 30.3996 26.1068 31.0636 31.1064 29.0882 * 31.1407 34.5768 23.4762 32.8007 26.0096 28.0609 22.8591 27.9005 20.0633 23.8601 22.2585 23.7738 31.5754 21.6011 27.2234 24.2924 22.0479 33.3880 24.5645 26.3052 24.8540 26.4991 24.5272 29.7304 21.7084 21.6033 25.1022 * 22.2156 30.9590 30.1159 * 27.7908 30.2424 31.9981 29.5674 31.2804 28.7898 30.8727 33.0426 30.5507 29.6606 30.2897 29.6479 31.0150 27.4200 29.4199 28.7481 31.6605 * 20.5257 34.0021 29.4610 33.4267 Average hourly wage** (3 years) 21.3080 30.0224 24.3029 26.5861 28.9853 22.1661 21.5478 29.7348 24.8944 29.7176 30.5424 27.7224 18.4714 30.6976 33.0335 22.7087 30.7266 24.7677 28.1665 21.7047 27.4450 18.9182 21.3923 21.5748 23.4420 30.2370 22.0502 26.0060 24.5380 21.8312 32.5794 24.7827 25.6427 23.5883 24.9905 25.2129 28.5402 20.4154 21.0527 23.9470 18.8212 21.7484 29.8777 28.7418 28.4040 26.7261 28.4006 31.3389 28.5127 30.1111 28.2209 29.7602 31.8709 29.7260 28.9003 29.4131 28.4857 27.7895 26.6304 25.5710 29.1019 30.2562 27.9161 20.2837 32.6125 27.3150 32.2165 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23739 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 110203 ..................................................... 110205 ..................................................... 110209 ..................................................... 110212 ..................................................... 110214 ..................................................... 110215 ..................................................... 110219 ..................................................... 110220 ..................................................... 110221 ..................................................... 110222 ..................................................... 110223 ..................................................... 110224 ..................................................... 110225 ..................................................... 110226 ..................................................... 110228 ..................................................... 110229 ..................................................... 110230 ..................................................... 120001 ..................................................... 120002 ..................................................... 120004 ..................................................... 120005 ..................................................... 120006 ..................................................... 120007 ..................................................... 120010 ..................................................... 120011 ..................................................... 120014 ..................................................... 120019 ..................................................... 120022 ..................................................... 120026 ..................................................... 120027 ..................................................... 120028 ..................................................... 120029 ..................................................... 130002 ..................................................... 130003 ..................................................... 130006 ..................................................... 130007 ..................................................... 130013 ..................................................... 130014 ..................................................... 130018 ..................................................... 130024 ..................................................... 130025 ..................................................... 130028 ..................................................... 130049 ..................................................... 130062 ..................................................... 130063 ..................................................... 130065 ..................................................... 130066 ..................................................... 130067 ..................................................... 140001 ..................................................... 140002 ..................................................... 140007 ..................................................... 140008 ..................................................... 1400103 .................................................... 140B103 ................................................... 140011 ..................................................... 140012 ..................................................... 140013 ..................................................... 140015 ..................................................... 140018 ..................................................... 140019 ..................................................... 140026 ..................................................... 140029 ..................................................... 140030 ..................................................... 140032 ..................................................... 140033 ..................................................... 140034 ..................................................... 140040 ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.9588 1.1768 0.6196 1.2087 *** 1.3584 1.4002 *** *** *** *** *** 1.2065 1.1952 0.8800 1.2950 1.3685 1.7874 1.2448 1.2549 1.2949 1.2614 1.6360 1.9848 1.4966 1.3531 1.1710 1.8673 1.4190 1.3261 1.2595 *** 1.4057 1.4692 1.7566 1.7298 1.3634 1.2442 1.7489 1.1981 1.2309 1.4347 1.5627 *** 1.4068 1.9441 2.0484 2.5439 1.1235 1.3464 1.4044 1.4402 1.4980 *** 1.2146 1.3120 1.4671 1.3506 1.3731 0.9139 1.1531 1.5837 1.5087 1.2668 *** 1.1683 1.2236 PO 00000 Frm 00213 Average hourly wage FY 2007 0.9760 0.8347 0.7840 0.8163 * 0.9760 0.9760 * * * * * 0.9760 0.9760 0.9760 0.9760 0.7840 1.1608 1.1219 1.1608 1.1219 1.1608 1.1608 1.1608 1.1608 1.1219 1.1219 1.1608 1.1608 1.1608 1.1608 * 0.9100 0.9560 0.9290 0.9290 0.9290 0.9290 0.9327 0.8272 0.7597 0.9103 1.0315 * 0.9290 0.9327 0.9504 * 0.8797 0.8993 1.0334 1.0334 1.0334 * 0.8428 1.0334 0.9043 0.8993 1.0334 0.8428 0.8743 1.0334 1.0334 0.8993 * 0.8993 0.9043 Fmt 4701 Sfmt 4702 29.7888 22.0207 21.1534 * 37.1450 27.5566 28.8814 37.5741 28.0500 35.6189 * * * * * * * 34.1385 32.3784 30.0668 31.1985 31.6785 30.2473 29.5714 37.1792 30.3463 30.4257 29.9527 32.4566 28.7905 32.4847 * 24.7871 28.6158 27.2158 28.7246 30.9609 27.2543 27.3439 23.6212 21.1998 27.2195 27.3597 25.6467 26.0955 21.9792 * * 22.3001 27.0165 30.7378 29.1767 31.8806 * 23.8575 29.0336 23.9269 24.4687 26.3533 21.3438 25.9669 30.2688 30.2776 26.7310 27.9993 24.0470 23.2293 Average hourly wage FY 2008 32.3441 23.9738 21.2428 * * 29.5238 32.2603 * * * 25.3071 33.6464 29.5373 * * * * 39.6348 34.1709 31.3555 33.6942 34.2231 30.8773 30.8526 39.1941 30.9839 33.0114 32.5326 34.2244 29.5825 34.0451 44.6382 24.7266 28.6136 28.0048 30.4958 36.1570 27.5936 28.4041 24.8035 22.7962 28.4934 29.0185 29.1925 27.7607 30.4547 28.9883 21.3867 22.2003 27.4779 31.4024 31.8008 40.1360 40.1360 25.8864 31.8213 25.0951 24.6409 30.7398 22.3179 26.0493 36.7722 31.6822 27.5367 29.5256 24.4653 24.5589 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 32.0585 26.1963 22.4539 * * 30.1770 33.4462 * * * * * 28.9757 32.1814 * * * 39.0344 37.7249 32.5141 35.1716 35.7058 35.0167 34.3338 44.0519 34.2101 36.1586 34.9024 35.8383 31.8146 34.6327 * 24.3491 29.8774 28.8325 31.2250 33.8909 28.2815 30.2030 25.3184 23.8581 29.3360 29.7190 28.3416 27.7664 25.8977 28.1483 26.8243 23.2221 29.1084 32.4342 32.7592 39.3702 39.3702 26.2125 31.9498 26.4178 25.2491 31.5604 22.2899 28.1690 36.3824 32.1110 28.5229 31.4328 26.7233 28.4995 Average hourly wage** (3 years) 31.3300 24.0311 21.6327 * 37.1450 29.1787 31.6155 37.5741 28.0500 35.6189 25.3071 33.6464 29.2212 32.1814 * * * 37.5738 34.7927 31.3602 33.3840 33.9086 31.9560 31.4351 40.3992 31.8841 33.2188 32.4610 34.2218 30.1238 33.7338 44.6382 24.6130 29.0074 28.0328 30.1204 33.6903 27.7157 28.6009 24.5765 22.6625 28.3737 28.7360 27.9024 27.1825 26.3095 28.5227 23.8814 22.5895 27.9303 31.5521 31.2208 36.3250 39.7545 25.4083 30.8913 25.1250 24.8022 29.4466 21.9787 26.7518 34.4448 31.3500 27.5996 29.1997 25.0924 25.3375 23740 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 140043 140046 140048 140049 140051 140052 140053 140054 140058 140059 140062 140063 140064 140065 140066 140067 140068 140075 140077 140080 140082 140083 140084 140088 140089 140091 140093 140094 140095 140100 140101 140103 140105 140110 140113 140114 140115 140116 140117 140118 140119 140120 140122 140124 140125 140127 140130 140133 140135 140137 140143 140145 140147 140148 140150 140151 140152 140155 140158 140160 140161 140162 140164 140166 140167 140172 140174 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2647 1.4727 1.2788 1.5369 1.5614 1.3408 1.7853 1.4862 1.2320 1.0669 1.3719 1.4103 1.2191 1.4143 1.1167 1.8104 1.2321 1.2712 0.9374 1.4286 1.6302 0.9706 1.2689 1.8601 1.2292 1.7570 1.2251 1.0614 1.2067 1.4165 1.2742 1.1919 *** 1.1348 1.5825 1.5001 1.2630 1.3668 1.5097 1.4623 1.8095 1.3098 1.5055 1.2504 1.1586 1.6283 1.2280 1.4054 1.4168 1.0555 1.1818 1.0941 1.0800 1.6364 1.6423 0.7986 *** 1.3176 1.3565 1.1748 1.1449 1.5506 1.7462 1.1830 1.1518 1.3856 1.5880 PO 00000 Frm 00214 Average hourly wage FY 2007 0.8606 0.8993 1.0334 1.0334 1.0334 0.8993 0.9133 1.0334 0.8993 0.8993 1.0334 1.0334 0.9043 1.0334 0.8993 0.9043 1.0334 1.0334 0.8993 1.0334 1.0334 1.0334 1.0334 1.0334 0.8428 0.9353 0.9711 1.0334 1.0334 1.0334 1.0334 1.0334 * 1.0334 0.9353 1.0334 1.0334 1.0341 1.0334 1.0334 1.0334 0.9043 1.0334 1.0334 0.8993 0.9520 1.0334 1.0334 0.8840 0.8993 1.0334 0.8993 0.8428 0.9133 1.0334 1.0334 * 1.0334 1.0334 0.9756 0.8596 0.9520 0.8993 0.8428 0.8428 1.0334 1.0334 Fmt 4701 Sfmt 4702 27.3469 24.7334 29.3877 29.0976 30.9696 25.9617 27.4518 33.1406 24.6058 22.6743 34.1230 28.6559 23.8639 30.1856 22.1524 28.3506 28.3938 26.2626 20.3999 28.8791 28.3429 26.8919 30.5036 30.5450 24.1066 27.8536 28.3298 27.3841 28.7617 41.3374 29.4081 23.6406 29.5274 28.6364 29.5452 28.2151 26.0383 34.5537 27.7201 32.5518 34.2118 23.9724 30.5653 35.7563 22.7571 25.6668 32.6209 31.0269 23.3196 23.4174 27.4499 26.0875 21.0686 25.5677 52.0970 27.0312 30.2209 29.5734 27.3721 25.8684 25.2898 29.4121 24.6009 26.4800 22.8703 32.1220 30.5905 Average hourly wage FY 2008 29.8633 25.6230 30.6686 30.8617 32.1730 26.9907 28.4513 34.2378 25.2568 21.6230 36.8271 30.5465 25.7551 31.5510 22.0225 29.8982 26.7166 35.9507 21.6468 29.9067 31.0516 27.2189 30.7251 32.6866 24.9120 28.2095 28.6709 28.7647 29.7385 37.2961 28.9723 24.0926 29.6590 30.3432 30.2542 29.8316 25.4576 34.3876 30.9679 33.1987 32.2185 25.9275 30.2888 38.2191 26.5801 27.8363 32.5425 30.3259 24.6645 31.4349 26.1126 25.2040 21.1817 27.0038 35.5951 26.0825 29.8647 32.7960 30.4445 27.6905 28.8266 32.1810 25.9726 26.2875 24.9904 33.0926 31.2231 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 31.3736 25.7906 31.6262 32.0217 32.7506 26.7896 29.9472 34.5342 26.5660 22.8588 36.6461 31.1242 26.6231 32.4631 23.6295 30.6882 31.3440 33.6844 22.5061 30.3760 32.0539 26.1622 31.3281 34.0556 26.6942 29.4099 31.2955 28.8596 29.9452 37.3023 31.0048 25.3608 30.7135 31.3460 31.6124 31.1390 26.2578 34.1356 28.5785 33.6634 34.3896 26.2398 32.4728 38.8956 27.6333 29.3326 34.5053 32.8907 25.9046 * 27.0294 26.9326 22.1026 28.9453 45.8193 27.3539 32.2789 35.0804 32.1130 28.9023 28.8132 33.0967 27.3117 27.2398 24.2733 33.4586 34.2433 Average hourly wage** (3 years) 29.5994 25.3934 30.5704 30.6556 31.9766 26.5759 28.5957 33.9734 25.4975 22.3764 35.8580 30.0979 25.4620 31.3610 22.6003 29.6686 28.7631 31.5469 21.5537 29.7135 30.4270 26.6852 30.8596 32.5121 25.2540 28.5130 29.5310 28.3324 29.4617 38.5940 29.8038 24.3942 29.8404 30.1323 30.5020 29.7616 25.9061 34.3550 29.0528 33.1346 33.5609 25.4006 31.1094 37.6290 25.6694 27.6412 33.2090 31.4186 24.6639 26.5232 26.8354 26.0849 21.4534 27.2136 44.1226 26.8313 30.7789 32.3959 30.0627 27.4932 27.6822 31.5165 26.0022 26.6846 24.0635 32.9106 32.0655 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23741 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 140176 140177 140179 140180 140181 140182 140184 140185 140186 140187 140189 140191 140197 140200 140202 140206 140207 140208 140209 140210 140211 140213 140217 140223 140224 140228 140231 140233 140234 140239 140240 140242 140250 140251 140252 140258 140275 140276 140280 140281 140286 140288 140289 140290 140291 140292 140294 140300 140301 140303 150001 150002 150003 150004 150005 150006 150007 150008 150009 150010 150011 150012 150015 150017 150018 150021 150022 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2311 0.9832 1.3098 1.1869 1.1559 1.4662 1.3087 1.4359 1.4967 1.5073 1.1619 1.3271 1.0759 1.5134 1.4541 1.2021 1.1245 1.6424 1.5750 1.0667 1.3317 1.2466 1.4736 1.4965 1.3728 1.4758 1.4738 1.6742 1.0951 1.5089 1.4543 1.5121 1.2451 1.3749 1.4509 1.5542 1.3633 1.9223 1.4877 1.7853 1.2031 1.4810 1.2801 1.3716 1.5227 1.1466 1.1034 1.1745 1.0712 2.1328 1.1896 1.4747 1.5897 1.4569 1.2612 1.3702 1.4525 1.4479 1.4395 1.5221 1.3308 1.5537 1.3616 1.8267 1.5912 1.8098 1.0584 PO 00000 Frm 00215 Average hourly wage FY 2007 1.0341 1.0334 1.0334 1.0334 1.0334 1.0334 0.8428 0.8993 1.0334 0.8993 0.8428 1.0334 1.0334 1.0334 1.0334 1.0334 1.0334 1.0334 0.9043 0.8428 1.0334 1.0334 1.0334 1.0334 1.0334 0.9862 1.0334 0.9862 0.8743 0.9862 1.0334 1.0334 1.0334 1.0334 1.0334 1.0334 0.8606 1.0334 0.8606 1.0334 1.0334 1.0334 0.8993 1.0334 1.0334 1.0334 0.8428 1.0334 1.0334 1.0334 0.9827 1.0328 0.8960 1.0328 0.9827 0.9353 0.9254 1.0328 0.9238 0.9254 0.9707 0.9644 0.9320 0.9004 0.9353 0.9004 0.8637 Fmt 4701 Sfmt 4702 32.9794 26.4340 29.3657 27.8887 25.0226 30.1755 25.2327 25.2423 29.8022 24.8332 22.5965 28.5836 24.0463 28.8435 32.7915 29.7953 26.0535 29.5380 26.3230 20.6954 30.3286 31.6926 32.1277 31.7267 29.6181 27.9456 30.0236 29.7093 24.5476 31.1879 31.5637 34.6120 29.6305 28.0622 34.4268 34.2333 27.8186 31.6359 24.9401 33.3903 30.3237 31.5197 23.8452 31.8135 31.9052 28.5094 24.0750 35.1494 49.9507 29.6470 28.9075 26.6222 26.7585 28.7336 29.5371 25.6265 29.4971 27.5703 25.4496 27.2272 25.3178 30.0348 28.0931 26.3973 27.3689 28.9196 23.1041 Average hourly wage FY 2008 32.6145 25.5725 30.2944 29.1352 27.6835 32.8972 26.6104 26.5398 30.7212 25.5873 24.7013 31.9943 24.9103 30.6641 32.9433 29.6275 28.2262 31.4035 29.7965 19.2053 31.4539 32.1031 32.9404 33.5083 31.2237 28.2855 34.8291 31.5168 25.7353 31.0918 32.7986 35.2351 31.2533 28.3598 35.8762 33.0093 28.5064 32.1048 26.6536 35.6589 32.0048 31.5944 25.6847 32.5247 33.8706 30.6917 26.1595 42.5240 39.4295 * 31.8089 27.6481 26.9771 30.9626 30.5367 27.1364 30.0500 27.0525 25.7616 28.4118 26.7686 31.2282 27.3811 26.3379 29.1137 30.0030 23.8971 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 33.2116 26.0709 31.3599 29.7982 27.3815 26.4085 27.5837 27.9409 41.2521 26.9246 29.1349 29.7497 24.8700 31.3692 34.3762 31.1376 31.6793 26.1728 27.4032 22.2507 34.5893 33.3902 33.2151 34.6969 30.1050 28.7440 35.2199 32.3348 25.7647 33.7241 28.0966 36.6696 32.9392 29.5921 36.1503 34.5667 26.7377 32.7052 26.9815 37.5673 32.2227 32.5446 26.0851 35.9647 32.7857 32.4476 26.9772 37.1204 38.0581 32.2920 32.9797 28.1057 29.0575 31.6781 31.6148 28.3389 31.0369 29.1473 26.1499 28.2599 27.7857 30.4819 30.1474 27.1249 30.0478 31.1140 26.8394 Average hourly wage** (3 years) 32.9375 26.0349 30.3150 28.9361 26.6876 29.5346 26.4843 26.5570 33.4222 25.7702 25.4810 30.0468 24.5943 30.2724 33.4137 30.1671 28.4326 28.8260 27.7656 20.7150 32.1847 32.4246 32.8054 33.3189 30.3035 28.3351 33.3358 31.1982 25.3480 31.9840 30.7320 35.4606 31.3008 28.6552 35.4953 33.9309 27.6728 32.1538 26.2013 35.5869 31.5106 31.8981 25.2075 33.4767 32.8705 30.3851 25.8209 38.1961 40.7701 30.8365 31.2747 27.6106 27.6017 30.3933 30.6086 27.0718 30.2270 27.9333 25.7891 27.9486 26.5785 30.5840 28.5072 26.6388 28.9018 30.0142 24.4351 23742 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 150023 150024 150026 150029 150030 150033 150034 150035 150037 150038 150042 150044 150045 150046 150047 150048 150051 150056 150057 150058 150059 150061 150064 150065 150069 150072 150074 150075 150076 150082 150084 150086 150088 150089 150090 150091 150097 150100 150101 150102 150104 150109 150112 150113 150115 150125 150126 150128 150129 150132 150133 150134 150146 150147 150149 150150 150153 150154 150155 150156 150157 150158 150159 150160 150161 150162 150163 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.5869 1.4757 1.3515 1.3421 1.1963 1.4204 1.4624 1.5482 1.2521 1.1402 1.3656 1.4443 1.0453 1.5575 1.7059 1.4375 1.6111 1.9795 2.0656 1.6334 1.4852 1.1299 1.2404 1.2493 1.1831 1.1283 1.4309 1.1406 1.2974 1.5914 1.8344 1.2227 1.2980 1.5552 1.5584 1.1569 1.1855 1.6039 1.0840 1.0268 1.1443 1.5465 1.4960 1.2097 1.3474 1.5500 1.3476 1.4329 1.1906 *** 1.2148 *** 1.1296 1.4431 0.9337 1.3583 2.3079 2.4814 *** *** 1.7719 1.2495 *** 2.0971 1.6006 1.8254 1.0174 PO 00000 Frm 00216 Average hourly wage FY 2007 0.9707 0.9827 0.9353 0.9644 0.9707 0.9827 1.0328 0.9320 0.9827 0.9827 0.8791 0.9238 0.9004 0.9130 0.9004 0.9583 0.9707 0.9827 0.9827 0.9644 0.9827 0.8479 0.8479 0.9707 0.9583 0.8584 0.9827 0.9004 0.9353 0.8525 0.9827 0.9583 0.9707 0.8479 1.0328 0.9004 0.9827 0.8525 0.9004 0.9320 0.9827 0.8960 0.9707 0.9707 0.8479 1.0328 1.0328 0.9827 0.9827 * 0.9353 * 0.9547 1.0328 0.8525 0.9004 0.9827 0.9827 * * 0.9827 0.9827 * 0.9827 0.9827 0.9827 0.9238 Fmt 4701 Sfmt 4702 26.9095 28.1655 28.6517 28.7187 29.1493 28.6838 28.6429 26.9700 31.0935 29.3156 22.8786 25.2137 26.9818 24.5593 25.5194 27.1233 26.5655 28.8727 28.9529 29.1444 31.4987 21.3711 25.4987 27.9283 26.2028 21.2120 25.9321 25.1568 29.3249 28.3494 31.1720 25.1992 27.2103 24.7233 30.4835 30.4234 27.7468 25.7997 29.0301 25.7424 28.2552 25.3367 28.0068 24.7960 22.0747 27.6535 28.9454 28.7810 29.7398 27.6560 25.1322 26.3249 29.5256 27.2339 23.7026 27.0542 32.1022 29.8514 45.0121 25.9681 * * * * * * * Average hourly wage FY 2008 27.7520 28.4170 30.4967 29.9307 29.3588 29.7744 28.0434 27.8904 29.0161 33.0112 25.1403 25.2685 27.5340 26.5876 25.8497 28.1525 28.9157 29.3500 30.3287 29.1255 31.3362 22.6746 28.7978 30.2053 26.0909 21.7644 28.5655 25.7245 30.1120 26.4544 33.1784 26.6745 29.1509 24.8045 30.6412 32.1627 29.1359 26.9724 30.5475 25.8742 28.7788 26.8464 29.8540 25.9814 22.5793 29.3596 29.4300 29.5008 31.4317 * 24.2538 21.6740 30.3343 26.1646 24.9629 26.7700 35.0617 29.8894 * * 32.3106 * * * * * * E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 30.3560 30.6133 31.9378 29.7461 31.1964 33.1990 30.0027 29.2014 30.4623 31.9539 25.2440 25.9260 29.4308 27.6210 27.1835 29.5578 30.3742 30.5758 29.1268 31.7536 36.2553 23.2415 28.9419 30.8254 27.0720 23.0612 29.4124 26.5972 29.2703 28.1280 34.8522 27.2568 30.2378 26.7270 30.8754 33.0402 29.4776 27.6326 31.6018 25.4704 30.8970 28.7412 31.7711 26.9088 22.3560 31.2081 32.5356 31.1046 32.9621 * 23.0651 27.3963 31.8743 28.9248 25.3324 26.5963 37.3920 30.5758 * * 32.9148 30.4337 27.5574 28.6108 * * * Average hourly wage** (3 years) 28.3734 29.0364 30.4512 29.4587 29.9386 30.5371 28.9357 28.0374 30.1390 31.4556 24.4073 25.4830 27.9971 26.2766 26.1904 28.3255 28.6837 29.6152 29.4500 30.0001 33.0486 22.4414 27.8440 29.6617 26.4651 21.9963 28.0120 25.8595 29.5697 27.6224 33.0904 26.4089 28.8855 25.4200 30.6754 31.9030 28.7947 26.7725 30.3780 25.6892 29.3100 26.9892 29.8902 25.9097 22.3407 29.4320 30.2297 29.8290 31.3709 27.6560 24.1076 24.7453 30.6315 27.6245 24.7398 26.7808 35.1885 30.1310 45.0121 25.9681 32.6153 30.4337 27.5574 28.6108 * * * Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23743 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 150164 150165 150166 160001 160005 160008 160013 160016 160024 160028 160029 160030 160032 160033 160040 160045 160047 160057 160058 160064 160067 160069 160079 160080 160082 160083 160089 160101 160104 160110 160112 160117 160122 160124 160146 160147 160153 160155 170001 170006 170009 170010 170012 170013 170014 170016 170017 170020 170023 170027 170033 170039 170040 170049 170058 170068 170074 170075 170086 170094 170103 170104 170105 170109 170110 170114 170120 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.1402 1.3537 1.0260 1.2035 1.2221 1.0503 1.1826 1.5621 1.5070 1.3546 1.5290 1.4497 1.0815 1.6123 1.3560 1.6650 1.3438 1.3696 1.9928 1.5613 1.3956 1.5119 1.4505 1.2258 1.7394 1.6319 1.2114 1.1157 1.6343 1.4968 1.2363 1.3763 1.1372 1.1221 1.4330 1.2223 1.6977 2.0066 1.1220 1.3222 1.0785 1.2334 1.6303 1.7166 1.0389 1.5893 1.1359 1.5631 1.4632 1.4379 1.3317 0.9397 1.9332 1.5092 1.0992 1.2130 1.1942 0.8436 1.5732 0.9157 1.2784 1.4059 1.1156 1.0350 0.8962 0.5755 1.3720 PO 00000 Frm 00217 Average hourly wage FY 2007 0.9419 0.9320 0.9320 0.8881 0.8709 0.8709 0.8888 0.8881 0.9460 0.9360 0.9337 0.9457 0.8944 0.8709 0.9248 0.8746 0.9360 0.9107 0.9337 0.9248 0.9248 0.8709 0.8746 0.8709 0.9460 0.9460 0.9107 0.9460 0.8709 0.9248 0.8709 0.8709 0.8709 0.8709 0.8745 0.8881 0.8745 0.8709 0.8086 0.9351 0.9453 0.8086 0.8785 0.8785 0.9453 0.8873 0.8980 0.8785 0.8785 0.8086 0.8086 0.8980 0.9453 0.9453 0.8086 0.8885 0.8086 0.8086 0.8873 0.8086 0.8980 0.9453 0.8086 0.9453 0.8086 * 0.9351 Fmt 4701 Sfmt 4702 * * * 24.5108 23.1034 22.1402 24.0956 24.5338 27.4158 27.8535 28.7324 28.7786 25.4662 26.5315 25.9032 26.6463 26.0227 25.1272 28.4167 28.7668 24.8137 27.4473 24.7372 25.8252 27.4718 27.3004 23.2149 25.0503 28.1891 26.6633 24.7957 25.4659 23.9177 22.5482 22.6949 28.6303 29.9378 * 23.1260 24.2068 30.9025 23.9707 26.1367 25.2476 23.8135 25.8061 26.9657 23.2757 24.0561 23.1766 21.9709 26.9852 28.4458 25.2070 22.9210 23.0635 23.7829 19.7760 26.1362 21.5295 23.8042 26.2990 21.9606 23.1088 23.3260 * 22.0253 Average hourly wage FY 2008 * * * 25.7255 24.7755 22.4758 24.4099 27.1460 29.3756 30.0576 30.6687 30.9415 26.2935 27.2060 26.8110 27.5289 28.1280 25.6274 28.9924 28.4209 26.0243 27.6157 26.1618 27.2370 28.7831 28.3921 23.2888 25.4740 29.8126 28.8134 25.2886 27.3927 24.4996 24.3063 24.8485 29.8992 30.6173 * 23.8863 27.1033 29.6386 25.5573 27.1195 26.7124 24.2322 26.7536 27.2925 24.1149 23.9812 23.4037 24.1882 26.0952 30.2468 26.4086 26.5949 23.8812 23.0567 19.9351 26.3615 16.5136 24.2003 27.6211 22.7412 23.8515 23.9572 * 22.2805 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 * * * 25.8676 24.8586 24.1271 25.5144 26.6516 32.4228 29.8324 32.2010 30.4757 28.5629 27.4787 28.2966 28.1662 29.4261 27.7953 29.8956 33.6067 26.7671 28.4064 28.5014 27.8729 31.7482 29.9472 23.9184 26.8503 27.0516 29.9071 26.1706 24.3309 25.3176 25.5031 25.1816 33.6376 30.4338 * 24.5932 28.3509 32.2817 28.1793 28.7852 28.3035 25.8151 28.6802 29.1445 25.0539 24.8758 24.1118 25.0393 23.5961 30.0807 31.8575 28.1316 23.8492 24.8855 21.1954 28.5234 17.1709 25.5653 29.5069 23.4317 29.0177 24.7910 * 23.5271 Average hourly wage** (3 years) * * * 25.3903 24.2778 22.9093 24.6765 26.0785 29.7117 29.2977 30.5406 30.0901 26.7834 27.0636 27.0153 27.4620 27.7499 26.1996 29.1104 30.2004 25.8721 27.8032 26.4591 26.9717 29.3428 28.5559 23.4747 25.8119 28.2560 28.6042 25.4488 25.6596 24.5888 24.1100 24.2135 30.7344 30.3298 * 23.8766 26.6135 30.9531 25.9458 27.3256 26.7042 24.6246 27.0793 27.8530 24.1602 24.3255 23.5721 23.6609 25.4102 29.6659 27.9185 25.7970 23.5912 23.9145 20.2943 27.0437 18.5438 24.5527 27.8074 22.7174 25.4500 24.0231 * 22.6059 23744 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 170122 170123 170133 170137 170142 170145 170146 170147 170150 170166 170175 170176 170180 170182 170183 170185 170186 170187 170188 170190 170191 170192 170193 170194 170195 170196 170197 170198 180001 180002 180004 180005 180007 180009 180010 180011 180012 180013 180016 180017 180018 180019 180020 180021 180024 180025 180027 180029 180035 180036 180037 180038 180040 180043 180044 180045 180046 180048 180049 180050 180051 180053 180056 180064 180066 180067 180069 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.6975 1.6684 1.0196 1.3249 1.3711 1.0867 1.5002 *** 1.1410 1.0165 1.4832 1.5583 *** 1.4504 1.9858 1.2572 2.5220 1.6421 1.9852 1.0158 1.8259 1.7639 1.3485 1.2331 2.4249 2.4635 2.3250 1.9320 1.3069 1.0662 1.0759 1.1460 1.5443 1.7525 1.8312 1.6281 1.4715 1.5001 1.2868 1.3104 1.3551 1.1134 1.0616 0.9634 1.1593 1.2308 1.2008 1.4670 1.4807 1.3287 *** 1.5441 1.8313 1.1741 1.5998 1.3277 1.0026 1.3531 1.4067 1.1306 1.2266 0.9909 1.1314 1.2227 1.1136 1.9454 1.0930 PO 00000 Frm 00218 Average hourly wage FY 2007 0.8980 0.8980 0.9453 0.8086 0.8720 0.8086 0.9453 * 0.8252 0.8086 0.8785 0.9453 * 0.9453 0.8980 0.9453 0.8980 0.8086 0.9453 0.8720 0.8086 0.8980 0.8785 0.9453 0.9453 0.8980 0.8980 0.8086 0.9590 0.8062 0.7837 0.8767 0.8950 0.9127 0.8950 0.8756 0.9123 0.9276 0.9245 0.8230 0.7837 0.7837 0.7837 0.7837 0.9123 0.9245 0.8302 0.8756 0.9590 0.9127 * 0.8764 0.9245 0.7978 0.8767 0.9590 0.8950 0.9123 0.8756 0.7919 0.8302 0.7837 0.8531 0.8151 0.9276 0.8950 0.8767 Fmt 4701 Sfmt 4702 26.6605 27.6653 23.1226 24.7096 23.9527 23.2162 29.8858 22.4973 20.9448 21.0762 25.6281 27.2332 32.5010 27.3503 25.8340 27.8139 32.8392 22.8493 30.6844 22.9540 22.1197 26.2724 20.6821 29.9014 30.1001 * * * 27.6917 25.7862 22.0797 24.9779 25.7042 26.4101 25.6153 25.5463 25.6000 23.7075 24.8408 21.8885 20.9857 24.0283 24.6953 20.7950 31.1159 22.6897 20.8303 25.6479 31.0794 25.2972 26.3132 26.0440 27.9979 20.9326 24.4569 27.4732 27.1034 23.9230 22.4769 26.3604 23.5299 21.3044 24.3074 17.1009 22.2713 26.0238 26.3701 Average hourly wage FY 2008 28.7175 27.0843 25.2301 25.3395 24.6019 23.3967 29.0720 24.3268 19.6160 22.6968 26.7229 29.0735 * 28.9710 26.1890 28.1780 30.2613 24.1461 32.2573 26.2625 24.3813 27.7421 24.8531 27.6989 29.5947 32.1832 * * 29.7423 26.5488 20.8805 25.6159 27.1924 27.3228 27.7600 24.9909 26.7279 24.8125 24.7091 21.9715 23.3035 24.6279 25.9975 22.0740 26.3532 28.5935 21.7639 26.1528 32.8461 25.6959 27.8506 26.9752 28.5162 20.6439 25.8060 29.4127 27.0962 24.3696 24.3699 25.9557 24.3916 22.1921 24.5326 20.1799 23.7860 27.9852 26.6714 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 29.6314 28.7608 25.7108 26.8014 25.5550 25.3728 31.6994 21.4565 22.0251 24.1063 31.7582 30.1114 * 30.3781 27.7178 29.3202 30.7638 24.6391 33.7221 27.3023 26.0279 30.9200 24.4126 28.1972 29.1763 29.9641 * * 29.9655 27.3339 22.0615 27.4304 26.9425 28.7030 28.1667 25.0355 27.2829 26.8088 26.9522 25.4164 23.9155 27.6787 26.8856 22.3752 26.9538 28.4153 23.3873 26.3892 34.0348 30.2621 33.1874 28.2413 30.2450 24.0566 25.7978 29.9346 28.5552 24.6786 23.5737 26.7714 25.2356 23.0290 26.3959 21.9508 24.9530 29.6029 27.6777 Average hourly wage** (3 years) 28.2843 27.8479 24.7246 25.6444 24.7027 23.9852 30.2197 23.0046 20.8653 22.6638 28.0191 28.8494 32.5010 28.8971 26.5683 28.5075 31.2790 23.8933 32.2678 25.5425 24.3247 28.4741 22.9315 28.5250 29.5492 30.9601 * * 29.1412 26.5496 21.6721 26.0705 26.6126 27.5584 27.1559 25.1733 26.5352 25.0983 25.4644 23.1027 22.7447 25.4951 25.8897 21.7644 28.0398 26.7267 21.9095 26.0660 32.7266 27.0558 29.1431 27.1328 28.9050 21.9172 25.3776 28.9840 27.5846 24.3395 23.4731 26.3675 24.4156 22.2290 25.0679 19.7362 23.6732 27.9902 26.8870 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23745 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 180070 180078 180079 180080 180087 180088 180092 180093 180095 180101 180102 180103 180104 180105 180106 180115 180116 180117 180124 180127 180128 180130 180132 180138 180139 180141 180143 180144 180147 180148 180149 180150 190001 190002 190003 190004 190005 190006 190007 190008 190009 190011 190013 190014 190015 190017 190019 190020 190025 190026 190027 190034 190036 190037 190039 190040 190041 190044 190045 190046 190050 190053 190054 190060 190064 190065 190078 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.1929 1.0594 1.1477 1.2693 1.2269 1.7069 1.1677 1.6170 1.0117 1.3146 1.5042 2.0473 1.5676 0.9511 0.8902 0.9040 1.1839 0.9408 1.3223 1.3584 0.9392 1.6779 1.4346 1.1879 1.0065 1.8666 1.6777 *** *** *** 1.0087 1.8775 1.0903 1.5733 1.4214 1.5112 1.5223 1.2838 1.1753 1.7450 1.3606 1.0090 1.5563 1.2264 1.3070 1.4841 1.7201 1.2827 1.3344 1.6101 1.6236 1.2092 1.6604 *** 1.5115 1.4212 1.4648 1.2898 1.5439 1.4309 1.1484 1.2074 1.3250 1.4709 1.6110 1.5904 1.0906 PO 00000 Frm 00219 Average hourly wage FY 2007 0.8077 0.8767 0.8096 0.7889 0.7837 0.9245 0.8950 0.8131 0.7837 0.8950 0.8302 0.8950 0.8302 0.7837 0.7837 0.7837 0.8320 0.7837 0.9276 0.9123 0.7837 0.9245 0.8756 0.9245 0.7837 0.9245 0.8950 * * * 0.7837 0.9245 0.7682 0.8438 0.8438 0.7870 0.9140 0.8438 0.7682 0.7870 0.8127 0.7961 0.7682 0.7682 0.9140 0.8438 0.8127 0.8142 0.7682 0.8127 0.7682 0.7871 0.9140 * 0.9140 0.9140 0.8547 0.7943 0.9140 0.9140 0.7726 0.7783 0.7767 0.7682 0.8142 0.8142 0.7869 Fmt 4701 Sfmt 4702 20.6741 27.6806 20.2100 21.5818 20.8841 28.0916 23.7909 20.5807 17.9146 27.4506 21.0896 28.4583 25.6157 21.6002 20.2884 20.5539 23.5354 22.8469 24.8292 24.6774 22.6056 27.8900 24.5105 28.1901 23.3569 25.3357 28.1924 29.5052 * * * * 22.1394 23.3368 25.8294 25.3473 22.6029 22.7979 21.8205 24.6074 21.1005 21.4052 21.4573 22.7151 23.7789 24.5390 24.0468 22.1967 23.5007 23.7702 24.3006 20.7334 25.4164 19.4071 24.4386 28.6297 28.5376 20.9993 25.8238 23.8552 21.0259 17.9788 23.1471 23.7393 23.1358 22.1880 22.2431 Average hourly wage FY 2008 20.2189 28.2762 23.6005 23.7788 22.0302 28.6107 23.7866 21.4392 21.5639 28.1621 25.2343 28.1734 25.9689 23.1917 20.7220 20.3089 25.8927 24.7378 25.4664 26.3947 23.8144 29.1712 25.3789 28.6871 24.7575 27.5912 30.8734 * 31.1615 30.1250 * * 22.1569 24.6984 26.7844 25.0803 24.2899 24.8836 23.1426 26.3638 24.0696 21.6991 23.7333 22.6405 25.1767 24.7537 25.4624 23.4602 24.5024 24.1556 26.7132 21.2130 25.6551 20.7271 25.4003 28.0169 28.0050 21.2604 27.1996 24.7370 20.9142 18.5819 22.7011 22.6291 23.7298 23.1202 22.2346 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 21.3693 29.2125 24.9898 25.2996 22.1044 30.7936 25.2884 22.3324 21.2154 28.8758 27.3887 29.7626 27.1274 24.3659 21.2265 22.7088 26.8836 24.9567 27.1341 28.3610 23.7770 29.6725 29.0546 29.2584 26.2434 28.7307 28.2122 * * * 16.4909 * 22.5328 25.9371 28.0895 24.6536 28.3303 25.2490 24.0527 27.2663 25.0269 21.9165 22.8372 24.5399 26.9572 25.5465 27.5462 24.2346 26.5944 25.3736 31.5026 22.9658 30.2172 28.0447 24.6075 28.2426 28.7683 22.2461 27.5854 * 22.7951 20.6282 23.5129 19.8899 26.9941 22.9847 25.6940 Average hourly wage** (3 years) 20.7657 28.3867 22.8630 23.5872 21.6767 29.1743 24.3103 21.4596 20.0750 28.2013 24.3942 28.8044 26.2415 23.0870 20.7447 21.1833 25.4592 24.2081 25.8362 26.4554 23.4109 28.9399 26.3805 28.7287 24.7763 27.2557 29.0557 29.5052 31.1615 30.1250 16.4909 * 22.2811 24.6300 26.9253 25.0228 24.2844 24.3632 23.0456 26.0087 23.3881 21.6827 22.6699 23.2756 25.3336 24.9732 25.7258 23.3365 24.8092 24.4572 27.4175 21.6044 26.9231 21.7538 24.8194 28.2870 28.4375 21.5123 26.9044 24.2936 21.5828 19.0432 23.1218 21.9229 24.6370 22.7749 23.4396 23746 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 190079 190081 190086 190088 190090 190098 190099 190102 190106 190111 190114 190115 190116 190118 190122 190124 190125 190128 190131 190133 190135 190140 190144 190145 190146 190151 190152 190158 190160 190161 190162 190164 190167 190175 190176 190177 190182 190183 190184 190185 190190 190191 190196 190197 190199 190200 190201 190202 190203 190204 190205 190206 190208 190218 190236 190241 190242 190245 190246 190247 190248 190249 190250 190251 190252 190253 190254 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.1812 0.8736 1.2760 1.1378 1.0338 1.7595 1.0153 1.5441 1.1415 1.6311 1.0602 1.2209 1.1880 0.9844 1.4015 *** 1.5711 1.0269 1.3325 0.9162 1.6174 0.9876 1.2672 0.9764 1.5575 0.9239 1.1740 *** 1.5637 1.0278 *** 1.1308 1.2763 1.2783 1.7856 1.6464 *** 1.2357 0.9592 *** 0.9248 1.3760 0.9701 *** 1.1052 *** 1.2572 1.5245 *** 1.4475 1.6677 2.0426 0.8467 1.0293 1.4591 2.2461 1.1726 1.6582 1.8467 *** *** 1.7284 2.1126 1.3045 *** *** *** PO 00000 Frm 00220 Average hourly wage FY 2007 0.9140 0.7682 0.7785 0.8547 0.7682 0.8547 0.7871 0.8438 0.8127 0.8547 0.7682 0.8547 0.7767 0.8547 0.8142 * 0.7961 0.8142 0.8142 0.7784 0.9140 0.7717 0.8547 0.7772 0.9140 0.7682 0.9140 * 0.7961 0.7682 * 0.8127 0.8438 0.9140 0.9140 0.9140 * 0.7870 0.7785 * 0.7843 0.8438 0.8438 * 0.8142 * 0.7682 0.8142 * 0.9140 0.8438 0.9140 0.7682 0.8547 0.8547 0.7870 0.8142 0.7961 0.7843 * * 0.8142 0.9140 0.8142 * * * Fmt 4701 Sfmt 4702 24.0985 20.0121 22.0610 23.8562 23.1241 25.6854 22.0610 27.3126 23.5376 25.5729 17.2678 28.2066 22.3710 22.8809 22.0072 26.0032 25.5463 28.3257 27.8465 18.2045 27.7540 18.9652 22.9181 19.9265 27.4824 18.7467 28.1334 26.4787 22.9325 22.6187 25.2953 25.2560 26.4669 26.0547 25.8826 27.7792 27.1682 22.6928 24.9476 25.6394 24.3327 24.1923 24.0385 25.8071 27.3304 28.8173 25.1010 27.6084 28.1832 28.1033 26.6832 26.7401 28.7308 26.7262 24.7142 25.2123 24.8461 25.5751 * 32.7499 23.2220 20.0468 31.5101 21.4464 23.6924 22.8060 32.9290 Average hourly wage FY 2008 23.8192 21.4510 22.2895 23.1638 24.3303 25.7449 23.2343 26.9700 26.6227 26.5722 19.1586 26.0797 23.4013 21.2580 22.2371 27.9484 24.8256 29.6682 28.6795 22.4311 30.5646 23.0485 23.7875 20.8579 28.7200 18.8391 30.8512 30.6450 24.7822 22.9035 * 26.6207 25.3283 27.4256 26.2596 28.2751 29.8656 22.0119 24.1626 28.9759 26.7043 26.1628 25.8472 26.4825 32.0194 27.4781 24.4563 29.6612 29.9753 30.5140 28.2484 29.2371 27.9908 28.1039 26.4614 25.7906 25.0035 26.7642 22.7833 * * 25.2523 33.3302 23.8389 * 23.8037 * E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 25.3327 20.4101 22.2837 24.7445 25.8607 27.5043 25.7481 28.3071 24.2755 27.3180 20.3639 26.0278 24.2156 22.6571 22.8671 28.6694 26.6254 31.1762 28.5938 23.9545 35.0524 23.6705 24.8858 21.3982 28.5963 20.6962 34.6485 21.9727 25.8632 23.8066 * 27.7247 27.1969 30.5928 * 29.7229 30.7038 23.3452 22.6137 36.7292 27.5056 26.9649 27.7801 28.7026 36.7076 * 26.8537 * * 32.9125 30.1674 32.0163 24.9395 26.5243 26.9046 26.5307 26.9715 26.4147 31.7133 * * 27.0954 32.8347 25.1576 * 22.2212 * Average hourly wage** (3 years) 24.4472 20.6028 22.2151 23.9122 24.3672 26.3126 23.6613 27.5010 24.7510 26.5044 18.9135 26.7727 23.3424 22.2425 22.4040 27.4838 25.6717 29.7845 28.3736 22.0666 30.2944 21.8176 23.8764 20.7221 28.2726 19.4061 30.9971 27.7355 24.4460 23.1213 25.2953 26.5855 26.3225 28.0066 26.0715 28.5969 29.2917 22.7038 23.9160 29.7365 26.1460 25.7635 25.9541 26.9781 31.6410 28.3200 25.4868 28.6936 29.0343 30.3814 28.3935 29.3053 26.8779 27.0954 26.0708 25.8664 25.6625 26.2436 27.5712 32.7499 23.2220 23.4238 32.5070 23.4538 23.6924 23.0780 32.9290 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23747 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 190255 190256 190257 190258 190259 190260 190261 190262 190263 190264 190265 190266 190267 190268 190270 190272 190273 190274 190275 190276 190277 200001 200002 200008 200009 200018 200019 200020 200021 200024 200025 200031 200032 200033 200034 200037 200039 200040 200041 200050 200052 200063 210001 210002 210003 210004 210005 210006 210007 210008 210009 210011 210012 210013 210015 210016 210017 210018 210019 210022 210023 210024 210025 210027 210028 210029 210030 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.7692 0.8038 1.6689 *** 2.0814 *** 1.3897 *** 2.3211 *** *** 2.3213 1.3728 1.6840 1.8665 1.2748 1.7599 1.6077 1.3329 0.8985 0.8585 1.3378 1.1591 1.3906 1.9207 1.3207 1.2779 1.3255 1.2204 1.6748 1.1710 1.3018 1.1782 1.8241 1.3255 1.1982 1.2970 1.2039 1.2079 1.2398 1.1153 1.1834 1.3549 1.9987 1.6222 1.4250 1.2610 1.0725 1.7994 1.4105 1.6490 1.3847 1.5973 1.1768 1.2997 1.6120 1.2904 1.2011 1.7205 1.4645 1.4878 1.8236 1.2388 1.4130 1.0692 1.2751 1.1883 PO 00000 Frm 00221 Average hourly wage FY 2007 0.8438 0.9140 0.7785 * 0.8438 * 0.7961 * 0.8438 * * 0.8142 0.9140 0.8438 0.9140 0.8438 0.8142 0.9140 0.9140 0.8547 0.8069 1.0115 0.8609 0.9927 0.9927 0.8609 0.9927 1.0007 0.9927 0.9644 0.9927 0.8609 0.9075 1.0115 0.9644 0.8609 0.9644 0.9927 0.8609 1.0115 0.8609 0.8609 0.9460 0.9981 1.0670 1.1018 1.1018 0.9981 0.9981 0.9981 0.9981 0.9981 0.9981 0.9981 0.9981 1.1018 0.8795 1.1018 0.9194 1.1018 1.0060 0.9981 0.8795 0.8795 0.9307 0.9981 0.8795 Fmt 4701 Sfmt 4702 22.2412 * * 31.3715 * * * * * * * * * * * * * * * * * 25.2542 25.7212 27.7137 30.7510 23.5632 25.6649 32.6436 27.1381 27.5410 26.3124 21.2370 26.3322 29.3108 27.0582 24.1732 25.1179 25.9893 24.9670 27.6825 22.5159 25.8623 28.2858 32.3005 34.1109 33.6056 28.9554 25.9005 31.8767 24.3341 27.7900 30.8575 30.3078 28.5328 29.9261 32.3506 25.1890 29.5533 27.3731 35.4727 32.1812 30.6359 23.8552 24.6343 26.3469 31.0266 26.9763 Average hourly wage FY 2008 16.1593 25.9577 26.5505 26.1141 26.5084 29.3947 27.0441 30.3719 26.4202 26.5842 22.6231 * * * * * * * * * * 26.3045 27.1151 29.1836 32.5812 22.5027 27.7896 34.0916 29.2054 29.7817 28.5750 22.2151 26.8993 31.7007 27.0103 24.9418 26.6409 27.8053 26.6777 29.5033 24.4204 27.9748 29.3471 33.7388 30.7334 31.7132 29.5835 27.3620 30.7124 28.8850 30.2661 31.0966 31.1778 28.9917 32.2774 33.5493 26.8592 29.6521 28.7844 37.3092 33.0212 32.9434 24.8570 24.4821 26.7462 31.8539 32.2033 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 23.8013 25.9352 22.7493 25.1970 27.5500 33.6205 25.4725 * 29.7034 * 30.9242 24.3790 24.2777 29.1407 * 28.4541 * * * * * 28.1124 33.2665 29.3519 35.0717 24.6780 28.3393 34.5740 28.7597 30.9932 29.3588 23.7539 27.2259 33.6270 28.0397 26.7798 28.8029 25.5506 27.5049 30.1456 25.6220 28.2184 31.2328 36.0222 28.2547 33.9015 32.4052 27.9844 31.4098 31.8512 31.8249 30.7517 32.5280 32.1151 31.6875 35.3218 26.6187 31.5431 30.5458 36.1806 34.1635 34.5523 23.5138 25.2106 28.5196 32.9078 29.1777 Average hourly wage** (3 years) 20.1015 25.9454 24.6724 27.3097 27.0088 31.1711 26.2680 30.3719 28.0032 26.5842 27.1318 24.3790 24.2777 29.1407 * 28.4541 * * * * * 26.5658 28.3561 28.7769 32.7319 23.5929 27.2843 33.7902 28.4046 29.4721 28.1289 22.4062 26.8277 31.6171 27.3625 25.3841 26.8816 26.3685 26.3961 29.1592 24.1936 27.3991 29.6476 34.1104 30.8148 33.0686 30.3394 27.0796 31.3077 28.2947 29.9840 30.9025 31.3781 29.7726 31.3239 33.6933 26.2235 30.2539 28.9499 36.3038 33.1583 32.7596 24.0665 24.7916 27.2373 31.9592 29.4507 23748 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 210032 ..................................................... 210033 ..................................................... 210034 ..................................................... 210035 ..................................................... 210037 ..................................................... 210038 ..................................................... 210039 ..................................................... 210040 ..................................................... 210043 ..................................................... 210044 ..................................................... 210045 ..................................................... 210048 ..................................................... 210049 ..................................................... 210051 ..................................................... 210054 ..................................................... 210055 ..................................................... 210056 ..................................................... 210057 ..................................................... 210058 ..................................................... 210060 ..................................................... 210061 ..................................................... 220001 ..................................................... 220002 ..................................................... 220006 ..................................................... 220008 ..................................................... 220010 ..................................................... 220011 ..................................................... 220012 ..................................................... 220015 ..................................................... 220016 ..................................................... 220017 ..................................................... 220019 ..................................................... 220020 ..................................................... 220024 ..................................................... 220025 ..................................................... 220028 ..................................................... 220029 ..................................................... 220030 ..................................................... 220031 ..................................................... 220033 ..................................................... 220035 ..................................................... 220036 ..................................................... 220046 ..................................................... 220049 ..................................................... 220050 ..................................................... 220051 ..................................................... 220052 ..................................................... 220058 ..................................................... 220060 ..................................................... 220062 ..................................................... 220063 ..................................................... 220065 ..................................................... 220066 ..................................................... 220067 ..................................................... 220070 ..................................................... 220071 ..................................................... 220073 ..................................................... 2200744 .................................................... 220B744 ................................................... 220075 ..................................................... 220076 ..................................................... 220077 ..................................................... 220080 ..................................................... 220082 ..................................................... 220083 ..................................................... 220084 ..................................................... 220086 ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.1828 1.1640 1.2631 1.3018 1.2037 1.1889 1.1193 1.2216 1.3058 1.3653 0.9952 1.3768 1.2275 1.2948 1.2558 1.2394 1.3104 1.3542 1.1208 1.2448 1.2566 1.2273 1.3729 *** 1.2887 1.2326 1.1369 1.4655 1.2984 1.1282 1.3194 1.0429 1.1312 1.2349 1.0377 *** 1.1472 1.1059 1.5532 1.1976 1.4173 1.5119 1.4449 1.2309 1.0897 1.3081 1.1432 1.0116 1.1603 0.6341 1.2647 1.2613 1.3284 1.2302 1.1429 1.8365 1.1896 1.3507 *** 1.5438 *** 1.6655 1.1645 1.2899 1.0693 1.2134 1.7222 PO 00000 Frm 00222 Average hourly wage FY 2007 1.0645 0.9981 0.9981 1.0670 0.8795 0.9981 1.0670 0.9981 1.0060 0.9981 0.9194 0.9981 0.9981 1.0670 1.0670 1.0670 0.9981 1.1018 0.9981 1.0670 0.8983 1.1338 1.1338 * 1.1338 1.1338 1.1338 1.2672 1.0343 1.0343 1.1994 1.1338 1.1338 1.0343 1.1338 * 1.1338 1.0343 1.1994 1.1338 1.1338 1.1994 1.0445 1.1338 1.0343 1.0199 1.1994 1.1338 1.1994 1.1338 1.1338 1.0343 1.0343 1.1994 1.1338 1.1994 1.1338 1.1338 * 1.1994 * 1.0972 1.1338 1.1338 1.1994 1.1338 1.1994 Fmt 4701 Sfmt 4702 27.0727 28.5534 30.2908 28.6484 27.3287 29.8121 30.4991 28.3559 26.6524 29.7339 14.2223 27.5043 26.0900 29.8892 27.4328 30.6941 30.0810 31.6787 31.0873 27.1764 23.1645 30.6070 32.4356 30.7673 31.3385 30.7804 34.7655 37.8763 29.6315 30.4813 31.6170 24.4009 28.5288 28.7342 25.6478 31.7122 30.6935 26.8849 36.8477 31.8249 31.4470 33.1436 30.4460 30.4740 28.3434 30.2552 32.4130 25.7247 32.5477 25.0766 30.2866 27.6009 27.8073 30.2222 33.1299 36.5065 34.2989 30.5607 * 30.9175 27.5148 31.7325 29.9595 30.0611 34.5118 30.9527 34.2388 Average hourly wage FY 2008 27.9359 29.2504 32.3827 27.3901 27.8394 32.3206 32.4139 29.2390 32.6961 30.3349 16.3724 26.0650 27.0161 29.5219 27.7607 31.4905 32.3518 32.8299 31.1988 29.9626 25.0253 31.2316 33.6649 33.6438 34.7924 32.0925 36.5640 39.7564 32.4903 32.5863 33.3020 25.7855 30.8458 31.9491 30.4369 39.3089 31.6363 28.1347 38.9433 32.3495 34.8739 35.9124 31.4510 32.4652 29.5194 30.1022 32.3532 27.8893 34.7336 25.4224 32.9283 30.1103 29.9736 32.4019 34.2598 37.4087 36.0289 31.4730 31.4731 32.2957 * 34.0168 31.1268 30.8230 34.5969 31.6955 35.3451 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 29.2770 28.4332 33.0382 30.6664 28.8691 31.1537 35.1146 31.0827 29.2744 31.5436 19.6097 29.2439 28.5947 30.7936 28.6884 30.1989 32.7755 33.7244 32.0642 32.5116 26.6822 32.0820 35.9738 * 35.8651 33.7364 39.1211 41.7040 35.2353 33.1404 34.6550 26.3006 32.1503 32.8073 27.6958 * 32.6767 29.3701 39.4182 34.6977 36.1775 37.7268 33.8585 35.1108 30.3160 32.8672 34.9126 30.0325 36.8641 27.3304 32.2417 32.3793 * 33.9807 35.6244 40.0281 37.4224 33.2051 33.2051 33.3538 * 33.7563 33.1617 32.2105 35.2728 34.6254 36.2359 Average hourly wage** (3 years) 28.1114 28.7353 31.9423 28.8614 28.0163 31.0730 32.6902 29.5738 29.4113 30.5467 16.8133 27.5592 27.3346 30.0807 27.9549 30.7527 31.8047 32.7501 31.4531 29.9224 25.0230 31.3057 34.0706 32.1319 34.0329 32.2148 36.8964 39.8247 32.4365 32.0656 33.1982 25.5037 30.5508 31.1791 27.7639 35.2808 31.6963 28.1501 38.4392 33.0203 35.0964 35.6257 31.9500 32.7132 29.4110 31.0914 33.2019 27.9127 34.7665 25.9567 31.8295 30.0468 28.8792 32.2180 34.3611 38.0115 35.9320 31.7041 32.3862 32.1942 27.5148 33.1765 31.3799 31.0609 34.8205 32.3748 35.3173 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23749 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 220088 220089 220090 220095 220098 220100 220101 220105 220108 220110 220111 220116 220119 220126 220133 220135 220153 220154 220162 220163 220171 220174 220175 220176 230002 230003 230004 230005 230013 230015 230017 230019 230020 230021 230022 230024 230029 230030 230031 230034 230035 230036 230037 230038 230040 230041 230046 230047 230053 230054 230055 230058 230059 230060 230065 230066 230069 230070 230071 230072 230075 230077 230078 230080 230081 230085 230089 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.9446 *** 1.2394 1.1576 1.1400 1.3072 1.2971 1.1814 1.1999 2.0011 1.2206 1.8714 1.1333 1.1806 *** 1.3038 *** *** 1.5970 1.6172 1.6935 1.1926 1.2681 1.6474 1.3237 1.2416 1.7110 1.2402 1.3836 1.1593 1.6518 1.6077 1.7476 1.5495 1.2686 1.6538 1.6160 1.2847 1.3571 1.3764 1.1994 1.4140 1.3059 1.7649 1.1794 1.5803 1.9162 1.4494 1.6700 1.8803 1.2587 1.1167 1.5346 1.2934 *** 1.3058 1.1826 1.6502 0.9448 1.3622 1.3557 1.8799 1.1903 1.2607 1.2326 1.2326 1.3435 PO 00000 Frm 00223 Average hourly wage FY 2007 1.1994 * 1.1338 1.1338 1.1338 1.1994 1.1338 1.1338 1.1994 1.1994 1.1994 1.1994 1.1994 1.1994 * 1.2672 * * * 1.1338 1.1338 1.1338 * 1.1338 1.0113 0.9455 1.0227 0.9337 1.0052 0.9159 1.0910 1.0052 1.0113 1.0365 0.9652 1.0113 1.0052 0.8864 0.9972 0.8864 0.9305 0.9472 1.0113 0.9455 0.9305 0.9472 1.0444 1.0052 1.0113 0.9412 0.8864 0.8864 0.9455 0.8864 * 1.0227 1.0810 0.9034 1.0052 0.9455 1.0086 1.0810 0.8864 0.9472 0.8864 1.0910 1.0113 Fmt 4701 Sfmt 4702 35.8255 32.6305 32.9011 28.0673 30.5869 31.9859 35.3464 33.2625 32.6131 39.2167 33.6167 36.4149 30.9965 31.4882 29.4855 36.0203 * * * 34.4874 32.7414 30.0406 * * 32.9010 27.5824 29.3934 25.8768 24.6511 26.2782 31.8821 32.3401 28.5646 26.5659 25.6683 32.1483 32.3538 23.8082 29.7232 24.4845 24.8822 29.3754 28.9244 28.2012 25.5154 27.8853 31.6235 31.1771 32.5711 25.7591 27.4349 25.9291 27.9091 28.2874 32.6255 30.6184 30.2663 25.6778 28.3064 26.2838 28.2540 29.8538 25.6809 24.1573 24.7374 23.4959 31.0522 Average hourly wage FY 2008 34.7637 34.8205 34.1963 30.8626 31.5403 34.6599 37.7809 34.4029 33.8854 40.7382 34.2498 38.8799 32.0863 32.6938 34.9182 37.5189 19.8085 28.7898 * 37.4968 35.9948 30.9503 * * 32.7578 28.4716 31.5136 27.7463 27.2075 27.2541 32.5396 34.3213 29.5324 28.6169 30.1195 32.5892 32.3845 25.1100 30.0120 24.4141 25.6715 29.9642 28.5311 29.1263 26.3190 27.9569 32.2924 31.7075 32.1566 26.3251 28.4787 27.3156 28.5875 27.0288 * 30.2104 31.3406 26.8315 29.6728 27.4742 30.9525 30.5567 25.7232 24.5432 26.4337 25.4289 32.8450 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 37.0808 * 35.8940 31.1619 30.6593 35.7276 36.0984 35.8155 35.6985 43.8401 35.6193 40.0952 33.7174 35.6250 * 38.7180 17.9600 * * 39.4859 36.4545 32.9113 34.1550 31.4195 33.9675 28.9871 33.4620 29.0625 28.6417 28.9588 36.8018 35.1415 29.9072 29.5397 25.7829 34.5253 33.1460 24.9719 30.8859 29.1079 25.7083 31.0922 28.8529 30.1019 27.2835 30.3060 33.5285 32.0225 33.5420 28.1223 28.1872 27.9625 28.3586 28.7744 * 32.3459 31.9653 28.0349 28.2055 28.8006 32.1146 31.0097 27.0050 25.6193 27.8091 27.6459 32.2293 Average hourly wage** (3 years) 35.9288 33.7125 34.3697 30.0333 30.9378 34.1807 36.4336 34.5228 34.0752 41.3123 34.5167 38.4127 32.3365 33.2716 32.1170 37.4435 18.7803 28.7898 * 37.2285 35.0735 31.3266 34.1550 31.4195 33.2532 28.3360 31.5262 27.5854 26.7586 27.5253 33.8177 33.9317 29.3527 28.2368 27.0325 33.1061 32.6277 24.6466 30.2337 25.8635 25.4572 30.1636 28.7691 29.1994 26.3819 28.7057 32.5197 31.6475 32.7704 26.7475 28.0393 27.0813 28.2947 28.0391 32.6255 31.0702 31.2223 26.8663 28.7253 27.5408 30.4322 30.4726 26.0991 24.7905 26.3288 25.5347 31.9436 23750 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 230092 ..................................................... 230093 ..................................................... 230095 ..................................................... 230096 ..................................................... 230097 ..................................................... 230099 ..................................................... 230100 ..................................................... 230101 ..................................................... 2301045 .................................................... 230B045 ................................................... 230105 ..................................................... 230106 ..................................................... 230108 ..................................................... 230110 ..................................................... 230117 ..................................................... 230118 ..................................................... 230119 ..................................................... 230121 ..................................................... 230130 ..................................................... 230132 ..................................................... 230133 ..................................................... 230135 ..................................................... 230141 ..................................................... 230142 ..................................................... 230144 ..................................................... 230146 ..................................................... 230151 ..................................................... 230156 ..................................................... 230165 ..................................................... 230167 ..................................................... 230174 ..................................................... 230176 ..................................................... 230180 ..................................................... 230184 ..................................................... 230190 ..................................................... 230193 ..................................................... 230195 ..................................................... 230197 ..................................................... 230204 ..................................................... 230207 ..................................................... 230208 ..................................................... 230212 ..................................................... 230216 ..................................................... 230217 ..................................................... 230222 ..................................................... 230223 ..................................................... 230227 ..................................................... 230230 ..................................................... 230236 ..................................................... 230239 ..................................................... 230241 ..................................................... 230244 ..................................................... 230254 ..................................................... 230257 ..................................................... 230259 ..................................................... 230264 ..................................................... 230269 ..................................................... 230270 ..................................................... 230273 ..................................................... 230275 ..................................................... 230277 ..................................................... 230279 ..................................................... 230283 ..................................................... 230294 ..................................................... 230295 ..................................................... 230296 ..................................................... 230297 ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.3964 1.2159 1.2754 1.1779 1.6913 1.2173 1.1914 1.1683 1.5934 *** 1.7842 1.2381 1.1549 1.2539 1.8415 1.0095 1.4381 1.2621 1.6817 1.5413 1.4288 1.3171 1.6173 1.2688 1.8275 1.3735 1.3314 1.5950 1.5974 1.6088 1.3451 1.3115 1.1167 *** *** 1.3561 1.4319 1.6021 1.4349 1.2451 1.2210 1.0426 1.4778 1.4015 1.4250 1.3052 1.4799 1.4804 1.5428 1.3021 1.1943 1.4607 1.4847 0.9794 1.2691 2.0641 1.4701 1.3480 1.4692 0.5428 1.4612 0.5480 *** *** *** *** 1.6971 PO 00000 Frm 00224 Average hourly wage FY 2007 1.0113 0.8922 0.9472 1.0365 0.9305 1.0113 0.8864 0.8864 1.0113 * 0.9472 0.9455 0.8864 0.8864 1.0910 0.8864 1.0113 0.9652 1.0052 1.1258 0.8864 1.0113 1.1258 1.0113 1.0444 1.0113 1.0052 1.0444 1.0113 0.9899 0.9455 1.0113 0.8864 * * 0.9972 1.0052 1.1258 1.0052 1.0052 0.9305 1.0444 0.9972 1.0086 0.9472 1.0052 1.0052 0.9899 0.9455 0.8864 0.9972 1.0113 1.0052 1.0052 1.0444 1.0052 1.0052 1.0113 1.0113 0.9034 1.0052 1.0810 * * * * 1.0052 Fmt 4701 Sfmt 4702 28.6829 25.5804 22.8681 30.6024 28.2526 29.0221 24.1881 25.4839 32.4634 * 32.4583 25.3243 20.2539 27.0040 32.7994 23.6110 30.7488 26.4940 30.1608 32.3939 23.9442 25.9583 31.6152 27.8377 * 26.8156 27.4546 32.3755 29.6376 29.8071 30.0563 28.1498 26.0707 34.6295 30.7875 25.1626 29.5656 32.0063 31.5615 25.4268 23.7523 31.9818 29.0147 30.1136 29.9341 28.6745 30.8218 29.8763 31.3110 21.0814 27.6106 29.6283 29.2653 29.6712 27.4217 22.7768 31.3226 28.5372 31.9862 23.8104 29.8372 27.2816 33.5531 31.6195 27.1298 * * Average hourly wage FY 2008 29.3442 27.4463 25.1854 31.7399 29.8962 29.3720 25.2118 28.4372 32.4125 * 30.5515 27.8584 24.4337 25.7196 33.0602 24.8890 31.9696 26.8361 31.2744 35.5304 25.0647 23.6005 33.2553 29.7417 * 27.2621 29.8366 33.9034 31.4242 31.0657 29.7488 28.9798 24.9696 * 33.8229 26.4728 30.9702 33.7128 32.2882 25.1983 24.3476 32.8567 29.2061 31.9732 30.6482 29.8430 33.6716 31.1712 30.8556 22.1579 28.5516 30.0405 29.5874 30.6372 27.5982 28.5416 31.3800 28.8173 31.5396 25.2133 31.4023 27.9726 * * * 34.2107 * E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 30.5399 27.0555 25.9196 27.7873 31.5152 28.7386 25.6583 28.8595 34.0171 34.0171 32.1103 30.0195 25.7463 27.0263 33.9148 24.8631 33.2026 27.7495 32.5589 38.2428 25.8516 31.5185 36.3094 29.9882 * 29.0197 28.6704 34.7840 32.2831 32.8063 31.2452 29.2664 24.6000 * 33.6707 28.4624 32.5528 34.8039 30.1956 26.8215 25.2472 33.4362 28.9567 33.0815 32.4389 31.9496 34.2728 31.4931 31.9088 23.5448 30.0233 32.1407 31.2379 30.0667 27.9557 29.2178 34.2667 29.2388 32.5706 22.3717 32.2518 26.8539 * * * * * Average hourly wage** (3 years) 29.5449 26.7238 24.6699 29.8976 29.8782 29.0351 25.0492 27.6204 32.9570 34.0171 31.7057 27.7687 23.4436 26.5809 33.2761 24.4400 32.0127 27.0478 31.3612 35.3551 24.9772 26.7530 33.7170 29.2232 * 27.7279 28.6311 33.7042 31.1343 31.2488 30.3405 28.8186 25.1971 34.6295 32.7904 26.7218 31.0477 33.5209 31.3391 25.8117 24.4569 32.7601 29.0586 31.7828 30.9827 30.1361 32.7518 30.8595 31.3744 22.2557 28.7406 30.6177 30.0646 30.1067 27.6540 26.4132 32.3991 28.8712 32.0372 23.7470 31.1889 27.3521 33.5531 31.6195 27.1298 34.2107 * Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23751 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 230298 230300 230301 240001 240002 240004 240006 240010 240014 240017 240018 240019 240020 240022 240030 240036 240038 240040 240043 240044 240047 240050 240052 240053 240056 240057 240059 240061 240063 240064 240066 240069 240071 240075 240076 240078 240080 240084 240088 240093 240100 240101 240104 240106 240115 240117 240128 240132 240141 240166 240187 240196 240206 240207 240210 240211 240213 250001 250002 250004 250006 250007 250009 250010 250012 250015 250017 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.7864 3.3739 1.0374 1.5531 1.8744 1.5878 1.2147 1.9657 1.0726 *** 1.2598 1.0353 1.1144 1.0632 1.3950 1.6415 1.4964 1.0575 1.2453 1.0841 1.5230 1.0910 1.2031 1.5039 1.3585 1.7902 1.0937 1.8510 1.5799 1.1730 1.5245 1.1972 1.1037 1.1903 1.0213 1.6519 1.9537 1.1356 1.2998 1.4599 1.3409 1.1984 1.2063 1.6106 1.4822 1.1647 *** 1.2651 1.1039 1.1593 1.2972 0.8466 0.9236 1.2383 1.2823 1.0511 1.4161 1.9650 0.9549 1.7720 1.1563 1.2323 1.2588 1.0456 0.9464 1.1829 1.0987 PO 00000 Frm 00225 Average hourly wage FY 2007 1.0052 1.0052 1.0052 1.0997 1.0519 1.0997 1.0982 1.0982 1.0997 * 0.9925 1.0519 1.0997 0.9120 1.0638 1.0997 1.0997 1.0519 0.9120 0.9745 1.0519 1.0997 0.9120 1.0997 1.0997 1.0997 1.0997 1.0982 1.0997 1.0401 1.0997 1.0997 1.0997 1.0638 1.0997 1.0997 1.0997 1.0519 1.0638 1.0997 0.9120 0.9120 1.0997 1.0997 1.0997 0.9647 * 1.0997 1.0997 0.9120 1.0997 1.0997 1.4448 1.0997 1.0997 0.9932 1.0997 0.8095 0.7883 0.8909 0.8909 0.8898 0.8361 0.7653 0.9329 0.7653 0.7653 Fmt 4701 Sfmt 4702 * * * 33.1499 31.6000 32.7010 31.0777 33.4668 29.8905 24.3596 28.1432 33.7546 31.3874 26.1920 26.5508 32.7028 31.9891 27.5074 23.3489 25.0988 28.6406 27.5553 28.7206 31.4324 33.1728 30.7703 31.0911 33.1799 33.7895 34.3757 35.3441 29.3718 28.6950 27.5039 30.6936 32.5785 32.5725 26.5975 28.0603 27.2928 30.8391 25.6963 31.6511 30.5927 32.0107 24.5750 23.3334 32.1233 31.4468 27.6987 27.8844 31.5965 * 32.5589 32.7123 22.5430 33.8680 23.5222 23.4063 24.7907 24.4282 24.8929 23.0352 21.4322 21.5540 22.0067 22.7660 Average hourly wage FY 2008 * * * 34.7673 33.1051 32.5777 33.4777 32.7261 30.7519 * 29.4995 32.7052 33.2449 27.3137 27.1312 34.2980 33.0554 28.9009 24.0708 26.8681 29.7835 30.9805 29.4617 33.1148 34.0845 33.4713 32.4803 32.0828 35.2877 27.2407 36.0705 30.9719 31.7754 29.1171 33.1439 34.6118 34.8064 27.0995 29.1387 29.1717 31.5774 26.8849 35.0736 32.8156 33.5288 27.6950 * 34.6191 32.8689 26.5328 29.1582 34.3743 * 34.6792 34.4184 17.4044 35.7818 23.7773 25.4201 25.8722 25.9199 27.7665 23.4866 21.8665 23.4837 22.2803 33.6840 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 * * * 37.2179 34.6345 33.5085 32.8229 35.9102 33.4476 * 30.5632 34.2538 34.5686 28.5889 27.6584 37.2177 34.7330 30.0238 25.7420 28.5689 35.6742 33.7946 31.0917 34.4186 35.8580 34.8349 32.5938 34.6008 36.9798 29.9902 39.6582 31.1660 32.5442 30.3218 33.7939 36.1976 36.5363 29.0260 30.7223 30.4718 30.9460 28.5492 35.8816 33.9953 36.2755 29.0889 * 36.4224 34.2453 26.1726 30.9633 35.0319 * 36.4537 36.5922 16.6144 37.4575 24.3386 25.0335 24.8072 27.0493 29.3457 24.9100 22.7976 26.4108 22.3674 25.7397 Average hourly wage** (3 years) * * * 35.0462 33.1529 32.9298 32.4953 34.0521 31.3959 24.3596 29.4372 33.5836 33.0762 27.3645 27.1136 34.8308 33.2508 28.8059 24.4201 26.7906 31.1184 30.9171 29.7873 33.0264 34.4096 33.0717 32.0866 33.3406 35.4057 30.4614 37.0745 30.5144 30.9915 29.0129 32.5944 34.5440 34.6282 27.5332 29.3333 29.0677 31.1194 27.1176 34.3219 32.4894 33.9354 27.1230 23.3334 34.2571 32.8961 26.6670 29.4012 33.6757 * 34.6384 34.6233 18.6322 35.7765 23.8768 24.6387 25.1647 25.8303 27.3747 23.8155 22.0351 23.6996 22.2133 26.7933 23752 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 250018 250019 250020 250023 250025 250027 250031 250034 250035 250036 250038 250040 250042 250043 250044 250048 250049 250050 250051 250057 250058 250059 250060 250061 250067 250069 250072 250077 250078 250079 250081 250082 250084 250085 250093 250094 250095 250096 250097 250099 250100 250102 250104 250112 250117 250120 250122 250123 250124 250125 250126 250127 250128 250134 250136 250138 250141 250149 250151 250152 250155 250156 250157 250162 260001 260004 260005 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.8867 1.5607 1.0028 0.8728 1.1390 0.9541 1.3451 1.5368 0.8649 1.0485 0.9523 1.4898 1.2547 0.9847 1.0363 1.6491 0.8715 1.3084 0.8661 1.1739 1.2366 0.9358 0.8110 0.8867 1.0949 1.4416 1.6783 0.9717 1.5855 0.8932 1.3682 1.4127 1.2526 1.0182 1.1850 1.6982 1.0314 1.2042 1.4899 1.2725 1.5271 1.5947 1.4396 0.9616 1.1581 *** 1.1272 1.3504 0.8367 1.3788 1.0192 0.8041 0.9631 0.9291 1.0279 1.3091 1.4795 0.8769 0.5535 0.8224 *** *** *** 1.0520 1.6886 0.9098 1.5296 PO 00000 Frm 00226 Average hourly wage FY 2007 0.7653 0.8898 0.7653 0.8156 0.7653 0.7653 0.8095 0.8909 0.7653 0.8030 0.8095 0.8156 0.8909 0.7653 0.7883 0.8095 0.7653 0.7653 0.7653 0.7653 0.7653 0.7653 0.7653 0.7653 0.7653 0.8280 0.8095 0.7653 0.8156 0.7653 0.8280 0.8150 0.7653 0.7653 0.7653 0.8156 0.7653 0.8095 0.8146 0.8095 0.8280 0.8095 0.8280 0.7653 0.8156 * 0.7653 0.8898 0.8095 0.8898 0.9329 1.4448 0.8099 0.8095 0.8095 0.8095 0.9329 0.7653 0.7653 0.8095 * * * 0.8912 0.9704 0.8470 0.8986 Fmt 4701 Sfmt 4702 17.1276 25.7376 22.1851 18.0108 22.5621 24.4937 24.8139 26.1887 20.1622 20.3625 22.2571 24.5962 25.6807 18.8979 24.0508 25.2092 19.1044 20.8084 14.3741 22.7601 19.2502 23.8997 28.1431 17.8267 23.1193 22.6353 25.8399 18.3735 22.1243 45.5166 23.9995 23.0287 19.6492 22.5513 23.0984 24.1422 21.7488 24.9187 21.8139 21.1269 25.6846 24.6652 23.4303 24.3069 22.2450 24.6370 27.2795 26.6221 20.4394 27.5158 24.4126 * 17.7624 22.2167 22.9468 24.3018 28.5922 16.8796 18.8846 26.9334 22.5728 * * * 27.9230 20.3217 27.7855 Average hourly wage FY 2008 17.9025 26.2199 23.7245 18.5067 23.1738 26.9922 25.9189 26.7996 19.1038 19.7951 26.9621 27.3366 26.1190 20.8841 24.9199 24.7659 20.4775 21.1657 13.9532 24.3654 18.9970 26.7491 25.4779 18.7413 25.2189 22.4194 25.5337 19.0416 22.8430 43.0845 25.6808 23.5399 19.1604 24.2915 23.9128 24.7718 23.6140 26.3743 22.0211 21.5656 27.0286 25.4050 24.4311 26.3357 23.7337 26.6522 27.4424 27.9058 20.5667 26.7687 25.0019 * 21.7882 21.0211 25.2241 25.2642 30.5112 17.2268 22.8238 26.4559 * 16.8659 29.6398 * 29.5271 21.3629 27.9477 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 19.1099 27.7207 23.1510 19.5072 23.0544 32.5430 26.7496 27.9267 20.5237 22.5661 30.7941 26.2250 27.4593 21.1254 26.1725 27.6318 24.2222 22.4407 14.1652 22.9665 19.6711 25.5976 27.0347 25.1493 23.8020 23.4494 27.5770 19.6329 23.9580 46.0338 24.8259 25.6206 19.5676 24.6743 26.4337 25.4215 25.9001 27.7270 22.7899 27.5739 27.5468 25.5308 25.3986 27.4138 24.5692 * 23.4884 29.8280 21.9411 32.7395 25.2582 * 23.5915 22.0830 27.1454 27.3114 33.4397 17.0956 * 28.5527 * * * * 31.1839 24.1888 31.1215 Average hourly wage** (3 years) 18.0552 26.5559 23.0478 18.7146 22.9290 27.8433 25.8093 26.9950 19.9107 20.8304 25.9485 26.0460 26.4125 20.3156 25.0759 25.8347 21.0940 21.4799 14.1687 23.3314 19.3080 25.3587 26.8919 20.4689 24.0644 22.8355 26.3178 19.0451 22.9829 44.8458 24.8305 24.1469 19.4638 23.8551 24.4984 24.7893 23.7842 26.3759 22.2472 23.2182 26.7620 25.2035 24.4448 26.0536 23.5009 25.6905 26.0511 28.1116 20.9862 28.5834 24.9087 * 21.3639 21.7636 25.0260 25.5721 31.0006 17.0712 19.4286 27.2309 22.5728 16.8659 29.6398 * 29.5270 22.1072 28.9388 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23753 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 260006 260009 260011 260015 260017 260020 260021 260022 260023 260024 260025 260027 260032 260034 260040 260047 260048 260050 260052 260057 260059 260061 260062 260064 260065 260068 260070 260074 260077 260078 260080 260081 260085 260091 260094 260095 260096 260097 260102 260104 260105 260107 260108 260110 260113 260115 260116 260119 260137 260138 260141 260142 260147 260159 260160 260162 260163 260166 260175 260176 260177 260178 260179 260180 260183 260186 260190 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.4493 1.2153 1.5894 1.0293 1.3008 1.7335 1.3073 1.3246 1.3719 1.1889 1.3981 1.6154 1.8506 1.0142 1.7140 1.4348 1.1808 1.1398 1.3065 1.0872 1.2943 1.1720 1.2709 1.3641 1.7935 1.7301 0.9682 1.2162 1.6229 1.2711 1.0066 1.4925 1.5513 1.4867 1.6133 1.3868 1.5240 1.1896 0.9841 1.5825 1.8539 *** 1.8291 1.6476 1.1410 1.2609 1.0435 1.2922 1.7457 1.8944 1.8592 1.0838 0.9526 *** 1.0612 1.4383 1.2130 1.2356 1.1172 1.7557 1.2272 1.9689 1.5286 1.5853 1.6733 1.4640 1.2175 PO 00000 Frm 00227 Average hourly wage FY 2007 0.8470 0.9444 0.9038 0.8470 0.8736 0.8986 0.8986 0.8738 0.8986 0.8470 0.8986 0.9444 0.8986 0.9444 0.8470 0.8470 0.9444 1.0267 0.8986 0.9444 0.8547 0.8470 0.9444 0.8470 0.8470 0.8470 0.8470 0.8470 0.8986 0.8470 0.8470 0.8986 0.9444 0.8986 0.8470 0.9444 0.9444 0.8770 0.9444 0.8986 0.8986 * 0.8986 0.8470 0.8470 0.8986 0.8470 0.8470 0.9704 0.9444 0.8470 0.8470 0.8470 * 0.8470 0.8986 0.8557 0.9444 0.9444 0.8986 0.9444 0.8470 0.8986 0.8986 0.8986 0.8470 0.9444 Fmt 4701 Sfmt 4702 30.3440 24.2360 25.6387 24.6139 23.5713 27.4730 29.3646 23.3393 24.3192 19.4952 22.2451 26.3590 25.6763 25.0573 24.3938 25.4978 27.6117 25.0506 26.0052 20.9639 22.6922 22.4766 28.1661 22.2395 27.1014 26.0295 24.6331 25.6218 26.7466 20.1983 17.9107 28.1182 26.6718 28.0537 24.1473 24.2698 29.7312 25.0624 27.2145 28.6247 29.8848 25.8177 26.6374 24.7656 21.2072 23.1396 21.3503 27.9769 24.3273 30.4410 24.1555 21.5923 21.4235 22.6276 23.8257 27.0236 21.6408 29.1225 25.1817 29.3034 27.0185 25.4782 26.6069 28.2931 27.5577 26.9797 27.9137 Average hourly wage FY 2008 27.3754 25.7546 27.5762 25.0640 25.0461 29.3080 32.6735 24.8713 25.4314 19.2199 24.0358 29.3811 27.4857 27.1685 25.9074 26.6343 28.1515 26.2346 27.6360 21.5925 22.3885 22.8589 28.4975 23.3498 29.3564 27.3475 21.9701 28.0468 27.6624 21.1539 18.6070 29.1890 28.0306 28.5473 23.8654 27.6196 30.7267 25.5634 26.7624 28.0235 29.4766 27.9710 27.0758 26.6030 21.8884 24.6389 20.7479 31.5490 27.6592 30.6284 25.5663 21.7609 22.1928 23.9515 25.5096 28.4660 21.5566 28.5858 24.6064 31.1056 28.7942 27.1201 28.3234 29.3820 29.2684 28.8610 30.5343 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 33.7767 26.6670 31.2590 25.0244 26.2612 30.9576 19.4693 25.9379 25.5884 20.7131 24.5032 31.0217 28.7163 28.7725 27.2449 27.2646 29.6955 27.8050 29.6982 23.8167 24.9630 23.6708 29.6135 21.4934 27.9224 28.1227 25.2991 28.6203 28.7183 23.1780 18.6804 32.3581 29.6492 30.1154 25.1476 29.9069 32.9353 27.3117 30.7667 29.6366 32.4075 29.7754 28.5633 28.0368 23.0810 25.5643 22.5593 31.4981 31.4059 31.7554 26.6672 22.8201 22.9670 24.3018 26.6702 30.5739 23.8630 29.5234 25.7060 30.6112 29.0786 26.9886 29.6937 30.7313 31.4894 29.1853 30.8981 Average hourly wage** (3 years) 30.5981 25.5689 28.1581 24.8950 24.9757 29.2687 25.9620 24.7192 25.1233 19.8199 23.6143 28.7832 27.3241 27.0780 25.8128 26.4797 28.5297 26.4419 27.7827 22.1481 23.3714 22.9805 28.7754 22.3902 28.1492 27.1642 24.0399 27.4572 27.7262 21.5534 18.3878 29.9070 28.1046 28.9182 24.3842 27.0422 31.1666 26.0306 28.2426 28.7794 30.5702 27.7676 27.4377 26.5197 22.0233 24.4735 21.5340 30.2546 27.8364 30.9538 25.5210 22.0857 22.1968 23.5847 25.4076 28.7100 22.3617 29.0824 25.1720 30.3581 28.3077 26.5981 28.2012 29.4593 29.4549 28.3616 29.7909 23754 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 260191 260193 260195 260198 260200 260207 260209 260210 260211 260213 260214 260216 260218 260219 260220 270002 270003 270004 270011 270012 270014 270017 270023 270032 270049 270051 270057 270074 270081 270086 270087 280003 280009 280013 280020 280023 280030 280032 280040 280060 280061 280065 280077 280081 280105 280111 280119 280123 280125 280127 280128 280129 280130 290001 290002 290003 290005 290006 290007 290008 290009 290012 290019 290020 290021 290022 290027 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.4412 1.2305 1.2498 *** 1.2908 1.1540 1.1532 1.3929 1.4262 *** 1.2306 1.3065 0.8126 1.3191 2.3259 1.1469 1.2563 1.6239 1.0779 1.5992 1.8067 1.3001 1.5599 1.0422 1.7681 1.5064 1.2964 0.8884 1.0022 1.2443 1.3324 1.7687 1.8349 1.7183 1.6559 1.3206 1.9392 1.2928 1.5775 1.6610 1.4476 1.2542 1.3602 1.6812 1.2560 1.1718 0.8951 0.9698 1.5858 1.8312 2.7488 2.0416 1.3820 1.7753 0.8657 1.7934 1.4648 1.0851 1.7274 1.2072 1.6426 1.3313 1.4604 1.0227 1.6689 1.7132 0.8931 PO 00000 Frm 00228 Average hourly wage FY 2007 0.8986 0.9444 0.8470 * 0.8986 0.8470 0.9038 0.8986 0.9444 * 0.9444 0.9444 * 0.8986 * 0.8640 0.8679 0.9045 * 0.8679 0.8992 0.8909 0.8909 0.8640 0.9045 0.8909 0.8640 1.4448 * 0.8679 0.8640 0.9620 0.9336 0.9400 0.9620 0.9336 0.9400 0.9336 0.9400 0.9400 0.9223 0.9611 0.8841 0.9400 0.9400 0.8761 1.4448 0.8884 0.8761 0.9620 0.9620 0.9400 0.9400 1.0476 0.9837 1.1666 1.1666 1.0476 1.1666 0.9824 1.0476 1.1666 1.0476 0.9824 1.1666 1.1666 0.9824 Fmt 4701 Sfmt 4702 24.6973 26.8922 22.6870 28.0021 28.2453 22.6109 25.0098 26.8745 40.9821 * * * * * * 24.0534 28.8700 26.1319 22.7061 25.2914 25.8231 26.5404 25.5682 20.3469 27.1634 26.5621 25.5811 * 19.5612 21.0808 25.9772 30.6124 27.0705 27.0250 27.3284 26.7980 29.5102 24.3995 28.7207 27.7496 26.0208 28.0581 27.0860 28.7464 27.8599 24.5617 * 15.4047 22.1345 29.3684 28.5422 * * 36.3129 17.3876 30.3373 28.3366 31.7301 38.1938 27.3019 36.2724 32.3966 29.3650 23.2103 32.7894 29.9717 23.9959 Average hourly wage FY 2008 26.3244 28.1060 24.0411 27.2555 27.4784 22.9579 25.0749 30.5975 35.9113 34.8953 * * * * * 25.2907 29.1938 26.6779 24.4696 26.5854 27.4811 27.4150 26.3076 20.4330 28.6880 24.9371 27.1838 * 20.0438 20.7976 24.8022 30.1057 29.3634 27.9523 32.3896 29.5132 30.6991 24.7539 29.5276 30.3049 26.4824 28.0132 28.2206 31.1212 29.8488 27.4853 * 22.2185 23.2900 25.6806 28.8734 27.8793 29.8588 35.5113 23.9348 32.8182 31.7107 31.9838 39.7323 31.1116 32.3348 35.7988 30.5964 27.6277 36.7310 33.5330 23.9818 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 27.8627 29.5416 25.0275 27.9073 30.3290 23.6383 26.4196 36.4040 37.1525 * 31.0153 * * * * 28.3363 28.0533 28.5851 * 28.0655 28.2567 29.3524 28.1878 21.6349 29.8869 29.3917 28.3612 * * 21.8997 24.9177 32.3760 28.1542 30.3102 29.4807 30.0701 31.8740 25.6529 30.7378 30.8594 28.9580 29.5456 29.9204 28.9675 30.0457 28.3536 * 20.2745 24.7453 26.5628 27.1001 27.9490 29.9628 33.3287 22.7349 34.6402 34.2346 33.1563 41.2361 33.2436 34.0900 38.5049 32.2793 27.2889 36.8695 38.8235 29.1114 Average hourly wage** (3 years) 26.3553 28.1851 23.9191 27.7138 28.7369 23.1705 25.5826 30.6935 38.3586 34.8953 31.0153 * * * * 25.9060 28.6560 27.1552 23.5588 26.6761 27.1793 27.7689 26.6584 20.8153 28.6461 26.9486 27.1309 * 19.8033 21.2340 25.2095 30.9970 28.1942 28.4716 29.7217 28.7818 30.6841 24.9364 29.6445 29.5587 27.1706 28.5374 28.4615 29.5979 29.2896 26.8743 * 18.6147 23.4399 26.9797 28.1534 27.9189 29.9161 34.9942 20.8853 32.6118 31.0980 32.3337 39.7802 30.5242 34.1940 35.5355 30.8005 25.9788 35.4886 33.9036 25.2225 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23755 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 290032 290039 290041 290042 290044 290045 290046 290047 290049 290051 290052 290053 300001 300003 300005 300011 300012 300014 300017 300018 300019 300020 300023 300029 300034 310001 310002 310003 310005 310006 310008 310009 310010 310011 310012 310013 310014 310015 310016 310017 310018 310019 310020 310021 310022 310024 310025 310026 310027 310028 310029 310031 310032 310034 310037 310038 310039 310040 310041 310042 310044 310045 310047 310048 310050 310051 310052 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.4391 1.5440 1.4922 *** *** 1.6567 1.4029 1.4035 1.3302 1.8934 1.1590 1.5711 1.4434 2.0357 1.3788 1.3319 1.3235 1.2318 1.2863 1.3172 1.2444 1.1991 1.4459 1.8204 1.8504 1.7571 1.7914 1.1900 1.3414 1.4339 1.3390 1.3656 1.2858 1.2607 1.5959 *** 1.8164 1.9106 1.3313 1.3644 1.1472 1.5510 1.5807 1.6495 1.3231 1.3886 1.4248 1.3243 1.4636 1.1907 1.7792 2.8606 1.3218 1.4121 1.4765 1.8931 1.2417 1.2573 1.3358 *** 1.3493 1.6491 1.3458 1.3736 1.2457 1.4905 1.3237 PO 00000 Frm 00229 Average hourly wage FY 2007 1.0476 1.1666 1.1666 * * 1.1666 1.1666 1.1666 1.0476 1.0027 0.9824 1.1666 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.0807 1.2878 1.2693 1.2878 1.1440 1.2878 1.2878 1.2693 1.1313 1.1599 1.2878 * 1.1221 1.2693 1.2878 1.2693 1.2693 1.2878 1.2878 1.1316 1.1221 1.1440 1.2878 1.2878 1.1440 1.1440 1.1221 1.1221 1.1221 1.1221 1.2878 1.2693 1.2693 1.2878 1.1221 * 1.1313 1.2878 1.1666 1.1316 1.2693 1.1440 1.1221 Fmt 4701 Sfmt 4702 31.6711 32.1423 34.2436 * 37.1662 33.1512 * * * * * * 29.2260 34.7900 27.8000 30.9403 30.4972 29.7667 29.9560 29.4270 27.5672 30.8491 31.0040 29.8117 30.7676 41.7460 37.9183 36.2346 32.1319 28.4771 32.6788 33.6940 33.9552 31.2907 38.3590 31.0447 30.0793 36.8818 35.6155 32.2434 30.3234 30.3518 33.5516 32.1929 30.4043 33.3415 34.3687 29.1588 29.7793 32.2977 32.9246 37.0668 30.7865 31.7012 38.5415 35.9190 31.4278 33.8535 32.8390 34.4986 31.9678 36.7862 34.1520 32.9681 29.1732 35.0121 32.5778 Average hourly wage FY 2008 34.6589 34.9622 37.6077 22.4859 * 34.4584 38.7966 33.4695 26.0725 * * * 29.8145 37.0886 27.8431 31.8928 31.2655 29.1847 31.6699 31.7891 28.2287 30.9783 31.2726 31.4429 31.6880 39.3391 37.8652 39.0785 33.6311 28.7321 33.3172 33.6165 33.7009 34.3497 39.8568 35.6260 32.9016 39.2928 38.2740 35.7308 32.9704 30.6369 37.3372 31.6562 31.1951 33.8622 32.2630 30.1392 31.5967 33.9911 33.6695 39.3783 33.0258 32.7523 38.2865 36.3344 33.2100 37.7945 33.9799 * 33.7614 38.4424 37.3695 33.9506 32.3686 38.1174 33.5849 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 36.9148 34.6334 38.4409 * * 38.3841 38.3084 35.6348 33.4248 32.5253 * * 31.0102 37.7215 28.7980 33.0771 33.0547 30.7717 33.4139 31.5012 28.3103 32.4635 32.3183 32.0012 33.5519 41.4917 37.9453 40.1509 34.7634 30.4276 34.3243 35.4592 36.0797 37.4820 41.9596 32.9465 36.5996 40.8200 41.0326 35.9780 32.6937 31.8909 38.4230 32.2042 32.8059 36.6897 32.1469 30.1294 34.6445 34.8312 35.2057 39.5882 35.2379 36.8586 40.4608 39.8671 32.6403 41.2219 35.1979 * 33.5843 39.2064 37.7198 34.5223 37.9191 39.7645 36.5463 Average hourly wage** (3 years) 34.3264 33.9791 36.9258 22.4859 37.1662 35.4482 38.5269 34.5601 30.0551 32.5253 * * 30.0651 36.5476 28.1664 31.9916 31.6597 29.9265 31.6768 30.9778 28.0672 31.4527 31.5692 31.1343 32.0214 40.8275 37.9105 38.5759 33.5607 29.2523 33.4553 34.2954 34.6164 34.3008 40.0664 33.1378 33.3018 39.0289 38.2707 34.6067 31.9526 30.9689 37.3143 32.0219 31.4436 34.6507 32.9318 29.8053 31.9780 33.7159 33.9510 38.6577 33.0201 33.7114 39.0092 37.3872 32.4242 37.4721 33.9784 34.4986 33.0824 38.1273 36.4657 33.8353 32.9302 37.6891 34.2544 23756 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 310054 310057 310058 310060 310061 310063 310064 310069 310070 310073 310074 310075 310076 310077 310078 310081 310083 310084 310086 310088 310090 310091 310092 310093 310096 310105 310108 310110 310111 310112 310113 310115 310116 310118 310119 310120 310122 310123 310124 310125 310126 320001 320002 320003 320004 320005 320006 320009 320011 320013 320014 320016 320017 320018 320019 320021 320022 320030 320033 320037 320038 320057 320058 320059 320060 320061 320062 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.4134 1.4334 1.0541 1.2546 1.2219 1.3448 1.5372 1.2581 1.4555 1.7821 1.4656 1.4250 1.6465 *** *** 1.2620 1.3189 1.2659 1.2615 1.1243 1.2372 1.1327 1.4052 1.2201 1.9372 1.1572 1.4030 1.3096 1.2536 1.3277 1.2425 1.3224 1.2972 1.3587 1.8782 1.0851 *** *** *** *** *** 1.6823 1.5341 1.1298 1.3299 1.4214 1.2584 1.5798 1.1519 1.1126 1.0864 1.1842 1.2575 1.5461 1.4058 1.6185 1.1799 1.0361 1.2183 1.2261 1.2596 0.9342 0.7891 0.9914 1.0159 1.0245 0.9174 PO 00000 Frm 00230 Average hourly wage FY 2007 1.2693 1.1221 1.2878 1.1221 1.1221 1.1440 1.1666 1.1221 1.2693 1.1221 1.2878 1.1221 1.2693 * * 1.1221 1.2693 1.1221 1.1221 1.1666 1.1440 1.1221 1.1313 1.2693 1.2693 1.2878 1.2693 1.1313 1.1221 1.1221 1.1221 1.1221 1.2878 1.2878 1.2693 1.1440 * * * * * 0.9499 1.0587 1.0207 0.8858 0.9295 0.9295 0.9499 0.9300 1.0207 0.8858 0.8858 0.9499 0.8882 0.9499 0.9499 0.8858 0.8858 1.0207 0.9499 0.8858 1.4430 1.4430 1.4430 1.4430 1.4430 1.4430 Fmt 4701 Sfmt 4702 34.4431 31.1268 27.1555 27.3415 31.6648 31.9247 35.7607 31.7642 34.3225 32.6733 40.3494 31.5226 38.0643 34.6085 30.5761 30.1561 30.3580 33.5941 29.5566 29.9929 32.8191 29.3969 29.7958 29.1288 34.1524 30.1069 33.0172 33.2246 31.8393 31.2372 31.0436 29.5320 29.2748 31.1803 43.1238 29.2535 * * * * * 29.6182 32.0477 27.6222 24.7803 24.7543 26.9080 32.0116 25.6693 22.8283 27.2806 25.0835 31.6357 26.5109 27.8067 26.9918 23.9595 21.0378 31.7114 24.9657 21.7022 * * * * * * Average hourly wage FY 2008 36.9095 31.8933 30.4080 27.8242 39.0538 33.8519 38.6310 34.4669 36.3279 34.2858 39.6196 32.5338 37.5163 * * 31.0699 31.9151 32.6051 29.8794 30.3552 33.4615 31.9762 32.7054 30.2860 35.0707 32.5672 34.5866 33.4809 34.8284 32.2676 33.6771 31.9208 29.8144 31.2296 41.5702 33.3861 41.9029 37.1022 41.8827 36.2186 * 30.0077 33.1342 31.4473 26.2073 28.7893 28.0964 27.8084 27.9522 30.5865 28.7089 27.1492 33.3496 25.9248 35.0217 28.8504 25.3707 24.4497 30.1471 25.2876 32.7192 * * * * * * E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 38.2409 34.2018 30.4416 27.9121 33.5561 38.1450 39.4132 35.1354 36.9963 36.9226 39.0709 33.5226 38.1641 * * 31.7950 28.3385 34.9604 30.9445 31.2420 33.9146 35.2892 32.8408 32.3840 34.2007 32.0252 36.2821 35.6793 36.0727 34.5315 35.0222 32.1173 27.5857 32.8252 41.2971 35.1643 * * * * 34.3166 31.4174 34.1580 31.5768 28.2392 25.2152 28.5156 31.3279 28.9931 31.2869 30.4781 26.6374 30.5759 28.3438 28.6731 30.4499 27.5132 25.5246 30.1829 27.8969 31.6504 * * * * * * Average hourly wage** (3 years) 36.5602 32.3544 29.4040 27.7048 34.7375 34.4537 38.0057 33.8309 35.8869 34.6721 39.6558 32.5111 37.9202 34.6085 30.5761 31.0154 30.1096 33.7173 30.1377 30.5505 33.3953 32.2224 31.7803 30.5687 34.4697 31.5545 34.6390 34.1565 34.2677 32.6218 33.3347 31.2475 28.8828 31.7711 41.9830 32.4707 41.9029 37.1022 41.8827 36.2186 34.3166 30.3597 33.1619 30.3534 26.4283 26.1577 27.8949 30.3184 27.5536 27.7697 28.8685 26.3150 31.7120 26.9103 30.2204 28.7977 25.6817 23.7752 30.6567 26.0664 29.0042 * * * * * * Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23757 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 320063 320065 320067 320069 320070 320074 320079 320083 320084 320085 320086 320087 330002 330003 330004 330005 330006 330008 330009 330010 330011 330013 330014 330016 330019 330023 330024 330025 330027 330028 330029 330030 330033 330036 330037 330041 330043 330044 330045 330046 330047 330049 330053 330055 330056 330057 330058 330059 330061 330064 330065 330066 330067 330072 330073 330074 330075 330078 330079 330080 330084 330085 330086 330088 330090 330091 330094 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.3932 1.3072 0.8947 1.0782 0.9255 1.2421 1.2567 2.4454 0.9653 1.7562 1.4744 1.3725 1.5701 1.3545 1.3501 1.5906 1.2783 1.1757 1.3652 1.0125 1.3772 1.9475 1.3374 *** 1.3063 1.5312 1.7996 1.0483 1.3943 1.5319 0.5241 1.1544 1.2323 1.2126 1.2293 1.3098 1.4593 1.3446 1.4086 1.3696 1.2132 1.4907 1.0857 1.5415 1.3947 1.6802 1.2665 1.5527 1.1594 1.2603 1.0618 1.2729 1.3961 1.3012 1.1090 1.1944 1.1190 1.4677 1.3733 1.1760 1.0851 1.1551 1.3189 1.0110 1.4588 1.3843 1.2631 PO 00000 Frm 00231 Average hourly wage FY 2007 0.9273 0.9273 0.8858 0.8858 1.4430 0.9499 0.9499 0.9499 0.8858 0.8882 0.8858 1.0587 1.3043 0.8833 1.0709 0.9593 1.3043 0.9593 1.3043 0.8375 0.8721 0.8833 1.3043 * 1.3043 1.2855 1.3043 0.9593 1.2855 1.3043 0.9593 0.8911 0.8531 1.3043 0.8911 1.3043 1.2729 0.8721 1.2729 1.3043 0.8375 1.2694 0.8911 1.3043 1.3043 0.8833 0.8911 1.3043 1.3043 1.3043 0.9593 0.8833 1.2694 1.3043 0.8911 0.8911 0.9865 0.9593 0.8308 1.3043 0.8308 0.9471 1.3043 1.2729 0.9101 0.9593 0.9901 Fmt 4701 Sfmt 4702 25.0031 27.3163 24.9865 22.4128 * 31.1333 26.1188 26.6921 17.5788 27.9944 * * 30.9600 24.4326 28.0594 30.3200 33.6284 23.4429 36.2820 20.7476 25.1308 26.4578 42.1759 22.0493 38.5368 35.9428 42.7691 21.2565 42.8000 36.6498 23.2039 24.6175 24.5510 29.1884 22.3689 37.4883 39.1643 26.5669 38.1269 50.3152 24.3932 29.8350 20.6272 41.5934 36.0136 26.4989 22.2524 41.7343 36.0587 38.0437 25.3043 29.1780 27.8900 37.8505 22.5592 22.6629 23.1592 25.8073 24.6054 39.1417 22.5573 25.3285 32.7675 34.0789 25.5351 25.9378 25.7116 Average hourly wage FY 2008 26.0104 25.7945 24.7025 23.9863 * 28.4396 27.6877 29.5483 22.7706 27.4100 * * 32.1956 25.2223 30.2236 31.5030 34.2001 25.2005 38.9166 19.7098 27.4747 26.8382 45.7619 23.0769 39.7429 36.4736 43.2342 23.2424 45.1920 36.2901 24.0679 25.3454 24.8022 30.3757 21.9246 36.9934 38.8060 28.2293 40.0326 47.4975 24.9934 34.8585 21.8383 42.2007 38.8910 27.7121 22.6852 44.9162 37.8828 38.2332 24.4004 25.8174 29.2571 39.6996 23.4020 23.4576 24.2552 27.2870 24.9941 38.9405 25.6880 26.6235 35.5269 35.3871 26.8730 27.0040 26.9148 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 27.4933 26.9113 25.4100 25.3134 * 28.8072 31.5635 32.9443 24.2897 28.4513 * * 34.7252 26.8348 30.3204 33.2828 36.3279 26.2131 41.3767 20.5800 26.8258 28.8015 46.3155 * 44.5627 37.5106 44.8034 24.2691 45.9531 38.0116 22.9321 25.5081 25.0205 30.4633 23.4904 37.1640 40.6059 28.2619 41.6537 52.2364 26.1791 34.9720 20.1297 44.2313 39.9628 30.1910 23.6285 45.3660 37.8620 41.5714 26.2272 27.2069 30.7516 41.4567 25.1380 23.1004 23.7516 27.6659 27.9464 40.2059 27.3430 27.1697 40.9743 35.9962 27.7287 28.3015 28.6203 Average hourly wage** (3 years) 26.1576 26.6843 25.0450 23.9141 * 29.1304 28.5357 29.7645 21.5109 27.9647 * * 32.6020 25.5129 29.4839 31.7049 34.6900 24.9414 38.8011 20.3266 26.4851 27.3879 44.6761 22.5738 40.8880 36.6960 43.6032 22.9268 44.5412 36.9910 23.3384 25.1586 24.7863 30.0049 22.5870 37.2203 39.5013 27.6916 39.9715 49.9699 25.2159 33.3441 20.8283 42.7264 38.2393 28.1436 22.8634 44.0375 37.2887 39.3164 25.3188 27.4291 29.2920 39.5848 23.7034 23.0807 23.7241 26.9471 25.8287 39.4431 25.1537 26.3813 36.5723 35.1584 26.7363 27.0881 27.1128 23758 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 330096 330100 330101 330102 330103 330104 330106 330107 330108 330111 330115 330119 330125 330126 330127 330128 330132 330133 330135 330136 330140 330141 330144 330151 330152 330153 330154 330157 330158 330159 330160 330162 330163 330164 330166 330167 330169 330171 330175 330177 330180 330181 330182 330184 330185 330188 330189 330191 330193 330194 330195 330196 330197 330198 330199 330201 330202 330203 330204 330205 330208 330209 330211 330213 330214 330215 330218 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.1987 1.1185 1.8970 1.4096 1.2008 1.3423 1.6914 1.2407 1.1289 0.9674 1.1888 1.7304 1.7378 1.3038 1.3108 1.2304 1.1001 1.3704 1.2101 1.5320 1.7962 1.3202 0.9865 1.2083 1.3015 1.7175 1.6921 1.3796 1.6713 1.3553 1.5503 1.3383 1.1132 1.4898 1.0613 1.6290 1.3998 *** 1.1285 0.9936 1.1924 1.3033 2.2878 1.3645 1.2668 1.2402 1.2886 1.2850 1.4383 1.7941 1.7054 1.2884 1.1174 1.3922 1.1949 1.8000 1.4107 1.4153 1.4550 1.2337 1.1951 *** 1.0836 1.0678 1.8791 1.2792 1.0910 PO 00000 Frm 00232 Average hourly wage FY 2007 0.8308 1.3043 1.3043 0.9593 0.8351 1.3043 1.2855 1.2729 0.8347 0.9593 0.9865 1.3043 0.8911 1.2855 1.3043 1.3043 0.8439 1.3043 1.1586 0.9471 0.9865 1.2729 0.8362 0.8362 1.3043 0.8833 * 0.9471 1.3043 0.9865 1.3043 1.3043 0.9593 0.8911 0.8308 1.2855 1.3043 * 0.8568 0.8308 0.8833 1.2855 1.2855 1.3043 1.2729 0.9593 0.8833 0.8833 1.3043 1.3043 1.3043 1.3043 0.8308 1.2855 1.3043 1.3043 1.3043 0.9865 1.3043 1.1586 1.3043 * 0.8308 0.8308 1.3043 0.8721 0.9865 Fmt 4701 Sfmt 4702 22.7189 38.3333 40.1929 25.3879 22.8242 33.7537 43.8210 34.9047 23.2919 20.3473 25.2373 39.0528 27.2920 35.2257 45.3680 39.5197 21.0479 39.3837 27.9132 25.8531 27.6183 39.4701 22.9561 21.7665 37.6721 26.4386 * 26.5686 38.2033 28.2774 36.6208 34.9460 27.1933 27.7217 20.4680 36.7653 45.3774 30.4005 23.8509 20.6338 24.3761 41.4104 40.9014 35.8102 36.3155 25.1153 22.3484 25.5656 39.9327 45.5639 39.7802 36.7178 26.8921 33.4930 38.6407 37.2064 37.4150 32.1207 39.6393 31.9510 32.1256 30.2038 24.4470 24.4049 41.8719 23.7361 26.9638 Average hourly wage FY 2008 24.2422 39.6244 43.7944 26.6887 24.5585 35.1076 46.3657 35.7384 23.9368 40.4349 23.8235 42.2901 28.0584 36.5689 45.2993 41.7790 21.7648 38.5228 32.0525 26.6680 29.3461 39.3741 23.3874 19.7959 38.2079 28.4446 * 27.1432 41.7010 31.7835 37.1915 37.6226 28.3910 27.8746 20.7121 39.1251 46.4939 35.1577 24.1005 22.9834 25.4170 43.0977 41.3033 39.0437 38.4002 27.5988 22.4383 26.4328 39.8910 46.8880 41.7885 38.2525 25.9872 34.8985 40.3948 42.6707 37.4158 34.0499 41.9953 33.9418 33.5287 * 25.8752 27.4890 42.1339 23.9583 26.9982 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 24.7885 37.8618 45.5381 27.2523 25.4907 36.5857 48.2871 38.0246 25.3011 23.2125 24.3889 41.2326 29.4802 37.7797 45.2542 43.3424 22.1446 39.9011 33.2291 25.4193 31.1320 39.1699 24.9303 21.6335 39.5722 28.9924 * 29.7604 39.5913 33.8472 39.1048 38.7613 28.6229 29.8437 22.8498 39.1824 47.5367 * 26.7868 23.4294 26.8643 46.2154 42.7924 39.7213 39.6695 29.7302 25.8116 28.2938 40.0256 49.8845 43.3185 38.6925 26.5516 35.8688 39.4065 46.5096 38.7609 34.6499 39.5313 35.3766 37.1706 * 24.9417 28.5365 43.2434 26.3964 28.4109 Average hourly wage** (3 years) 23.9177 38.6066 43.2279 26.4449 24.2904 35.1622 46.1844 36.2529 24.1893 25.3142 24.4744 40.8420 28.3192 36.5514 45.3069 41.5728 21.6691 39.2582 31.0896 25.9628 29.4083 39.3348 23.7658 21.0260 38.4999 27.9865 * 27.7881 39.8276 31.2089 37.6457 37.1390 28.0754 28.5199 21.3014 38.3281 46.4021 32.5880 24.8937 22.3276 25.5779 43.5483 41.6641 38.2058 38.1531 27.4385 23.5448 26.8175 39.9494 47.4698 41.6774 37.9124 26.4718 34.8129 39.4834 42.1336 37.8756 33.6383 40.4252 33.7848 34.2436 30.2038 25.1105 26.7727 42.4360 24.6837 27.4690 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23759 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 330219 330221 330222 330223 330224 330225 330226 330229 330230 330231 330232 330233 330234 330235 330236 330238 330239 330240 330241 330242 330245 330246 330247 330249 330250 330259 330261 330263 330264 330265 330267 330268 330270 330273 330276 330277 330279 330285 330286 330290 330304 330306 330307 330314 330316 330331 330332 330338 330339 330340 330350 330353 330354 330357 330372 330385 330386 330389 330390 330393 330394 330395 330396 330397 330399 330401 330403 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.7127 1.3708 1.2774 0.9707 1.3100 1.2228 1.4002 1.2244 1.0278 1.1135 1.2072 1.5357 2.3425 1.1520 1.5494 1.2738 1.2402 1.4609 1.8409 1.3112 1.7745 1.3715 1.1834 1.3392 1.3845 1.5072 1.2365 1.0140 1.3203 1.2419 1.3921 0.9313 2.0758 1.3499 1.1594 1.2068 1.6224 1.9771 1.3514 1.6233 1.3053 1.4567 1.3412 *** 1.2398 1.2869 1.3105 *** 0.7634 1.2284 1.5260 1.2443 2.1246 1.2886 1.2901 1.0504 1.3408 1.7338 1.2394 1.7385 1.6520 1.4204 1.3480 1.4094 1.1317 1.3519 0.9101 PO 00000 Frm 00233 Average hourly wage FY 2007 0.9593 1.3043 0.8833 0.8308 1.0709 1.2855 0.8911 0.8420 1.3043 1.3043 0.8833 1.3043 1.3043 0.9471 1.3043 0.8911 0.8420 1.3043 0.9865 1.3043 0.8721 1.2729 1.3043 0.9865 0.9216 1.2855 1.3043 0.8308 1.1586 0.8911 1.3043 0.8308 1.3043 1.3043 0.8344 0.9101 0.9593 0.8911 1.2729 1.3043 1.3043 1.3043 0.9561 * 1.3043 1.2855 1.2855 * 0.8833 1.2729 1.3043 1.3043 * 1.3043 1.2855 1.3043 1.1461 1.3043 1.3043 1.2729 0.8721 1.3043 1.3043 1.3043 1.3043 1.2729 0.8911 Fmt 4701 Sfmt 4702 29.8889 39.2080 25.8507 23.3669 27.9231 32.3585 24.5646 21.9356 37.1298 40.6697 26.3313 47.3497 48.2306 27.7031 40.2386 21.7435 22.3854 43.5753 30.2304 37.4870 26.1811 37.1611 35.4980 25.3246 27.1606 35.1514 33.7834 23.8738 30.4701 21.6477 32.8541 25.3567 57.3596 37.0157 24.3300 26.4535 27.4539 30.1928 35.5895 39.4690 36.2845 36.3552 29.2529 26.2719 34.8567 39.8402 35.1646 37.7497 23.5786 37.9000 41.1339 45.9692 * 38.2286 36.1840 48.6175 29.9366 37.1862 36.3842 38.0619 27.3388 36.3921 37.4998 37.5682 34.7394 37.8559 25.5163 Average hourly wage FY 2008 32.5658 40.0514 27.7198 26.1264 29.1738 35.7651 24.8471 23.0577 38.6569 44.9422 27.4639 52.7070 49.3219 29.4346 42.8981 21.8386 23.1885 40.5001 32.7683 36.9015 27.4326 35.7416 39.0219 24.6091 29.0080 36.4788 40.2579 24.1333 31.0557 23.9081 34.9885 23.8793 55.2136 35.9298 26.0935 30.9053 29.6385 31.1235 37.6040 40.6933 37.3537 38.7713 29.5885 28.1788 37.1766 41.2694 37.0111 * 24.3066 37.4161 44.4617 45.0977 * 40.3850 35.1297 49.0859 33.3216 39.6871 35.5562 39.2186 28.4597 37.5791 39.4904 41.4448 36.7626 40.4485 25.2937 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 33.2132 42.5461 28.7835 27.1959 30.4765 32.9013 26.3674 23.9230 39.3870 48.9002 27.9601 40.8517 49.8754 30.8007 42.6166 23.3946 24.6380 41.6117 32.9148 38.7839 28.6678 35.9559 41.3428 26.9847 29.6168 39.0189 38.0192 24.2125 32.1770 22.7426 35.3884 23.9129 52.3126 39.7849 27.0432 30.8138 31.2369 31.9305 38.8533 39.8010 39.4605 39.0391 30.8103 22.6868 37.9320 44.1690 38.6906 * 25.0041 38.4698 44.2368 46.0175 * 40.2097 37.0288 47.3989 32.9974 37.5883 38.7634 38.9295 28.8056 50.1276 39.1940 41.1659 39.8000 41.7804 28.7267 Average hourly wage** (3 years) 31.8655 40.6770 27.5072 25.6000 29.2021 33.6812 25.2746 22.9668 38.3808 44.9236 27.2541 46.1530 49.1340 29.3076 41.9558 22.3482 23.4006 41.8580 32.0133 37.7206 27.4605 36.2356 38.4848 25.6366 28.6244 36.8295 37.2335 24.0872 31.4635 22.7616 34.4218 24.3479 54.6691 37.6016 25.8320 29.1290 29.4467 31.0944 37.3699 39.9779 37.8134 38.0888 29.9028 26.0606 36.6690 41.7977 36.9311 37.7497 24.2976 37.9265 43.3333 45.7015 * 39.5419 36.1053 48.3826 32.1005 38.1257 36.9285 38.7593 28.2126 40.5815 38.7397 39.9850 37.1071 40.0688 26.3688 23760 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 330404 330405 330406 330407 340001 340002 340003 340004 340008 340010 340011 340012 340013 340014 340015 340016 340017 340020 340021 340023 340024 340025 340027 340028 340030 340032 340035 340036 340037 340038 340039 340040 340041 340042 340047 340049 340050 340051 340053 340055 340060 340061 340064 340068 340069 340070 340071 340072 340073 340075 340084 340085 340087 340090 340091 340096 340097 340098 340099 340104 340106 340107 340109 340113 340114 340115 340116 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.9366 0.9452 0.9450 0.9449 1.4870 1.7858 1.2344 1.4318 1.2672 1.3315 1.1738 1.2246 1.2360 1.6086 1.3956 1.3330 1.2759 1.1889 1.3379 1.3629 1.1349 1.2988 1.2181 1.5011 1.9766 1.4553 1.0979 1.3100 1.1218 1.2380 1.2806 1.9081 1.3315 1.2353 1.8051 1.7851 1.2008 1.1886 1.4900 1.2129 1.0621 1.7496 1.1205 1.2915 1.8414 1.2531 1.0621 1.1433 1.6527 1.2349 1.1236 1.1506 1.2341 1.3071 1.6022 1.2333 1.2431 1.4670 1.2912 0.7848 1.1406 1.1991 1.2448 1.9457 1.5304 1.6260 1.7476 PO 00000 Frm 00234 Average hourly wage FY 2007 1.3043 1.3043 0.8833 0.8833 0.9570 0.9192 0.8632 0.9096 0.9567 0.9557 0.8632 0.8632 0.9307 0.8984 0.9570 0.8632 0.9192 0.8788 0.9570 0.9307 0.8809 0.9192 0.9174 0.9923 0.9693 0.9570 0.8632 0.9685 0.8794 0.8885 0.9570 0.9346 0.8946 0.8632 0.8984 0.9693 0.9567 0.8794 0.9570 0.8946 0.9141 0.9693 0.8632 0.8632 0.9693 0.8984 0.9557 * 0.9693 0.8946 0.9570 0.8882 0.8632 0.9685 0.9096 0.8882 0.8632 0.9570 0.8632 0.8794 0.8632 0.9068 0.8868 0.9570 0.9693 0.9693 0.8946 Fmt 4701 Sfmt 4702 * * * * 28.3988 28.4860 24.1602 26.6404 26.7443 27.2105 19.7441 23.2288 23.9492 27.4888 28.0585 25.6454 25.7780 26.4465 29.4864 26.4225 23.6638 23.5881 25.5973 28.0323 29.6630 26.5958 23.9669 27.2691 25.6262 22.4829 27.4457 27.6626 24.3595 25.0110 27.4022 30.6791 26.0365 23.9612 27.8577 26.0647 22.9097 27.0089 23.4233 22.6814 29.3439 25.3226 26.3921 25.2493 30.9849 25.1551 21.1363 26.5164 22.4287 26.4031 27.1285 24.9036 26.2228 28.2493 21.8564 16.1204 26.0892 24.1762 25.4464 28.5587 28.3222 26.7592 27.5881 Average hourly wage FY 2008 * * * * 29.5709 29.6622 26.0888 27.5283 27.7206 28.7544 22.0047 24.7576 26.3607 27.8384 28.3928 27.2365 27.5672 27.5473 29.3835 26.2716 26.4001 24.0101 26.3840 30.7591 30.4591 28.7636 24.6262 27.3860 29.0618 24.2111 27.8228 28.7434 26.8314 25.6349 28.4968 29.6826 27.5274 24.4561 28.9355 26.5752 25.1791 29.8574 23.9701 23.6757 31.4951 26.6546 27.9748 24.1350 31.6803 25.1438 23.1300 27.9572 25.4730 26.7428 28.8044 26.5438 29.8005 29.7180 23.9702 17.0165 26.1340 26.5626 26.6383 30.3841 28.1311 27.2781 29.3698 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 36.1044 35.2698 28.2727 * 29.9082 30.7384 26.6393 27.9184 29.0639 29.5207 22.5138 24.9253 26.9137 29.5330 30.0958 27.9629 28.4845 28.3440 31.3610 27.6909 26.8984 25.2827 26.6506 31.9846 31.1985 29.2058 26.0827 29.0626 30.5346 26.2582 29.5042 30.1256 27.1270 27.0573 28.7600 31.5524 29.2266 25.4961 30.8320 29.0098 26.8366 31.2885 25.0796 24.7388 32.2147 27.7660 29.7321 * 33.2859 26.8298 25.6868 29.1072 23.8343 28.3594 30.4345 26.5795 27.9788 31.3896 26.0062 19.9477 24.5134 27.3548 26.6462 32.3765 30.1188 28.0955 29.9425 Average hourly wage** (3 years) 36.1044 35.2698 28.2727 * 29.3235 29.6332 25.6927 27.3734 27.8645 28.5197 21.4242 24.3215 25.7232 28.3119 28.8519 26.9654 27.2551 27.4399 30.1011 26.8311 25.6597 24.3044 26.2232 30.2233 30.4842 28.2291 24.8874 27.9422 28.5630 24.3742 28.2768 28.8796 26.1141 25.9214 28.2338 30.6567 27.6025 24.6507 29.2316 27.1555 24.9813 29.4140 24.1848 23.6999 31.0749 26.6186 28.0710 24.6895 32.0279 25.7432 23.2795 27.8491 23.9111 27.2234 28.8160 26.0408 27.9546 29.8226 24.0248 17.8305 25.5139 26.0750 26.2343 30.4662 28.8788 27.3861 28.9452 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23761 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 340119 340120 340121 340123 340124 340126 340127 340129 340130 340131 340132 340133 340137 340138 340141 340142 340143 340144 340145 340147 340148 340151 340153 340155 340156 340158 340159 340160 340166 340168 340171 340173 340177 340179 340182 340183 350002 350003 350006 350009 350010 350011 350014 350015 350017 350019 350030 350063 350064 350070 360001 360002 360003 360006 360008 360009 360010 360011 360012 360013 360014 360016 360017 360019 360020 360025 360026 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2861 1.0708 1.0930 1.2779 *** 1.3283 1.1942 1.3110 1.3497 1.4690 1.2127 1.0197 *** 0.9092 1.6729 1.2123 1.5447 1.2183 1.2148 1.3027 1.5007 1.2153 1.9232 1.4750 0.8722 1.1294 1.2146 1.3520 1.3505 0.4196 1.1184 1.3301 *** *** *** 1.1992 1.8113 1.2133 1.5637 1.0718 1.0699 1.9136 0.9542 1.5991 1.2273 1.6984 0.9524 0.9136 0.7388 1.7656 1.4815 1.2851 1.7681 1.8125 1.3172 1.5509 1.2398 1.2808 1.3492 1.0853 1.1225 1.4873 1.6193 1.3267 1.5825 1.4547 1.3750 PO 00000 Frm 00235 Average hourly wage FY 2007 0.9570 0.8632 0.9087 0.9141 * 0.9557 0.9693 0.9570 0.9570 0.9174 0.8632 0.8940 * 0.9693 0.9087 0.8632 0.8946 0.9570 0.9570 0.9557 0.8984 0.8684 0.9570 0.9693 1.4446 0.9087 0.9693 0.8632 0.9570 0.9087 0.9570 0.9693 * * * 0.9570 0.7336 0.7336 0.7336 0.8212 * 0.8212 * 0.7336 0.7336 0.7709 0.7336 1.4365 1.4365 0.8212 0.9581 0.8723 0.9581 0.9869 0.8759 0.9299 0.8784 0.9657 0.9869 0.9299 0.9657 0.9581 0.9869 0.9266 0.9266 0.9267 0.9321 Fmt 4701 Sfmt 4702 25.6226 25.9134 23.1343 26.0637 22.2988 26.9866 26.4746 25.7976 26.1717 27.4750 23.5856 23.4678 22.1741 * 29.3878 26.6886 28.0082 26.1865 25.8459 26.9162 25.3660 22.7736 27.6509 30.3443 * 27.7816 24.2588 21.7923 27.1132 * 27.8539 28.3502 26.7155 34.1895 27.8071 * 22.4307 23.9639 21.2726 23.8681 20.1290 23.8400 19.1684 20.9046 22.4359 23.2018 20.2722 * * 25.2365 25.8669 24.5155 28.9672 30.1363 26.2632 25.0007 23.7825 27.6036 30.1416 27.0893 27.1017 27.8031 29.8525 26.9178 23.6400 27.4533 25.5379 Average hourly wage FY 2008 29.4470 25.5399 23.8854 28.5669 23.5480 28.2247 28.2161 26.7606 28.1594 28.8542 24.6162 24.8579 28.9672 * 29.3171 27.7555 27.9777 27.0150 26.7482 28.2626 25.8325 23.2158 28.5979 30.9501 * 27.6526 25.3108 23.4631 28.5395 * 27.4701 30.2815 * * * * 23.5869 24.9975 22.4626 24.5737 20.4198 24.1135 17.5837 21.3342 21.6187 24.9615 22.5976 * * 26.2454 28.8623 25.4859 30.7812 30.9806 27.5683 27.0618 24.7352 31.5587 31.0526 29.8412 27.0743 29.6298 31.7081 27.2997 25.6328 27.1546 25.2945 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 27.2924 26.1449 25.1565 28.7125 25.7275 30.6880 28.8647 31.7833 29.5278 29.6545 25.3247 26.8831 27.0855 * 29.3351 28.2393 29.3839 27.6523 28.0628 29.6936 27.9119 24.5768 29.8260 31.7547 * 29.4088 28.1688 24.2003 29.9101 * 31.1928 30.9813 * * * 30.1224 23.6039 24.5802 23.4334 23.9783 * 26.0184 * 22.9107 24.0965 24.9880 23.1013 * * 26.2850 30.1018 25.2198 31.8948 31.8259 28.0182 28.2407 25.5935 29.9864 31.9806 30.2383 28.1800 30.2164 33.2491 28.3226 27.6681 28.4754 27.5409 Average hourly wage** (3 years) 27.4283 25.8647 24.0798 27.7861 23.7126 28.6662 27.8604 27.9613 27.9862 28.6874 24.5295 25.1020 25.1884 * 29.3465 27.5936 28.4856 26.9370 26.9029 28.3096 26.4048 23.5273 28.7235 31.0367 * 28.3011 25.9712 23.1718 28.5234 * 28.9088 29.9351 26.7155 34.1895 27.8071 30.1224 23.2267 24.5236 22.3834 24.1447 20.2749 24.6622 18.3437 21.7900 22.7331 24.4055 22.0048 * * 25.9334 28.2801 25.0794 30.5710 31.0038 27.2862 26.7836 24.7214 29.6800 31.0579 29.0666 27.4862 29.2161 31.6157 27.5252 25.6284 27.6992 26.1280 23762 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 360027 360029 360032 360035 360036 360037 360038 360039 360040 360041 360044 360046 360048 360049 360051 360052 360054 360055 360056 360058 360059 360062 360064 360065 360066 360068 360070 360071 360072 360074 360075 360076 360077 360078 360079 360080 360081 360082 360084 360085 360086 360087 360089 360090 360091 360092 360095 360096 360098 360100 360101 360107 360109 360112 360113 360115 360116 360118 360121 360123 360125 360130 360131 360132 360133 360134 360137 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.5168 1.1810 1.2265 1.6390 1.1944 1.5004 1.5826 1.4590 1.2069 1.4496 1.1770 1.2150 1.8237 *** 1.6897 1.5471 1.3413 1.4007 1.5488 1.1206 1.4695 1.5597 1.5123 1.2709 1.4332 1.8584 1.6693 1.1466 1.5262 1.2813 1.2013 1.5143 1.5018 1.2814 1.7270 1.1032 1.3032 1.3735 1.6319 2.0543 1.6514 1.4326 1.1327 1.4661 1.3415 1.2566 1.4803 1.1353 1.4304 1.3412 1.4779 1.1819 1.0429 1.8522 1.2805 1.3320 1.2122 1.4755 1.2872 1.4063 1.2052 1.5015 1.3679 1.3742 1.5965 1.7642 1.7064 PO 00000 Frm 00236 Average hourly wage FY 2007 0.9266 0.9267 0.8582 0.9869 0.9266 0.9266 0.9581 0.9657 0.8969 0.9266 0.8709 0.9581 0.9267 * 0.9321 0.9321 0.8759 0.8931 0.9581 0.8582 0.9266 0.9869 0.8931 0.9266 0.9299 0.9267 0.8845 0.8617 0.9869 0.9267 0.9266 0.9581 0.9266 0.9266 0.9321 0.8582 0.9267 0.9266 0.8845 0.9869 0.9321 0.9266 0.8582 0.9267 0.9266 0.9869 0.9267 0.8582 0.9266 0.8845 0.9266 0.9267 0.8582 0.9267 0.9581 0.9266 0.9581 0.9295 0.9267 0.9266 0.8582 0.9266 0.8845 0.9581 0.9321 0.9581 0.9266 Fmt 4701 Sfmt 4702 27.4454 24.3216 25.0034 30.0172 27.8343 29.0046 25.4274 23.9783 24.8569 26.1522 21.5619 25.4673 29.3415 26.2222 26.8501 26.2066 22.9359 27.3941 26.5318 23.8119 29.3624 31.7422 25.2336 28.0405 27.1436 26.2065 27.2389 23.4619 25.9589 25.8959 26.8925 28.1013 28.4449 25.7885 27.2437 21.4526 29.8366 29.2561 27.3917 31.5800 25.4218 29.6579 25.3465 29.0199 25.8657 25.4954 26.4635 25.9275 25.5973 25.4523 27.6030 24.6095 26.3131 30.5715 26.6556 25.9841 25.1717 27.3884 27.4442 27.1920 24.1388 25.6570 25.3719 27.7724 29.8684 27.7339 26.1250 Average hourly wage FY 2008 28.2923 26.4208 25.9916 31.3181 29.3514 30.0446 31.0611 24.7873 25.5337 26.6755 24.3840 26.2417 29.4378 * 28.1167 26.8806 24.8248 30.0143 30.3677 24.5003 30.6173 32.8893 27.7795 29.7155 29.7605 26.6933 27.8891 26.4081 27.2286 27.5328 26.1657 29.0148 28.0133 27.4689 30.1230 22.7020 29.5312 28.7925 28.5402 32.8502 27.3124 28.4185 25.5608 30.7530 27.6809 25.4055 29.3787 26.8653 26.6382 23.6167 29.7817 26.0534 30.1382 31.1356 30.2871 26.1821 26.4968 28.5643 28.3835 28.0334 25.9067 26.3986 26.6635 29.4070 31.7521 28.5141 27.6894 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 29.6304 27.8825 27.2621 31.2432 29.9390 30.6535 31.3759 25.8206 26.7437 28.4427 24.7681 28.2956 30.0370 * 29.4411 28.4711 23.6593 31.4776 31.1802 25.9278 30.6279 32.8990 28.6078 31.5056 30.9636 28.6320 28.8717 25.7940 28.3666 27.9970 28.3916 29.2102 28.3010 27.3636 31.3114 21.8797 31.4274 30.5823 29.2435 33.1267 28.3559 28.6324 28.0769 29.2643 28.1671 28.0797 30.1514 27.9493 26.5824 25.8131 30.6609 26.8168 30.4624 32.4383 30.3893 26.8438 26.8619 29.9812 31.6755 28.5418 27.1761 28.1792 27.3408 29.8386 33.1791 29.9175 30.3093 Average hourly wage** (3 years) 28.4671 26.2449 26.0956 30.8528 29.0664 29.8835 29.1457 24.8982 25.7182 27.1150 23.5345 26.6958 29.6170 26.2222 28.1381 27.2049 23.7903 29.5863 29.4451 24.7681 30.2152 32.5514 27.1789 29.7621 29.2899 27.1929 27.9936 25.2133 27.2276 27.1581 27.1857 28.7968 28.2547 26.8573 29.5585 22.0297 30.2589 29.5279 28.4167 32.5905 27.0242 28.8850 26.2935 29.6802 27.2522 26.3112 28.6022 26.9250 26.3001 24.9650 29.3460 25.8586 28.9111 31.4039 29.0672 26.3395 26.2113 28.5726 29.0943 27.9298 25.6993 26.7600 26.4479 28.9945 31.6376 28.7663 28.0256 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23763 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 360141 360143 360144 360145 360147 360148 360150 360151 360152 360153 360155 360156 360159 360161 360163 360170 360172 360174 360175 360179 360180 360185 360187 360189 360192 360195 360197 360203 360210 360211 360212 360218 360230 360234 360236 360239 360241 360242 360245 360247 360253 360259 360261 360262 360263 360264 360265 360266 360267 360268 360269 360270 360271 360272 360273 360274 360276 370001 370002 370004 370006 370007 370008 370011 370013 370014 370015 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.6073 1.3047 1.3394 1.6504 1.2554 1.1785 1.3213 1.4719 1.5125 0.9954 1.4645 1.1512 1.3312 1.3364 1.8747 1.1878 1.3762 1.2862 1.2487 1.5492 2.3387 1.2624 1.4967 1.1420 1.3279 1.0799 1.1347 1.1898 1.2170 1.6076 1.3076 1.2246 1.5275 1.4185 1.3057 1.3536 *** 1.9535 0.6344 0.4196 2.2617 1.2301 1.5079 1.2975 1.9432 *** *** 2.1538 *** *** 1.7035 1.1268 *** *** *** 1.5016 1.1341 1.6484 1.1271 1.1127 1.2372 1.0227 1.4408 1.0018 1.5415 1.0690 1.0296 PO 00000 Frm 00237 Average hourly wage FY 2007 0.8931 0.9266 0.9266 0.9266 0.8582 0.8582 0.9266 0.8845 0.9869 0.8582 0.9266 0.8701 0.9657 0.8931 0.9581 0.9869 0.9266 0.9321 0.9657 0.9581 0.9266 0.8582 0.9321 0.9869 0.9266 0.9266 0.9657 0.8582 0.9869 0.8582 0.9266 0.9869 0.9266 0.9581 0.9581 0.9321 * * 0.9266 0.9869 0.9581 0.9267 0.9118 0.9267 0.9299 * * 0.9869 * * 0.9581 0.8582 * * * 0.9321 0.8931 0.8652 0.8016 0.9349 0.8784 0.8016 0.8686 0.8686 0.8686 0.9291 0.8652 Fmt 4701 Sfmt 4702 29.7937 28.3057 28.2473 27.1908 25.5854 26.0837 25.1217 25.3780 29.9425 19.8499 26.9127 24.3281 29.1529 25.4433 28.9742 28.5474 27.5669 26.8586 28.1531 30.0311 29.6633 25.6800 24.9353 26.3756 26.4616 25.0922 28.7580 24.4433 28.2976 25.7053 25.6080 29.8662 28.8018 25.9360 25.6728 27.2939 23.0662 * 20.6504 19.3677 33.2371 25.9878 22.3614 28.6995 25.1652 36.0754 36.6265 * * * * * * * * * * 26.0194 22.0476 26.7434 22.4802 19.4036 25.3352 21.9649 26.5364 25.9393 24.7547 Average hourly wage FY 2008 31.1778 26.9394 28.9177 28.1835 27.5548 26.3399 28.2561 26.5636 31.5377 20.2147 28.9521 25.0833 28.6174 27.0875 30.0724 29.5954 28.8283 28.3143 28.3054 29.8299 31.4342 26.1080 25.7600 27.5097 27.5991 27.6155 28.9207 25.3692 29.6476 26.5459 26.6976 30.0101 30.0661 31.0656 29.5321 30.7728 25.7290 * 20.3426 * 34.3347 27.2902 25.6332 30.1559 25.4864 * * 31.7565 34.0936 34.0526 24.8552 * * * * * * 26.8884 23.6886 26.8521 23.9935 20.3706 26.6563 22.3391 27.2667 26.4488 25.5815 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 31.9380 28.0681 29.6531 29.3247 29.2356 25.7446 27.8825 26.9664 33.3560 21.8404 28.8915 26.2253 29.0171 27.7406 31.2057 30.0025 30.2315 28.3749 29.7479 31.3518 32.0205 26.4201 27.3727 28.2736 29.1980 27.2619 28.5250 27.7551 31.8161 27.2721 28.5868 31.0690 30.5975 30.7904 29.9348 31.7919 25.8138 * 20.4587 * 34.6849 28.0868 26.6241 31.5616 28.1657 * * 29.8358 * * 25.5163 28.8661 28.4331 38.0986 37.6617 * * 28.4890 26.2488 28.2786 25.2294 21.1255 27.9923 23.1755 28.3486 28.8951 27.8050 Average hourly wage** (3 years) 30.9580 27.7625 28.9566 28.2623 27.4482 26.0498 27.0949 26.3114 31.6190 20.6626 28.2820 25.2574 28.9284 26.7559 30.0774 29.4160 28.8817 27.8656 28.7375 30.4088 31.0895 26.0786 26.0387 27.4040 27.8031 26.6349 28.7314 25.8598 29.9477 26.4875 26.9659 30.3264 29.8409 29.2950 28.6891 29.9651 24.8236 * 20.4760 19.3677 34.0994 27.1587 24.8458 30.2316 26.3875 36.0754 36.6265 30.6488 34.0936 34.0526 25.2427 28.8661 28.4331 38.0986 37.6617 * * 27.1483 23.9833 27.2955 23.8425 20.2911 26.6850 22.5131 27.4244 27.1129 26.1032 23764 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 370016 370018 370019 370020 370022 370023 370025 370026 370028 370029 370030 370032 370034 370036 370037 370039 370040 370041 370047 370048 370049 370051 370054 370056 370057 370060 370065 370072 370078 370080 370083 370084 370089 370091 370093 370094 370097 370099 370100 370103 370105 370106 370112 370113 370114 370138 370139 370148 370149 370153 370156 370158 370166 370169 370170 370171 370172 370173 370174 370176 370178 370180 370183 370190 370192 370196 370199 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.5756 1.5016 1.1994 1.4065 1.1935 1.2804 1.3471 1.4489 1.9475 1.1365 1.0209 1.4768 1.2643 1.0929 1.6173 1.0375 0.9726 0.8769 1.4262 1.0294 1.3024 1.0519 1.2382 1.8723 1.0258 1.0456 1.0154 0.8329 1.5381 0.9489 0.9450 1.0056 1.4095 1.6019 1.6611 1.3751 1.2821 1.0542 0.9080 1.0407 2.0282 1.4171 0.9279 1.1274 1.5752 1.0937 0.9151 1.5372 1.3311 1.1065 1.0044 0.9394 0.8545 0.9454 0.9052 0.9693 0.8569 0.9838 0.9087 1.3084 0.9114 1.1405 0.9683 1.5039 1.9589 *** 0.9156 PO 00000 Frm 00238 Average hourly wage FY 2007 0.8686 0.8652 0.8016 0.8016 0.8016 0.8106 0.8652 0.8686 0.8686 0.8016 0.8652 0.8686 0.8016 0.8016 0.8686 0.8652 0.8016 0.8652 0.8686 0.8016 0.8686 0.8016 0.8016 0.8630 0.8652 0.8652 0.8112 0.8274 0.8652 0.8016 0.8067 0.8016 0.8016 0.8652 0.8686 0.8686 0.8630 0.8016 0.8116 0.8016 0.8686 0.8686 0.8016 0.8950 0.8652 0.8016 0.8016 0.8686 0.8686 0.8016 0.8137 0.8686 0.8652 0.8179 1.4446 1.4446 1.4704 1.4446 1.4446 0.8652 0.8016 1.4446 0.8652 0.8652 0.8686 * 0.8686 Fmt 4701 Sfmt 4702 26.7938 25.3573 22.0221 20.8723 24.6099 23.5170 23.9873 25.8428 27.8621 26.8508 24.1483 24.8626 19.5099 19.2318 24.9553 23.0254 22.8356 22.6731 24.1991 21.4543 23.8844 19.8329 22.4652 24.3986 19.8683 19.9025 21.2343 11.7942 27.8611 19.9595 19.2568 19.6230 20.6153 24.1438 26.0459 24.5555 26.3168 24.9971 17.9732 18.8933 26.7973 27.8979 16.0592 26.9720 23.0006 20.2528 19.4287 27.0904 23.3493 23.2778 25.2562 20.7641 25.1107 16.8252 * * * * * 24.7655 16.0179 * 24.7103 29.1568 27.6367 22.3498 23.3989 Average hourly wage FY 2008 29.8284 24.6868 25.2814 22.7566 22.2289 24.0376 24.5547 25.5172 28.5619 28.5309 25.8212 26.2642 20.4106 19.8162 25.2350 23.5745 26.7395 22.9834 24.4766 22.0627 22.8755 19.3222 25.2142 25.5453 22.1337 23.3858 23.5815 13.0963 26.6972 22.4113 20.9878 20.7326 22.1523 25.8697 27.5356 26.5265 26.8138 26.7206 19.4002 19.4273 26.6399 28.5957 16.7888 26.4608 25.9841 22.1675 20.5156 28.1933 23.3423 24.1667 23.0104 21.5228 24.7251 16.6752 * * * * * 24.9650 16.0747 * 23.8419 34.6942 19.0638 20.8296 23.7412 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 30.4646 31.2325 26.7609 27.7807 26.4826 24.9575 24.8323 26.0190 29.9829 30.0133 26.0822 28.0726 23.2177 21.1549 26.8975 25.3412 19.7632 29.5069 27.8930 23.4845 24.2087 21.8711 23.4638 27.6169 23.1808 25.5560 24.0050 22.8589 30.4817 23.7218 21.9159 17.4201 22.0592 28.0464 26.7255 28.3484 28.0905 30.5425 20.6297 22.2665 30.5423 29.6782 19.0125 30.0045 27.3069 23.6337 21.0751 29.3428 23.0749 25.9232 22.7138 22.0059 26.3414 24.5386 * * * * * 26.6672 15.5266 * 30.3849 32.5630 19.1330 24.6968 23.9357 Average hourly wage** (3 years) 28.9272 27.0624 24.7201 23.6027 24.3184 24.1637 24.4542 25.7953 28.8114 28.4170 25.3421 26.3353 21.1222 20.1518 25.7110 23.9675 23.1713 24.8467 25.5715 22.3179 23.6440 20.3135 23.6682 25.8232 21.6643 22.9757 22.9087 14.5180 28.2974 22.0520 20.6845 19.1737 21.6429 26.0375 26.7691 26.4229 27.0817 27.4897 19.4038 20.0894 27.9853 28.7253 17.3058 27.8038 25.4424 21.8806 20.3636 28.2968 23.2542 24.4635 23.5680 21.4295 25.3950 19.7622 * * * * * 25.4759 15.8654 * 26.4222 32.3673 21.1807 22.8178 23.7085 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23765 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 370200 370201 370202 370203 370206 370210 370211 370212 370214 370215 370216 370217 370218 370219 370220 370222 370223 370226 370227 370228 380001 380002 380004 380005 380007 380009 380010 380014 380017 380018 380020 380021 380022 380025 380027 380029 380033 380037 380038 380039 380040 380047 380050 380051 380052 380056 380060 380061 380071 380075 380081 380082 380089 380090 380091 380100 390001 390002 390003 390004 390006 390008 390009 390010 390011 390012 390013 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.0572 1.7010 1.4934 1.9356 1.7577 2.1582 1.1931 1.8217 0.8902 2.3013 2.0050 *** 1.9640 *** 2.3081 1.8753 0.8701 1.4674 0.9326 1.2387 1.2850 1.2143 1.6454 1.4198 1.9643 2.0934 *** 1.8838 1.7891 1.8551 1.4577 1.4597 1.3523 1.1973 1.3782 1.2617 1.7377 1.3322 1.2761 *** 1.4621 1.8056 1.4231 1.7594 1.2624 1.1073 1.4994 1.6390 1.3775 1.3482 *** 1.2966 1.3399 1.3418 1.4734 *** 1.5668 1.3393 1.2164 1.6088 1.9527 1.1400 1.8038 1.1889 *** 1.1856 1.3619 PO 00000 Frm 00239 Average hourly wage FY 2007 0.8016 0.8686 0.8652 0.8686 0.8686 0.8652 0.8686 0.8686 0.8137 0.8686 0.8652 * 0.8652 * 0.8686 0.8686 0.8686 0.8016 0.8652 0.8652 1.1204 1.0298 1.1204 1.0298 1.1204 1.1204 * 1.1076 1.1204 1.0298 1.1157 1.1204 1.0572 1.1204 1.1157 1.0725 1.1157 1.1204 1.1204 * 1.0298 1.1043 1.0298 1.1204 1.0298 1.0725 1.1204 1.1204 1.1204 1.0298 * 1.1204 1.1204 1.1157 1.1204 * 0.8342 0.8579 0.8342 0.9185 0.9185 0.8402 0.8708 0.8579 * 1.0992 0.9185 Fmt 4701 Sfmt 4702 20.5175 23.8090 26.1132 22.8869 26.0353 23.3786 27.8737 19.1720 20.6217 31.5652 27.2429 26.8677 * * * * * * * * 29.5842 30.3385 32.6901 30.9087 33.9601 32.4016 34.4208 33.6078 34.2605 30.9923 29.6053 29.2164 30.1742 35.5084 26.4982 28.7994 33.4828 32.4033 34.5971 38.0989 31.2286 31.0584 27.1814 30.8891 25.6085 27.7253 32.0101 32.3699 31.7761 33.8962 26.8149 35.6708 34.6015 33.0990 39.9703 * 23.6075 24.7867 23.3672 24.4068 26.8581 22.8042 26.7462 24.5785 21.4856 30.7542 25.0037 Average hourly wage FY 2008 21.7153 24.2364 25.7966 25.7770 27.5752 27.2111 28.6537 20.3495 21.0732 32.4087 25.8260 * 30.3445 * * * * * * * 32.0770 31.5246 34.5432 33.2849 35.1697 34.5635 * 33.1928 35.3734 31.8181 34.6183 32.6142 29.6224 36.4910 28.0247 29.4461 34.0094 32.7922 35.1105 * 32.9081 32.8188 29.7329 32.8545 28.6119 29.1686 33.8863 34.5230 31.0901 31.6884 * 35.7821 35.4850 35.5535 40.5066 * 24.3251 25.0860 24.5099 25.2424 28.6926 22.6297 26.7234 24.8196 20.2291 32.4856 26.2323 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 19.7049 25.5862 25.8246 30.3614 30.8129 25.7890 30.9637 20.0910 20.1491 32.0922 29.6639 * 23.7493 41.4373 21.3140 26.9158 24.0138 * * * 33.8473 32.6801 36.1178 33.5739 36.4198 36.5661 * 35.7074 37.0024 32.4859 35.7367 33.0611 30.9162 38.1479 31.4378 33.3348 36.0221 34.0301 35.0334 * 34.4710 35.8144 31.3064 34.6659 27.7647 31.0190 35.1087 35.7630 31.6798 34.0174 * 37.7239 36.9989 41.4499 38.4947 45.3849 25.4178 25.9811 26.2863 26.5037 30.9901 22.9409 28.7325 26.0951 * 34.1980 28.3024 Average hourly wage** (3 years) 20.6651 24.5320 25.9084 26.3098 28.1710 25.4309 29.3408 19.8981 20.5858 32.0514 27.5894 26.8677 26.4612 41.4373 21.3140 26.9158 24.0138 * * * 31.8553 31.5496 34.4710 32.5875 35.2082 34.5647 34.4208 34.1739 35.5661 31.7959 32.9979 31.5746 30.2422 36.7332 28.6431 30.6606 34.5420 33.1177 34.9145 38.0989 32.9570 33.3095 29.4427 32.8426 27.2628 29.2586 33.6769 34.2152 31.5133 33.2050 26.8149 36.4069 35.7198 36.7267 39.6719 45.3849 24.4575 25.2995 24.7251 25.3610 28.9685 22.7921 27.4264 25.1622 20.8697 32.4294 26.5751 23766 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 390016 390019 390022 390023 390024 390025 390026 390027 390028 390030 390031 390032 390035 390036 390037 390039 390041 390042 390043 390044 390045 390046 390048 390049 390050 390052 390054 390056 390057 390058 390061 390062 390063 390065 390066 390067 390068 390070 390071 390072 390073 390074 390076 390079 390080 390081 390084 390086 390090 390091 390093 390095 390096 390097 390100 390101 390102 390103 390104 390107 390108 390110 390111 390112 390113 390114 390115 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2430 1.1210 *** 1.2632 *** 0.4329 1.3079 1.6538 1.5828 1.1870 1.2126 1.2693 1.1907 1.4853 1.4598 1.2528 1.3077 1.3624 1.1959 1.5562 1.4816 1.6617 1.1221 1.5809 2.0142 1.1476 *** 1.1124 1.3322 1.3063 1.5170 1.1231 1.8374 1.3159 1.3881 1.7872 1.3404 1.3523 1.0062 1.0663 1.6919 *** 1.3189 1.8491 1.3943 1.2389 1.1285 1.5931 1.9186 1.1759 1.1913 1.1678 1.6015 1.2500 1.6431 1.2844 1.4773 *** 1.1021 1.5861 1.1988 1.5950 2.1581 1.3266 1.3312 1.6377 1.4264 PO 00000 Frm 00240 Average hourly wage FY 2007 0.8559 0.9675 * 1.0992 * 1.0992 1.0992 1.0992 0.8579 0.8626 0.9204 0.8579 1.0992 0.8579 0.8579 0.8342 0.8579 0.8579 0.8342 1.0788 0.8342 0.9799 0.9185 0.9675 0.8579 0.8389 * 0.8378 1.0992 0.9185 0.9799 0.8342 0.8708 1.1006 0.9185 0.9185 0.9799 1.0992 0.8342 0.8342 0.8342 * 1.0992 0.8560 1.0992 1.0992 0.8342 0.8342 0.8579 0.8559 0.8559 0.8342 1.0788 1.0992 0.9799 0.9666 0.8579 * 0.8342 0.8579 1.0992 0.8579 1.0992 0.8342 0.8559 0.8579 1.0992 Fmt 4701 Sfmt 4702 23.2095 24.0538 30.3565 35.4452 33.5186 19.1362 31.8512 35.5692 27.1869 23.6063 26.2654 23.9466 28.4564 21.6358 25.4290 22.0208 22.9814 28.3633 23.2378 28.7758 23.9343 29.6574 28.5342 29.6121 27.2599 24.9510 24.4435 23.5077 29.7982 26.9546 29.1318 21.2999 26.4998 27.6249 25.9645 29.7234 26.7358 33.3185 24.6462 25.3029 25.7822 23.6500 31.8500 22.5607 28.7063 31.7569 23.2039 23.5141 27.3528 21.7010 22.6082 22.6150 28.8258 26.1741 30.0132 23.1497 24.8369 20.5741 19.2326 24.1159 27.8171 27.7311 34.2990 20.2380 23.3686 26.9620 29.6905 Average hourly wage FY 2008 24.3488 25.7515 29.6308 34.7787 38.8750 20.3878 31.8309 39.2158 27.1451 24.6343 27.2033 24.5243 29.5417 24.4917 25.2296 23.2300 24.2257 28.0996 24.2087 29.4057 24.6495 30.5115 28.3152 30.7431 27.3481 25.1462 27.4805 23.5821 30.9198 27.7296 30.0597 21.0713 26.8381 29.5654 25.4407 30.6128 29.0962 34.4935 24.8467 26.2568 26.4083 25.4098 32.7671 24.4452 29.2645 33.6247 24.3372 25.0992 27.0122 23.3562 22.6023 24.6290 28.6055 27.9858 30.0234 24.8377 24.4589 20.4446 19.6630 24.6565 28.5928 25.3407 34.8756 21.5439 24.2593 27.9184 30.8063 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 26.1785 25.3173 * 36.2584 37.4780 * 36.0580 40.9084 29.6197 26.5661 26.1246 25.3739 27.2114 26.1934 27.0768 22.1517 25.1175 29.6193 24.3584 29.9946 25.8784 32.5260 28.4555 30.4709 29.6697 26.3688 27.5682 24.7026 31.0260 29.6597 30.9185 22.8844 28.3963 31.8827 29.0022 32.2862 29.6963 34.5477 26.3816 28.8131 27.0855 * 33.9877 26.0178 31.6193 36.4760 24.3181 24.7444 30.1231 23.2108 23.8837 25.3848 30.3896 28.1266 32.5896 27.3460 25.5321 * 20.4543 25.6775 34.3038 25.7142 38.6429 18.4179 24.8661 28.5319 32.5023 Average hourly wage** (3 years) 24.5413 24.9933 29.9808 35.4918 36.5096 19.7743 33.1365 38.5953 27.9531 24.9940 26.5387 24.6172 28.3541 24.0498 25.9180 22.4609 24.1286 28.7201 23.9394 29.4217 24.8306 30.9440 28.4340 30.2929 28.1208 25.5002 26.3435 23.9359 30.6011 28.1041 29.9889 21.7734 27.2925 29.7493 26.8307 30.8943 28.5413 34.1258 25.3085 26.7355 26.4996 24.5222 32.8740 24.3375 29.8842 33.9941 23.9420 24.4724 28.1610 22.7618 23.0312 24.2111 29.2646 27.3784 30.9302 25.1596 24.9493 20.5090 19.7621 24.8676 30.1995 26.1477 35.9670 19.9664 24.1707 27.8260 31.0518 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23767 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 390116 390117 390118 390119 390121 390122 390123 390125 390127 390128 390130 390131 390132 390133 390136 390137 390138 390139 390142 390145 390146 390147 390150 390151 390153 390154 390156 390157 390160 390162 390163 390164 390166 390168 390169 390173 390174 390176 390178 390179 390180 390181 390183 390184 390185 390189 390192 390194 390195 390196 390197 390198 390199 390201 390203 390204 390211 390217 390219 390220 390222 390223 390225 390226 390228 390231 390233 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2605 1.1784 1.1738 1.2800 *** 1.1069 1.1993 1.2499 1.3561 1.2331 1.1985 1.3570 1.4504 1.7609 *** 1.4546 1.1966 1.3522 1.5286 1.5880 1.1823 1.3781 1.1119 1.3436 1.3705 1.2171 1.3593 1.3257 1.3326 1.5041 1.2454 2.1300 *** 1.4758 1.4118 1.2178 1.6824 1.1316 1.3247 1.4264 1.3926 *** 1.1452 1.0915 1.2586 1.1436 1.0388 1.2037 1.6565 1.6460 1.4171 1.1294 1.1366 1.3518 1.5297 1.2911 1.2835 1.2278 1.3577 1.0888 1.2691 1.9836 1.1877 1.7135 1.3609 1.4014 1.3823 PO 00000 Frm 00241 Average hourly wage FY 2007 1.0992 0.8344 0.8342 0.8342 * 0.8395 1.0992 0.8364 1.0992 0.8579 0.8342 0.8579 1.0992 0.9675 * 0.8342 0.9185 1.0992 1.0992 0.8579 0.8364 0.8579 0.8579 1.1006 1.0992 0.8342 1.0992 0.8579 0.8579 1.1449 0.8559 0.8579 * 0.8579 0.8342 0.8342 1.0992 0.8579 0.8930 1.0992 1.0992 * 0.8342 0.8579 0.9675 0.8342 0.8342 0.9675 1.0992 * 0.9675 0.8708 0.8342 0.9512 1.0992 1.0992 0.8930 0.8579 0.8579 1.0992 1.0992 1.0992 0.9799 1.0992 0.8579 1.0992 0.9666 Fmt 4701 Sfmt 4702 32.2513 20.7821 20.5614 23.0928 25.4826 23.1866 32.4528 22.4033 31.9091 24.1628 23.0592 23.0577 29.6396 31.1083 23.9813 24.2878 25.3410 34.1447 33.8224 24.6672 22.6752 26.8522 22.8228 29.9254 32.8234 22.8391 32.2688 21.5923 24.0208 35.5057 23.2055 26.3087 20.9272 26.1365 26.5514 23.9927 34.2069 23.9779 22.6006 28.0688 34.9832 25.9871 27.0122 22.7451 25.4256 22.6796 20.5459 27.5890 34.2980 * 26.8270 20.5979 22.3224 27.0054 29.4930 29.5251 25.1689 23.5879 25.4886 28.9128 30.9464 30.2523 27.5803 32.6658 23.9845 30.9339 25.6904 Average hourly wage FY 2008 33.2562 21.5038 21.8917 24.3245 * 23.3220 34.0062 22.8816 33.6557 24.1390 23.2504 23.5783 31.1168 32.9812 * 26.1457 27.4231 34.0836 34.5773 25.6980 25.1805 28.6606 22.7668 31.4067 33.2427 23.3559 32.8999 22.1112 22.9696 34.5809 22.8341 27.1950 23.3255 26.9816 26.2643 25.6455 34.8999 24.1247 23.1452 30.1219 35.5291 26.6021 27.8358 23.9736 27.1119 23.6215 23.6171 26.3152 34.5594 * 27.2455 20.4350 23.0046 27.3542 29.1370 30.7346 26.5052 24.1886 26.1196 30.7435 31.7361 34.3280 27.2555 32.6508 24.2242 32.8353 27.2597 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 33.9272 22.2319 23.6529 25.3896 * 24.6425 35.1219 24.0182 33.1200 25.1844 30.3208 27.7127 30.0723 33.0697 * 26.9140 27.7549 36.4969 33.3491 26.9194 23.9869 29.0974 22.6473 31.8952 36.0259 23.9776 33.7034 23.0975 25.2027 35.1818 24.8747 29.7760 28.2160 27.3654 26.6049 27.6024 34.9029 12.3126 23.9151 31.5474 38.2969 27.8820 28.2196 23.9958 25.5306 23.4893 23.7948 23.7351 37.2471 * 28.1394 21.0850 24.5461 28.5649 30.7209 32.0218 27.7862 26.2690 26.3253 32.0869 32.3724 37.4105 26.3628 35.4653 25.5103 35.2285 28.3647 Average hourly wage** (3 years) 33.1578 21.5356 22.0851 24.2630 25.4826 23.7140 33.8960 23.1230 32.8957 24.5037 25.3350 24.8832 30.2692 32.4255 23.9813 25.8031 26.8681 34.9221 33.9107 25.7780 23.9695 28.1881 22.7481 31.1171 34.1045 23.4008 32.9631 22.2734 24.0528 35.0918 23.6452 27.7684 23.9468 26.8304 26.4723 25.7719 34.6825 18.1769 23.2190 29.9836 36.3036 26.8191 27.6769 23.5369 25.9878 23.2864 22.6673 25.7636 35.3797 * 27.4100 20.7061 23.3008 27.6588 29.8038 30.7952 26.4993 24.6769 25.9698 30.6085 31.7085 33.8814 26.9591 33.6044 24.5893 33.0470 27.1364 23768 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 390236 390237 390246 390256 390258 390263 390265 390266 390267 390268 390270 390272 390278 390285 390286 390287 390288 390289 390290 390302 390303 390304 390305 390306 390307 390308 390309 390310 390311 390312 390313 390314 390315 390316 390318 400001 400002 400003 400004 400005 400006 400007 400009 400010 400011 400012 400013 400014 400015 400016 400017 400018 400019 400021 400022 400024 400026 400028 400032 400044 400048 400061 400079 400087 400098 400102 400103 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.9818 1.5868 1.1777 1.9774 1.4533 1.5092 1.5374 1.1912 1.2760 1.4064 1.6183 0.6051 0.6005 1.4914 1.2124 *** *** *** 1.8004 0.8675 *** 1.2958 *** *** 2.0387 *** *** *** *** 1.2883 1.1642 1.9344 1.6395 1.6856 0.8280 1.3295 1.9377 1.3791 1.2115 1.2533 1.1625 1.1605 0.9834 0.9051 1.1055 1.4864 1.3650 1.3749 1.4718 1.4676 0.8958 1.1103 1.5158 1.3614 1.4439 0.8933 1.1373 1.1913 1.1451 1.4861 1.3035 2.2573 1.2280 1.3360 1.3491 1.1900 1.9297 PO 00000 Frm 00242 Average hourly wage FY 2007 0.8345 0.8342 * 0.9185 1.0992 0.9675 0.8579 0.8930 0.8579 0.8810 0.8342 1.0992 1.0992 1.0992 1.0992 * * * 1.0992 1.0992 * 1.0992 * * 0.8930 * * * * 1.0992 0.9204 0.9675 0.8579 0.9518 0.9675 0.4404 0.4122 0.4122 0.4404 0.4404 0.4404 0.4404 0.3137 0.3311 0.4404 0.4404 0.4404 0.3896 0.4404 0.4404 0.4404 0.4404 0.4404 0.4648 0.4122 0.3896 0.3137 0.4122 0.4404 0.4122 0.3137 0.4404 0.3311 0.4404 0.4404 0.4404 0.3896 Fmt 4701 Sfmt 4702 22.1144 27.4944 25.1956 28.0617 30.4142 28.5864 24.0675 20.8789 24.2428 25.6643 24.9510 * 26.6664 36.7163 29.5281 39.3176 30.9701 30.7583 38.3776 * 27.5580 30.4832 * * * * * * * * * * * * * 13.9386 15.3833 13.9258 12.0923 10.3505 8.1841 11.8203 9.3834 9.8132 9.6641 12.3362 11.1414 10.5286 13.7043 16.6472 10.3123 11.9184 12.8380 14.4549 14.9089 10.8439 9.9262 11.3260 10.3736 14.6420 9.6416 18.1303 9.5296 11.0377 13.8034 10.5879 10.6971 Average hourly wage FY 2008 23.1290 28.4337 26.0179 28.8970 31.7164 29.9850 25.0166 22.2228 24.8309 26.7342 26.5010 * 28.6323 37.6669 31.3393 42.2401 * * 41.1426 * * 32.1633 29.3217 40.3789 24.5393 36.1737 37.8924 44.3991 * * * * * * * 14.9151 12.9440 15.7906 12.5928 11.1152 8.1381 12.0743 9.5114 10.7993 8.5503 10.1156 11.4222 9.9395 22.2017 16.1931 9.9185 12.3942 14.7133 13.9217 15.3625 12.6226 7.1179 10.6711 10.7141 11.3551 9.6860 18.0093 10.4599 11.4162 13.7878 12.1761 11.7488 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 24.5566 29.0645 * 28.5871 32.0531 31.7255 27.7776 23.0128 25.7553 28.4188 27.0286 32.9893 28.8290 38.4678 31.7320 * * * 47.7624 * * 33.4111 * * 22.9455 * * * 49.8990 51.3342 * * * * * 15.4246 12.9793 14.6853 13.5193 11.7582 * 10.4935 10.1204 10.4202 9.4065 * 12.3068 12.3295 21.9216 17.9101 10.0587 13.1567 15.2358 14.9779 15.2119 13.7214 8.9063 9.6940 10.7841 12.1404 10.5172 17.4499 10.6123 12.0032 12.8752 12.1258 11.3309 Average hourly wage** (3 years) 23.2393 28.3719 25.6189 28.5302 31.4303 30.1997 25.6284 22.0423 24.9521 27.0040 26.2567 32.9893 28.0560 37.6177 30.8704 40.3959 30.9701 30.7583 42.2989 * 27.5580 32.1082 29.3217 40.3789 23.6860 36.1737 37.8924 44.3991 49.8990 51.3342 * * * * * 14.7738 13.6878 14.8161 12.7362 11.0789 8.1610 11.4512 9.6757 10.3256 9.2136 11.0797 11.6476 10.8952 18.9475 16.9079 10.0981 12.5002 14.0763 14.4495 15.1640 12.2509 8.4875 10.5465 10.6281 12.5283 9.9689 17.8500 10.2200 11.4590 13.4675 11.5565 11.2618 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23769 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 400104 400105 400106 400109 400110 400111 400112 400113 400114 400115 400117 400118 400120 400121 400122 400123 400124 400125 400126 400127 400128 410001 410004 410005 410006 410007 410008 410009 410010 410011 410012 410013 420002 420004 420005 420006 420007 420009 420010 420011 420015 420016 420018 420019 420020 420023 420026 420027 420030 420033 420036 420037 420038 420039 420043 420048 420049 420051 420053 420054 420055 420056 420057 420062 420064 420065 420066 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.2190 1.2578 1.1085 1.4302 1.2156 1.2130 1.2446 1.1764 1.1726 1.0815 1.1347 1.2649 1.3351 1.1129 1.8905 1.2353 2.6860 1.2073 1.2894 2.0911 1.0184 1.3144 1.3107 1.2724 1.3911 1.6113 1.3225 1.2374 1.1305 1.4882 1.5728 1.2045 1.5630 1.9671 1.1610 *** 1.6315 1.4114 1.1406 1.1778 1.3156 0.9672 1.8307 1.0990 1.3500 1.7169 1.8642 1.5767 1.3204 1.1839 1.2480 1.3390 1.2831 1.0529 1.1111 1.2885 1.2591 1.7106 1.2316 1.1106 1.0931 1.3487 1.2036 1.1026 1.2630 1.4161 0.9980 PO 00000 Frm 00243 Average hourly wage FY 2007 0.4404 0.4404 0.4404 0.4404 0.3358 0.3311 0.4404 0.4122 0.4404 0.4404 0.4404 0.4404 0.4404 0.4404 0.4404 0.3896 0.4404 0.4067 0.4648 0.4404 0.4404 1.1338 1.1338 1.1338 1.0669 1.1338 1.0669 1.0669 1.1338 1.1338 1.1338 1.1587 0.9561 0.9231 0.8609 * 0.9294 0.9294 0.8609 0.9605 0.9605 0.8609 0.8984 0.8767 0.9231 0.9605 0.8984 0.9294 0.9231 0.9605 0.9557 0.9605 0.9605 0.9017 0.8766 0.8984 0.8683 0.8609 0.8644 0.8612 0.8609 0.8609 0.8609 0.9557 0.8683 0.9231 0.8609 Fmt 4701 Sfmt 4702 11.4322 15.6626 13.4097 14.4386 11.1812 14.1718 10.1512 10.5305 10.1379 12.0713 9.5929 12.8692 13.4069 9.7427 8.9478 12.8317 17.2139 11.9787 14.1062 17.8303 * 29.0877 29.4953 28.1141 30.1855 33.2896 30.9505 31.7300 32.0704 33.8781 33.6072 35.8075 29.5592 28.1455 25.0420 26.3293 26.8165 27.0147 25.1452 22.1787 24.1685 21.6266 25.6687 22.5489 28.4344 27.4589 27.8986 26.4472 27.8435 30.4162 23.8742 29.8321 24.6642 28.2220 24.0971 25.9610 26.0953 25.9056 23.2246 25.6779 24.0965 27.7250 24.9313 26.7467 24.3540 25.5483 25.1062 Average hourly wage FY 2008 12.8404 16.9029 12.9272 14.8208 9.9278 10.2141 13.5177 10.9503 10.8913 9.6200 11.6258 12.7861 14.0817 9.1826 9.5814 12.5609 17.9140 13.5394 16.5726 20.7775 12.3520 30.0315 31.3023 31.4387 32.8456 32.0730 32.5889 32.8422 32.7379 30.1941 37.0299 41.0010 30.5111 28.9250 24.6968 27.7764 29.0901 29.9378 25.5710 25.5130 26.3499 22.5681 27.5563 25.4954 27.5000 28.9321 28.0647 28.5621 28.4433 31.1608 24.6505 30.9556 26.6435 26.5582 25.7951 26.9625 25.7060 26.4710 24.4793 25.6444 25.1738 28.4512 26.2489 25.9569 24.6507 26.8118 25.0932 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 12.6932 17.0458 14.8543 14.5707 10.8210 10.7888 11.2302 11.5947 11.6870 10.6805 12.1537 12.6196 14.5200 9.9712 10.0960 13.8597 19.1698 13.1075 * * * 30.5848 35.2360 34.5807 33.5403 34.2549 33.5128 34.3405 34.8380 36.7639 35.5818 40.1823 31.2220 30.2325 26.5027 29.1383 28.9533 28.6625 26.5503 25.9543 27.4912 23.4313 29.0897 25.8113 29.2372 30.4471 29.5039 31.3772 30.3403 32.4244 26.3463 32.7083 27.1507 26.3100 25.8352 27.4313 28.0020 27.4172 25.5724 26.7888 25.3132 29.7763 25.6602 27.2249 25.0602 28.1872 * Average hourly wage** (3 years) 12.3296 16.5427 13.7089 14.6114 10.6067 11.5139 11.5795 11.0441 10.9257 10.8173 11.0019 12.7539 14.0199 9.6244 9.5553 13.0762 18.1028 12.8846 15.3043 19.5304 12.3520 29.9101 31.9950 31.2615 32.1894 33.1928 32.3511 32.9948 33.2523 33.5131 35.4055 38.9884 30.4468 29.1286 25.3750 27.7486 28.2944 28.5279 25.7612 24.5702 26.0287 22.5462 27.4853 24.4094 28.3934 28.9941 28.4725 28.7401 28.8720 31.3429 24.9665 31.1311 26.1466 26.9774 25.2415 26.8137 26.6253 26.6012 24.4361 26.0196 24.8604 28.7570 25.6193 26.6400 24.6890 26.8671 25.0997 23770 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 420067 420068 420069 420070 420071 420072 420073 420078 420079 420080 420082 420083 420085 420086 420087 420089 420091 420093 420098 420099 420100 420101 420102 430005 430008 430012 430013 430014 430015 430016 430027 430048 430060 430064 430077 430081 430082 430083 430084 430085 430089 430090 430091 430092 430093 430094 430095 430096 440001 440002 440003 440006 440007 440008 440009 440010 440011 440012 440015 440016 440017 440018 440019 440020 440024 440025 440026 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.3639 1.3759 1.2054 1.3136 1.4339 1.1634 1.3829 1.8607 1.5040 1.4321 1.5113 1.4528 1.5909 1.4584 1.8044 1.3777 1.4537 *** 1.2041 *** *** 1.2049 1.4677 1.3356 1.1161 1.3044 1.2029 1.4127 1.1983 1.5975 1.7417 1.2671 0.9444 0.9859 1.7222 0.9388 0.8463 0.8496 0.9068 0.8878 1.8588 1.6017 2.2308 1.8871 1.3555 1.7381 2.4765 1.9114 1.1662 1.7208 1.3386 1.4409 0.9815 0.9673 1.1674 0.9494 1.3656 1.5047 1.8290 1.0436 1.7685 1.1100 1.6911 1.0903 1.1324 1.1246 *** PO 00000 Frm 00244 Average hourly wage FY 2007 0.8827 0.9231 0.8609 0.8984 0.9294 0.8609 0.8984 0.9605 0.9231 0.8827 0.9597 0.9294 0.9074 0.8984 0.9231 0.9231 0.8609 * 0.8609 * * 0.8609 0.9605 0.8428 0.8963 0.9262 0.9262 0.8428 0.8428 0.9379 0.9379 0.8557 0.8428 0.8428 0.9618 1.4448 1.4448 1.4448 1.4448 1.4448 0.8783 0.9379 0.9502 0.8428 0.9502 0.8557 0.9379 0.8428 0.7999 0.8886 0.9445 0.9445 0.8176 0.8339 0.7957 0.7957 0.7957 0.7964 0.7957 0.8101 0.7964 0.7999 0.7957 0.8614 0.8717 0.8611 * Fmt 4701 Sfmt 4702 25.8561 25.6857 22.3445 24.7899 25.2862 17.8019 25.5204 29.5135 27.5439 28.6060 31.2671 26.4932 27.8386 28.0485 25.4697 28.1855 26.0592 28.0765 30.7532 * * * * 22.4111 24.4277 24.0326 25.9828 26.8752 23.6296 28.9376 26.6044 24.1969 13.2618 18.3125 25.8572 * * * * * 22.3335 26.4862 25.1105 21.6478 27.5326 22.9091 31.3409 21.6713 21.2398 25.7434 28.4862 29.7146 19.9754 23.2126 23.9279 19.3669 23.6154 24.0169 25.0430 23.0350 25.0588 23.2107 25.3592 24.0995 23.9745 22.5407 28.0349 Average hourly wage FY 2008 26.5658 27.7315 23.7494 27.5988 27.6371 21.6587 26.1120 30.9001 28.6374 31.5670 33.9874 28.9007 29.1127 27.9523 26.8409 29.5862 27.2520 33.0474 27.1939 30.3089 * * * 23.8694 26.0873 25.2030 27.0427 27.9288 26.5787 32.8765 27.5759 25.1715 * 16.4916 27.2116 * * * * * 23.2467 29.0197 24.7274 21.9197 26.0232 23.2894 32.2326 24.6041 21.5755 26.3802 28.3557 31.5533 18.8273 27.3732 23.8148 19.6231 23.6698 23.7871 26.0601 24.5812 24.6707 25.0780 25.2230 24.7785 24.7705 22.6571 26.8153 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 27.7148 28.0296 24.4638 27.6406 28.1087 20.7707 28.2651 32.0165 30.5954 32.8693 34.8836 29.6565 29.9059 29.6321 28.4609 31.7347 27.9042 * 27.6701 * 29.2958 33.1975 * 25.4368 27.2262 27.0179 28.4945 28.9278 28.0396 31.1313 29.2595 25.6411 * 17.7325 31.1926 * * * * * 24.9033 32.7369 26.7238 23.2508 24.7398 23.6605 32.5850 24.9608 25.4844 26.9121 26.0107 31.7373 22.7570 26.8850 24.4410 20.2498 24.8292 24.9243 27.1580 25.2515 26.1800 24.5898 26.2435 27.5620 26.2519 24.0274 28.4597 Average hourly wage** (3 years) 26.7379 27.1430 23.5595 26.7218 27.0462 19.9748 26.7147 30.8100 28.9420 30.8888 33.3515 28.4194 28.9688 28.5671 26.9052 29.8346 27.0840 30.2237 28.2065 30.3089 29.2958 33.1975 * 23.9203 25.9003 25.4023 27.1837 27.9157 26.1008 30.9581 27.8481 25.0133 13.2618 17.4427 28.0482 * * * * * 23.5426 29.5038 25.5162 22.2946 26.0952 23.3062 32.0536 23.8070 22.7818 26.3584 27.4326 31.0128 20.4815 25.9985 24.0653 19.7446 24.0419 24.2664 26.0995 24.2770 25.3213 24.3284 25.5920 25.4792 25.0623 23.0928 27.7725 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23771 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 440029 440030 440031 440032 440033 440034 440035 440039 440040 440046 440047 440048 440049 440050 440051 440052 440053 440054 440056 440057 440058 440059 440060 440061 440063 440064 440065 440067 440068 440070 440072 440073 440081 440082 440083 440084 440091 440102 440104 440105 440109 440110 440111 440115 440120 440125 440130 440131 440132 440133 440135 440137 440141 440144 440147 440148 440150 440151 440152 440153 440156 440159 440161 440162 440166 440168 440173 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.4650 1.2893 1.1356 1.1644 1.0637 1.6302 1.3910 2.1051 0.9210 1.3069 0.9617 1.8071 1.6747 1.2834 0.9337 1.0032 1.2712 1.0962 1.2127 1.1032 1.2003 1.4855 1.1325 1.1295 1.6197 0.9999 1.2421 1.1905 1.1835 1.0014 1.0393 1.4453 1.1673 1.9913 0.9577 1.1762 1.7581 1.0796 1.7788 0.9119 1.0139 1.1221 1.2820 0.9684 1.4947 1.6557 1.1217 1.1784 1.2291 1.7069 0.6898 1.0639 0.9917 1.2549 *** 1.1236 1.4307 1.1663 2.0008 1.0509 1.6421 1.4818 1.9267 *** *** 1.0456 1.4350 PO 00000 Frm 00245 Average hourly wage FY 2007 0.9445 0.8013 0.7976 0.7957 0.7984 0.7957 0.9252 0.9445 0.7957 0.9445 0.8295 0.9305 0.9305 0.7964 0.8039 0.7957 0.9445 0.7957 0.7957 0.7978 0.7957 0.9252 0.8339 0.7957 0.7999 0.8857 0.9445 0.7957 0.8717 0.8066 0.8886 0.9252 0.8009 0.9445 0.7957 0.7982 0.8857 0.7957 0.8857 0.7999 0.8027 0.7957 0.9445 0.8295 0.7957 0.7957 0.7957 0.9305 0.7957 0.9445 0.7957 0.8695 0.7957 0.9252 * 0.9252 0.9445 0.9252 0.9305 0.7964 0.8857 0.9305 0.9445 * * 0.9305 0.7957 Fmt 4701 Sfmt 4702 30.1204 23.7670 20.8964 19.7150 21.1087 24.6994 25.9613 29.8611 20.8637 27.9539 21.7892 29.4789 26.4772 24.4616 23.9253 22.8016 27.1197 23.5137 22.7820 16.6346 24.3522 28.3565 24.1024 23.9678 24.2566 23.7176 24.6169 24.4772 24.8146 20.0938 23.9563 26.3570 20.7125 30.6115 25.6099 18.6043 26.5687 20.7363 26.5741 22.9372 20.8924 20.9179 29.0975 23.1409 25.7161 22.8097 23.9955 25.6666 23.9410 29.2829 28.1925 22.2538 24.2406 23.9241 33.1756 23.9810 28.1012 27.1729 27.1877 23.6473 27.7309 26.9098 28.7074 27.6837 35.3064 28.1215 23.1167 Average hourly wage FY 2008 31.2310 22.2607 22.6790 21.0380 22.7991 25.5061 26.2451 30.1790 20.8817 29.7377 22.8323 29.3187 28.8742 24.9694 23.4866 22.6128 27.8180 23.7931 23.2313 17.2176 26.0706 27.9467 25.0795 23.7360 23.9644 26.1246 25.8536 24.6553 26.1071 21.9166 25.7089 27.6154 20.7688 32.2479 23.6356 18.8699 28.1989 21.6762 27.9756 22.7962 21.4629 22.5929 28.8453 23.7107 24.7572 23.6328 25.1262 26.9649 24.0708 29.6093 27.7037 22.9547 24.9917 25.2293 34.8199 22.6188 29.4381 28.2203 28.4612 24.9388 28.5645 25.8289 29.9894 24.8705 * 29.4028 24.0621 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 31.4630 22.3131 22.0708 23.8016 23.9790 25.9124 27.9203 30.1901 21.1282 30.7314 25.2156 30.6710 29.8603 26.3815 23.6554 24.4075 30.3887 21.9638 24.0623 19.3540 29.1174 29.4514 26.5869 25.4125 26.0741 26.7947 25.6096 26.0852 27.9066 23.2223 26.1643 27.5114 21.9671 32.8913 25.7074 19.8938 28.9678 22.1103 28.0888 23.7139 22.5885 23.6262 29.7446 24.9776 26.0604 24.0920 26.3188 28.3153 29.3371 32.5699 27.2084 24.6130 24.8736 26.3207 36.6955 28.0703 30.5491 28.6580 29.0563 23.3772 30.5139 27.2779 31.0647 24.6410 * 31.3312 23.1355 Average hourly wage** (3 years) 30.9557 22.8053 21.8517 21.5383 22.5856 25.3762 26.6992 30.0895 20.9641 29.5270 23.3140 29.8250 28.4462 25.3086 23.6741 23.2437 28.4325 23.0467 23.3523 17.6957 26.6028 28.5989 25.2908 24.3711 24.7976 25.5515 25.3745 25.0966 26.2722 21.7288 25.2966 27.1567 21.1573 31.8790 24.9682 19.1297 27.9314 21.5215 27.5200 23.1599 21.7090 22.5559 29.2213 23.9354 25.5176 23.4915 25.1413 26.9308 25.7508 30.4215 27.7046 23.2371 24.6802 25.2055 34.8975 24.8107 29.3876 27.9977 28.2859 23.9591 28.9635 26.6811 29.9300 25.6902 35.3064 29.7029 23.4173 23772 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 440174 440175 440176 440180 440181 440182 440183 440184 440185 440186 440187 440189 440192 440193 440194 440197 440200 440203 440217 440218 440222 440225 440226 440227 440228 450002 450005 450007 450008 450010 450011 450015 450018 450021 450023 450024 450028 450029 450031 450032 450033 450034 450035 450037 450039 450040 450042 450044 450046 450047 450051 450052 450054 450055 450056 450058 450059 450064 450068 450072 450073 450076 450078 450079 450080 450082 450083 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.8828 1.0111 1.3339 1.3459 0.9020 0.9536 1.6228 1.1292 1.1883 0.9919 1.0974 1.4158 1.0765 1.3104 1.2925 1.3992 0.9829 *** 1.3768 2.0116 1.0088 0.8097 1.5694 1.2974 1.5738 1.4448 1.2408 1.3344 1.3803 1.5960 1.6560 1.5911 1.5354 1.8903 1.4138 1.5693 1.5788 1.6143 1.4439 1.2547 1.5969 1.5308 1.5326 1.5845 1.5955 1.7553 1.7455 1.6959 1.5774 0.8561 1.9250 0.9850 1.7911 1.0449 1.6824 1.5743 1.2980 1.5113 2.0486 1.2155 0.8877 1.6904 0.8999 1.6789 1.2493 1.1597 1.7529 PO 00000 Frm 00246 Average hourly wage FY 2007 0.8269 0.7957 0.7964 0.7984 0.8322 0.8101 0.9305 0.7999 0.8717 0.9445 0.7957 0.8452 0.9252 0.9445 0.9445 0.9445 0.9445 * 0.9305 0.9445 0.9305 0.7957 0.7957 0.9445 0.9305 0.8867 0.8595 0.8949 0.8855 0.9175 0.9193 0.9852 0.9925 0.9852 0.8153 0.8867 0.9226 0.8816 0.9852 0.8407 0.9226 0.8595 0.9925 0.8666 0.9852 0.8712 0.8703 0.9852 0.8494 0.9226 0.9852 0.8153 0.8855 0.8153 0.9521 0.8949 0.9024 0.9852 0.9925 0.9925 0.8153 * 0.8153 0.9852 0.8666 0.8153 0.8901 Fmt 4701 Sfmt 4702 25.4829 24.4848 22.9631 24.9841 24.8857 24.3302 29.1982 24.5786 25.3817 27.3733 24.0723 28.2621 27.3917 24.3622 29.4706 29.4275 21.1860 23.7451 28.8641 23.7257 28.4664 24.8328 26.5831 * * 28.0936 24.4933 23.0026 24.4701 25.5503 26.7418 29.9193 30.2383 29.5658 25.4450 26.9113 29.1438 25.0602 29.0824 21.5084 29.2468 26.5313 28.0668 26.6207 26.7503 25.4734 26.6382 31.0381 24.8947 21.8824 28.8829 22.6448 27.5399 22.9245 28.3092 26.6926 26.8325 26.8355 29.5876 25.8619 26.9446 * 21.4716 30.2420 27.9191 23.9025 27.4955 Average hourly wage FY 2008 26.2087 24.7869 23.7695 22.3070 25.9450 25.0111 30.6599 23.3970 26.7473 28.9124 25.8238 28.8974 29.6272 25.2124 30.8593 30.1184 23.8654 17.9041 29.8888 18.7275 29.0062 27.8860 27.1348 30.7785 28.3687 28.8521 24.5405 23.9490 24.5965 25.5582 28.5329 29.4919 30.7852 31.3107 25.5346 28.2047 29.5792 26.9361 30.3542 25.5785 27.8680 27.6929 28.8049 28.3403 28.2081 26.8412 26.5429 29.4293 25.5903 23.8457 29.9038 23.0007 26.5599 23.6382 31.4971 26.9918 27.3856 28.2786 30.5001 27.1081 26.1567 * 20.0758 30.5968 26.2439 24.2018 32.6462 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 27.4573 26.7698 24.9405 24.3370 26.4759 24.9897 30.9900 26.9069 26.3958 28.2842 27.4029 30.5766 30.6519 25.9713 32.3002 31.4294 23.8295 * 31.6636 36.9244 30.5130 26.9656 28.3176 31.9097 29.5349 29.7157 27.3460 24.4625 24.4362 30.1022 29.9285 30.3151 31.3118 31.7338 25.1670 27.3787 29.5668 28.6442 29.2123 26.3146 29.7653 29.6291 30.3345 28.2594 29.8132 28.5453 27.6115 32.9897 27.2425 24.9663 30.3953 24.3959 30.2202 24.1423 32.0873 27.7297 28.5629 29.0474 32.0346 28.0902 22.2326 * 20.7809 36.8906 26.8091 25.5648 30.2031 Average hourly wage** (3 years) 26.4456 25.3295 23.9373 23.7701 25.8145 24.8044 30.2946 24.9779 26.1839 28.1940 25.7687 29.1873 29.2789 25.1845 30.9187 30.3064 22.9591 20.6007 30.1328 25.9465 29.3485 26.4719 27.3318 31.3743 29.0087 28.8515 25.4548 23.8045 24.5017 27.0858 28.4349 29.9209 30.7838 30.8752 25.3821 27.5109 29.4314 26.7635 29.5392 24.2723 28.9230 28.1119 29.0806 27.7345 28.2727 26.9585 26.9555 31.1698 25.9770 23.5090 29.7565 23.3480 28.0403 23.5765 30.6432 27.1586 27.5865 28.0416 30.7379 27.0430 25.0645 * 20.7567 32.4452 27.0298 24.5569 29.9862 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23773 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 450085 450087 450090 450092 450096 450097 450099 450101 450102 450104 450107 450108 450119 450121 450123 450124 450126 450128 450130 450131 450132 450133 450135 450137 450143 450144 450147 450148 450151 450152 450154 450155 450162 450163 450165 450176 450177 450178 450184 450187 450188 450191 450192 450193 450194 450196 450200 450201 450203 450209 450210 450211 450213 450214 450219 450221 450222 450224 450229 450231 450234 450235 450236 450237 450239 450241 450243 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.0822 1.3998 1.2615 1.2126 *** 1.4580 1.3019 1.6171 1.7083 1.1855 1.5806 1.1922 1.3181 *** 1.3318 1.7511 1.3989 1.2318 1.1977 *** 1.6322 1.5320 1.6395 1.6679 1.0277 1.0083 1.4564 1.2241 *** 1.2565 1.3302 1.1251 1.3269 1.0627 1.1447 1.4003 1.0905 0.9986 1.5684 1.2150 0.9254 1.1258 1.1180 2.0321 1.2632 1.4595 1.6042 0.9730 1.2116 1.8278 1.0215 1.3455 1.7959 1.2281 0.9660 1.1119 1.6824 1.3283 1.6525 1.6726 1.0198 1.0077 1.1319 1.6540 0.9770 1.0252 1.0024 PO 00000 Frm 00247 Average hourly wage FY 2007 0.8153 0.9852 0.8803 0.8153 * 0.9925 0.8883 0.8703 0.8901 0.8949 0.8867 0.8949 0.9118 * 0.8595 0.9521 0.9925 0.9118 0.8949 * 0.9425 0.9283 0.9852 0.9852 0.9521 0.8712 0.8153 0.9852 * 0.8855 0.8153 0.8153 0.8712 0.8207 0.8949 0.9118 0.8153 0.9283 0.9925 0.9925 0.8153 0.9521 0.8424 0.9925 0.8366 0.9852 0.8195 0.8153 0.9684 0.8997 0.8304 0.8666 0.8949 0.9925 0.8153 0.8153 0.9925 0.8901 0.8408 0.8997 0.8153 0.8153 0.8542 0.8949 0.8855 0.8153 0.8153 Fmt 4701 Sfmt 4702 24.3637 30.0095 21.3837 24.9917 26.5103 29.0142 31.3495 25.4409 25.6318 24.6169 27.6064 21.6557 27.8027 29.1296 24.9674 28.2571 29.3768 25.1122 24.3295 25.9494 30.1620 28.4647 27.8983 31.4950 23.4592 26.2881 24.3562 27.0894 23.9558 23.3428 21.7237 21.7604 33.3285 24.1267 28.6490 23.1284 23.7624 27.8405 28.5399 28.3243 23.0595 26.5863 24.1186 34.4545 22.9605 24.0161 23.5012 23.2510 26.5237 27.5668 21.8722 28.4581 25.9169 27.4357 21.9207 19.3793 30.0314 26.8302 24.4450 27.1674 20.6889 23.5212 23.5426 25.7939 21.2586 20.8732 15.4510 Average hourly wage FY 2008 25.6440 31.2668 21.8839 26.2781 28.1902 29.8734 31.7829 26.7457 26.4161 28.8063 27.8177 19.3245 31.1026 27.7472 26.2469 30.9140 30.5540 26.3296 24.3842 * 31.9981 30.0648 30.1385 31.9644 23.6834 29.2987 24.7221 29.6777 26.2011 23.1056 22.9357 24.8052 32.9317 24.7857 29.1839 24.4338 24.4064 27.1184 29.5940 27.7374 23.2280 28.3937 26.4722 36.4793 24.3531 23.4577 25.6413 23.2800 27.8795 30.6146 22.5736 28.3770 26.8566 27.9913 23.9636 21.3721 30.3801 28.4382 25.1370 26.9783 20.4659 21.8967 22.9622 30.5885 19.1359 21.3641 17.2966 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 26.3606 32.6536 22.7815 28.2267 * 31.9758 29.8469 28.4201 27.3343 27.7838 29.0310 22.4281 34.4129 * 24.0420 31.9772 32.0348 28.3156 26.9201 * 31.1340 30.9597 30.7885 35.7749 24.4333 31.1551 26.3019 30.0530 22.8759 24.3424 24.2578 24.8768 33.7803 27.0963 30.2222 25.8569 26.0891 28.5998 30.9705 29.2737 24.6816 31.1321 26.9874 37.1873 30.4368 25.4820 27.9825 22.5445 28.0968 31.9858 22.9049 28.8471 28.0289 28.2247 24.7267 20.7113 31.9231 28.7921 26.8016 27.0533 21.6802 23.8005 24.5926 31.2172 18.4232 28.4948 19.0176 Average hourly wage** (3 years) 25.4425 31.3363 22.0412 26.4935 27.3122 30.2412 30.9845 26.8726 26.4779 26.9841 28.1649 21.1092 30.7679 28.4439 24.9404 30.4250 30.6758 26.5694 25.2414 25.9494 31.0941 29.8077 29.6276 33.2271 23.8654 28.7443 25.1662 28.8673 24.2772 23.6074 22.9598 23.6641 33.3236 25.3188 29.3460 24.4742 24.7683 27.8381 29.6894 28.4472 23.6817 28.6333 25.8921 36.0649 25.7167 24.2962 25.4502 22.9956 27.5107 29.9981 22.4486 28.5692 26.9446 27.8829 23.5184 20.5035 30.7843 28.0121 25.3958 27.0671 21.1358 23.0639 23.6934 28.9557 19.4675 23.5112 17.2995 23774 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 450253 450270 450271 450272 450280 450283 450289 450292 450293 450296 450299 450306 450315 450324 450330 450340 450346 450347 450348 450351 450352 450353 450358 450369 450370 450372 450373 450378 450379 450388 450389 450393 450395 450399 450400 450403 450411 450418 450419 450422 450424 450431 450438 450446 450447 450451 450460 450462 450465 450469 450475 450484 450488 450489 450497 450498 450508 450514 450518 450530 450537 450539 450547 450558 450563 450565 450571 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 0.9321 1.2113 1.2778 1.2096 1.4612 1.0893 1.4524 1.2808 0.8910 1.0439 1.5997 0.9802 2.4335 1.5212 1.2552 1.4092 1.4343 1.2208 1.0018 1.2791 1.1062 *** 1.9716 0.9268 1.2579 1.4550 0.9144 1.3092 1.4002 1.7004 1.1714 0.7662 1.0730 0.8925 1.0684 1.3192 1.0061 *** 1.3124 1.2786 1.3562 1.6067 1.1486 0.7131 1.3552 1.0753 0.9426 1.7253 1.1257 1.4624 1.1940 1.4990 1.1180 0.9839 0.9966 0.9829 1.4530 *** 1.4419 1.2667 1.5128 1.2202 0.9744 1.7678 1.5299 1.3270 1.6222 PO 00000 Frm 00248 Average hourly wage FY 2007 0.9925 0.8424 0.9684 0.9521 0.9852 0.9852 0.9925 0.9852 0.8153 0.9925 0.9193 0.8408 0.9852 0.9852 0.9925 0.8600 0.8595 0.9925 0.8153 0.9684 0.9852 * 0.9925 0.8153 0.8388 0.9852 0.8153 0.9925 0.9852 0.8949 0.9852 0.9852 0.9925 0.8153 0.8153 0.9852 0.8153 * 0.9852 0.9852 0.9925 0.9521 0.8388 0.9925 0.9852 0.8689 0.8206 0.9852 0.9925 0.9852 0.8666 0.8666 0.8666 0.8153 0.8528 0.8153 0.8666 * 0.8595 0.9925 0.9852 0.8220 0.9852 0.8408 0.9852 0.9684 0.8600 Fmt 4701 Sfmt 4702 24.2435 15.2190 22.7035 26.2576 29.9730 22.7938 32.2645 26.3242 23.6413 30.4324 27.5797 21.4558 37.1721 25.1633 26.0771 25.0344 23.6072 28.7667 21.6787 26.5388 26.2281 27.0248 31.4926 19.9148 25.5834 30.8886 24.8286 30.3883 33.7521 27.4328 25.6732 21.9347 27.5189 20.3528 23.6358 29.0359 20.9372 28.4362 31.9966 34.4331 28.2463 26.3263 27.8659 17.0691 25.4200 24.6201 22.4227 29.6069 26.2759 26.3262 23.0942 26.7242 22.3981 23.4806 22.0918 18.6563 28.4471 26.3704 28.1755 29.1349 27.7757 23.1829 23.7820 26.9407 30.8332 26.7942 25.2108 Average hourly wage FY 2008 24.1056 19.8180 24.1269 27.0521 31.6575 24.1754 32.6533 26.8110 24.0827 31.5596 28.4171 22.9486 * 26.6093 27.1100 25.6791 23.8720 30.7825 21.0484 29.2560 27.2983 27.9576 32.5922 22.8525 26.3235 29.5022 27.0726 32.2278 35.3807 27.8155 26.9638 * 26.7743 22.1731 26.2871 29.8643 21.5746 * 34.2427 31.3454 30.7228 27.3926 26.5223 17.2871 26.5238 26.5477 24.9870 30.1466 27.0835 26.3445 24.5176 28.3913 23.7985 25.2680 23.1860 20.2475 27.2850 27.3043 29.1322 29.9720 28.7448 24.2151 34.3349 28.0655 32.0507 28.1741 27.4605 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 22.9919 12.9994 23.9525 29.0903 34.9324 28.2079 32.6122 29.0226 24.1552 33.4528 29.4576 22.6822 31.4204 27.9889 27.7403 30.5228 24.8416 28.5780 22.6822 29.9580 27.6466 * 33.9078 24.1950 29.0806 30.9328 27.4243 33.0566 35.0613 29.5360 26.8481 39.0250 28.4265 20.6300 29.5008 31.7040 21.7875 * 34.9949 32.4640 29.8269 28.5263 27.7728 15.4631 28.3710 25.8824 25.2172 30.6488 28.1840 31.1333 24.7023 27.7774 24.9095 26.9542 23.0703 20.6876 29.1501 26.4002 27.5863 30.7727 30.9146 25.0188 25.4122 28.7729 32.6847 27.4760 26.5303 Average hourly wage** (3 years) 23.7733 15.5383 23.6286 27.4843 32.1866 24.8171 32.5225 27.3779 23.9551 31.7845 28.5044 22.3403 33.9617 26.5490 26.9930 26.9242 24.1224 29.3911 21.8120 28.5841 27.0615 27.5079 32.6875 22.2632 27.0009 30.4453 26.4835 31.9025 34.7094 28.2774 26.4861 28.4483 27.6022 21.0332 26.1110 30.2580 21.4276 28.4362 33.8163 32.6976 29.5962 27.4173 27.3852 16.6064 26.7880 25.6945 24.1531 30.1364 27.2041 27.8724 24.0834 27.6347 23.7092 25.1940 22.7799 19.8494 28.3018 26.6921 28.1826 29.9520 29.1361 24.1139 27.1653 27.9448 31.9164 27.4805 26.3740 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23775 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 450573 450578 450580 450584 450586 450587 450591 450596 450597 450604 450605 450610 450615 450617 450620 450630 450634 450638 450639 450641 450643 450644 450646 450647 450651 450653 450654 450656 450658 450659 450661 450662 450668 450669 450670 450672 450674 450675 450677 450678 450683 450684 450686 450688 450690 450694 450697 450698 450702 450709 450711 450713 450715 450716 450718 450723 450730 450742 450743 450746 450747 450749 450751 450754 450755 450758 450760 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.0770 0.9673 1.0515 1.0829 1.0201 1.2259 1.1895 1.1854 0.9963 1.3397 0.9810 1.5974 0.9986 1.5826 0.9635 1.5054 1.6203 1.5993 1.4598 0.9799 1.3367 1.5467 1.4527 1.8764 1.5358 1.1592 0.9049 1.4220 0.9793 1.4021 1.4614 1.6460 1.5414 1.2189 1.4361 1.8349 0.9478 1.4578 1.3166 1.4170 1.2015 1.2814 1.6149 1.2727 1.3408 1.1759 1.4748 0.9175 1.6153 1.4034 1.4823 1.5563 1.3146 1.4070 1.4669 1.4494 1.3722 1.1754 1.4478 0.8780 1.1965 0.9371 *** 0.9429 0.9660 *** 1.0061 PO 00000 Frm 00249 Average hourly wage FY 2007 0.8279 0.8153 0.8153 0.8153 0.8153 0.8153 0.9925 0.9684 0.8153 0.8153 0.8494 0.9925 0.8185 0.9925 0.8153 0.9925 0.9852 0.9925 0.9852 0.8528 0.8816 0.9925 0.8867 0.9852 0.9852 0.8153 0.8153 0.8666 0.8153 0.9925 0.9425 0.9226 0.8867 0.9852 0.9925 0.9852 0.9925 0.9852 0.9852 0.9852 0.9852 0.9925 0.8712 0.9852 0.8901 0.8153 0.8949 0.8280 0.8666 0.9925 0.9118 0.9521 0.9852 0.9925 0.9521 0.9852 0.9852 0.9852 0.9852 0.8153 0.8901 0.8153 * 0.8153 0.8429 * 0.8867 Fmt 4701 Sfmt 4702 22.0797 22.5167 22.3886 20.5257 18.9107 23.1202 25.7031 27.4011 24.7853 24.4743 20.9276 27.7317 21.8442 28.0225 18.6183 29.1462 28.7312 30.6572 30.4019 19.4389 22.7355 29.7918 25.6313 30.6924 30.4484 25.2144 21.5002 25.5050 22.2293 31.5024 30.2610 29.0535 28.8635 27.9796 25.9638 30.1191 28.7101 28.9005 25.9555 31.1563 27.4925 29.3025 24.2331 26.8599 26.5528 23.9961 24.8667 20.0955 26.8384 26.8146 26.7472 28.8285 17.3991 32.3960 27.3215 28.5103 31.3324 27.2023 28.3362 20.6343 23.8314 20.0487 18.7456 22.1819 19.8988 28.7342 24.7489 Average hourly wage FY 2008 22.1492 25.0498 23.9004 22.5204 20.6699 25.0174 27.1744 29.8462 24.2586 25.9133 23.9332 28.3713 24.1902 28.8323 20.3723 29.8431 30.3274 32.4911 32.6255 20.2483 24.4999 30.7815 26.8060 32.4236 31.9261 26.1756 22.5447 28.1493 24.7856 34.2380 30.0751 29.0532 30.6114 30.2374 26.4266 31.8420 29.8971 30.9562 27.2760 33.3386 21.1737 30.2139 25.8530 26.9897 26.1743 24.0031 26.4132 21.5742 26.3696 27.1077 27.5622 29.4980 17.0235 33.7096 28.1560 30.1704 32.7293 30.0583 28.4736 22.7873 25.8175 22.1562 21.4223 24.7797 22.2006 28.2803 25.1637 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 24.6744 25.2476 25.9872 23.6045 18.3294 25.9358 27.9847 31.6577 24.8439 29.1526 14.8030 30.5957 22.6324 30.2898 21.2530 31.7991 31.7983 33.3208 34.3727 21.7288 27.2517 31.6848 27.4611 34.0988 33.6467 26.5346 25.0736 29.7276 22.7086 34.2632 29.2361 30.9608 30.2059 32.1221 26.2942 33.0834 31.9284 32.6351 27.1594 33.5496 24.8430 31.2746 26.4851 29.4376 30.0569 27.0859 28.2983 23.3052 27.1300 31.3218 28.1016 30.4912 * 33.9898 29.7584 31.0456 32.8896 30.4185 29.5077 23.3483 28.3918 23.9271 * 22.8559 24.7427 28.3285 23.7138 Average hourly wage** (3 years) 22.9817 24.2617 23.9915 22.1623 19.3042 24.6518 26.9265 29.6788 24.6216 26.5819 19.8571 28.8793 22.8680 29.0536 20.0799 30.2292 30.2933 32.0988 32.4471 20.4546 24.7934 30.7914 26.6291 32.4013 32.0226 25.9882 23.0141 27.7366 23.2037 33.2709 29.8375 29.6825 29.8659 30.1382 26.2315 31.7654 30.1847 30.8652 26.8126 32.6557 24.2908 30.2639 25.5754 27.7076 27.4939 24.8819 26.4744 21.6138 26.7835 28.4257 27.5198 29.6225 17.2098 33.3800 28.4466 29.9614 32.3004 29.2913 28.8191 22.2429 25.8472 21.9555 20.1469 23.2191 22.1319 28.4884 24.5602 23776 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 450766 450770 450771 450774 450775 450779 450780 450788 450795 450796 450797 450801 450803 450804 450808 450809 450811 450813 450820 450822 450824 450825 450827 450828 450829 450830 450831 450832 450833 450834 450838 450839 450840 450841 450844 450845 450847 450848 450850 450851 450853 450854 450855 450856 450857 450860 450861 450862 450863 450864 450865 450866 450867 450868 450869 450870 450871 450872 450873 450874 450875 450876 450877 450878 450879 450880 450881 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 2.0334 1.1706 1.7003 1.7600 1.3943 1.2842 2.5251 1.5291 1.1739 1.8173 1.2450 1.4989 1.2105 2.0345 1.8935 1.6551 1.7218 1.1338 1.4186 1.3260 2.6758 1.4768 1.4405 1.3774 *** 1.0119 0.9180 1.3167 1.1878 1.6180 1.0772 0.9688 1.2996 1.9116 1.3797 1.8834 1.2564 1.2904 1.5769 2.3662 1.7353 *** 1.6258 2.0970 *** 1.8529 *** 1.5594 *** 2.1890 1.1032 *** 1.1589 1.7418 2.1455 *** 1.8768 1.3756 *** 1.6738 1.7360 1.9264 1.4979 2.5641 1.3352 1.5477 *** PO 00000 Frm 00250 Average hourly wage FY 2007 0.9852 0.9521 0.9852 0.9925 0.9925 0.9852 0.8949 0.8494 0.9925 0.8997 0.9925 0.8195 0.9925 0.9925 0.9521 0.9521 0.9118 0.8949 0.9925 0.9852 0.9521 0.9118 0.9175 0.8153 * 0.9283 0.9925 0.9925 0.9852 0.9193 0.8279 0.8153 0.9852 0.9226 0.9925 0.8867 0.9925 0.9925 0.9562 0.9852 0.9852 * 0.9226 0.8949 * 0.9925 * 0.9925 * 0.8901 0.9521 * 0.9521 0.9425 0.9118 * 0.9521 0.9852 * 0.9852 0.8997 0.8712 0.8867 0.8949 0.8816 0.9852 * Fmt 4701 Sfmt 4702 30.8004 24.1647 30.7105 27.2080 28.1428 29.9674 26.7611 26.2840 25.2007 36.4073 24.8950 24.6328 28.9235 27.8775 21.9793 26.4223 27.2584 20.1710 31.4666 32.2968 31.2375 20.6457 23.7554 24.4740 20.6016 28.5902 23.3880 26.5229 27.0133 20.9607 19.5754 25.8222 30.1743 20.9410 30.7887 29.4933 28.5548 29.5355 21.9266 32.6950 36.1169 27.1868 30.8855 39.0865 30.4632 24.0171 34.9290 31.2224 24.8825 23.3765 29.1763 15.2959 28.2289 27.9579 22.6253 37.4364 * * * * * * * * * * * Average hourly wage FY 2008 30.2341 24.3244 32.0500 25.7436 29.8230 31.8403 27.0084 28.3759 32.9803 37.6274 24.8598 23.6072 29.0106 29.1282 23.0312 27.3080 31.2208 22.9289 33.9030 32.2145 33.3653 25.1521 24.1984 24.8236 19.5842 27.8005 23.9467 27.3290 27.9649 27.4844 18.9620 27.2199 32.2538 20.9424 33.7978 29.9265 29.7356 30.5546 31.9606 35.1102 37.1043 * 32.6916 37.7362 * 29.1075 * 31.8095 * 24.5049 29.9559 * 29.5879 25.3486 26.1616 * 28.9150 27.2833 14.8821 34.6083 23.2763 28.4343 26.1867 31.6750 35.5672 35.9572 24.5464 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 31.2061 23.6084 32.4987 27.5052 31.6636 32.0748 28.5545 29.7646 43.8548 39.4710 26.0293 25.6368 28.7024 31.1869 29.6456 29.4671 31.7219 26.5793 34.7415 34.4032 31.8377 25.7993 24.3655 26.9546 * 28.4004 24.4124 28.1375 29.0241 26.7240 19.2941 27.5319 32.4135 24.4366 33.0727 28.5011 30.7409 31.1455 27.2645 32.8357 38.3572 * 30.7321 35.4977 * 33.3360 * 33.7932 * 25.3514 31.9179 * 31.4926 27.7398 28.7406 * 32.3967 31.7321 * 35.6817 23.2949 30.3498 29.2330 33.6233 36.4836 32.6680 * Average hourly wage** (3 years) 30.7524 24.0129 31.7652 26.8202 29.9048 31.3351 27.4508 28.1299 34.0292 37.9807 25.2371 24.6370 28.8861 29.4370 24.9240 27.7555 29.8931 23.2366 33.5465 32.9996 32.1641 23.7848 24.1145 25.5737 20.0933 28.2670 23.8672 27.3874 28.0113 24.5166 19.2971 26.8415 31.6992 22.2249 32.7243 29.2842 29.7031 30.4213 26.5516 33.5034 37.3449 27.1868 31.4205 37.3569 30.4632 29.3070 34.9290 32.2128 24.8825 24.5415 30.4451 15.2959 29.7806 27.0759 27.5500 37.4364 30.6337 29.8421 14.8821 35.2071 23.2862 29.4575 27.6968 32.6691 36.0727 34.0899 24.5464 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23777 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 450882 450883 450884 450885 450886 450887 450888 450889 450890 450891 450892 450893 450894 450895 460001 460003 460004 460005 460006 460007 460008 460009 460010 460011 460013 460014 460015 460017 460018 460019 460020 460021 460023 460026 460030 460033 460035 460039 460041 460042 460043 460044 460047 460049 460051 460052 460054 460055 470001 470003 470005 470011 470012 470024 490001 490002 490004 490005 490007 490009 490011 490012 490013 490017 490018 490019 490020 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index *** 2.4793 1.0281 1.4517 1.5017 *** 1.7096 1.5530 1.8266 1.4143 *** 1.3909 1.7932 *** 1.8307 1.5382 1.7729 1.5237 1.4480 1.3341 1.3382 1.9760 2.0995 1.3236 1.3909 1.1488 1.3542 1.5067 0.8937 1.1962 0.9177 1.7949 1.2032 1.0634 1.1657 0.8711 0.9610 1.0970 1.3694 1.4973 0.9867 1.3270 1.6851 1.9801 1.4090 1.6516 1.6931 1.4742 1.2668 1.8776 1.3533 1.1581 1.2088 1.1462 1.0923 1.0162 1.2931 1.5720 2.0360 1.9926 1.5707 1.0101 1.3744 1.5021 1.3622 1.1503 1.2876 PO 00000 Frm 00251 Average hourly wage FY 2007 * 0.9852 0.8715 0.9852 0.9852 * 0.9708 0.9852 0.9852 0.9852 * 0.9852 0.9852 * 0.9075 0.9271 0.9271 0.9271 0.9271 0.9228 0.9271 0.9271 0.9271 0.8395 0.9075 0.9271 0.8827 0.8778 0.8395 0.8395 * 1.1388 0.9075 0.9052 0.8395 0.8395 0.8395 0.8827 0.9271 0.9271 0.9075 0.9271 0.9271 0.9271 0.9271 0.9075 0.8827 0.9075 0.9297 0.9275 0.9275 0.9275 0.9275 0.9275 0.8061 0.8061 0.9449 1.0669 0.8869 0.9728 0.8869 0.8061 0.9694 0.8869 0.9449 1.0669 0.9203 Fmt 4701 Sfmt 4702 * * * * * * * * * * * * * * 28.7150 31.4135 28.2040 25.0239 27.1392 27.1308 29.5907 27.2885 29.0063 24.4402 27.7381 28.2647 27.2506 24.3030 22.0517 24.3756 18.5159 28.0291 26.9512 26.9295 23.5942 25.3422 20.6322 29.5651 26.4640 24.9454 28.2008 27.4928 28.2336 26.6702 27.0160 26.1629 24.9926 * 28.3017 28.1137 30.7872 28.1330 26.0225 27.0394 23.2174 20.8609 27.1676 29.8215 27.6572 30.4722 26.4766 21.0605 24.7521 25.8216 26.2510 25.9885 27.3142 Average hourly wage FY 2008 26.6910 35.2646 27.8213 34.1148 * * * * * * * * * 18.4142 30.0040 32.3427 29.6342 26.0731 28.3678 28.0035 31.5485 28.3836 30.4606 24.9677 29.2731 29.5963 29.1318 26.1589 22.8028 23.2202 * 29.5761 28.5884 27.9487 24.4218 26.6606 21.9115 30.4912 26.3807 26.8389 28.6668 28.7023 29.9990 28.4884 27.8841 27.1995 25.7870 * 29.7540 30.1973 33.1981 29.6269 27.0751 26.6351 24.0368 21.7092 27.5890 30.5349 29.3098 28.4642 27.4764 22.9922 25.5560 27.5902 27.2644 25.8264 29.3468 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 * 37.1500 23.5791 36.0926 30.1552 25.5574 28.5970 35.6125 32.1973 39.0842 39.5303 36.2633 25.9422 * * 29.6430 29.8751 29.4163 28.9633 29.1171 27.6886 29.4687 30.9793 26.5474 29.7232 30.6427 28.7993 28.7101 22.0916 25.1607 * 29.7373 28.9445 29.2757 26.8971 27.9090 23.8672 30.0656 26.7342 36.2868 29.5636 29.5056 30.9988 28.6251 28.1118 28.7433 26.3926 * 32.2867 30.0513 33.9946 30.8723 29.8242 27.3091 24.6876 24.0666 28.8643 31.4889 30.7391 31.4238 28.8762 21.8319 27.3086 29.6761 27.8664 29.8874 30.5993 Average hourly wage** (3 years) 26.6910 36.2387 25.5501 35.1477 30.1552 25.5574 28.5970 35.6125 32.1973 39.0842 39.5303 36.2633 25.9422 18.4142 29.3648 31.1480 29.2534 26.8371 28.1485 28.1204 29.5829 28.4457 30.1575 25.3370 28.9118 29.4780 28.4031 26.4243 22.3156 24.2508 18.5159 29.2069 28.1975 28.0634 24.9667 26.6490 22.1202 30.0667 26.5286 28.7517 28.8137 28.5642 29.7618 27.9963 27.6918 27.4110 25.7328 * 30.1248 29.4645 32.7064 29.5547 27.6835 26.9932 23.9910 22.0939 27.8908 30.6457 29.2722 30.0808 27.6271 21.9360 25.8824 27.7176 27.1379 27.1451 29.0707 23778 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 490021 490022 490023 490024 490027 490032 490033 490037 490038 490040 490041 490042 490043 490044 490045 490046 490048 490050 490052 490053 490057 490059 490060 490063 490066 490067 490069 490071 490073 490075 490077 490079 490084 490088 490089 490090 490092 490093 490094 490097 490098 490101 490104 490105 490106 490107 490108 490109 490110 490111 490112 490113 490114 490115 490116 490117 490118 490119 490120 490122 490123 490126 490127 490130 490134 490135 490136 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.4622 1.4112 1.3297 1.6994 1.1143 1.9515 1.0967 1.2781 1.2238 1.5127 1.5635 1.3157 1.3375 1.4493 1.3427 1.5416 1.4333 1.5231 1.6678 1.1871 1.6362 1.6585 1.0194 1.8759 1.3873 1.2870 1.5365 1.4069 *** 1.3188 1.4181 1.2674 1.1427 1.0983 1.1018 1.0545 1.0775 1.5429 0.9727 1.0690 1.2889 1.4144 0.7712 0.8355 0.7733 1.4215 1.0546 0.9060 1.3576 1.1082 1.7315 1.2911 1.1439 1.2011 1.1712 1.1002 1.6337 1.3013 1.4551 1.5919 1.1435 1.1732 1.1178 1.2203 0.8323 0.7518 1.4451 PO 00000 Frm 00252 Average hourly wage FY 2007 0.8646 1.0669 1.0669 0.8889 0.8061 0.9203 1.0669 0.8061 0.8061 1.1017 0.8869 0.8750 1.1017 0.8869 1.0669 0.8869 0.8646 1.0669 0.8869 0.8061 0.8869 0.9203 0.8061 1.1017 0.8869 0.9203 0.9203 0.9203 * 0.8483 0.9728 0.8985 0.8248 0.8646 0.8889 0.8061 0.8061 0.8869 0.9203 0.9203 0.8061 1.1017 0.9203 0.8061 0.8061 1.1017 0.8646 0.8869 0.8307 0.8061 0.9203 1.0669 0.8061 0.8061 0.8061 0.8061 0.9203 0.8869 0.8869 1.1017 0.8061 0.8061 0.8061 0.8869 0.8061 0.8889 0.9203 Fmt 4701 Sfmt 4702 25.7938 32.2676 30.3416 26.1125 24.0288 25.2654 31.2922 24.7711 21.8509 32.6564 26.0897 24.4650 33.7096 23.3527 32.0937 26.6517 26.2828 31.3885 23.5973 23.3315 26.6898 27.3611 23.6113 31.3619 27.8250 24.9021 27.3181 29.7186 33.1829 25.2022 26.6806 25.3103 24.9007 24.1471 24.9438 25.1157 23.3439 25.6531 28.2165 26.5322 23.2782 31.2377 * 25.5329 23.8334 32.2672 22.9076 22.7854 24.2887 22.1476 27.1932 31.8177 22.5255 22.4058 24.2258 19.6398 27.6749 26.5756 25.8795 32.0743 24.3490 23.6690 21.3735 23.9982 * * * Average hourly wage FY 2008 27.0641 30.1203 30.9920 27.9689 23.0017 28.5897 31.8282 25.2859 22.6504 34.1841 27.1613 25.7333 35.8872 23.3793 30.3772 27.9604 27.0620 32.2993 25.0046 23.8004 27.4918 30.8669 24.3192 31.6069 29.5917 25.9497 29.1527 31.7061 34.5774 25.7323 28.1506 25.2340 25.7657 25.0619 25.9902 25.5418 25.7405 26.7886 28.9155 27.1470 25.1625 32.3695 17.0548 26.3827 25.7352 33.5430 23.3204 24.2296 24.9861 22.7336 29.0816 32.4547 22.1387 23.5718 24.3853 18.1138 29.0569 27.8866 25.9610 33.3719 24.2254 24.0908 23.5161 25.3352 33.2405 25.9998 * E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 28.1233 31.7964 32.6291 29.0379 24.3832 28.0097 30.9894 26.2942 24.0844 35.6796 29.1224 26.6055 36.5934 24.1751 32.8751 29.3861 28.0302 31.1346 25.1956 24.6193 29.0678 32.1008 25.7752 34.1154 31.4281 26.7787 30.1463 33.7101 46.4178 27.3411 31.0002 24.2052 26.3132 26.0270 27.4562 27.0746 27.5268 28.7103 29.7975 27.4607 26.7140 32.9490 19.0055 * 26.2318 35.0239 25.1884 21.6710 26.3071 26.4282 31.2526 34.7813 23.0526 23.2109 25.0343 20.3031 31.2383 29.5203 27.1973 35.2212 24.5997 25.3282 23.1390 25.9771 31.1474 27.2771 31.2889 Average hourly wage** (3 years) 26.9966 31.3740 31.3336 27.6964 23.7446 27.3514 31.3730 25.4675 22.8205 34.1603 27.4587 25.6256 35.4348 23.6463 31.7663 28.0339 27.1308 31.5946 24.5749 23.9160 27.7786 30.0791 24.5807 32.3880 29.7032 25.8584 28.8658 31.7115 36.1085 26.0795 28.6185 24.9039 25.6727 25.0928 26.1612 25.9182 25.4745 27.0735 28.9991 27.0696 25.0883 32.2107 18.0437 25.9379 25.2383 33.6804 23.8173 22.7835 25.2068 23.6179 29.1894 33.0718 22.5829 23.0488 24.5470 19.3436 29.3451 28.0191 26.3518 33.5744 24.3927 24.3545 22.6004 25.1170 32.1153 26.6418 31.2889 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23779 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 490138 500001 500002 500003 500005 500007 500008 500011 500012 500014 500015 500016 500019 500021 500024 500025 500026 500027 500030 500031 500033 500036 500037 500039 500041 500044 500049 500050 500051 500052 500053 500054 500058 500060 500064 500072 500077 500079 500084 500088 500108 500119 500124 500129 500134 500139 500141 500143 500148 500150 510001 510002 510006 510007 510008 510012 510013 510018 510022 510023 510024 510026 510029 510030 510031 510033 510038 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.9348 1.6024 1.3750 1.3968 1.8014 1.3520 1.9737 1.3817 1.7799 1.6593 1.4000 1.6703 1.2524 1.3071 1.7453 1.9117 1.4550 1.4942 1.6959 1.2671 1.2468 1.3290 1.0577 1.5629 1.4344 1.8913 1.3698 1.5082 1.7917 1.4632 1.2557 1.9737 1.6843 1.3541 1.8909 1.2605 1.4765 1.3733 1.2608 1.4739 1.6172 1.3809 1.4071 1.5755 0.5967 1.4903 1.2645 0.5889 1.2204 1.2775 1.9319 1.2681 1.3528 1.6750 1.3363 0.9584 1.1635 1.0730 1.8098 1.2565 1.7530 0.9848 1.2995 1.1499 1.4626 1.5988 1.0704 PO 00000 Frm 00253 Average hourly wage FY 2007 0.8646 1.1562 1.0164 1.1377 1.1562 1.1377 1.1562 1.1562 1.0164 1.1562 1.1562 1.1377 1.0295 1.1377 1.1462 1.1562 1.1562 1.1562 1.1395 1.1297 1.0164 1.0164 1.0164 1.1377 1.1186 1.0514 1.0164 1.1186 1.1562 1.1562 1.0164 1.0514 1.0164 1.1562 1.1562 1.0576 1.0514 1.1377 1.1562 1.1562 1.1377 1.0514 1.1562 1.1377 1.1562 1.1462 1.1562 1.1462 1.0164 1.1186 0.8569 0.8732 0.8631 0.9107 0.9253 0.7759 0.7635 0.8398 0.8398 0.8011 0.8569 0.7635 0.8398 0.7635 0.8398 0.8028 0.7635 Fmt 4701 Sfmt 4702 * 31.1605 27.6400 30.6939 33.5117 29.2869 32.6052 31.4514 30.0509 36.1380 34.5877 31.4905 30.5594 30.7927 32.6171 37.7952 32.8369 34.6164 32.4426 32.8833 30.6292 28.7096 28.1056 32.2245 30.3627 29.0214 27.7170 32.6751 32.5764 * 28.2901 31.6595 30.7487 37.4869 31.6112 31.2000 31.6153 31.3280 30.2411 35.3770 31.8483 29.7028 32.3505 32.1102 27.2428 33.9739 31.3308 23.6766 26.4206 * 25.2973 23.8921 24.9627 24.7264 26.3554 18.8984 22.7882 22.4597 26.9511 20.6435 25.5634 17.9908 22.7104 24.3936 23.2624 22.6189 20.6565 Average hourly wage FY 2008 * 33.0901 29.1448 32.1262 35.0997 30.5263 33.5666 32.6223 33.8101 36.5833 37.5724 32.9177 31.6242 32.4702 36.1647 40.6369 34.5881 39.2906 34.9174 33.2391 31.8891 30.5938 31.2654 33.5606 34.2017 31.0936 29.8189 33.7713 34.7610 * 30.2811 32.5105 30.7034 38.7682 32.3581 32.5269 33.2223 32.5809 32.7883 36.7953 34.3872 31.2233 34.4790 34.4447 28.1374 34.6412 33.7532 25.3099 37.7830 * 25.8693 23.7270 24.8777 27.1149 27.5241 20.8455 22.8779 23.1043 26.8328 21.0940 26.6621 19.2025 24.0872 24.2007 24.0237 24.0796 20.9180 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 * 37.5297 30.1855 32.7960 36.0900 31.0289 34.7787 38.3960 33.1661 37.2677 40.8644 34.2801 33.8866 33.5572 37.4510 44.7077 35.5055 42.4941 36.7964 34.1649 32.6732 31.9136 29.1752 34.5710 36.9240 32.0719 30.8120 35.7229 36.4745 * 28.5649 34.8088 32.6820 40.3002 34.7906 33.1128 34.3082 34.2468 33.3057 38.5166 35.8890 31.7102 36.3296 37.3169 28.9744 37.5682 34.2350 26.3882 24.6331 34.7828 26.7901 24.8834 26.6403 28.5769 27.4687 22.9026 22.9605 23.7726 27.6095 23.1446 31.1308 17.8264 25.3908 25.5580 26.7854 24.2824 21.7526 Average hourly wage** (3 years) * 33.7723 29.0190 31.8089 34.9342 30.3229 33.6731 33.9417 32.2294 36.6858 37.5957 32.9164 32.0653 32.3511 35.4266 41.0323 34.3334 38.7477 34.7347 33.4481 31.7837 30.4918 29.5198 33.5071 33.8434 30.6373 29.5153 34.0820 34.6036 * 29.0318 32.9758 31.4274 38.8996 32.9459 32.3268 33.0354 32.6847 32.1164 36.8898 34.0321 30.8549 34.3958 34.6824 28.2246 35.2949 33.1511 25.1082 30.3555 34.7828 26.0184 24.1721 25.4772 26.8115 27.1395 20.8292 22.8737 23.1223 27.1376 21.6346 27.8371 18.3206 24.0179 24.7270 24.6110 23.6905 21.1101 23780 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued Case-mix index 2 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 510039 510046 510047 510048 510050 510053 510055 510058 510059 510062 510067 510070 510071 510072 510077 510082 510085 510086 510090 520002 520004 520008 520009 520011 520013 520017 520019 520021 520027 520028 520030 520033 520034 520035 520037 520038 520040 520041 520044 520045 520048 520049 520051 520057 520059 520060 520062 520063 520064 520066 520070 520071 520075 520076 520078 520083 520087 520088 520089 520091 520095 520096 520097 520098 520100 520102 520103 ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 FY 2009 wage index 1.3740 1.3781 1.2053 1.1872 1.5377 1.0938 1.5578 1.3382 *** 1.2241 1.0951 1.2034 1.2818 1.0733 1.0382 1.1006 1.2021 1.0879 *** 1.3026 1.4018 1.5695 1.6546 1.2826 1.4977 1.1201 1.3503 1.3207 1.4430 1.3966 1.6874 1.2248 1.2622 1.3586 1.7405 1.2048 *** 1.0813 1.3626 1.5915 1.5102 2.0434 1.5346 1.1885 1.3571 *** 1.3331 1.1678 1.5219 1.4182 1.6950 1.2135 1.6946 1.2239 1.4666 1.7215 1.7126 1.3463 1.5744 1.2752 1.2282 1.3683 1.3252 2.0129 1.3329 1.1961 1.5575 PO 00000 Frm 00254 Average hourly wage FY 2007 0.7635 0.7795 0.8569 0.7635 0.8569 0.7635 0.9107 0.8028 * 0.8398 0.7635 0.8398 0.7795 0.7635 0.8748 0.7635 0.8398 0.7635 * 0.9823 0.9796 1.0182 0.9511 0.9511 1.0976 0.9599 0.9511 1.0315 1.0182 1.1014 0.9823 0.9511 0.9511 0.9587 0.9823 1.0182 * 1.1232 0.9587 0.9511 0.9511 0.9511 1.0182 0.9704 1.0026 * 1.0182 1.0182 1.0182 0.9824 0.9599 1.0026 0.9511 1.1014 1.0182 1.1232 0.9796 0.9523 1.1232 0.9511 0.9704 1.0026 0.9511 1.1232 0.9824 1.0026 1.0182 Fmt 4701 Sfmt 4702 19.8751 22.1712 27.1214 18.8576 21.0772 22.3318 28.4615 23.9015 22.1435 26.2296 25.0437 23.5639 23.4508 20.5146 24.5010 19.9081 26.3877 19.8735 * 27.7705 27.6530 30.7553 27.4044 26.6268 29.0018 28.4699 28.6971 28.4182 31.4284 26.7260 29.4678 28.0662 26.1094 27.3276 30.1799 29.3134 29.1262 23.5495 27.3685 27.3336 26.8080 26.9851 31.9949 27.7528 29.5801 24.8638 28.8510 29.0993 30.3225 29.2088 27.6771 30.0262 29.2920 27.3335 29.9837 30.8826 28.5810 30.7450 33.8793 25.4593 30.4216 27.8896 29.1479 32.5785 29.3243 29.1680 30.3165 Average hourly wage FY 2008 20.4719 22.2935 27.6859 22.7930 21.9009 21.5338 29.4111 25.3248 20.8847 26.7066 25.2130 23.9742 23.2954 19.4370 25.9515 20.3279 26.2617 19.2606 * 29.0501 28.9857 33.8057 28.8591 28.0224 30.1834 29.3278 29.8640 29.1129 32.4137 28.0813 30.5724 29.0236 26.8886 28.1048 32.2144 29.6339 31.2038 25.3764 28.2382 29.2556 29.1870 28.0936 31.5974 29.1158 30.4491 * 32.8584 30.3391 31.5723 31.0644 28.2059 30.6930 30.1582 27.4423 31.6606 32.7728 30.5659 30.6657 33.4098 27.3442 32.0381 29.5985 29.9998 36.5776 29.9458 30.7990 32.6269 E:\FR\FM\30APP2.SGM 30APP2 Average hourly wage FY 2009 1 21.3807 24.7175 28.8777 23.6384 23.5780 22.6278 30.7366 24.8750 21.9025 27.7962 25.2231 25.4968 23.4542 20.2379 27.1603 21.1654 26.8122 20.1963 39.0764 31.9053 30.9192 33.6749 29.6272 29.5006 32.1701 31.0517 30.2175 29.7788 33.5809 29.4683 31.6785 30.2616 28.1800 29.4053 31.6795 30.5249 35.9633 26.1572 28.6601 30.0840 30.1468 29.4223 32.4111 31.3292 31.1783 * 32.6992 31.5185 33.1248 31.6673 30.0451 31.5435 32.2755 26.8932 32.0179 34.7200 31.9747 30.7462 34.9331 28.7166 33.2399 28.5204 31.0204 38.0962 31.7748 31.5735 34.5620 Average hourly wage** (3 years) 20.5901 23.0443 27.9077 21.5406 22.1906 22.1640 29.5844 24.7020 21.6378 26.9089 25.1585 24.3383 23.4003 20.0443 25.8349 20.4929 26.4911 19.7687 39.0764 29.6240 29.2469 32.7716 28.6360 28.0213 30.5206 29.6386 29.6442 29.1139 32.5077 28.3047 30.5738 29.1742 27.0611 28.2938 31.3757 29.8341 32.0420 25.0721 28.1191 28.8905 28.5889 28.1983 32.0738 29.4114 30.4093 24.8638 31.5738 30.3770 31.5779 30.6304 28.7359 30.8053 30.5484 27.2252 31.1768 32.8276 30.3890 30.7187 34.0808 27.1741 31.9187 28.6435 30.0765 35.8078 30.3552 30.5379 32.5629 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23781 TABLE 2.—HOSPITAL CASE-MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 2007; HOSPITAL WAGE INDEXES FOR FEDERAL FISCAL YEAR 2009; HOSPITAL AVERAGE HOURLY WAGES FOR FEDERAL FISCAL YEARS 2007 (2003 WAGE DATA), 2008 (2004 WAGE DATA) AND 2009 (2005 WAGE DATA); AND 3-YEAR AVERAGE OF HOSPITAL AVERAGE HOURLY WAGES—Continued 520107 520109 520113 520116 520132 520136 520138 520139 520140 520152 520160 520170 520173 520177 520189 520193 520194 520195 520196 520197 520198 520199 520202 520203 530002 530006 530008 530009 530010 530011 530012 530014 530015 530017 530025 530032 FY 2009 wage index Case-mix index 2 Provider No. ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... ..................................................... 1.3439 1.0451 1.2659 1.2564 *** 1.6351 1.8898 1.3351 *** *** 1.7768 1.4785 1.0888 1.5992 1.1684 1.7185 1.5801 0.6565 1.7736 *** 1.3572 2.0438 1.6509 2.9989 1.1984 1.2359 1.1650 0.9602 1.2145 1.1265 1.7040 1.5582 1.1779 0.9134 1.2876 1.0528 Average hourly wage FY 2007 0.9523 0.9511 0.9511 1.0026 * 1.0182 1.0182 1.0182 * * 0.9511 1.0182 * 1.0182 1.0315 0.9511 1.0182 1.0182 0.9599 * 0.9511 1.0182 0.9823 1.1232 0.9223 0.9223 0.9223 0.9223 0.9223 0.9223 0.9618 0.9611 0.9327 0.9223 0.9223 0.9223 28.9878 24.7228 31.4708 27.9688 25.0006 30.6522 30.8016 28.8870 31.0043 29.7308 27.9548 30.4309 29.2429 31.4555 28.0014 27.8113 30.1668 36.3116 36.9266 * * * * * 28.3063 27.2421 24.0090 24.6719 25.9852 27.8772 26.9582 26.7156 29.8310 29.8503 24.4392 23.9004 Average hourly wage FY 2008 Average hourly wage FY 2009 1 29.4178 25.0697 33.3475 30.2156 27.3431 32.1479 31.6581 30.4903 31.1315 * 29.5582 31.4710 31.0599 32.5714 29.0295 29.2007 31.4379 36.2900 31.1175 30.1917 28.5975 36.5699 * * 29.2069 29.2104 26.5180 26.0490 27.4121 27.8613 28.7524 28.5469 29.8306 31.1105 29.4346 24.6580 30.0343 25.9723 33.3023 31.6687 * 32.3480 32.5653 31.7060 * * 30.3037 31.7586 * 33.1218 29.2212 29.4715 30.9993 41.6044 31.6125 * 29.9781 37.0103 * * 29.2407 30.3704 30.5992 27.0529 28.5518 31.1309 30.6085 29.6709 33.4886 25.8172 28.8951 25.4254 Average hourly wage** (3 years) 29.4887 25.2667 32.7086 29.9794 26.0481 31.6992 31.6762 30.3322 31.0699 29.7308 29.2715 31.2272 30.1478 32.4064 28.7600 28.8651 30.8959 37.9667 32.7571 30.1917 29.2918 36.7943 * * 28.9305 28.9041 27.0161 25.9191 27.3468 28.8654 28.7888 28.4442 31.0902 28.8536 27.4712 24.6844 1 Based on salaries adjusted for occupational mix, according to the calculation in section III.D.2. of the preamble to this proposed rule. case-mix index is based on the billed DRGs in the FY 2007 MedPAR file. It is not transfer adjusted. 3 Provider 140010 is part of a multicampus provider (MCH) that is comprised of campuses that are located in two different CBSAs. The provider number with a ‘‘B’’ in the 4th position, 140B10, indicates the portion of the wage and hours of the MCH that is allocated to CBSA 29404; provider number 140010 indicates the portion of wages and hours of the MCH that is allocated to CBSA 16974. 4 Provider 220074 is part of a multicampus provider (MCH) that is comprised of campuses that are located in two different CBSAs. The provider number with a ‘‘B’’ in the 4th position, 220B74, indicates the portion of the wage and hours of the MCH that is allocated to CBSA 14484; provider number 220074 indicates the portion of wages and hours of the MCH that is allocated to CBSA 39300. 5 Provider 230104 is part of a multicampus provider (MCH) that is comprised of campuses that are located in two different CBSAs. The provider number with a ‘‘B’’ in the 4th position, 230B04, indicates the portion of the wage and hours of the MCH that is allocated to CBSA 47644; provider number 230104 indicates the portion of wages and hours of the MCH that is allocated to CBSA 19804. *Denotes wage data not available for the provider for that year. **Based on the sum of the salaries and hours computed for Federal FYs 2007, 2008, and 2009. ***Denotes MedPAR data not available for the provider for FY 2007. 2 The TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA [*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 10180 10380 10420 10500 10580 10740 10780 10900 11020 ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 FY 2009 average hourly wage Urban area Abilene, TX ........................................................................................................................................ ´ Aguadilla-Isabela-San Sebastian, PR ............................................................................................... Akron, OH .......................................................................................................................................... Albany, GA ......................................................................................................................................... Albany-Schenectady-Troy, NY .......................................................................................................... Albuquerque, NM ............................................................................................................................... Alexandria, LA ................................................................................................................................... Allentown-Bethlehem-Easton, PA-NJ ................................................................................................ Altoona, PA ........................................................................................................................................ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00255 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 27.1004 10.6709 28.3319 28.2617 28.4655 30.6500 26.1655 31.2097 26.7060 3-Year average hourly wage 25.7723 10.7622 26.9292 27.2184 27.2227 29.7201 24.7913 30.7425 25.9824 23782 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 11100 11180 11260 11300 11340 11460 11500 11540 11700 12020 12060 12100 12220 12260 12420 12540 12580 12620 12700 12940 12980 13020 13140 13380 13460 13644 13740 13780 13820 13900 13980 14020 14060 14260 14484 14500 14540 14600 14740 14860 15180 15260 15380 15500 15540 15764 15804 15940 15980 16180 16220 16300 16580 16620 16700 16740 16820 16860 16940 16974 17020 17140 17300 17420 17460 17660 17780 17820 17860 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 FY 2009 average hourly wage Urban area Amarillo, TX ....................................................................................................................................... Ames, IA ............................................................................................................................................ Anchorage, AK ................................................................................................................................... Anderson, IN ...................................................................................................................................... Anderson, SC .................................................................................................................................... Ann Arbor, MI .................................................................................................................................... Anniston-Oxford, AL .......................................................................................................................... Appleton, WI ...................................................................................................................................... Asheville, NC ..................................................................................................................................... Athens-Clarke County, GA ................................................................................................................ Atlanta-Sandy Springs-Marietta, GA ................................................................................................. Atlantic City-Hammonton, NJ ............................................................................................................ Auburn-Opelika, AL ........................................................................................................................... Augusta-Richmond County, GA-SC .................................................................................................. Austin-Round Rock, TX ..................................................................................................................... Bakersfield, CA .................................................................................................................................. Baltimore-Towson, MD ...................................................................................................................... Bangor, ME ........................................................................................................................................ Barnstable Town, MA ........................................................................................................................ Baton Rouge, LA ............................................................................................................................... Battle Creek, MI ................................................................................................................................. Bay City, MI ....................................................................................................................................... Beaumont-Port Arthur, TX ................................................................................................................. Bellingham, WA ................................................................................................................................. Bend, OR ........................................................................................................................................... Bethesda-Frederick-Gaithersburg, MD .............................................................................................. Billings, MT ........................................................................................................................................ Binghamton, NY ................................................................................................................................. Birmingham-Hoover, AL .................................................................................................................... Bismarck, ND ..................................................................................................................................... Blacksburg-Christiansburg-Radford, VA ............................................................................................ Bloomington, IN ................................................................................................................................. Bloomington-Normal, IL ..................................................................................................................... Boise City-Nampa, ID ........................................................................................................................ Boston-Quincy, MA ............................................................................................................................ Boulder, CO ....................................................................................................................................... Bowling Green, KY ............................................................................................................................ Bradenton-Sarasota-Venice, FL ........................................................................................................ Bremerton-Silverdale, WA ................................................................................................................. Bridgeport-Stamford-Norwalk, CT ..................................................................................................... Brownsville-Harlingen, TX ................................................................................................................. Brunswick, GA ................................................................................................................................... Buffalo-Niagara Falls, NY .................................................................................................................. Burlington, NC ................................................................................................................................... Burlington-South Burlington, VT ........................................................................................................ Cambridge-Newton-Framingham, MA ............................................................................................... Camden, NJ ....................................................................................................................................... Canton-Massillon, OH ........................................................................................................................ Cape Coral-Fort Myers, FL ................................................................................................................ Carson City, NV ................................................................................................................................. Casper, WY ....................................................................................................................................... Cedar Rapids, IA ............................................................................................................................... Champaign-Urbana, IL ...................................................................................................................... Charleston, WV .................................................................................................................................. Charleston-North Charleston-Summerville, SC ................................................................................. Charlotte-Gastonia-Concord, NC-SC ................................................................................................ Charlottesville, VA ............................................................................................................................. Chattanooga, TN-GA ......................................................................................................................... Cheyenne, WY ................................................................................................................................... Chicago-Naperville-Joliet, IL .............................................................................................................. Chico, CA ........................................................................................................................................... Cincinnati-Middletown, OH-KY-IN ..................................................................................................... Clarksville, TN-KY .............................................................................................................................. Cleveland, TN .................................................................................................................................... Cleveland-Elyria-Mentor, OH ............................................................................................................. Coeur d’Alene, ID .............................................................................................................................. College Station-Bryan, TX ................................................................................................................. Colorado Springs, CO ....................................................................................................................... Columbia, MO .................................................................................................................................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00256 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 29.0008 30.4757 38.0798 28.7750 31.3772 33.6572 25.8029 30.0406 29.6273 30.9008 31.4502 38.0743 24.3605 30.9498 30.6888 36.5786 32.1655 32.5961 40.8356 26.2494 32.3508 30.3060 27.7045 36.7964 35.6036 33.9508 29.1465 28.1030 28.3138 23.2350 26.1759 30.3742 30.6807 29.9365 38.6504 32.3079 26.8895 31.5095 34.5710 42.0944 29.7382 32.6731 30.9123 27.7660 29.6973 35.6990 34.1250 28.5297 30.6869 32.3122 30.6085 28.3050 30.1432 27.1192 29.7955 30.8456 31.3517 28.6158 29.6709 33.3033 35.0695 30.9027 26.7544 26.2909 29.8896 29.5998 29.6321 31.4793 27.2133 3-Year average hourly wage 28.2619 30.0901 36.6236 27.5948 28.7401 32.6579 24.6804 29.0241 28.5517 29.8591 30.3269 36.7794 24.4407 29.7603 29.3079 34.6045 30.9372 30.6397 39.1326 25.0384 30.7409 28.7057 26.7778 34.7347 33.2554 32.8571 27.7805 27.6136 27.3821 22.4949 25.2599 28.6837 29.0683 29.1371 36.7387 31.3052 25.3106 30.2345 33.5071 39.8678 29.0319 31.3350 29.5833 26.6186 29.1460 34.3809 32.6476 27.6782 29.4302 30.2124 28.7888 27.0341 29.1751 26.3071 28.4097 29.4515 29.8273 27.6439 28.4442 32.5973 34.2761 29.7285 25.7478 25.3790 28.9336 28.7256 28.1756 29.6470 26.2863 23783 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 17900 17980 18020 18140 18580 18700 19060 19124 19140 19180 19260 19340 19380 19460 19500 19660 19740 19780 19804 20020 20100 20220 20260 20500 20740 20764 20940 21060 21140 21300 21340 21500 21660 21780 21820 21940 22020 22140 22180 22220 22380 22420 22500 22520 22540 22660 22744 22900 23020 23060 23104 23420 23460 23540 23580 23844 24020 24140 24220 24300 24340 24500 24540 24580 24660 24780 24860 25020 25060 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 FY 2009 average hourly wage Urban area Columbia, SC ..................................................................................................................................... Columbus, GA-AL .............................................................................................................................. Columbus, IN ..................................................................................................................................... Columbus, OH ................................................................................................................................... Corpus Christi, TX ............................................................................................................................. Corvallis, OR ...................................................................................................................................... Cumberland, MD-WV ......................................................................................................................... Dallas-Plano-Irving, TX ...................................................................................................................... Dalton, GA ......................................................................................................................................... Danville, IL ......................................................................................................................................... Danville, VA ....................................................................................................................................... Davenport-Moline-Rock Island, IA-IL ................................................................................................. Dayton, OH ........................................................................................................................................ Decatur, AL ........................................................................................................................................ Decatur, IL ......................................................................................................................................... Deltona-Daytona Beach-Ormond Beach, FL ..................................................................................... Denver-Aurora, CO ............................................................................................................................ Des Moines-West Des Moines, IA .................................................................................................... Detroit-Livonia-Dearborn, MI ............................................................................................................. Dothan, AL ......................................................................................................................................... Dover, DE .......................................................................................................................................... Dubuque, IA ....................................................................................................................................... Duluth, MN-WI ................................................................................................................................... Durham, NC ....................................................................................................................................... Eau Claire, WI ................................................................................................................................... Edison-New Brunswick, NJ ............................................................................................................... El Centro, CA ..................................................................................................................................... Elizabethtown, KY .............................................................................................................................. Elkhart-Goshen, IN ............................................................................................................................ Elmira, NY .......................................................................................................................................... El Paso, TX ........................................................................................................................................ Erie, PA .............................................................................................................................................. Eugene-Springfield, OR ..................................................................................................................... Evansville, IN-KY ............................................................................................................................... Fairbanks, AK .................................................................................................................................... Fajardo, PR ........................................................................................................................................ Fargo, ND-MN ................................................................................................................................... Farmington, NM ................................................................................................................................. Fayetteville, NC ................................................................................................................................. Fayetteville-Springdale-Rogers, AR-MO ........................................................................................... Flagstaff, AZ ...................................................................................................................................... Flint, MI .............................................................................................................................................. Florence, SC ...................................................................................................................................... Florence-Muscle Shoals, AL .............................................................................................................. Fond du Lac, WI ................................................................................................................................ Fort Collins-Loveland, CO ................................................................................................................. Fort Lauderdale-Pompano Beach-Deerfield Beach, FL .................................................................... Fort Smith, AR-OK ............................................................................................................................. Fort Walton Beach-Crestview-Destin, FL .......................................................................................... Fort Wayne, IN .................................................................................................................................. Fort Worth-Arlington, TX .................................................................................................................... Fresno, CA ......................................................................................................................................... Gadsden, AL ...................................................................................................................................... Gainesville, FL ................................................................................................................................... Gainesville, GA .................................................................................................................................. Gary, IN ............................................................................................................................................. Glens Falls, NY .................................................................................................................................. Goldsboro, NC ................................................................................................................................... Grand Forks, ND-MN ......................................................................................................................... Grand Junction, CO ........................................................................................................................... Grand Rapids-Wyoming, MI .............................................................................................................. Great Falls, MT .................................................................................................................................. Greeley, CO ....................................................................................................................................... Green Bay, WI ................................................................................................................................... Greensboro-High Point, NC ............................................................................................................... Greenville, NC ................................................................................................................................... Greenville-Mauldin-Easley, SC .......................................................................................................... Guayama, PR .................................................................................................................................... Gulfport-Biloxi, MS ............................................................................................................................. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00257 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 28.9948 29.2007 31.7711 31.8334 27.3797 35.7074 24.2686 31.7539 27.3868 31.2955 27.3411 27.2010 30.0672 24.8584 26.3336 28.4632 34.1438 30.6173 32.3846 24.8722 34.3823 26.5562 33.8981 31.2419 30.9902 36.1487 29.1074 27.2829 30.6988 26.8991 28.5812 28.0896 35.9675 27.4904 36.1891 13.1075 26.0887 25.2152 31.9846 29.4256 37.5481 36.2781 27.3900 25.2619 30.7462 30.8219 31.6349 25.2751 28.1059 28.8955 31.2137 35.7716 25.7517 30.4476 30.0367 30.0576 28.2938 29.5207 24.9880 31.2200 29.9037 27.9340 32.4200 30.6825 29.4639 30.1256 31.0004 10.1106 28.6731 3-Year average hourly wage 27.6672 27.4844 29.8902 30.9635 26.2260 34.1739 24.3744 30.5827 26.8521 29.5310 26.0795 26.8964 28.7100 24.2893 25.3091 27.8441 32.7970 28.7458 31.4605 23.3546 32.3013 26.9190 31.7842 30.0944 29.6325 34.5118 28.1129 26.5352 29.4323 25.8564 28.1095 26.9188 34.2186 26.7119 34.2975 12.8846 24.9864 26.1577 30.2233 27.9239 35.8798 34.1503 26.5639 24.0763 30.7188 29.2764 30.8485 24.4937 26.8450 28.1729 29.8330 34.2816 24.9688 29.0940 28.8932 28.8628 26.8175 28.5197 24.4055 29.9879 29.1399 26.5446 30.9988 29.5078 28.1363 28.8796 29.7649 09.6176 27.0856 23784 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 25180 25260 25420 25500 25540 25620 25860 25980 26100 26180 26300 26380 26420 26580 26620 26820 26900 26980 27060 27100 27140 27180 27260 27340 27500 27620 27740 27780 27860 27900 28020 28100 28140 28420 28660 28700 28740 28940 29020 29100 29140 29180 29340 29404 29420 29460 29540 29620 29700 29740 29820 29940 30020 30140 30300 30340 30460 30620 30700 30780 30860 30980 31020 31084 31140 31180 31340 31420 31460 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 FY 2009 average hourly wage Urban area Hagerstown-Martinsburg, MD-WV ..................................................................................................... Hanford-Corcoran, CA ....................................................................................................................... Harrisburg-Carlisle, PA ...................................................................................................................... Harrisonburg, VA ............................................................................................................................... Hartford-West Hartford-East Hartford, CT ......................................................................................... Hattiesburg, MS ................................................................................................................................. Hickory-Lenoir-Morganton, NC .......................................................................................................... 1 Hinesville-Fort Stewart, GA. Holland-Grand Haven, MI .................................................................................................................. Honolulu, HI ....................................................................................................................................... Hot Springs, AR ................................................................................................................................. Houma-Bayou Cane-Thibodaux, LA .................................................................................................. Houston-Sugar Land-Baytown, TX .................................................................................................... Huntington-Ashland, WV-KY-OH ....................................................................................................... Huntsville, AL ..................................................................................................................................... Idaho Falls, ID ................................................................................................................................... Indianapolis-Carmel, IN ..................................................................................................................... Iowa City, IA ...................................................................................................................................... Ithaca, NY .......................................................................................................................................... Jackson, MI ........................................................................................................................................ Jackson, MS ...................................................................................................................................... Jackson, TN ....................................................................................................................................... Jacksonville, FL ................................................................................................................................. Jacksonville, NC ................................................................................................................................ Janesville, WI ..................................................................................................................................... Jefferson City, MO ............................................................................................................................. Johnson City, TN ............................................................................................................................... Johnstown, PA ................................................................................................................................... Jonesboro, AR ................................................................................................................................... Joplin, MO .......................................................................................................................................... Kalamazoo-Portage, MI ..................................................................................................................... Kankakee-Bradley, IL ........................................................................................................................ Kansas City, MO-KS .......................................................................................................................... Kennewick-Pasco-Richland, WA ....................................................................................................... Killeen-Temple-Fort Hood, TX ........................................................................................................... Kingsport-Bristol-Bristol, TN-VA ........................................................................................................ Kingston, NY ...................................................................................................................................... Knoxville, TN ...................................................................................................................................... Kokomo, IN ........................................................................................................................................ La Crosse, WI-MN ............................................................................................................................. Lafayette, IN ...................................................................................................................................... Lafayette, LA ...................................................................................................................................... Lake Charles, LA ............................................................................................................................... Lake County-Kenosha County, IL-WI ................................................................................................ Lake Havasu City-Kingman, AZ ........................................................................................................ Lakeland-Winter Haven, FL ............................................................................................................... Lancaster, PA .................................................................................................................................... Lansing-East Lansing, MI .................................................................................................................. Laredo, TX ......................................................................................................................................... Las Cruces, NM ................................................................................................................................. Las Vegas-Paradise, NV ................................................................................................................... Lawrence, KS .................................................................................................................................... Lawton, OK ........................................................................................................................................ Lebanon, PA ...................................................................................................................................... Lewiston, ID-WA ................................................................................................................................ Lewiston-Auburn, ME ........................................................................................................................ Lexington-Fayette, KY ....................................................................................................................... Lima, OH ............................................................................................................................................ Lincoln, NE ........................................................................................................................................ Little Rock-North Little Rock-Conway, AR ........................................................................................ Logan, UT-ID ..................................................................................................................................... Longview, TX ..................................................................................................................................... Longview, WA .................................................................................................................................... Los Angeles-Long Beach-Glendale, CA ............................................................................................ Louisville-Jefferson County, KY-IN .................................................................................................... Lubbock, TX ....................................................................................................................................... Lynchburg, VA ................................................................................................................................... Macon, GA ......................................................................................................................................... Madera, CA ........................................................................................................................................ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00258 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 3-Year average hourly wage 29.8828 35.7293 29.4620 28.8643 36.0188 24.2839 28.8353 28.7638 33.4052 28.6481 27.8908 34.1981 23.4139 27.7789 29.3296 37.4061 29.4741 25.3740 31.9906 29.4107 28.9607 29.3359 31.6890 30.2168 30.8103 30.5399 25.9122 27.3080 29.3541 27.0573 31.7184 29.1505 25.8452 25.9505 26.0204 31.3014 35.1589 38.7329 30.4624 31.3630 28.5417 25.3719 30.3965 25.4214 29.8433 31.6291 28.8946 27.2063 24.4720 33.4390 31.6370 28.1459 31.0576 31.9010 28.4147 28.3851 37.5945 26.8014 27.8148 29.0022 29.8774 30.0517 28.8431 29.9606 31.0009 28.2114 28.3537 27.3041 36.9240 38.9626 29.7925 28.0803 27.7933 31.6291 26.7719 28.2605 34.9722 27.9457 24.7942 30.9869 27.7644 27.8624 28.2699 30.3105 29.3116 29.9028 29.5811 24.9687 26.6865 28.3904 25.9214 30.5036 27.2519 24.5939 24.9881 24.6491 28.6510 33.2912 33.0300 29.0579 30.6561 26.9557 24.5154 29.3492 24.8943 29.2845 30.0294 27.2885 25.9638 24.0434 32.6639 29.6383 27.5004 30.0449 30.9914 26.3095 27.2925 35.4889 25.6444 26.3376 26.8307 29.0074 28.7720 27.8163 28.3617 30.3915 28.2530 27.8958 26.9355 33.8434 36.6108 28.3269 26.7835 26.6660 30.3409 26.0576 23785 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 31540 31700 31900 32420 32580 32780 32820 32900 33124 33140 33260 33340 33460 33540 33660 33700 33740 33780 33860 34060 34100 34580 34620 34740 34820 34900 34940 34980 35004 35084 35300 35380 35644 35660 35980 36084 36100 36140 36220 36260 36420 36500 36540 36740 36780 36980 37100 37340 37380 37460 37620 37700 37764 37860 37900 37964 38060 38220 38300 38340 38540 38660 38860 38900 38940 39100 39140 39300 39340 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 FY 2009 average hourly wage Urban area Madison, WI ....................................................................................................................................... Manchester-Nashua, NH ................................................................................................................... Mansfield, OH .................................................................................................................................... ¨ Mayaguez, PR ................................................................................................................................... McAllen-Edinburg-Mission, TX .......................................................................................................... Medford, OR ...................................................................................................................................... Memphis, TN-MS-AR ......................................................................................................................... Merced, CA ........................................................................................................................................ Miami-Miami Beach-Kendall, FL ........................................................................................................ Michigan City-La Porte, IN ................................................................................................................ Midland, TX ........................................................................................................................................ Milwaukee-Waukesha-West Allis, WI ................................................................................................ Minneapolis-St. Paul-Bloomington, MN-WI ....................................................................................... Missoula, MT ..................................................................................................................................... Mobile, AL .......................................................................................................................................... Modesto, CA ...................................................................................................................................... Monroe, LA ........................................................................................................................................ Monroe, MI ......................................................................................................................................... Montgomery, AL ................................................................................................................................ Morgantown, WV ............................................................................................................................... Morristown, TN .................................................................................................................................. Mount Vernon-Anacortes, WA ........................................................................................................... Muncie, IN .......................................................................................................................................... Muskegon-Norton Shores, MI ............................................................................................................ Myrtle Beach-North Myrtle Beach-Conway, SC ................................................................................ Napa, CA ........................................................................................................................................... Naples-Marco Island, FL ................................................................................................................... Nashville-Davidson-Murfreesboro-Franklin, TN ................................................................................. Nassau-Suffolk, NY ........................................................................................................................... Newark-Union, NJ-PA ........................................................................................................................ New Haven-Milford, CT ..................................................................................................................... New Orleans-Metairie-Kenner, LA ..................................................................................................... New York-White Plains-Wayne, NY-NJ ............................................................................................. Niles-Benton Harbor, MI .................................................................................................................... Norwich-New London, CT ................................................................................................................. Oakland-Fremont-Hayward, CA ........................................................................................................ Ocala, FL ........................................................................................................................................... Ocean City, NJ .................................................................................................................................. Odessa, TX ........................................................................................................................................ Ogden-Clearfield, UT ......................................................................................................................... Oklahoma City, OK ............................................................................................................................ Olympia, WA ...................................................................................................................................... Omaha-Council Bluffs, NE-IA ............................................................................................................ Orlando-Kissimmee, FL ..................................................................................................................... Oshkosh-Neenah, WI ........................................................................................................................ Owensboro, KY .................................................................................................................................. Oxnard-Thousand Oaks-Ventura, CA ............................................................................................... Palm Bay-Melbourne-Titusville, FL .................................................................................................... 2 Palm Coast, FL ................................................................................................................................ Panama City-Lynn Haven, FL ........................................................................................................... Parkersburg-Marietta-Vienna, WV-OH .............................................................................................. Pascagoula, MS ................................................................................................................................. Peabody, MA ..................................................................................................................................... Pensacola-Ferry Pass-Brent, FL ....................................................................................................... Peoria, IL ........................................................................................................................................... Philadelphia, PA ................................................................................................................................ Phoenix-Mesa-Scottsdale, AZ ........................................................................................................... Pine Bluff, AR .................................................................................................................................... Pittsburgh, PA .................................................................................................................................... Pittsfield, MA ...................................................................................................................................... Pocatello, ID ...................................................................................................................................... Ponce, PR .......................................................................................................................................... Portland-South Portland-Biddeford, ME ............................................................................................ Portland-Vancouver-Beaverton, OR-WA ........................................................................................... Port St. Lucie, FL ............................................................................................................................... Poughkeepsie-Newburgh-Middletown, NY ........................................................................................ Prescott, AZ ....................................................................................................................................... Providence-New Bedford-Fall River, RI-MA ...................................................................................... Provo-Orem, UT ................................................................................................................................ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00259 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 36.2618 33.0542 29.9812 12.5555 29.3886 33.0786 30.0626 39.1381 31.8599 29.1570 30.8197 32.8741 35.4391 28.2291 25.1640 39.1156 25.6673 28.7386 26.3999 27.8745 23.5598 32.2055 26.7339 32.9571 28.0263 45.2771 31.7163 30.5185 41.0210 37.3360 38.1842 29.4715 42.0303 29.3085 36.8468 49.9560 27.4049 37.4820 30.3782 29.7855 27.9928 37.0153 30.2913 29.6766 30.0761 28.2413 36.9286 30.3622 28.3179 27.4719 25.9281 25.8776 34.6216 26.1506 29.1439 35.4610 33.0972 26.6629 27.6753 33.6590 29.3360 13.2835 31.9890 36.1216 31.9898 35.2679 32.8634 34.3817 29.1600 3-Year average hourly wage 34.3945 31.4821 28.5726 11.7170 27.9884 32.3223 28.8798 36.7035 30.6911 27.7380 29.6993 31.8085 33.7580 26.9683 24.3569 36.9865 24.6843 29.0350 25.1056 26.4870 23.4073 31.3429 25.4260 31.3172 27.0772 42.3405 30.5323 29.8356 39.8184 36.1271 37.0168 27.1340 40.8866 28.0264 36.0398 47.7941 26.5357 34.3008 30.3247 28.2615 27.1135 34.9710 29.2081 28.9783 28.8544 27.1328 35.1055 29.2690 27.7197 25.9842 25.2122 25.5012 32.8179 24.9081 28.4392 33.9583 31.5810 25.9270 26.3759 31.7762 28.3737 13.4725 30.7480 34.7569 30.8026 33.9878 30.9614 33.0490 28.8274 23786 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 39380 39460 39540 39580 39660 39740 39820 39900 40060 40140 40220 40340 40380 40420 40484 40580 40660 40900 40980 41060 41100 41140 41180 41420 41500 41540 41620 41660 41700 41740 41780 41884 41900 41940 41980 42020 42044 42060 42100 42140 42220 42340 42540 42644 42680 43100 43300 43340 43580 43620 43780 43900 44060 44100 44140 44180 44220 44300 44700 44940 45060 45104 45220 45300 45460 45500 45780 45820 45940 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 FY 2009 average hourly wage Urban area Pueblo, CO ........................................................................................................................................ Punta Gorda, FL ................................................................................................................................ Racine, WI ......................................................................................................................................... Raleigh-Cary, NC ............................................................................................................................... Rapid City, SD ................................................................................................................................... Reading, PA ....................................................................................................................................... Redding, CA ...................................................................................................................................... Reno-Sparks, NV ............................................................................................................................... Richmond, VA .................................................................................................................................... Riverside-San Bernardino-Ontario, CA ............................................................................................. Roanoke, VA ...................................................................................................................................... Rochester, MN ................................................................................................................................... Rochester, NY ................................................................................................................................... Rockford, IL ....................................................................................................................................... Rockingham County-Strafford County, NH ....................................................................................... Rocky Mount, NC .............................................................................................................................. Rome, GA .......................................................................................................................................... Sacramento-Arden-Arcade-Roseville, CA ......................................................................................... Saginaw-Saginaw Township North, MI ............................................................................................. St. Cloud, MN .................................................................................................................................... St. George, UT .................................................................................................................................. St. Joseph, MO-KS ............................................................................................................................ St. Louis, MO-IL ................................................................................................................................. Salem, OR ......................................................................................................................................... Salinas, CA ........................................................................................................................................ Salisbury, MD .................................................................................................................................... Salt Lake City, UT ............................................................................................................................. San Angelo, TX ................................................................................................................................. San Antonio, TX ................................................................................................................................ San Diego-Carlsbad-San Marcos, CA ............................................................................................... Sandusky, OH .................................................................................................................................... San Francisco-San Mateo-Redwood City, CA .................................................................................. ´ San German-Cabo Rojo, PR ............................................................................................................. San Jose-Sunnyvale-Santa Clara, CA .............................................................................................. San Juan-Caguas-Guaynabo, PR ..................................................................................................... San Luis Obispo-Paso Robles, CA ................................................................................................... Santa Ana-Anaheim-Irvine, CA ......................................................................................................... Santa Barbara-Santa Maria-Goleta, CA ............................................................................................ Santa Cruz-Watsonville, CA .............................................................................................................. Santa Fe, NM .................................................................................................................................... Santa Rosa-Petaluma, CA ................................................................................................................ Savannah, GA ................................................................................................................................... Scranton-Wilkes-Barre, PA ................................................................................................................ Seattle-Bellevue-Everett, WA ............................................................................................................ Sebastian-Vero Beach, FL ................................................................................................................ Sheboygan, WI .................................................................................................................................. Sherman-Denison, TX ....................................................................................................................... Shreveport-Bossier City, LA .............................................................................................................. Sioux City, IA-NE-SD ......................................................................................................................... Sioux Falls, SD .................................................................................................................................. South Bend-Mishawaka, IN-MI .......................................................................................................... Spartanburg, SC ................................................................................................................................ Spokane, WA ..................................................................................................................................... Springfield, IL ..................................................................................................................................... Springfield, MA .................................................................................................................................. Springfield, MO .................................................................................................................................. Springfield, OH .................................................................................................................................. State College, PA .............................................................................................................................. Stockton, CA ...................................................................................................................................... Sumter, SC ........................................................................................................................................ Syracuse, NY ..................................................................................................................................... Tacoma, WA ...................................................................................................................................... Tallahassee, FL ................................................................................................................................. Tampa-St. Petersburg-Clearwater, FL .............................................................................................. Terre Haute, IN .................................................................................................................................. Texarkana, TX-Texarkana, AR .......................................................................................................... Toledo, OH ........................................................................................................................................ Topeka, KS ........................................................................................................................................ Trenton-Ewing, NJ ............................................................................................................................. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00260 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 27.8188 29.9874 28.8930 31.2156 30.6204 30.0875 41.6249 33.7604 29.6609 36.2653 28.6468 35.3899 28.7144 31.7824 31.9359 29.2288 31.2559 41.9426 29.1128 37.2177 29.7373 33.7767 28.9842 34.3369 47.9744 29.6266 29.8767 27.7212 28.8457 36.2686 28.4754 48.5597 14.9779 51.2569 14.1930 38.5623 38.1247 37.7124 51.5525 34.1580 49.2189 28.8176 26.5201 37.3352 30.7417 29.1159 29.9470 27.5578 28.3024 30.2235 31.0993 29.1025 33.9523 29.4330 33.3312 27.3178 27.8315 28.4188 38.6087 27.6406 31.7909 35.9647 29.0061 28.9032 29.4437 26.4165 29.8934 28.5929 34.3697 3-Year average hourly wage 26.8684 29.4798 28.8892 30.0484 27.7643 29.3819 39.4241 34.6330 28.3807 34.0181 27.4630 33.7865 27.8099 30.6686 31.0988 27.8751 29.9017 40.3835 28.2485 34.8308 29.2069 30.5981 27.8523 32.4058 45.4050 27.8982 29.1422 26.5502 27.6665 34.6834 27.6992 46.7826 14.5348 48.2592 13.8050 36.3112 35.9846 35.1162 48.3881 33.1619 45.6081 27.8424 25.6648 35.3387 30.0442 28.0863 27.3065 26.7863 27.7781 29.2197 30.1358 28.3525 32.3332 27.9091 31.8950 26.6919 26.5028 27.0040 36.4711 26.7218 30.5763 33.8969 27.8746 28.1723 27.6736 24.8363 28.9126 27.0599 33.3207 23787 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 3A.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR URBAN AREAS BY CBSA—Continued [*Based on the salaries and hours computed for Federal FYs 2007, 2008, and 2009] CBSA code 46060 46140 46220 46340 46540 46660 46700 47020 47220 47260 47300 47380 47580 47644 47894 47940 48140 48260 48300 48424 48540 48620 48660 48700 48864 48900 49020 49180 49340 49420 49500 49620 49660 49700 49740 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... FY 2009 average hourly wage Urban area Tucson, AZ ........................................................................................................................................ Tulsa, OK ........................................................................................................................................... Tuscaloosa, AL .................................................................................................................................. Tyler, TX ............................................................................................................................................ Utica-Rome, NY ................................................................................................................................. Valdosta, GA ...................................................................................................................................... Vallejo-Fairfield, CA ........................................................................................................................... Victoria, TX ........................................................................................................................................ Vineland-Millville-Bridgeton, NJ ......................................................................................................... Virginia Beach-Norfolk-Newport News, VA-NC ................................................................................. Visalia-Porterville, CA ........................................................................................................................ Waco, TX ........................................................................................................................................... Warner Robins, GA ........................................................................................................................... Warren-Troy-Farmington Hills, MI ..................................................................................................... Washington-Arlington-Alexandria, DC-VA-MD-WV ........................................................................... Waterloo-Cedar Falls, IA ................................................................................................................... Wausau, WI ....................................................................................................................................... Weirton-Steubenville, WV-OH ........................................................................................................... Wenatchee, WA ................................................................................................................................. West Palm Beach-Boca Raton-Boynton Beach, FL .......................................................................... Wheeling, WV-OH ............................................................................................................................. Wichita, KS ........................................................................................................................................ Wichita Falls, TX ................................................................................................................................ Williamsport, PA ................................................................................................................................ Wilmington, DE-MD-NJ ...................................................................................................................... Wilmington, NC .................................................................................................................................. Winchester, VA-WV ........................................................................................................................... Winston-Salem, NC ........................................................................................................................... Worcester, MA ................................................................................................................................... Yakima, WA ....................................................................................................................................... Yauco, PR .......................................................................................................................................... York-Hanover, PA .............................................................................................................................. Youngstown-Warren-Boardman, OH-PA ........................................................................................... Yuba City, CA .................................................................................................................................... Yuma, AZ ........................................................................................................................................... 30.4264 27.8831 28.0199 28.6912 28.1040 26.3052 45.6926 25.6787 35.2379 28.5838 33.2020 28.0515 30.5824 32.1363 34.3840 28.0510 31.6785 25.8721 30.3614 31.1027 22.6472 28.9395 29.5744 25.8784 34.0940 29.1370 31.4889 29.0508 35.2688 32.0317 10.8210 31.1804 28.8065 34.7445 31.9135 3-Year average hourly wage 29.2232 26.3265 26.8295 27.8517 27.1057 25.6427 44.8127 25.2869 33.0201 27.2923 31.5996 26.9091 28.8902 31.0932 33.3639 26.9028 30.5738 24.7386 31.9688 29.7030 21.8074 27.7964 26.8201 24.8306 32.8588 29.0123 30.6457 28.2246 34.2006 30.9552 10.6067 29.5691 27.5854 32.8688 30.1305 1 This area has no average hourly wage because there are no short-term, acute care hospitals in the area. is a new CBSA for FY 2008. To calculate the 3-year average hourly wage for this new area, we included the hospitals’ data from their previous geographic location for FY 2006 and FY 2007. 2 This TABLE 3B.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR RURAL AREAS BY CBSA [*Based on the sum of the salaries and hours computed for Federal FYs 2007, 2008, and 2009] Nonurban area FY 2009 average hourly wage 3-Year average hourly wage Alabama ............................................................................................................................................. Alaska ................................................................................................................................................ Arizona ............................................................................................................................................... Arkansas ............................................................................................................................................ California ............................................................................................................................................ Colorado ............................................................................................................................................ Connecticut ........................................................................................................................................ Delaware ............................................................................................................................................ Florida ................................................................................................................................................ Georgia .............................................................................................................................................. Hawaii ................................................................................................................................................ Idaho .................................................................................................................................................. Illinois ................................................................................................................................................. Indiana ............................................................................................................................................... Iowa ................................................................................................................................................... Kansas ............................................................................................................................................... Kentucky ............................................................................................................................................ Louisiana ............................................................................................................................................ Maine ................................................................................................................................................. Maryland ............................................................................................................................................ Massachusetts ................................................................................................................................... Michigan ............................................................................................................................................. 24.6411 38.4008 28.5407 24.6204 38.6569 30.0754 36.4301 32.6029 27.8797 25.2642 36.0283 24.4380 27.1642 27.3432 28.1850 25.9806 25.2536 24.7667 27.7429 28.3407 ........................ 28.5656 23.6242 35.4138 27.4573 23.3335 35.9246 28.7842 35.6330 30.8226 26.8062 24.2873 33.6508 24.1641 25.9705 26.4475 26.6791 24.8089 24.2249 23.6881 26.2711 27.4609 ........................ 27.6632 jlentini on PROD1PC65 with PROPOSALS2 CBSA code 01 02 03 04 05 06 07 08 10 11 12 13 14 15 16 17 18 19 20 21 22 23 ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00261 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23788 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 3B.—FY 2009 AND 3-YEAR* AVERAGE HOURLY WAGE FOR RURAL AREAS BY CBSA—Continued [*Based on the sum of the salaries and hours computed for Federal FYs 2007, 2008, and 2009] Nonurban area FY 2009 average hourly wage 3-Year average hourly wage Minnesota .......................................................................................................................................... Mississippi .......................................................................................................................................... Missouri .............................................................................................................................................. Montana ............................................................................................................................................. Nebraska ............................................................................................................................................ Nevada ............................................................................................................................................... New Hampshire ................................................................................................................................. New Jersey 1 ...................................................................................................................................... New Mexico ....................................................................................................................................... New York ........................................................................................................................................... North Carolina .................................................................................................................................... North Dakota ...................................................................................................................................... Ohio ................................................................................................................................................... Oklahoma ........................................................................................................................................... Oregon ............................................................................................................................................... Pennsylvania ...................................................................................................................................... Puerto Rico 1 ...................................................................................................................................... Rhode Island 1 ................................................................................................................................... South Carolina ................................................................................................................................... South Dakota ..................................................................................................................................... Tennessee ......................................................................................................................................... Texas ................................................................................................................................................. Utah ................................................................................................................................................... Vermont ............................................................................................................................................. Virginia ............................................................................................................................................... Washington ........................................................................................................................................ West Virginia ...................................................................................................................................... Wisconsin ........................................................................................................................................... Wyoming ............................................................................................................................................ 29.3894 24.6569 26.3804 27.8425 28.0119 31.6580 33.2526 ........................ 28.5810 26.7717 27.8184 23.7299 27.6801 25.8341 33.1220 26.9119 ........................ ........................ 27.7889 27.1581 25.6634 26.2796 27.0526 32.0308 25.9700 32.6127 24.6596 30.7058 29.7219 28.3126 23.9273 25.2174 26.4700 26.9486 29.6483 32.8237 ........................ 27.1089 25.8110 26.7060 22.7358 26.8138 24.3148 30.9016 25.8178 ........................ ........................ 26.8744 25.8858 24.6486 25.3601 25.6723 30.2935 24.9967 31.5030 23.6988 29.7224 28.3175 CBSA code 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 49 50 51 52 53 ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. 1 All counties within the State or territory are classified as urban. TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY STATE—FY 2009 [Constituent counties are listed in Table 4E.] jlentini on PROD1PC65 with PROPOSALS2 CBSA Code 10180 10380 10420 10500 10580 10740 10780 10900 10900 11020 11100 11180 11260 11300 11340 11460 11500 11540 11700 12020 12060 12100 12220 12260 12260 12420 12540 12580 12620 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 Urban area State Abilene, TX .................................................................................................................................... ´ Aguadilla-Isabela-San Sebastian, PR ........................................................................................... Akron, OH ...................................................................................................................................... Albany, GA ..................................................................................................................................... Albany-Schenectady-Troy, NY ...................................................................................................... Albuquerque, NM ........................................................................................................................... Alexandria, LA ............................................................................................................................... Allentown-Bethlehem-Easton, PA-NJ ............................................................................................ Allentown-Bethlehem-Easton, PA-NJ ............................................................................................ Altoona, PA .................................................................................................................................... Amarillo, TX ................................................................................................................................... Ames, IA ........................................................................................................................................ Anchorage, AK ............................................................................................................................... Anderson, IN .................................................................................................................................. Anderson, SC ................................................................................................................................ Ann Arbor, MI ................................................................................................................................ Anniston-Oxford, AL ...................................................................................................................... Appleton, WI .................................................................................................................................. Asheville, NC ................................................................................................................................. Athens-Clarke County, GA ............................................................................................................ Atlanta-Sandy Springs-Marietta, GA ............................................................................................. Atlantic City-Hammonton, NJ ........................................................................................................ Auburn-Opelika, AL ....................................................................................................................... Augusta-Richmond County, GA-SC .............................................................................................. Augusta-Richmond County, GA-SC .............................................................................................. Austin-Round Rock, TX ................................................................................................................. Bakersfield, CA .............................................................................................................................. Baltimore-Towson, MD .................................................................................................................. Bangor, ME .................................................................................................................................... TX ..... PR ..... OH .... GA ..... NY ..... NM .... LA ..... NJ ..... PA ..... PA ..... TX ..... IA ...... AK ..... IN ...... SC ..... MI ...... AL ..... WI ..... NC ..... GA ..... GA ..... NJ ..... AL ..... GA ..... SC ..... TX ..... CA ..... MD .... ME .... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00262 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.8408 0.3311 0.8784 0.8770 0.8833 0.9499 0.8127 1.1221 0.9675 0.8342 0.8997 0.9417 1.1884 0.8923 0.9721 1.0444 0.8007 0.9511 0.9192 0.9589 0.9760 1.1666 0.7647 0.9604 0.9589 0.9521 1.1822 0.9981 1.0115 GAF 0.8880 0.4691 0.9150 0.9140 0.9185 0.9654 0.8676 1.0821 0.9776 0.8833 0.9302 0.9597 1.1255 0.9249 0.9808 1.0302 0.8588 0.9662 0.9439 0.9717 0.9835 1.1113 0.8322 0.9727 0.9717 0.9669 1.1214 0.9987 1.0079 23789 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY STATE—FY 2009—Continued [Constituent counties are listed in Table 4E.] jlentini on PROD1PC65 with PROPOSALS2 CBSA Code 12700 12940 12980 13020 13140 13380 13460 13644 13740 13780 13820 13900 13980 14020 14060 14260 14484 14500 14540 14600 14740 14860 15180 15260 15380 15500 15540 15764 15804 15940 15980 16180 16220 16300 16580 16620 16700 16740 16740 16820 16860 16860 16940 16974 17020 17140 17140 17140 17300 17300 17420 17460 17660 17780 17820 17860 17900 17980 17980 18020 18140 18580 18700 19060 19060 19124 19140 19180 19260 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 Urban area State Barnstable Town, MA .................................................................................................................... Baton Rouge, LA ........................................................................................................................... Battle Creek, MI ............................................................................................................................. Bay City, MI ................................................................................................................................... Beaumont-Port Arthur, TX ............................................................................................................. Bellingham, WA ............................................................................................................................. Bend, OR ....................................................................................................................................... Bethesda-Frederick-Gaithersburg, MD .......................................................................................... Billings, MT .................................................................................................................................... Binghamton, NY ............................................................................................................................. Birmingham-Hoover, AL ................................................................................................................ Bismarck, ND ................................................................................................................................. Blacksburg-Christiansburg-Radford, VA ........................................................................................ Bloomington, IN ............................................................................................................................. Bloomington-Normal, IL ................................................................................................................. Boise City-Nampa, ID .................................................................................................................... Boston-Quincy, MA ........................................................................................................................ Boulder, CO ................................................................................................................................... Bowling Green, KY ........................................................................................................................ Bradenton-Sarasota-Venice, FL .................................................................................................... Bremerton-Silverdale, WA ............................................................................................................. Bridgeport-Stamford-Norwalk, CT ................................................................................................. Brownsville-Harlingen, TX ............................................................................................................. Brunswick, GA ............................................................................................................................... Buffalo-Niagara Falls, NY .............................................................................................................. Burlington, NC ............................................................................................................................... Burlington-South Burlington, VT .................................................................................................... Cambridge-Newton-Framingham, MA ........................................................................................... Camden, NJ ................................................................................................................................... Canton-Massillon, OH .................................................................................................................... Cape Coral-Fort Myers, FL ............................................................................................................ Carson City, NV ............................................................................................................................. Casper, WY ................................................................................................................................... Cedar Rapids, IA ........................................................................................................................... Champaign-Urbana, IL .................................................................................................................. Charleston, WV .............................................................................................................................. Charleston-North Charleston-Summerville, SC ............................................................................. Charlotte-Gastonia-Concord, NC-SC ............................................................................................ Charlotte-Gastonia-Concord, NC-SC ............................................................................................ Charlottesville, VA ......................................................................................................................... Chattanooga, TN-GA ..................................................................................................................... Chattanooga, TN-GA ..................................................................................................................... Cheyenne, WY ............................................................................................................................... Chicago-Naperville-Joliet, IL .......................................................................................................... Chico, CA ....................................................................................................................................... Cincinnati-Middletown, OH-KY-IN ................................................................................................. Cincinnati-Middletown, OH-KY-IN ................................................................................................. Cincinnati-Middletown, OH-KY-IN ................................................................................................. Clarksville, TN-KY .......................................................................................................................... Clarksville, TN-KY .......................................................................................................................... Cleveland, TN ................................................................................................................................ Cleveland-Elyria-Mentor, OH ......................................................................................................... Coeur d’Alene, ID .......................................................................................................................... College Station-Bryan, TX ............................................................................................................. Colorado Springs, CO ................................................................................................................... Columbia, MO ................................................................................................................................ Columbia, SC ................................................................................................................................. Columbus, GA-AL .......................................................................................................................... Columbus, GA-AL .......................................................................................................................... Columbus, IN ................................................................................................................................. Columbus, OH ............................................................................................................................... Corpus Christi, TX ......................................................................................................................... Corvallis, OR .................................................................................................................................. Cumberland, MD-WV ..................................................................................................................... Cumberland, MD-WV ..................................................................................................................... Dallas-Plano-Irving, TX .................................................................................................................. Dalton, GA ..................................................................................................................................... Danville, IL ..................................................................................................................................... Danville, VA ................................................................................................................................... MA .... LA ..... MI ...... MI ...... TX ..... WA .... OR .... MD .... MT ..... NY ..... AL ..... ND ..... VA ..... IN ...... IL ....... ID ...... MA .... CO .... KY ..... FL ...... WA .... CT ..... TX ..... GA ..... NY ..... NC ..... VT ..... MA .... NJ ..... OH .... FL ...... NV ..... WY .... IA ...... IL ....... WV .... SC ..... NC ..... SC ..... VA ..... GA ..... TN ..... WY .... IL ....... CA ..... IN ...... KY ..... OH .... KY ..... TN ..... TN ..... OH .... ID ...... TX ..... CO .... MO .... SC ..... AL ..... GA ..... IN ...... OH .... TX ..... OR .... MD .... WV .... TX ..... GA ..... IL ....... VA ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00263 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 1.2672 0.8142 1.0039 0.9472 0.8595 1.1395 1.1043 1.1018 0.9045 0.8721 0.8786 0.7336 0.8122 0.9419 0.9520 0.9290 1.1994 0.9994 0.8344 0.9757 1.0706 1.2591 0.9226 1.0139 0.9593 0.8632 0.9275 1.1078 1.1221 0.8845 0.9502 1.0027 0.9618 0.8746 0.9353 0.8398 0.9231 0.9570 0.9557 0.9728 0.8880 0.8857 0.9223 1.0334 1.1822 0.9583 0.9590 0.9581 0.8302 0.8280 0.8137 0.9266 0.9185 0.9193 0.9738 0.8470 0.8984 0.9061 0.9061 0.9852 0.9869 0.8494 1.1076 0.8795 0.7635 0.9852 0.8499 0.9711 0.8483 GAF 1.1761 0.8687 1.0027 0.9635 0.9015 1.0935 1.0703 1.0686 0.9336 0.9105 0.9152 0.8088 0.8672 0.9598 0.9669 0.9508 1.1326 0.9996 0.8834 0.9833 1.0478 1.1709 0.9463 1.0095 0.9719 0.9042 0.9498 1.0726 1.0821 0.9194 0.9656 1.0018 0.9737 0.9123 0.9552 0.8873 0.9467 0.9704 0.9694 0.9813 0.9219 0.9202 0.9461 1.0228 1.1214 0.9713 0.9717 0.9711 0.8804 0.8788 0.8683 0.9491 0.9434 0.9440 0.9820 0.8925 0.9293 0.9347 0.9347 0.9898 0.9910 0.8942 1.0725 0.9158 0.8313 0.9898 0.8946 0.9801 0.8935 23790 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY STATE—FY 2009—Continued [Constituent counties are listed in Table 4E.] jlentini on PROD1PC65 with PROPOSALS2 CBSA Code 19340 19340 19380 19460 19500 19660 19740 19780 19804 20020 20100 20220 20260 20260 20500 20740 20764 20940 21060 21140 21300 21340 21500 21660 21780 21780 21820 21940 22020 22020 22140 22180 22220 22220 22380 22420 22500 22520 22540 22660 22744 22900 22900 23020 23060 23104 23420 23460 23540 23580 23844 24020 24140 24220 24220 24300 24340 24500 24540 24580 24660 24780 24860 25020 25060 25180 25180 25260 25420 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 Urban area State Davenport-Moline-Rock Island, IA-IL ............................................................................................. Davenport-Moline-Rock Island, IA-IL ............................................................................................. Dayton, OH .................................................................................................................................... Decatur, AL .................................................................................................................................... Decatur, IL ..................................................................................................................................... Deltona-Daytona Beach-Ormond Beach, FL ................................................................................. Denver-Aurora, CO ........................................................................................................................ Des Moines-West Des Moines, IA ................................................................................................ Detroit-Livonia-Dearborn, MI ......................................................................................................... Dothan, AL ..................................................................................................................................... Dover, DE ...................................................................................................................................... Dubuque, IA ................................................................................................................................... Duluth, MN-WI ............................................................................................................................... Duluth, MN-WI ............................................................................................................................... Durham, NC ................................................................................................................................... Eau Claire, WI ............................................................................................................................... Edison-New Brunswick, NJ ........................................................................................................... El Centro, CA ................................................................................................................................. Elizabethtown, KY .......................................................................................................................... Elkhart-Goshen, IN ........................................................................................................................ Elmira, NY ...................................................................................................................................... El Paso, TX .................................................................................................................................... Erie, PA .......................................................................................................................................... Eugene-Springfield, OR ................................................................................................................. Evansville, IN-KY ........................................................................................................................... Evansville, IN-KY ........................................................................................................................... Fairbanks, AK ................................................................................................................................ Fajardo, PR .................................................................................................................................... Fargo, ND-MN ............................................................................................................................... Fargo, ND-MN ............................................................................................................................... Farmington, NM ............................................................................................................................. Fayetteville, NC ............................................................................................................................. Fayetteville-Springdale-Rogers, AR-MO ....................................................................................... Fayetteville-Springdale-Rogers, AR-MO ....................................................................................... Flagstaff, AZ .................................................................................................................................. Flint, MI .......................................................................................................................................... Florence, SC .................................................................................................................................. Florence-Muscle Shoals, AL .......................................................................................................... Fond du Lac, WI ............................................................................................................................ Fort Collins-Loveland, CO ............................................................................................................. Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ................................................................ Fort Smith, AR-OK ......................................................................................................................... Fort Smith, AR-OK ......................................................................................................................... Fort Walton Beach-Crestview-Destin, FL ...................................................................................... Fort Wayne, IN .............................................................................................................................. Fort Worth-Arlington, TX ................................................................................................................ Fresno, CA ..................................................................................................................................... Gadsden, AL .................................................................................................................................. Gainesville, FL ............................................................................................................................... Gainesville, GA .............................................................................................................................. Gary, IN ......................................................................................................................................... Glens Falls, NY .............................................................................................................................. Goldsboro, NC ............................................................................................................................... Grand Forks, ND-MN ..................................................................................................................... Grand Forks, ND-MN ..................................................................................................................... Grand Junction, CO ....................................................................................................................... Grand Rapids-Wyoming, MI .......................................................................................................... Great Falls, MT .............................................................................................................................. Greeley, CO ................................................................................................................................... Green Bay, WI ............................................................................................................................... Greensboro-High Point, NC ........................................................................................................... Greenville, NC ............................................................................................................................... Greenville-Mauldin-Easley, SC ...................................................................................................... Guayama, PR ................................................................................................................................ Gulfport-Biloxi, MS ......................................................................................................................... Hagerstown-Martinsburg, MD-WV ................................................................................................. Hagerstown-Martinsburg, MD-WV ................................................................................................. Hanford-Corcoran, CA ................................................................................................................... Harrisburg-Carlisle, PA .................................................................................................................. IL ....... IA ...... OH .... AL ..... IL ....... FL ...... CO .... IA ...... MI ...... AL ..... DE ..... IA ...... MN .... WI ..... NC ..... WI ..... NJ ..... CA ..... KY ..... IN ...... NY ..... TX ..... PA ..... OR .... IN ...... KY ..... AK ..... PR ..... MN .... ND ..... NM .... NC ..... AR ..... MO .... AZ ..... MI ...... SC ..... AL ..... WI ..... CO .... FL ...... AR ..... OK ..... FL ...... IN ...... TX ..... CA ..... AL ..... FL ...... GA ..... IN ...... NY ..... NC ..... MN .... ND ..... CO .... MI ...... MT ..... CO .... WI ..... NC ..... NC ..... SC ..... PR ..... MS .... MD .... WV .... CA ..... PA ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00264 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.8606 0.8709 0.9321 0.7714 0.8428 0.8814 1.0561 0.9460 1.0052 0.7718 1.0669 0.8709 1.0519 1.0499 0.9693 0.9599 1.1221 1.1822 0.8466 0.9547 0.8347 0.8867 0.8708 1.1157 0.8525 0.8531 1.1884 0.4067 0.9120 0.8212 0.8858 0.9923 0.9131 0.9123 1.1652 1.1258 0.8609 0.7883 0.9523 0.9581 1.0025 0.7843 0.8016 0.8703 0.9004 0.9684 1.1822 0.7991 0.9427 0.9321 0.9320 0.8780 0.9159 0.9120 0.7709 0.9925 0.9305 0.8679 1.0028 0.9511 0.9141 0.9346 0.9605 0.3137 0.8898 0.9273 0.9253 1.1822 0.9185 GAF 0.9023 0.9097 0.9530 0.8372 0.8895 0.9172 1.0381 0.9627 1.0036 0.8375 1.0453 0.9097 1.0353 1.0339 0.9789 0.9724 1.0821 1.1214 0.8922 0.9688 0.8836 0.9210 0.9096 1.0779 0.8965 0.8969 1.1255 0.5400 0.9389 0.8738 0.9203 0.9947 0.9396 0.9391 1.1104 1.0845 0.9025 0.8497 0.9671 0.9711 1.0017 0.8467 0.8595 0.9093 0.9307 0.9783 1.1214 0.8576 0.9604 0.9530 0.9529 0.9148 0.9416 0.9389 0.8368 0.9949 0.9519 0.9075 1.0019 0.9662 0.9403 0.9547 0.9728 0.4521 0.9232 0.9496 0.9482 1.1214 0.9434 23791 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY STATE—FY 2009—Continued [Constituent counties are listed in Table 4E.] jlentini on PROD1PC65 with PROPOSALS2 CBSA Code 25500 25540 25620 25860 26100 26180 26300 26380 26420 26580 26580 26580 26620 26820 26900 26980 27060 27100 27140 27180 27260 27340 27500 27620 27740 27780 27860 27900 28020 28100 28140 28140 28420 28660 28700 28700 28740 28940 29020 29100 29100 29140 29180 29340 29404 29404 29420 29460 29540 29620 29700 29740 29820 29940 30020 30140 30300 30300 30340 30460 30620 30700 30780 30860 30860 30980 31020 31084 31140 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 Urban area State Harrisonburg, VA ........................................................................................................................... Hartford-West Hartford-East Hartford, CT ..................................................................................... Hattiesburg, MS ............................................................................................................................. Hickory-Lenoir-Morganton, NC ...................................................................................................... Holland-Grand Haven, MI .............................................................................................................. Honolulu, HI ................................................................................................................................... Hot Springs, AR ............................................................................................................................. Houma-Bayou Cane-Thibodaux, LA .............................................................................................. Houston-Sugar Land-Baytown, TX ................................................................................................ Huntington-Ashland, WV-KY-OH ................................................................................................... Huntington-Ashland, WV-KY-OH ................................................................................................... Huntington-Ashland, WV-KY-OH ................................................................................................... Huntsville, AL ................................................................................................................................. Idaho Falls, ID ............................................................................................................................... Indianapolis-Carmel, IN ................................................................................................................. Iowa City, IA .................................................................................................................................. Ithaca, NY ...................................................................................................................................... Jackson, MI .................................................................................................................................... Jackson, MS .................................................................................................................................. Jackson, TN ................................................................................................................................... Jacksonville, FL ............................................................................................................................. Jacksonville, NC ............................................................................................................................ Janesville, WI ................................................................................................................................. Jefferson City, MO ......................................................................................................................... Johnson City, TN ........................................................................................................................... Johnstown, PA ............................................................................................................................... Jonesboro, AR ............................................................................................................................... Joplin, MO ...................................................................................................................................... Kalamazoo-Portage, MI ................................................................................................................. Kankakee-Bradley, IL .................................................................................................................... Kansas City, MO-KS ...................................................................................................................... Kansas City, MO-KS ...................................................................................................................... Kennewick-Pasco-Richland, WA ................................................................................................... Killeen-Temple-Fort Hood, TX ....................................................................................................... Kingsport-Bristol-Bristol, TN-VA .................................................................................................... Kingsport-Bristol-Bristol, TN-VA .................................................................................................... Kingston, NY .................................................................................................................................. Knoxville, TN .................................................................................................................................. Kokomo, IN .................................................................................................................................... La Crosse, WI-MN ......................................................................................................................... La Crosse, WI-MN ......................................................................................................................... Lafayette, IN .................................................................................................................................. Lafayette, LA .................................................................................................................................. Lake Charles, LA ........................................................................................................................... Lake County-Kenosha County, IL-WI ............................................................................................ Lake County-Kenosha County, IL-WI ............................................................................................ Lake Havasu City-Kingman, AZ .................................................................................................... Lakeland-Winter Haven, FL ........................................................................................................... Lancaster, PA ................................................................................................................................ Lansing-East Lansing, MI .............................................................................................................. Laredo, TX ..................................................................................................................................... Las Cruces, NM ............................................................................................................................. Las Vegas-Paradise, NV ............................................................................................................... Lawrence, KS ................................................................................................................................ Lawton, OK .................................................................................................................................... Lebanon, PA .................................................................................................................................. Lewiston, ID-WA ............................................................................................................................ Lewiston, ID-WA ............................................................................................................................ Lewiston-Auburn, ME .................................................................................................................... Lexington-Fayette, KY ................................................................................................................... Lima, OH ........................................................................................................................................ Lincoln, NE .................................................................................................................................... Little Rock-North Little Rock-Conway, AR .................................................................................... Logan, UT-ID ................................................................................................................................. Logan, UT-ID ................................................................................................................................. Longview, TX ................................................................................................................................. Longview, WA ................................................................................................................................ Los Angeles-Long Beach-Glendale, CA ........................................................................................ Louisville-Jefferson County, KY-IN ................................................................................................ VA ..... CT ..... MS .... NC ..... MI ...... HI ...... AR ..... LA ..... TX ..... KY ..... OH .... WV .... AL ..... ID ...... IN ...... IA ...... NY ..... MI ...... MS .... TN ..... FL ...... NC ..... WI ..... MO .... TN ..... PA ..... AR ..... MO .... MI ...... IL ....... KS ..... MO .... WA .... TX ..... TN ..... VA ..... NY ..... TN ..... IN ...... MN .... WI ..... IN ...... LA ..... LA ..... IL ....... WI ..... AZ ..... FL ...... PA ..... MI ...... TX ..... NM .... NV ..... KS ..... OK ..... PA ..... ID ...... WA .... ME .... KY ..... OH .... NE ..... AR ..... ID ...... UT ..... TX ..... WA .... CA ..... IN ...... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00265 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.8956 1.1897 0.7653 0.8946 0.9101 1.1608 0.9146 0.7870 0.9925 0.9127 0.9118 0.9107 0.8987 0.9327 0.9827 0.9337 0.9561 0.9477 0.8095 0.8452 0.9092 0.8632 0.9824 0.9038 0.7999 0.8342 0.8291 0.9704 1.0910 1.2018 0.9453 0.9444 1.0164 0.8855 0.7957 0.8061 0.9433 0.7957 0.9254 0.9815 0.9796 0.8960 0.8438 0.7682 1.0376 1.0357 0.9817 0.8715 0.9799 0.9899 0.8816 0.8858 1.1666 0.8317 0.8630 0.8991 0.9271 1.0164 0.9326 0.8950 0.9299 0.9620 0.8754 0.8827 0.8827 0.8666 1.1434 1.1916 0.9238 GAF 0.9273 1.1263 0.8326 0.9266 0.9375 1.1075 0.9407 0.8487 0.9949 0.9394 0.9387 0.9380 0.9295 0.9534 0.9881 0.9541 0.9697 0.9639 0.8653 0.8912 0.9369 0.9042 0.9879 0.9331 0.8582 0.8833 0.8796 0.9796 1.0615 1.1341 0.9622 0.9616 1.0112 0.9201 0.8551 0.8628 0.9608 0.8551 0.9483 0.9873 0.9860 0.9276 0.8902 0.8348 1.0256 1.0243 0.9874 0.9101 0.9862 0.9931 0.9173 0.9203 1.1113 0.8814 0.9040 0.9298 0.9495 1.0112 0.9533 0.9268 0.9514 0.9738 0.9129 0.9181 0.9181 0.9066 1.0961 1.1275 0.9472 23792 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY STATE—FY 2009—Continued [Constituent counties are listed in Table 4E.] jlentini on PROD1PC65 with PROPOSALS2 CBSA Code 31140 31180 31340 31420 31460 31540 31700 31900 32420 32580 32780 32820 32820 32820 32900 33124 33140 33260 33340 33460 33460 33540 33660 33700 33740 33780 33860 34060 34100 34580 34620 34740 34820 34900 34940 34980 35004 35084 35084 35300 35380 35644 35644 35660 35980 36084 36100 36140 36220 36260 36420 36500 36540 36540 36740 36780 36980 37100 37340 37380 37460 37620 37620 37700 37764 37860 37900 37964 38060 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 Urban area State Louisville-Jefferson County, KY-IN ................................................................................................ Lubbock, TX ................................................................................................................................... Lynchburg, VA ............................................................................................................................... Macon, GA ..................................................................................................................................... Madera, CA .................................................................................................................................... Madison, WI ................................................................................................................................... Manchester-Nashua, NH ............................................................................................................... Mansfield, OH ................................................................................................................................ ¨ Mayaguez, PR ............................................................................................................................... McAllen-Edinburg-Mission, TX ...................................................................................................... Medford, OR .................................................................................................................................. Memphis, TN-MS-AR ..................................................................................................................... Memphis, TN-MS-AR ..................................................................................................................... Memphis, TN-MS-AR ..................................................................................................................... Merced, CA .................................................................................................................................... Miami-Miami Beach-Kendall, FL .................................................................................................... Michigan City-La Porte, IN ............................................................................................................ Midland, TX .................................................................................................................................... Milwaukee-Waukesha-West Allis, WI ............................................................................................ Minneapolis-St. Paul-Bloomington, MN-WI ................................................................................... Minneapolis-St. Paul-Bloomington, MN-WI ................................................................................... Missoula, MT ................................................................................................................................. Mobile, AL ...................................................................................................................................... Modesto, CA .................................................................................................................................. Monroe, LA .................................................................................................................................... Monroe, MI ..................................................................................................................................... Montgomery, AL ............................................................................................................................ Morgantown, WV ........................................................................................................................... Morristown, TN .............................................................................................................................. Mount Vernon-Anacortes, WA ....................................................................................................... Muncie, IN ...................................................................................................................................... Muskegon-Norton Shores, MI ........................................................................................................ Myrtle Beach-North Myrtle Beach-Conway, SC ............................................................................ Napa, CA ....................................................................................................................................... Naples-Marco Island, FL ............................................................................................................... Nashville-Davidson-Murfreesboro-Franklin, TN ............................................................................. Nassau-Suffolk, NY ....................................................................................................................... Newark-Union, NJ-PA .................................................................................................................... Newark-Union, NJ-PA .................................................................................................................... New Haven-Milford, CT ................................................................................................................. New Orleans-Metairie-Kenner, LA ................................................................................................. New York-White Plains-Wayne, NY-NJ ......................................................................................... New York-White Plains-Wayne, NY-NJ ......................................................................................... Niles-Benton Harbor, MI ................................................................................................................ Norwich-New London, CT ............................................................................................................. Oakland-Fremont-Hayward, CA .................................................................................................... Ocala, FL ....................................................................................................................................... Ocean City, NJ .............................................................................................................................. Odessa, TX .................................................................................................................................... Ogden-Clearfield, UT ..................................................................................................................... Oklahoma City, OK ........................................................................................................................ Olympia, WA .................................................................................................................................. Omaha-Council Bluffs, NE-IA ........................................................................................................ Omaha-Council Bluffs, NE-IA ........................................................................................................ Orlando-Kissimmee, FL ................................................................................................................. Oshkosh-Neenah, WI .................................................................................................................... Owensboro, KY .............................................................................................................................. Oxnard-Thousand Oaks-Ventura, CA ........................................................................................... Palm Bay-Melbourne-Titusville, FL ................................................................................................ Palm Coast, FL .............................................................................................................................. Panama City-Lynn Haven, FL ....................................................................................................... Parkersburg-Marietta-Vienna, WV-OH .......................................................................................... Parkersburg-Marietta-Vienna, WV-OH .......................................................................................... Pascagoula, MS ............................................................................................................................. Peabody, MA ................................................................................................................................. Pensacola-Ferry Pass-Brent, FL ................................................................................................... Peoria, IL ....................................................................................................................................... Philadelphia, PA ............................................................................................................................ Phoenix-Mesa-Scottsdale, AZ ....................................................................................................... KY ..... TX ..... VA ..... GA ..... CA ..... WI ..... NH ..... OH .... PR ..... TX ..... OR .... AR ..... MS .... TN ..... CA ..... FL ...... IN ...... TX ..... WI ..... MN .... WI ..... MT ..... AL ..... CA ..... LA ..... MI ...... AL ..... WV .... TN ..... WA .... IN ...... MI ...... SC ..... CA ..... FL ...... TN ..... NY ..... NJ ..... PA ..... CT ..... LA ..... NJ ..... NY ..... MI ...... CT ..... CA ..... FL ...... NJ ..... TX ..... UT ..... OK ..... WA .... IA ...... NE ..... FL ...... WI ..... KY ..... CA ..... FL ...... FL ...... FL ...... OH .... WV .... MS .... MA .... FL ...... IL ....... PA ..... AZ ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00266 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.9245 0.8712 0.8646 0.9815 1.1822 1.1232 1.0807 0.9295 0.3896 0.9118 1.0298 0.9329 0.9329 0.9305 1.1969 0.9865 0.9041 0.9562 1.0182 1.0997 1.0976 0.8909 0.7809 1.1963 0.7961 0.8918 0.8192 0.8631 0.7957 1.0164 0.8479 1.0227 0.8683 1.3847 0.9820 0.9445 1.2729 1.1440 1.1574 1.1897 0.9140 1.2878 1.3043 0.9095 1.1897 1.5278 0.8633 1.1484 0.9425 0.9243 0.8686 1.1462 0.9360 0.9400 0.9189 0.9511 0.8764 1.1822 0.9401 0.8769 0.8633 0.8582 0.8028 0.8030 1.0744 0.8633 0.9043 1.0992 1.0271 GAF 0.9477 0.9099 0.9052 0.9873 1.1214 1.0828 1.0546 0.9512 0.5244 0.9387 1.0203 0.9535 0.9535 0.9519 1.1310 0.9907 0.9333 0.9698 1.0124 1.0672 1.0659 0.9239 0.8442 1.1306 0.8554 0.9246 0.8723 0.9041 0.8551 1.0112 0.8932 1.0155 0.9078 1.2497 0.9876 0.9617 1.1797 1.0965 1.1053 1.1263 0.9403 1.1891 1.1995 0.9371 1.1263 1.3367 0.9042 1.0994 0.9603 0.9475 0.9080 1.0979 0.9557 0.9585 0.9437 0.9662 0.9136 1.1214 0.9586 0.9140 0.9042 0.9006 0.8603 0.8605 1.0504 0.9042 0.9334 1.0669 1.0185 23793 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY STATE—FY 2009—Continued [Constituent counties are listed in Table 4E.] jlentini on PROD1PC65 with PROPOSALS2 CBSA Code 38220 38300 38340 38540 38660 38860 38900 38900 38940 39100 39140 39300 39300 39340 39380 39460 39540 39580 39660 39740 39820 39900 40060 40140 40220 40340 40380 40420 40484 40580 40660 40900 40980 41060 41100 41140 41140 41180 41180 41420 41500 41540 41620 41660 41700 41740 41780 41884 41900 41940 41980 42020 42044 42060 42100 42140 42220 42340 42540 42644 42680 43100 43300 43340 43580 43580 43580 43620 43780 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 Urban area State Pine Bluff, AR ................................................................................................................................ Pittsburgh, PA ................................................................................................................................ Pittsfield, MA .................................................................................................................................. Pocatello, ID .................................................................................................................................. Ponce, PR ...................................................................................................................................... Portland-South Portland-Biddeford, ME ........................................................................................ Portland-Vancouver-Beaverton, OR-WA ....................................................................................... Portland-Vancouver-Beaverton, OR-WA ....................................................................................... Port St. Lucie, FL ........................................................................................................................... Poughkeepsie-Newburgh-Middletown, NY .................................................................................... Prescott, AZ ................................................................................................................................... Providence-New Bedford-Fall River, RI-MA .................................................................................. Providence-New Bedford-Fall River, RI-MA .................................................................................. Provo-Orem, UT ............................................................................................................................ Pueblo, CO .................................................................................................................................... Punta Gorda, FL ............................................................................................................................ Racine, WI ..................................................................................................................................... Raleigh-Cary, NC ........................................................................................................................... Rapid City, SD ............................................................................................................................... Reading, PA ................................................................................................................................... Redding, CA .................................................................................................................................. Reno-Sparks, NV ........................................................................................................................... Richmond, VA ................................................................................................................................ Riverside-San Bernardino-Ontario, CA ......................................................................................... Roanoke, VA .................................................................................................................................. Rochester, MN ............................................................................................................................... Rochester, NY ............................................................................................................................... Rockford, IL ................................................................................................................................... Rockingham County-Strafford County, NH ................................................................................... Rocky Mount, NC .......................................................................................................................... Rome, GA ...................................................................................................................................... Sacramento—Arden-Arcade—Roseville, CA ................................................................................ Saginaw-Saginaw Township North, MI ......................................................................................... St. Cloud, MN ................................................................................................................................ St. George, UT .............................................................................................................................. St. Joseph, MO-KS ........................................................................................................................ St. Joseph, MO-KS ........................................................................................................................ St. Louis, MO-IL ............................................................................................................................. St. Louis, MO-IL ............................................................................................................................. Salem, OR ..................................................................................................................................... Salinas, CA .................................................................................................................................... Salisbury, MD ................................................................................................................................ Salt Lake City, UT ......................................................................................................................... San Angelo, TX ............................................................................................................................. San Antonio, TX ............................................................................................................................ San Diego-Carlsbad-San Marcos, CA ........................................................................................... Sandusky, OH ................................................................................................................................ San Francisco-San Mateo-Redwood City, CA .............................................................................. ´ San German-Cabo Rojo, PR ......................................................................................................... San Jose-Sunnyvale-Santa Clara, CA .......................................................................................... San Juan-Caguas-Guaynabo, PR ................................................................................................. San Luis Obispo-Paso Robles, CA ............................................................................................... Santa Ana-Anaheim-Irvine, CA ..................................................................................................... Santa Barbara-Santa Maria-Goleta, CA ........................................................................................ Santa Cruz-Watsonville, CA .......................................................................................................... Santa Fe, NM ................................................................................................................................ Santa Rosa-Petaluma, CA ............................................................................................................ Savannah, GA ............................................................................................................................... Scranton—Wilkes-Barre, PA ......................................................................................................... Seattle-Bellevue-Everett, WA ........................................................................................................ Sebastian-Vero Beach, FL ............................................................................................................ Sheboygan, WI .............................................................................................................................. Sherman-Denison, TX ................................................................................................................... Shreveport-Bossier City, LA .......................................................................................................... Sioux City, IA-NE-SD ..................................................................................................................... Sioux City, IA-NE-SD ..................................................................................................................... Sioux City, IA-NE-SD ..................................................................................................................... Sioux Falls, SD .............................................................................................................................. South Bend-Mishawaka, IN-MI ...................................................................................................... AR ..... PA ..... MA .... ID ...... PR ..... ME .... OR .... WA .... FL ...... NY ..... AZ ..... MA .... RI ...... UT ..... CO .... FL ...... WI ..... NC ..... SD ..... PA ..... CA ..... NV ..... VA ..... CA ..... VA ..... MN .... NY ..... IL ....... NH ..... NC ..... GA ..... CA ..... MI ...... MN .... UT ..... KS ..... MO .... IL ....... MO .... OR .... CA ..... MD .... UT ..... TX ..... TX ..... CA ..... OH .... CA ..... PR ..... CA ..... PR ..... CA ..... CA ..... CA ..... CA ..... NM .... CA ..... GA ..... PA ..... WA .... FL ...... WI ..... TX ..... LA ..... IA ...... NE ..... SD ..... SD ..... IN ...... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00267 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.8274 0.8579 1.0445 0.9103 0.4122 0.9927 1.1204 1.1186 0.9905 1.0944 1.0198 1.0669 1.0669 0.9052 0.9303 0.9286 0.9511 0.9685 0.9502 0.9327 1.2730 1.0476 0.9203 1.1822 0.8889 1.0982 0.8911 0.9862 1.0807 0.9068 0.9699 1.2827 0.9034 1.1549 0.9228 1.0481 1.0472 0.8993 0.8986 1.0650 1.4671 0.9194 0.9271 0.8600 0.8949 1.1822 0.8828 1.4879 0.4648 1.5758 0.4404 1.1822 1.1822 1.1822 1.5766 1.0587 1.5052 0.8943 0.8342 1.1562 0.9519 0.9511 0.9291 0.8547 0.8745 0.8783 0.8783 0.9379 0.9644 GAF 0.8783 0.9004 1.0303 0.9377 0.5450 0.9950 1.0810 1.0798 0.9935 1.0637 1.0135 1.0453 1.0453 0.9341 0.9517 0.9505 0.9662 0.9783 0.9656 0.9534 1.1797 1.0324 0.9447 1.1214 0.9225 1.0662 0.9241 0.9905 1.0546 0.9352 0.9793 1.1859 0.9328 1.1036 0.9465 1.0327 1.0321 0.9299 0.9294 1.0441 1.3001 0.9441 0.9495 0.9019 0.9268 1.1214 0.9182 1.3127 0.5918 1.3654 0.5703 1.1214 1.1214 1.1214 1.3658 1.0398 1.3232 0.9264 0.8833 1.1045 0.9668 0.9662 0.9509 0.8981 0.9123 0.9150 0.9150 0.9570 0.9755 23794 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4A.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR URBAN AREAS BY CBSA AND BY STATE—FY 2009—Continued [Constituent counties are listed in Table 4E.] jlentini on PROD1PC65 with PROPOSALS2 CBSA Code 43780 43900 44060 44100 44140 44180 44220 44300 44700 44940 45060 45104 45220 45300 45460 45500 45500 45780 45820 45940 46060 46140 46220 46340 46540 46660 46700 47020 47220 47260 47260 47300 47380 47580 47644 47894 47894 47894 47894 47940 48140 48260 48260 48300 48424 48540 48540 48620 48660 48700 48864 48864 48864 48900 49020 49020 49180 49340 49420 49500 49620 49660 49660 49700 49740 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 Urban area State South Bend-Mishawaka, IN-MI ...................................................................................................... Spartanburg, SC ............................................................................................................................ Spokane, WA ................................................................................................................................. Springfield, IL ................................................................................................................................. Springfield, MA .............................................................................................................................. Springfield, MO .............................................................................................................................. Springfield, OH .............................................................................................................................. State College, PA .......................................................................................................................... Stockton, CA .................................................................................................................................. Sumter, SC .................................................................................................................................... Syracuse, NY ................................................................................................................................. Tacoma, WA .................................................................................................................................. Tallahassee, FL ............................................................................................................................. Tampa-St. Petersburg-Clearwater, FL .......................................................................................... Terre Haute, IN .............................................................................................................................. Texarkana, TX-Texarkana, AR ...................................................................................................... Texarkana, TX-Texarkana, AR ...................................................................................................... Toledo, OH .................................................................................................................................... Topeka, KS .................................................................................................................................... Trenton-Ewing, NJ ......................................................................................................................... Tucson, AZ .................................................................................................................................... Tulsa, OK ....................................................................................................................................... Tuscaloosa, AL .............................................................................................................................. Tyler, TX ........................................................................................................................................ Utica-Rome, NY ............................................................................................................................. Valdosta, GA .................................................................................................................................. Vallejo-Fairfield, CA ....................................................................................................................... Victoria, TX .................................................................................................................................... Vineland-Millville-Bridgeton, NJ ..................................................................................................... Virginia Beach-Norfolk-Newport News, VA ................................................................................... Virginia Beach-Norfolk-Newport News, VA ................................................................................... Visalia-Porterville, CA .................................................................................................................... Waco, TX ....................................................................................................................................... Warner Robins, GA ....................................................................................................................... Warren-Troy-Farmington-Hills, MI ................................................................................................. Washington-Arlington-Alexandria, DC-VA-MD-WV ....................................................................... Washington-Arlington-Alexandria DC-VA-MD-WV ........................................................................ Washington-Arlington-Alexandria DC-VA-MD-WV ........................................................................ Washington-Arlington-Alexandria DC-VA-MD-WV ........................................................................ Waterloo-Cedar Falls, IA ............................................................................................................... Wausau, WI ................................................................................................................................... Weirton-Steubenville, WV-OH ....................................................................................................... Weirton-Steubenville, WV-OH ....................................................................................................... Wenatchee, WA ............................................................................................................................. West Palm Beach-Boca Raton-Boynton Beach, FL ...................................................................... Wheeling, WV-OH ......................................................................................................................... Wheeling, WV-OH ......................................................................................................................... Wichita, KS .................................................................................................................................... Wichita Falls, TX ............................................................................................................................ Williamsport, PA ............................................................................................................................ Wilmington, DE-MD-NJ .................................................................................................................. Wilmington, DE-MD-NJ .................................................................................................................. Wilmington, DE-MD-NJ .................................................................................................................. Wilmington, NC .............................................................................................................................. Winchester, VA-WV ....................................................................................................................... Winchester, VA-WV ....................................................................................................................... Winston-Salem, NC ....................................................................................................................... Worcester, MA ............................................................................................................................... Yakima, WA ................................................................................................................................... Yauco, PR ...................................................................................................................................... York-Hanover, PA .......................................................................................................................... Youngstown-Warren-Boardman, OH-PA ....................................................................................... Youngstown-Warren-Boardman, OH-PA ....................................................................................... Yuba City, CA ................................................................................................................................ Yuma, AZ ....................................................................................................................................... MI ...... SC ..... WA .... IL ....... MA .... MO .... OH .... PA ..... CA ..... SC ..... NY ..... WA .... FL ...... FL ...... IN ...... AR ..... TX ..... OH .... KS ..... NJ ..... AZ ..... OK ..... AL ..... TX ..... NY ..... GA ..... CA ..... TX ..... NJ ..... NC ..... VA ..... CA ..... TX ..... GA ..... MI ...... DC ..... MD .... VA ..... WV .... IA ...... WI ..... OH .... WV .... WA .... FL ...... OH .... WV .... KS ..... TX ..... PA ..... DE ..... MD .... NJ ..... NC ..... VA ..... WV .... NC ..... MA .... WA .... PR ..... PA ..... OH .... PA ..... CA ..... AZ ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00268 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.9651 0.9017 1.0514 0.9133 1.0343 0.8470 0.8629 0.8810 1.1822 0.8609 0.9865 1.1137 0.8981 0.8993 0.9130 0.8197 0.8195 0.9267 0.8873 1.1221 0.9442 0.8652 0.8695 0.8901 0.8721 0.8163 1.3974 0.8153 1.1221 0.8868 0.8869 1.1822 0.8703 0.9490 0.9972 1.0670 1.0670 1.0669 1.0647 0.9248 0.9823 0.8582 0.8011 1.0164 0.9631 0.8582 0.7635 0.8980 0.9175 0.8342 1.0645 1.0645 1.1221 0.9087 0.9771 0.9751 0.9096 1.0945 1.0164 0.3358 0.9666 0.8931 0.8930 1.1822 0.9903 GAF 0.9760 0.9316 1.0349 0.9398 1.0234 0.8925 0.9040 0.9169 1.1214 0.9025 0.9907 1.0765 0.9290 0.9299 0.9396 0.8727 0.8726 0.9492 0.9214 1.0821 0.9614 0.9056 0.9087 0.9234 0.9105 0.8702 1.2575 0.8695 1.0821 0.9210 0.9211 1.1214 0.9093 0.9648 0.9981 1.0454 1.0454 1.0453 1.0439 0.9479 0.9878 0.9006 0.8591 1.0112 0.9746 0.9006 0.8313 0.9290 0.9427 0.8833 1.0437 1.0437 1.0821 0.9365 0.9843 0.9829 0.9372 1.0638 1.0112 0.4737 0.9770 0.9255 0.9254 1.1214 0.9933 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23795 TABLE 4B.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR RURAL AREAS BY CBSA AND BY STATE—FY 2009 CBSA code 01 02 03 04 05 06 07 08 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 49 50 51 52 53 ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. Rural area State Wage index GAF Alabama ............................................................................................................................. Alaska ................................................................................................................................. Arizona ............................................................................................................................... Arkansas ............................................................................................................................ California ............................................................................................................................ Colorado ............................................................................................................................. Connecticut ........................................................................................................................ Delaware ............................................................................................................................ Florida ................................................................................................................................ Georgia ............................................................................................................................... Hawaii ................................................................................................................................. Idaho .................................................................................................................................. Illinois ................................................................................................................................. Indiana ................................................................................................................................ Iowa .................................................................................................................................... Kansas ............................................................................................................................... Kentucky ............................................................................................................................. Louisiana ............................................................................................................................ Maine .................................................................................................................................. Maryland ............................................................................................................................. Massachusetts ................................................................................................................... Michigan ............................................................................................................................. Minnesota ........................................................................................................................... Mississippi .......................................................................................................................... Missouri .............................................................................................................................. Montana ............................................................................................................................. Nebraska ............................................................................................................................ Nevada ............................................................................................................................... New Hampshire .................................................................................................................. New Jersey 1 ...................................................................................................................... New Mexico ........................................................................................................................ New York ............................................................................................................................ North Carolina .................................................................................................................... North Dakota ...................................................................................................................... Ohio .................................................................................................................................... Oklahoma ........................................................................................................................... Oregon ............................................................................................................................... Pennsylvania ...................................................................................................................... Puerto Rico 1 ...................................................................................................................... Rhode Island 1 .................................................................................................................... South Carolina ................................................................................................................... South Dakota ..................................................................................................................... Tennessee .......................................................................................................................... Texas .................................................................................................................................. Utah .................................................................................................................................... Vermont .............................................................................................................................. Virginia ............................................................................................................................... Washington ........................................................................................................................ West Virginia ...................................................................................................................... Wisconsin ........................................................................................................................... Wyoming ............................................................................................................................ AL ..... AK ..... AZ ..... AR ..... CA ..... CO .... CT ..... DE ..... FL ...... GA ..... HI ...... ID ...... IL ....... IN ...... IA ...... KS ..... KY ..... LA ..... ME .... MD .... MA .... MI ...... MN .... MS .... MO .... MT ..... NE ..... NV ..... NH ..... NJ ..... NM .... NY ..... NC ..... ND ..... OH .... OK ..... OR .... PA ..... PR ..... RI ...... SC ..... SD ..... TN ..... TX ..... UT ..... VT ..... VA ..... WA .... WV .... WI ..... WY .... 0.7647 1.1884 0.8857 0.7641 1.1822 0.9303 1.1897 1.0252 0.8633 0.7840 1.1219 0.7597 0.8428 0.8479 0.8709 0.8086 0.7837 0.7682 0.8609 0.8795 1.0199 0.8864 0.9120 0.7653 0.8470 0.8640 0.8761 0.9824 1.0807 1.1221 0.8858 0.8308 0.8632 0.7336 0.8582 0.8016 1.0298 0.8342 ........................ ........................ 0.8609 0.8428 0.7957 0.8153 0.8395 0.9275 0.8061 1.0164 0.7635 0.9511 0.9223 0.8322 1.1255 0.9202 0.8317 1.1214 0.9517 1.1263 1.0172 0.9042 0.8465 1.0820 0.8284 0.8895 0.8932 0.9097 0.8646 0.8463 0.8348 0.9025 0.9158 1.0136 0.9207 0.9389 0.8326 0.8925 0.9047 0.9134 0.9879 1.0546 1.0821 0.9203 0.8808 0.9042 0.8088 0.9006 0.8595 1.0203 0.8833 ........................ ........................ 0.9025 0.8895 0.8551 0.8695 0.8871 0.9498 0.8628 1.0112 0.8313 0.9662 0.9461 1 All counties in the State or Territory are classified as urban. The New Jersey floor is imputed as specified in § 412.64(h)(4) and discussed in the FY 2005 IPPS final rule (69 FR 49109) and in section III.B.2 of the preamble of this proposed rule. TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA AND BY STATE—FY 2009 jlentini on PROD1PC65 with PROPOSALS2 CBSA code 10420 10500 10500 10580 10740 10780 10900 11100 11100 ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 Area State Akron, OH ........................................................................................................................... Albany, GA ......................................................................................................................... Albany, GA ......................................................................................................................... Albany-Schenectady-Troy, NY ........................................................................................... Albuquerque, NM ................................................................................................................ Alexandria, LA .................................................................................................................... Allentown-Bethlehem-Easton, PA-NJ ................................................................................. Amarillo, TX ........................................................................................................................ Amarillo, TX ........................................................................................................................ OH .... AL ..... GA ..... NY ..... NM .... LA ..... PA ..... KS ..... TX ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00269 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.8784 0.8397 0.8397 0.8833 0.9295 0.8127 0.9675 0.8885 0.8883 GAF 0.9150 0.8872 0.8872 0.9185 0.9512 0.8676 0.9776 0.9222 0.9221 23796 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued jlentini on PROD1PC65 with PROPOSALS2 CBSA code 11180 11260 11460 12060 12060 12420 12620 12940 13020 13644 13644 13644 13780 13820 13900 13980 14020 14260 14260 14484 14484 14600 14740 14860 15380 15540 15764 16180 16220 16580 16620 16700 16740 16740 16820 16860 16860 16860 16974 16974 16974 17140 17140 17300 17460 17660 17820 17860 17900 17980 17980 18140 18700 19124 19340 19340 19380 19740 19804 20100 20260 20500 20500 20764 21060 21140 21500 21660 21780 21780 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 Area State Ames, IA ............................................................................................................................. Anchorage, AK ................................................................................................................... Ann Arbor, MI ..................................................................................................................... Atlanta-Sandy Springs-Marietta, GA .................................................................................. Atlanta-Sandy Springs-Marietta, GA .................................................................................. Austin-Round Rock, TX ...................................................................................................... Bangor, ME ......................................................................................................................... Baton Rouge, LA ................................................................................................................ Bay City, MI ........................................................................................................................ Bethesda-Frederick-Gaithersburg, MD ............................................................................... Bethesda-Frederick-Gaithersburg, MD ............................................................................... Bethesda-Frederick-Gaithersburg, MD ............................................................................... Binghamton, NY ................................................................................................................. Birmingham-Hoover, AL ..................................................................................................... Bismarck, ND ...................................................................................................................... Blacksburg-Christiansburg-Radford, VA ............................................................................. Bloomington, IN .................................................................................................................. Boise City-Nampa, ID ......................................................................................................... Boise City-Nampa, ID ......................................................................................................... Boston-Quincy, MA ............................................................................................................. Boston-Quincy, MA ............................................................................................................. Bradenton-Sarasota-Venice, FL ......................................................................................... Bremerton-Silverdale, WA .................................................................................................. Bridgeport-Stamford-Norwalk, CT ...................................................................................... Buffalo-Niagara Falls, NY ................................................................................................... Burlington-South Burlington, VT ......................................................................................... Cambridge-Newton-Framingham, MA ................................................................................ Carson City, NV .................................................................................................................. Casper, WY ........................................................................................................................ Champaign-Urbana, IL ....................................................................................................... Charleston, WV .................................................................................................................. Charleston-North Charleston-Summerville, SC .................................................................. Charlotte-Gastonia-Concord, NC-SC ................................................................................. Charlotte-Gastonia-Concord, NC-SC ................................................................................. Charlottesville, VA .............................................................................................................. Chattanooga, TN-GA .......................................................................................................... Chattanooga, TN-GA .......................................................................................................... Chattanooga, TN-GA .......................................................................................................... Chicago-Naperville-Joliet, IL ............................................................................................... Chicago-Naperville-Joliet, IL ............................................................................................... Chicago-Naperville-Joliet, IL ............................................................................................... Cincinnati-Middletown, OH-KY-IN ...................................................................................... Cincinnati-Middletown, OH-KY-IN ...................................................................................... Clarksville, TN-KY .............................................................................................................. Cleveland-Elyria-Mentor, OH .............................................................................................. Coeur d’Alene, ID ............................................................................................................... Colorado Springs, CO ........................................................................................................ Columbia, MO ..................................................................................................................... Columbia, SC ..................................................................................................................... Columbus, GA-AL ............................................................................................................... Columbus, GA-AL ............................................................................................................... Columbus, OH .................................................................................................................... Corvallis, OR ...................................................................................................................... Dallas-Plano-Irving, TX ....................................................................................................... Davenport-Moline-Rock Island, IA-IL ................................................................................. Davenport-Moline-Rock Island, IA-IL ................................................................................. Dayton, OH ......................................................................................................................... Denver-Aurora, CO ............................................................................................................. Detroit-Livonia-Dearborn, MI .............................................................................................. Dover, DE ........................................................................................................................... Duluth, MN-WI .................................................................................................................... Durham, NC ........................................................................................................................ Durham, NC ........................................................................................................................ Edison-New Brunswick, NJ ................................................................................................ Elizabethtown, KY .............................................................................................................. Elkhart-Goshen, IN ............................................................................................................. Erie, PA .............................................................................................................................. Eugene-Springfield, OR ...................................................................................................... Evansville, IN-KY ................................................................................................................ Evansville, IN-KY ................................................................................................................ IA ...... AK ..... MI ...... AL ..... GA ..... TX ..... ME .... MS .... MI ...... DC ..... PA ..... VA ..... PA ..... AL ..... ND ..... WV .... IN ...... ID ...... NV ..... MA .... RI ...... FL ...... WA .... NY ..... NY ..... NY ..... NH ..... NV ..... SD ..... IL ....... WV .... SC ..... NC ..... SC ..... VA ..... AL ..... GA ..... TN ..... IL ....... IN ...... WI ..... IN ...... OH .... KY ..... OH .... MT ..... CO .... MO .... SC ..... AL ..... GA ..... OH .... OR .... TX ..... IL ....... IA ...... OH .... CO .... MI ...... DE ..... MN .... NC ..... VA ..... NJ ..... KY ..... IN ...... NY ..... OR .... IN ...... KY ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00270 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.8881 1.1884 1.0113 0.9760 0.9760 0.9521 1.0115 0.8146 0.9472 1.1018 1.1006 1.1017 0.8560 0.8786 0.7336 0.7795 0.8791 0.9100 0.9824 1.1338 1.1338 0.9648 1.0576 1.2694 0.9593 0.9216 1.0807 0.9837 0.9618 0.8840 0.8398 0.9231 0.9570 0.9557 0.9449 0.8740 0.8740 0.8717 1.0334 1.0328 1.0315 0.9583 0.9581 0.8302 0.9266 0.8992 0.9738 0.8470 0.8984 0.8495 0.8495 0.9657 1.0572 0.9852 0.8606 0.8709 0.9321 1.0409 1.0052 1.0304 1.0401 0.9693 0.9694 1.1221 0.8230 0.9547 0.8420 1.1157 0.8479 0.8131 GAF 0.9219 1.1255 1.0077 0.9835 0.9835 0.9669 1.0079 0.8690 0.9635 1.0686 1.0678 1.0686 0.8990 0.9152 0.8088 0.8432 0.9155 0.9375 0.9879 1.0898 1.0898 0.9758 1.0391 1.1775 0.9719 0.9456 1.0546 0.9888 0.9737 0.9190 0.8873 0.9467 0.9704 0.9694 0.9619 0.9119 0.9119 0.9103 1.0228 1.0223 1.0215 0.9713 0.9711 0.8804 0.9491 0.9298 0.9820 0.8925 0.9293 0.8943 0.8943 0.9764 1.0388 0.9898 0.9023 0.9097 0.9530 1.0278 1.0036 1.0207 1.0273 0.9789 0.9789 1.0821 0.8751 0.9688 0.8889 1.0779 0.8932 0.8679 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23797 TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued jlentini on PROD1PC65 with PROPOSALS2 CBSA code 22020 22020 22180 22220 22220 22380 22420 22520 22520 22540 22660 22744 23020 23060 23104 23540 23844 24300 24340 24500 24540 24540 24580 24580 24660 24660 24780 24860 24860 25060 25420 25540 25540 25860 26180 26420 26580 26580 26580 26620 26620 26820 26820 26900 26980 27060 27140 27180 27180 27260 27260 27620 27780 27860 27860 27900 27900 28020 28140 28420 28420 28700 28700 28940 28940 29180 29460 29540 29620 29820 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 Area State Fargo, ND-MN .................................................................................................................... Fargo, ND-MN .................................................................................................................... Fayetteville, NC .................................................................................................................. Fayetteville-Springdale-Rogers, AR-MO ............................................................................ Fayetteville-Springdale-Rogers, AR-MO ............................................................................ Flagstaff, AZ ....................................................................................................................... Flint, MI ............................................................................................................................... Florence-Muscle Shoals, AL .............................................................................................. Florence-Muscle Shoals, AL .............................................................................................. Fond du Lac, WI ................................................................................................................. Fort Collins-Loveland, CO .................................................................................................. Ft Lauderdale-Pompano Beach-Deerfield Beach, FL ........................................................ Fort Walton Beach-Crestview-Destin, FL ........................................................................... Fort Wayne, IN ................................................................................................................... Fort Worth-Arlington, TX .................................................................................................... Gainesville, FL .................................................................................................................... Gary, IN .............................................................................................................................. Grand Junction, CO ............................................................................................................ Grand Rapids-Wyoming, MI ............................................................................................... Great Falls, MT ................................................................................................................... Greeley, CO ........................................................................................................................ Greeley, CO ........................................................................................................................ Green Bay, WI .................................................................................................................... Green Bay, WI .................................................................................................................... Greensboro-High Point, NC ............................................................................................... Greensboro-High Point, NC ............................................................................................... Greenville, NC .................................................................................................................... Greenville-Mauldin-Easley, SC ........................................................................................... Greenville-Mauldin-Easley, SC ........................................................................................... Gulfport-Biloxi, MS .............................................................................................................. Harrisburg-Carlisle, PA ....................................................................................................... Hartford-West Hartford-East Hartford, CT .......................................................................... Hartford-West Hartford-East Hartford, CT .......................................................................... Hickory-Lenoir-Morganton, NC ........................................................................................... Honolulu, HI ........................................................................................................................ Houston-Sugar Land-Baytown, TX ..................................................................................... Huntington-Ashland, WV-KY-OH ........................................................................................ Huntington-Ashland, WV-KY-OH ........................................................................................ Huntington-Ashland, WV-KY-OH ........................................................................................ Huntsville, AL ...................................................................................................................... Huntsville, AL ...................................................................................................................... Idaho Falls, ID .................................................................................................................... Idaho Falls, ID .................................................................................................................... Indianapolis-Carmel, IN ...................................................................................................... Iowa City, IA ....................................................................................................................... Ithaca, NY ........................................................................................................................... Jackson, MS ....................................................................................................................... Jackson, TN ........................................................................................................................ Jackson, TN ........................................................................................................................ Jacksonville, FL .................................................................................................................. Jacksonville, FL .................................................................................................................. Jefferson City, MO .............................................................................................................. Johnstown, PA .................................................................................................................... Jonesboro, AR .................................................................................................................... Jonesboro, AR .................................................................................................................... Joplin, MO .......................................................................................................................... Joplin, MO .......................................................................................................................... Kalamazoo-Portage, MI ...................................................................................................... Kansas City, MO-KS .......................................................................................................... Kennewick-Pasco-Richland, WA ........................................................................................ Kennewick-Pasco-Richland, WA ........................................................................................ Kingsport-Bristol-Bristol, TN-VA ......................................................................................... Kingsport-Bristol-Bristol, TN-VA ......................................................................................... Knoxville, TN ...................................................................................................................... Knoxville, TN ...................................................................................................................... Lafayette, LA ...................................................................................................................... Lakeland-Winter Haven, FL ................................................................................................ Lancaster, PA ..................................................................................................................... Lansing-East Lansing, MI ................................................................................................... Las Vegas-Paradise, NV .................................................................................................... ND ..... SD ..... NC ..... AR ..... OK ..... AZ ..... MI ...... AL ..... MS .... WI ..... CO .... FL ...... FL ...... IN ...... TX ..... FL ...... IN ...... CO .... MI ...... MT ..... NE ..... WY .... MI ...... WI ..... NC ..... VA ..... NC ..... NC ..... SC ..... MS .... PA ..... CT ..... MA .... NC ..... HI ...... TX ..... KY ..... OH .... WV .... AL ..... TN ..... ID ...... WY .... IN ...... IA ...... NY ..... MS .... MS .... TN ..... FL ...... GA ..... MO .... PA ..... AR ..... MO .... KS ..... OK ..... MI ...... MO .... ID ...... WA .... KY ..... TN ..... KY ..... TN ..... LA ..... FL ...... PA ..... MI ...... AZ ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00271 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.8212 0.8428 0.9567 0.8952 0.8950 1.1305 1.0810 0.7883 0.7883 0.9523 0.9581 1.0025 0.8633 0.9004 0.9684 0.9427 0.9320 0.9925 0.9305 0.8679 0.9611 0.9611 0.9412 0.9511 0.8984 0.8985 0.9174 0.9307 0.9294 0.8156 0.9185 1.1897 1.0972 0.8794 1.1608 0.9925 0.8767 0.8759 0.8748 0.8636 0.8614 0.9327 0.9327 0.9707 0.9107 0.9101 0.8095 0.8361 0.8339 0.9092 0.9112 0.8736 0.8342 0.8291 0.8470 0.9351 0.9349 1.0365 0.9444 0.9560 1.0164 0.7919 0.7957 0.7889 0.7957 0.8438 0.8715 0.9799 0.9652 1.1388 GAF 0.8738 0.8895 0.9701 0.9270 0.9268 1.0876 1.0548 0.8497 0.8497 0.9671 0.9711 1.0017 0.9042 0.9307 0.9783 0.9604 0.9529 0.9949 0.9519 0.9075 0.9732 0.9732 0.9594 0.9662 0.9293 0.9293 0.9427 0.9520 0.9511 0.8697 0.9434 1.1263 1.0656 0.9158 1.1075 0.9949 0.9138 0.9133 0.9125 0.9045 0.9029 0.9534 0.9534 0.9798 0.9380 0.9375 0.8653 0.8846 0.8830 0.9369 0.9383 0.9116 0.8833 0.8796 0.8925 0.9551 0.9549 1.0249 0.9616 0.9697 1.0112 0.8523 0.8551 0.8501 0.8551 0.8902 0.9101 0.9862 0.9760 1.0931 23798 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued jlentini on PROD1PC65 with PROPOSALS2 CBSA code 29820 30460 30620 30700 30780 30860 30980 31084 31140 31340 31420 31540 31700 32780 32820 32820 32820 33124 33340 33460 33460 33540 33700 33740 33740 33860 34060 34740 34820 34820 34980 34980 35004 35084 35084 35084 35300 35380 35644 35644 35644 35980 36084 36140 36220 36220 36420 36500 36740 37460 37700 37764 37860 37900 37964 37964 37964 38220 38300 38300 38300 38340 38340 38860 38900 38900 38940 39100 39140 39340 ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... VerDate Aug<31>2005 Area State Las Vegas-Paradise, NV .................................................................................................... Lexington-Fayette, KY ........................................................................................................ Lima, OH ............................................................................................................................ Lincoln, NE ......................................................................................................................... Little Rock-North Little Rock-Conway, AR ......................................................................... Logan, UT-ID ...................................................................................................................... Longview, TX ...................................................................................................................... Los Angeles-Long Beach-Glendale, CA ............................................................................ Louisville-Jefferson County, KY-IN ..................................................................................... Lynchburg, VA .................................................................................................................... Macon, GA .......................................................................................................................... Madison, WI ........................................................................................................................ Manchester-Nashua, NH .................................................................................................... Medford, OR ....................................................................................................................... Memphis, TN-MS-AR ......................................................................................................... Memphis, TN-MS-AR ......................................................................................................... Memphis, TN-MS-AR ......................................................................................................... Miami-Miami Beach-Kendall, FL ........................................................................................ Milwaukee-Waukesha-West Allis, WI ................................................................................. Minneapolis-St. Paul-Bloomington, MN-WI ........................................................................ Minneapolis-St. Paul-Bloomington, MN-WI ........................................................................ Missoula, MT ...................................................................................................................... Modesto, CA ....................................................................................................................... Monroe, LA ......................................................................................................................... Monroe, LA ......................................................................................................................... Montgomery, AL ................................................................................................................. Morgantown, WV ................................................................................................................ Muskegon-Norton Shores, MI ............................................................................................ Myrtle Beach-North Myrtle Beach-Conway, SC ................................................................. Myrtle Beach-North Myrtle Beach-Conway, SC ................................................................. Nashville-Davidson-Murfreesboro-Franklin, TN ................................................................. Nashville-Davidson-Murfreesboro-Franklin, TN ................................................................. Nassau-Suffolk, NY ............................................................................................................ Newark-Union, NJ-PA ........................................................................................................ Newark-Union, NJ-PA ........................................................................................................ Newark-Union, NJ-PA ........................................................................................................ New Haven-Milford, CT ...................................................................................................... New Orleans-Metairie-Kenner, LA ..................................................................................... New York-White Plains-Wayne, NY-NJ ............................................................................. New York-White Plains-Wayne, NY-NJ ............................................................................. New York-White Plains-Wayne, NY-NJ ............................................................................. Norwich-New London, CT .................................................................................................. Oakland-Fremont-Hayward, CA ......................................................................................... Ocean City, NJ ................................................................................................................... Odessa, TX ......................................................................................................................... Odessa, TX ......................................................................................................................... Oklahoma City, OK ............................................................................................................. Olympia, WA ....................................................................................................................... Orlando-Kissimmee, FL ...................................................................................................... Panama City-Lynn Haven, FL ............................................................................................ Pascagoula, MS ................................................................................................................. Peabody, MA ...................................................................................................................... Pensacola-Ferry Pass-Brent, FL ........................................................................................ Peoria, IL ............................................................................................................................ Philadelphia, PA ................................................................................................................. Philadelphia, PA ................................................................................................................. Philadelphia, PA ................................................................................................................. Pine Bluff, AR ..................................................................................................................... Pittsburgh, PA ..................................................................................................................... Pittsburgh, PA ..................................................................................................................... Pittsburgh, PA ..................................................................................................................... Pittsfield, MA ....................................................................................................................... Pittsfield, MA ....................................................................................................................... Portland-South Portland-Biddeford, ME ............................................................................. Portland-Vancouver-Beaverton, OR-WA ............................................................................ Portland-Vancouver-Beaverton, OR-WA ............................................................................ Port St. Lucie, FL ............................................................................................................... Poughkeepsie-Newburgh-Middletown, NY ......................................................................... Prescott, AZ ........................................................................................................................ Provo-Orem, UT ................................................................................................................. UT ..... KY ..... OH .... NE ..... AR ..... UT ..... TX ..... CA ..... KY ..... VA ..... GA ..... WI ..... NH ..... OR .... AR ..... MS .... TN ..... FL ...... WI ..... MN .... WI ..... MT ..... CA ..... AR ..... LA ..... AL ..... WV .... MI ...... NC ..... SC ..... KY ..... TN ..... CT ..... NJ ..... NY ..... PA ..... CT ..... LA ..... CT ..... NJ ..... NY ..... RI ...... CA ..... DE ..... NM .... TX ..... OK ..... WA .... FL ...... AL ..... AL ..... NH ..... AL ..... IL ....... DE ..... NJ ..... PA ..... MS .... OH .... PA ..... WV .... NY ..... VT ..... ME .... OR .... WA .... FL ...... NY ..... AZ ..... UT ..... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00272 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 1.1388 0.8756 0.9299 0.9336 0.8650 0.8827 0.8666 1.1822 0.9123 0.8646 0.9618 1.1014 1.0807 1.0298 0.8909 0.8909 0.8886 0.9865 1.0026 1.0997 1.0976 0.8909 1.1963 0.7789 0.7785 0.8192 0.8631 0.9455 0.8632 0.8609 0.9276 0.9252 1.2038 1.1316 1.1461 1.1449 1.1897 0.9140 1.2391 1.2693 1.2855 1.1587 1.5278 1.0909 0.9273 0.9283 0.8686 1.1297 0.9073 0.8322 0.8030 1.0807 0.8115 0.9043 1.0799 1.1221 1.0788 0.8150 0.8582 0.8579 0.8569 0.9901 0.9275 0.9644 1.1204 1.1186 0.9741 1.0709 1.0011 0.9052 GAF 1.0931 0.9130 0.9514 0.9540 0.9055 0.9181 0.9066 1.1214 0.9391 0.9052 0.9737 1.0684 1.0546 1.0203 0.9239 0.9239 0.9223 0.9907 1.0018 1.0672 1.0659 0.9239 1.1306 0.8427 0.8424 0.8723 0.9041 0.9623 0.9042 0.9025 0.9498 0.9482 1.1354 1.0884 1.0979 1.0971 1.1263 0.9403 1.1581 1.1774 1.1877 1.1061 1.3367 1.0614 0.9496 0.9503 0.9080 1.0871 0.9356 0.8818 0.8605 1.0546 0.8667 0.9334 1.0540 1.0821 1.0533 0.8693 0.9006 0.9004 0.8996 0.9932 0.9498 0.9755 1.0810 1.0798 0.9822 1.0480 1.0008 0.9341 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23799 TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued jlentini on PROD1PC65 with PROPOSALS2 CBSA code Area State 39580 ....... 39740 ....... 39820 ....... 39900 ....... 40060 ....... 40140 ....... 40220 ....... 40220 ....... 40380 ....... 40420 ....... 40484 ....... 40660 ....... 40900 ....... 40980 ....... 41060 ....... 41100 ....... 41140 ....... 41180 ....... 41180 ....... 41620 ....... 41700 ....... 41884 ....... 41940 ....... 42044 ....... 42100 ....... 42140 ....... 42220 ....... 42340 ....... 42340 ....... 42644 ....... 43300 ....... 43340 ....... 43580 ....... 43620 ....... 43780 ....... 43900 ....... 44060 ....... 44180 ....... 44180 ....... 44940 ....... 45060 ....... 45220 ....... 45300 ....... 45500 ....... 45780 ....... 45820 ....... 46140 ....... 46220 ....... 46340 ....... 46700 ....... 47260 ....... 47644 ....... 47894 ....... 47940 ....... 48140 ....... 48620 ....... 48620 ....... 48700 ....... 48864 ....... 48864 ....... 48900 ....... 49180 ....... 49340 ....... 49660 ....... 49660 ....... 04 ............. 05 ............. 10 ............. 14 ............. 14 ............. Raleigh-Cary, NC ............................................................................................................... Reading, PA ....................................................................................................................... Redding, CA ....................................................................................................................... Reno-Sparks, NV ................................................................................................................ Richmond, VA ..................................................................................................................... Riverside-San Bernardino-Ontario, CA .............................................................................. Roanoke, VA ...................................................................................................................... Roanoke, VA ...................................................................................................................... Rochester, NY .................................................................................................................... Rockford, IL ........................................................................................................................ Rockingham County-Strafford County, NH ........................................................................ Rome, GA ........................................................................................................................... Sacramento—Arden-Arcade—Roseville, CA ..................................................................... Saginaw-Saginaw Township North, MI .............................................................................. St. Cloud, MN ..................................................................................................................... St. George, UT ................................................................................................................... St. Joseph, MO-KS ............................................................................................................. St. Louis, MO-IL ................................................................................................................. St. Louis, MO-IL ................................................................................................................. Salt Lake City, UT .............................................................................................................. San Antonio, TX ................................................................................................................. San Francisco-San Mateo-Redwood City, CA ................................................................... San Jose-Sunnyvale-Santa Clara, CA ............................................................................... Santa Ana-Anaheim-Irvine, CA .......................................................................................... Santa Cruz-Watsonville, CA ............................................................................................... Santa Fe, NM ..................................................................................................................... Santa Rosa-Petaluma, CA ................................................................................................. Savannah, GA .................................................................................................................... Savannah, GA .................................................................................................................... Seattle-Bellevue-Everett, WA ............................................................................................. Sherman-Denison, TX ........................................................................................................ Shreveport-Bossier City, LA ............................................................................................... Sioux City, IA-NE-SD ......................................................................................................... Sioux Falls, SD ................................................................................................................... South Bend-Mishawaka, IN-MI ........................................................................................... Spartanburg, SC ................................................................................................................. Spokane, WA ...................................................................................................................... Springfield, MO ................................................................................................................... Springfield, MO ................................................................................................................... Sumter, SC ......................................................................................................................... Syracuse, NY ...................................................................................................................... Tallahassee, FL .................................................................................................................. Tampa-St. Petersburg-Clearwater, FL ............................................................................... Texarkana, TX-Texarkana, AR ........................................................................................... Toledo, OH ......................................................................................................................... Topeka, KS ......................................................................................................................... Tulsa, OK ............................................................................................................................ Tuscaloosa, AL ................................................................................................................... Tyler, TX ............................................................................................................................. Vallejo-Fairfield, CA ............................................................................................................ Virginia Beach-Norfolk-Newport News, VA ........................................................................ Warren-Troy-Farmington-Hills, MI ...................................................................................... Washington-Arlington-Alexandria, DC-VA .......................................................................... Waterloo-Cedar Falls, IA .................................................................................................... Wausau, WI ........................................................................................................................ Wichita, KS ......................................................................................................................... Wichita, KS ......................................................................................................................... Williamsport, PA ................................................................................................................. Wilmington, DE-MD-NJ ...................................................................................................... Wilmington, DE-MD-NJ ...................................................................................................... Wilmington, NC ................................................................................................................... Winston-Salem, NC ............................................................................................................ Worcester, MA .................................................................................................................... Youngstown-Warren-Boardman, OH-PA ............................................................................ Youngstown-Warren-Boardman, OH-PA ............................................................................ Arkansas ............................................................................................................................. California ............................................................................................................................. Florida ................................................................................................................................. Illinois .................................................................................................................................. Illinois .................................................................................................................................. NC ..... PA ..... CA ..... NV ..... VA ..... AZ ..... VA ..... WV .... NY ..... IL ....... ME .... AL ..... CA ..... MI ...... MN .... UT ..... MO .... IL ....... MO .... UT ..... TX ..... CA ..... CA ..... CA ..... CA ..... NM .... CA ..... GA ..... SC ..... WA .... OK ..... LA ..... NE ..... SD ..... IN ...... SC ..... ID ...... AR ..... MO .... SC ..... NY ..... GA ..... FL ...... AR ..... OH .... KS ..... OK ..... MS .... TX ..... CA ..... NC ..... MI ...... VA ..... IA ...... WI ..... KS ..... OK ..... PA ..... DE ..... NJ ..... SC ..... NC ..... NH ..... OH .... PA ..... LA ..... CA ..... FL ...... IL ....... KY ..... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00273 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Wage index 0.9557 0.9204 1.2730 1.0476 0.9203 1.1254 0.8750 0.8732 0.8911 0.9756 1.0007 0.9524 1.2710 0.8864 1.0638 0.9228 1.0267 0.8993 0.8986 0.9271 0.8949 1.4879 1.5758 1.1822 1.5766 1.0207 1.4497 0.8841 0.8827 1.1377 0.9291 0.8547 0.8761 0.9262 0.9353 0.9017 1.0315 0.8477 0.8470 0.8609 0.9471 0.8397 0.8993 0.8093 0.9267 0.8720 0.8652 0.8280 0.8901 1.3974 0.8868 0.9972 1.0669 0.9248 0.9823 0.8785 0.8784 0.8342 1.0645 1.1221 0.9074 0.9096 1.0807 0.8582 0.8559 0.7682 1.1822 0.8633 0.8428 0.8320 GAF 0.9694 0.9448 1.1797 1.0324 0.9447 1.0843 0.9126 0.9113 0.9241 0.9832 1.0005 0.9672 1.1785 0.9207 1.0433 0.9465 1.0182 0.9299 0.9294 0.9495 0.9268 1.3127 1.3654 1.1214 1.3658 1.0141 1.2896 0.9191 0.9181 1.0924 0.9509 0.8981 0.9134 0.9489 0.9552 0.9316 1.0215 0.8930 0.8925 0.9025 0.9635 0.8872 0.9299 0.8651 0.9492 0.9105 0.9056 0.8788 0.9234 1.2575 0.9210 0.9981 1.0453 0.9479 0.9878 0.9151 0.9150 0.8833 1.0437 1.0821 0.9356 0.9372 1.0546 0.9006 0.8989 0.8348 1.1214 0.9042 0.8895 0.8817 23800 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) FOR HOSPITALS THAT ARE RECLASSIFIED BY CBSA AND BY STATE—FY 2009—Continued CBSA code 14 16 17 22 23 25 26 30 33 34 36 37 38 39 39 44 44 45 49 49 50 53 Area Illinois .................................................................................................................................. Iowa .................................................................................................................................... Kansas ................................................................................................................................ Massachusetts .................................................................................................................... Michigan ............................................................................................................................. Mississippi .......................................................................................................................... Missouri .............................................................................................................................. New Hampshire .................................................................................................................. New York ............................................................................................................................ North Carolina .................................................................................................................... Ohio .................................................................................................................................... Oklahoma ........................................................................................................................... Oregon ................................................................................................................................ Pennsylvania ...................................................................................................................... Pennsylvania ...................................................................................................................... Tennessee .......................................................................................................................... Tennessee .......................................................................................................................... Texas .................................................................................................................................. Virginia ................................................................................................................................ Virginia ................................................................................................................................ Washington ......................................................................................................................... Wyoming ............................................................................................................................. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. State MO .... MO .... KS ..... MA .... MI ...... MS .... MO .... VT ..... NY ..... TN ..... OH .... OK ..... OR .... NY ..... PA ..... KY ..... TN ..... TX ..... KY ..... VA ..... WA .... NE ..... TABLE 4D–1.—RURAL FLOOR BUDGET NEUTRALITY FACTORS—FY 2009 Rural floor budget neutrality ajustment factor State Alabama ................................ Alaska ................................... Arizona .................................. Arkansas ............................... California ............................... Colorado ............................... Connecticut ........................... Delaware ............................... Washington, DC ................... Florida ................................... Georgia ................................. Hawaii ................................... Idaho ..................................... Illinois .................................... Indiana .................................. Iowa ...................................... Kansas .................................. Kentucky ............................... Louisiana .............................. Maine .................................... Maryland ............................... 1.00000 0.99734 1.00000 1.00000 0.98552 0.99683 0.96390 1.00000 1.00000 0.99781 1.00000 1.00000 1.00000 0.99993 0.99928 0.99572 1.00000 1.00000 0.99945 1.00000 ........................ TABLE 4D–1.—RURAL FLOOR BUDGET NEUTRALITY FACTORS—FY 2009— Continued Massachusetts ...................... Michigan ............................... Minnesota ............................. Mississippi ............................ Missouri ................................ Montana ................................ Nebraska .............................. Nevada ................................. New Hampshire .................... New Jersey ........................... New Mexico .......................... New York .............................. North Carolina ...................... North Dakota ........................ Ohio ...................................... Oklahoma ............................. Oregon .................................. Pennsylvania ........................ Puerto Rico ........................... 0.8470 0.8738 0.8086 1.0199 0.8864 0.7653 0.8470 0.9297 0.8308 0.8611 0.8582 0.8016 1.0298 0.8351 0.8342 0.7978 0.7957 0.8153 0.8062 0.8061 1.0164 0.9223 0.8925 0.9118 0.8646 1.0136 0.9207 0.8326 0.8925 0.9513 0.8808 0.9027 0.9006 0.8595 1.0203 0.8839 0.8833 0.8567 0.8551 0.8695 0.8628 0.8628 1.0112 0.9461 Rural floor budget neutrality ajustment factor State 1.00000 1.00000 1.00000 1.00000 0.99910 1.00000 1.00000 1.00000 0.97787 0.98738 0.99875 1.00000 0.99983 0.99424 0.99906 0.99983 0.99955 0.99895 1.00000 GAF TABLE 4D–1.—RURAL FLOOR BUDGET NEUTRALITY FACTORS—FY 2009— Continued Rural floor budget neutrality ajustment factor State Wage index Rhode Island ........................ South Carolina ...................... South Dakota ........................ Tennessee ............................ Texas .................................... Utah ...................................... Vermont ................................ Virginia .................................. Washington ........................... West Virginia ........................ Wisconsin ............................. Wyoming ............................... 1.00000 0.99840 1.00000 0.99741 0.99980 1.00000 0.90100 0.99991 0.99791 0.99782 0.99809 1.00000 * Maryland hospitals, under section 1814(b)(3) of the Act, are waived from the IPPS ratesetting. Therefore, the rural floor budget neutrality adjustment does not apply. ** The rural floor budget neutrality factor for New Jersey is based on an imputed floor (see Table 4B). TABLE 4D–2.—URBAN AREAS WITH HOSPITALS RECEIVING THE STATEWIDE RURAL FLOOR OR IMPUTED FLOOR WAGE INDEX—FY 2009 [*Only hospitals that are geographically located in the specified State receive the State’s rural or imputed floor wage index.] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 10900 11020 11260 11540 12220 12540 13900 15500 ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... VerDate Aug<31>2005 Urban area State * Allentown-Bethlehem-Easton, PA–NJ ................................................ Altoona, PA ......................................................................................... Anchorage, AK ................................................................................... Appleton, WI ....................................................................................... Auburn-Opelika, AL ............................................................................ Bakersfield, CA ................................................................................... Bismarck, ND ...................................................................................... Burlington, NC .................................................................................... NJ ............................... PA .............................. AK .............................. WI ............................... AL ............................... CA .............................. ND .............................. NC .............................. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00274 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Rural or imputed floor wage index 1.1221 0.8342 1.1884 0.9511 0.7647 1.1822 0.7336 0.8632 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23801 TABLE 4D–2.—URBAN AREAS WITH HOSPITALS RECEIVING THE STATEWIDE RURAL FLOOR OR IMPUTED FLOOR WAGE INDEX—FY 2009—Continued [*Only hospitals that are geographically located in the specified State receive the State’s rural or imputed floor wage index.] jlentini on PROD1PC65 with PROPOSALS2 CBSA code 15540 15804 16940 17020 17860 19060 19060 19340 19500 20220 20764 20940 21820 22020 22140 22500 22900 23420 24220 24580 25260 25540 25620 27340 27780 28420 28700 28700 28940 29340 29740 30300 31460 31700 32780 34100 34580 34620 35300 35980 36100 36780 37100 37460 37620 37860 39380 39540 40140 40484 41740 42020 42044 42060 42540 43100 44180 44700 44940 45940 47020 47220 47300 48260 48300 48540 48540 48700 48864 ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... ......................... VerDate Aug<31>2005 Urban area State * Burlington-South Burlington, VT ......................................................... Camden, NJ ........................................................................................ Cheyenne, WY ................................................................................... Chico, CA ........................................................................................... Columbia, MO ..................................................................................... Cumberland, MD–WV ......................................................................... Cumberland, MD–WV ......................................................................... Davenport-Moline-Rock Island, IA–IL ................................................. Decatur, IL .......................................................................................... Dubuque, IA ........................................................................................ Edison-New Brunswick, NJ ................................................................ El Centro, CA ..................................................................................... Fairbanks, AK ..................................................................................... Fargo, ND–MN ................................................................................... Farmington, NM .................................................................................. Florence, SC ....................................................................................... Fort Smith, AR–OK ............................................................................. Fresno, CA ......................................................................................... Grand Forks, ND–MN ......................................................................... Green Bay, WI .................................................................................... Hanford-Corcoran, CA ........................................................................ Hartford-West Hartford-East Hartford, CT .......................................... Hattiesburg, MS .................................................................................. Jacksonville, NC ................................................................................. Johnstown, PA .................................................................................... Kennewick-Pasco-Richland, WA ........................................................ Kingsport-Bristol-Bristol, TN–VA ........................................................ Kingsport-Bristol-Bristol, TN–VA ........................................................ Knoxville, TN ...................................................................................... Lake Charles, LA ................................................................................ Las Cruces, NM .................................................................................. Lewiston, ID–WA ................................................................................ Madera, CA ........................................................................................ Manchester-Nashua, NH .................................................................... Medford, OR ....................................................................................... Morristown, TN ................................................................................... Mount Vernon-Anacortes, WA ............................................................ Muncie, IN .......................................................................................... New Haven-Milford, CT ...................................................................... Norwich-New London, CT .................................................................. Ocala, FL ............................................................................................ Oshkosh-Neenah, WI ......................................................................... Oxnard-Thousand Oaks-Ventura, CA ................................................ Panama City-Lynn Haven, FL ............................................................ Parkersburg-Marietta-Vienna, WV–OH .............................................. Pensacola-Ferry Pass-Brent, FL ........................................................ Pueblo, CO ......................................................................................... Racine, WI .......................................................................................... Riverside-San Bernardino-Ontario, CA .............................................. Rockingham County-Strafford County, NH ........................................ San Diego-Carlsbad-San Marcos, CA ............................................... San Luis Obispo-Paso Robles, CA .................................................... Santa Ana-Anaheim-Irvine, CA .......................................................... Santa Barbara-Santa Maria-Goleta, CA ............................................. Scranton-Wilkes-Barre, PA ................................................................. Sheboygan, WI ................................................................................... Springfield, MO ................................................................................... Stockton, CA ....................................................................................... Sumter, SC ......................................................................................... Trenton-Ewing, NJ .............................................................................. Victoria, TX ......................................................................................... Vineland-Millville-Bridgeton, NJ .......................................................... Visalia-Porterville, CA ......................................................................... Weirton-Steubenville, WV–OH ........................................................... Wenatchee, WA .................................................................................. Wheeling, WV–OH ............................................................................. Wheeling, WV–OH ............................................................................. Williamsport, PA ................................................................................. Wilmington, DE–MD–NJ ..................................................................... VT .............................. NJ ............................... WY ............................. CA .............................. MO ............................. MD ............................. WV ............................. IA ................................ IL ................................ IA ................................ NJ ............................... CA .............................. AK .............................. MN ............................. NM ............................. SC .............................. OK .............................. CA .............................. MN ............................. WI ............................... CA .............................. CT .............................. MS .............................. NC .............................. PA .............................. WA ............................. TN .............................. VA .............................. TN .............................. LA ............................... NM ............................. WA ............................. CA .............................. NH .............................. OR .............................. TN .............................. WA ............................. IN ............................... CT .............................. CT .............................. FL ............................... WI ............................... CA .............................. FL ............................... OH .............................. FL ............................... CO .............................. WI ............................... CA .............................. NH .............................. CA .............................. CA .............................. CA .............................. CA .............................. PA .............................. WI ............................... MO ............................. CA .............................. SC .............................. NJ ............................... TX .............................. NJ ............................... CA .............................. OH .............................. WA ............................. OH .............................. WV ............................. PA .............................. NJ ............................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00275 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Rural or imputed floor wage index 0.9275 1.1221 0.9223 1.1822 0.8470 0.8795 0.7635 0.8709 0.8428 0.8709 1.1221 1.1822 1.1884 0.9120 0.8858 0.8609 0.8016 1.1822 0.9120 0.9511 1.1822 1.1897 0.7653 0.8632 0.8342 1.0164 0.7957 0.8061 0.7957 0.7682 0.8858 1.0164 1.1822 1.0807 1.0298 0.7957 1.0164 0.8479 1.1897 1.1897 0.8633 0.9511 1.1822 0.8633 0.8582 0.8633 0.9303 0.9511 1.1822 1.0807 1.1822 1.1822 1.1822 1.1822 0.8342 0.9511 0.8470 1.1822 0.8609 1.1221 0.8153 1.1221 1.1822 0.8582 1.0164 0.8582 0.7635 0.8342 1.1221 23802 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4D–2.—URBAN AREAS WITH HOSPITALS RECEIVING THE STATEWIDE RURAL FLOOR OR IMPUTED FLOOR WAGE INDEX—FY 2009—Continued [*Only hospitals that are geographically located in the specified State receive the State’s rural or imputed floor wage index.] Rural or imputed floor wage index CBSA code Urban area State * 49420 ......................... 49700 ......................... Yakima, WA ........................................................................................ Yuba City, CA ..................................................................................... WA ............................. CA .............................. TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009 CBSA code Urban area (constituent counties) 10180 ...... Abilene, TX Callahan County, TX Jones County, TX Taylor County, TX ´ Aguadilla-Isabela-San Sebastian, PR Aguada Municipio, PR Aguadilla Municipio, PR ˜ Anasco Municipio, PR Isabela Municipio, PR Lares Municipio, PR Moca Municipio, PR ´ Rincon Municipio, PR ´ San Sebastian Municipio, PR Akron, OH Portage County, OH Summit County, OH Albany, GA Baker County, GA Dougherty County, GA Lee County, GA Terrell County, GA Worth County, GA Albany-Schenectady-Troy, NY Albany County, NY Rensselaer County, NY Saratoga County, NY Schenectady County, NY Schoharie County, NY Albuquerque, NM Bernalillo County, NM Sandoval County, NM Torrance County, NM Valencia County, NM Alexandria, LA Grant Parish, LA Rapides Parish, LA Allentown-Bethlehem-Easton, PA-NJ Warren County, NJ Carbon County, PA Lehigh County, PA Northampton County, PA Altoona, PA Blair County, PA Amarillo, TX Armstrong County, TX Carson County, TX Potter County, TX Randall County, TX Ames, IA Story County, IA Anchorage, AK Anchorage Municipality, AK Matanuska-SusitnaBorough, AK Anderson, IN Madison County, IN Anderson, SC 10380 ...... 10420 ...... 10500 ...... 10580 ...... 10740 ...... 10780 ...... 10900 ...... 11020 ...... 11100 ...... jlentini on PROD1PC65 with PROPOSALS2 11180 ...... 11260 ...... 11300 ...... 11340 ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 11460 ...... 11500 ...... 11540 ...... 11700 ...... 12020 ...... 12060 ...... 12100 ...... 12220 ...... 12260 ...... PO 00000 Frm 00276 Urban area (constituent counties) Anderson County, SC Ann Arbor, MI Washtenaw County, MI Anniston-Oxford, AL Calhoun County, AL Appleton, WI Calumet County, WI Outagamie County, WI Asheville, NC Buncombe County, NC Haywood County, NC Henderson County, NC Madison County, NC Athens-Clarke County, GA Clarke County, GA Madison County, GA Oconee County, GA Oglethorpe County, GA 1 Atlanta-Sandy Springs-Marietta, GA Barrow County, GA Bartow County, GA Butts County, GA Carroll County, GA Cherokee County, GA Clayton County, GA Cobb County, GA Coweta County, GA Dawson County, GA DeKalb County, GA Douglas County, GA Fayette County, GA Forsyth County, GA Fulton County, GA Gwinnett County, GA Haralson County, GA Heard County, GA Henry County, GA Jasper County, GA Lamar County, GA Meriwether County, GA Newton County, GA Paulding County, GA Pickens County, GA Pike County, GA Rockdale County, GA Spalding County, GA Walton County, GA Atlantic City-Hammonton, NJ Atlantic County, NJ Hammonton County, NJ Auburn-Opelika, AL Lee County, AL Augusta-Richmond County, GASC Burke County, GA Columbia County, GA McDuffie County, GA Fmt 4701 Sfmt 4702 1.0164 1.1822 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 12420 ...... 12540 ...... 12580 ...... 12620 ...... 12700 ...... 12940 ...... 12980 ...... 13020 ...... 13140 ...... 13380 ...... 13460 ...... 13644 ...... 13740 ...... 13780 ...... 13820 ...... E:\FR\FM\30APP2.SGM Urban area (constituent counties) Richmond County, GA Aiken County, SC Edgefield County, SC 1 Austin-Round Rock, TX Bastrop County, TX Caldwell County, TX Hays County, TX Travis County, TX Williamson County, TX Bakersfield, CA Kern County, CA 1 Baltimore-Towson, MD Anne Arundel County, MD Baltimore County, MD Carroll County, MD Harford County, MD Howard County, MD Queen Anne’s County, MD Baltimore City, MD Bangor, ME Penobscot County, ME Barnstable Town, MA Barnstable County, MA Baton Rouge, LA Ascension Parish, LA East Baton Rouge Parish, LA East Feliciana Parish, LA Iberville Parish, LA Livingston Parish, LA Pointe Coupee Parish, LA St. Helena Parish, LA West Baton Rouge Parish, LA West Feliciana Parish, LA Battle Creek, MI Calhoun County, MI Bay City, MI Bay County, MI Beaumont-Port Arthur, TX Hardin County, TX Jefferson County, TX Orange County, TX Bellingham, WA Whatcom County, WA Bend, OR Deschutes County, OR 1 Bethesda-Frederick-Gaithersburg, MD Frederick County, MD Montgomery County, MD Billings, MT Carbon County, MT Yellowstone County, MT Binghamton, NY Broome County, NY Tioga County, NY 1 Birmingham-Hoover, AL Bibb County, AL Blount County, AL 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 13900 ...... 13980 ...... 14020 ...... 14060 ...... 14260 ...... 14484 ...... 14500 ...... 14540 ...... 14600 ...... 14740 ...... 14860 ...... 15180 ...... 15260 ...... 15380 ...... 15500 ...... 15540 ...... jlentini on PROD1PC65 with PROPOSALS2 15764 ...... 15804 ...... 15940 ...... VerDate Aug<31>2005 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued Urban area (constituent counties) CBSA code Urban area (constituent counties) Chilton County, AL Jefferson County, AL St. Clair County, AL Shelby County, AL Walker County, AL Bismarck, ND Burleigh County, ND Morton County, ND Blacksburg-ChristiansburgRadford, VA Giles County, VA Montgomery County, VA Pulaski County, VA Radford City, VA Bloomington, IN Greene County, IN Monroe County, IN Owen County, IN Bloomington-Normal, IL McLean County, IL Boise City-Nampa, ID Ada County, ID Boise County, ID Canyon County, ID Gem County, ID Owyhee County, ID 1 Boston-Quincy, MA Norfolk County, MA Plymouth County, MA Suffolk County, MA Boulder, CO Boulder County, CO Bowling Green, KY Edmonson County, KY Warren County, KY Bradenton-Sarasota-Venice, FL Bradenton County, FL Manatee County, FL Sarasota County, FL Bremerton-Silverdale, WA Kitsap County, WA Bridgeport-Stamford-Norwalk, CT Fairfield County, CT Brownsville-Harlingen, TX Cameron County, TX Brunswick, GA Brantley County, GA Glynn County, GA McIntosh County, GA 1 Buffalo-Niagara Falls, NY Erie County, NY Niagara County, NY Burlington, NC Alamance County, NC Burlington-South Burlington, VT Chittenden County, VT Franklin County, VT Grand Isle County, VT 1 Cambridge-Newton-Framingham, MA Middlesex County, MA 1 Camden, NJ Burlington County, NJ Camden County, NJ Gloucester County, NJ Canton-Massillon, OH Carroll County, OH Stark County, OH 15980 ...... Cape Coral-Fort Myers, FL Lee County, FL Carson City, NV Carson City, NV Casper, WY Natrona County, WY Cedar Rapids, IA Benton County, IA Jones County, IA Linn County, IA Champaign-Urbana, IL Champaign County, IL Ford County, IL Piatt County, IL Charleston, WV Boone County, WV Clay County, WV Kanawha County, WV Lincoln County, WV Putnam County, WV Charleston-North CharlestonSummerville, SC Berkeley County, SC Charleston County, SC Dorchester County, SC Summerville County, SC 1 Charlotte-Gastonia-Concord, NC-SC Anson County, NC Cabarrus County, NC Gaston County, NC Mecklenburg County, NC Union County, NC York County, SC Charlottesville, VA Albemarle County, VA Fluvanna County, VA Greene County, VA Nelson County, VA Charlottesville City, VA Chattanooga, TN-GA Catoosa County, GA Dade County, GA Walker County, GA Hamilton County, TN Marion County, TN Sequatchie County, TN Cheyenne, WY Laramie County, WY 1 Chicago-Naperville-Joliet, IL Cook County, IL DeKalb County, IL DuPage County, IL Grundy County, IL Kane County, IL Kendall County, IL McHenry County, IL Will County, IL Chico, CA Butte County, CA 1 Cincinnati-Middletown, OH-KYIN Dearborn County, IN Franklin County, IN Ohio County, IN Boone County, KY Bracken County, KY Campbell County, KY Gallatin County, KY 19:42 Apr 29, 2008 Jkt 214001 16180 ...... 16220 ...... 16300 ...... 16580 ...... 16620 ...... 16700 ...... 16740 ...... 16820 ...... 16860 ...... 16940 ...... 16974 ...... 17020 ...... 17140 ...... PO 00000 Frm 00277 Fmt 4701 Sfmt 4702 23803 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 17300 ...... 17420 ...... 17460 ...... 17660 ...... 17780 ...... 17820 ...... 17860 ...... 17900 ...... 17980 ...... 18020 ...... 18140 ...... 18580 ...... 18700 ...... 19060 ...... 19124 ...... E:\FR\FM\30APP2.SGM Urban area (constituent counties) Grant County, KY Kenton County, KY Pendleton County, KY Brown County, OH Butler County, OH Clermont County, OH Hamilton County, OH Warren County, OH Clarksville, TN-KY Christian County, KY Trigg County, KY Montgomery County, TN Stewart County, TN Cleveland, TN Bradley County, TN Polk County, TN 1 Cleveland-Elyria-Mentor, OH Cuyahoga County, OH Geauga County, OH Lake County, OH Lorain County, OH Medina County, OH Coeur d’Alene, ID Kootenai County, ID College Station-Bryan, TX Brazos County, TX Burleson County, TX Robertson County, TX Colorado Springs, CO El Paso County, CO Teller County, CO Columbia, MO Boone County, MO Howard County, MO Columbia, SC Calhoun County, SC Fairfield County, SC Kershaw County, SC Lexington County, SC Richland County, SC Saluda County, SC Columbus, GA-AL Russell County, AL Chattahoochee County, GA Harris County, GA Marion County, GA Muscogee County, GA Columbus, IN Bartholomew County, IN 1 Columbus, OH Delaware County, OH Fairfield County, OH Franklin County, OH Licking County, OH Madison County, OH Morrow County, OH Pickaway County, OH Union County, OH Corpus Christi, TX Aransas County, TX Nueces County, TX San Patricio County, TX Corvallis, OR Benton County, OR Cumberland, MD-WV Allegany County, MD Mineral County, WV 1 Dallas-Plano-Irving, TX Collin County, TX 30APP2 23804 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 19140 ...... 19180 ...... 19260 ...... 19340 ...... 19380 ...... 19460 ...... 19500 ...... 19660 ...... 19740 ...... 19780 ...... 19804 ...... 20020 ...... 20100 ...... jlentini on PROD1PC65 with PROPOSALS2 20220 ...... 20260 ...... 20500 ...... VerDate Aug<31>2005 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued Urban area (constituent counties) CBSA code Dallas County, TX Delta County, TX Denton County, TX Ellis County, TX Hunt County, TX Kaufman County, TX Rockwall County, TX Dalton, GA Murray County, GA Whitfield County, GA Danville, IL Vermilion County, IL Danville, VA Pittsylvania County, VA Danville City, VA Davenport-Moline-Rock Island, IA-IL Henry County, IL Mercer County, IL Rock Island County, IL Scott County, IA Dayton, OH Greene County, OH Miami County, OH Montgomery County, OH Preble County, OH Decatur, AL Lawrence County, AL Morgan County, AL Decatur, IL Macon County, IL Deltona-Daytona Beach-Ormond Beach, FL Volusia County, FL 1 Denver-Aurora, CO Adams County, CO Arapahoe County, CO Broomfield County, CO Clear Creek County, CO Denver County, CO Douglas County, CO Elbert County, CO Gilpin County, CO Jefferson County, CO Park County, CO Des Moines-West Des Moines, IA Dallas County, IA Guthrie County, IA Madison County, IA Polk County, IA Warren County, IA 1 Detroit-Livonia-Dearborn, MI Wayne County, MI Dothan, AL Geneva County, AL Henry County, AL Houston County, AL Dover, DE Kent County, DE Dubuque, IA Dubuque County, IA Duluth, MN-WI Carlton County, MN St. Louis County, MN Douglas County, WI Durham, NC Chatham County, NC Durham County, NC 19:42 Apr 29, 2008 Jkt 214001 20740 ...... 20764 ...... 20940 ...... 21060 ...... 21140 ...... 21300 ...... 21340 ...... 21500 ...... 21660 ...... 21780 ...... 21820 ...... 21940 ...... 22020 ...... 22140 ...... 22180 ...... 22220 ...... 22380 ...... 22420 ...... 22500 ...... 22520 ...... 22540 ...... 22660 ...... PO 00000 Frm 00278 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued Urban area (constituent counties) CBSA code Orange County, NC Person County, NC Eau Claire, WI Chippewa County, WI Eau Claire County, WI 1 Edison-New Brunswick, NJ Middlesex County, NJ Monmouth County, NJ New Brunswick County, NJ Ocean County, NJ Somerset County, NJ El Centro, CA Imperial County, CA Elizabethtown, KY Hardin County, KY Larue County, KY Elkhart-Goshen, IN Elkhart County, IN Elmira, NY Chemung County, NY El Paso, TX El Paso County, TX Erie, PA Erie County, PA Eugene-Springfield, OR Lane County, OR Evansville, IN-KY Gibson County, IN Posey County, IN Vanderburgh County, IN Warrick County, IN Henderson County, KY Webster County, KY Fairbanks, AK Fairbanks North Star Borough, AK Fajardo, PR Ceiba Municipio, PR Fajardo Municipio, PR Luquillo Municipio, PR Fargo, ND-MN Clay County, MN Cass County, ND Farmington, NM San Juan County, NM Fayetteville, NC Cumberland County, NC Hoke County, NC Fayetteville-Springdale-Rogers, AR-MO Benton County, AR Madison County, AR Washington County, AR McDonald County, MO Flagstaff, AZ Coconino County, AZ Flint, MI Genesee County, MI Florence, SC Darlington County, SC Florence County, SC Florence-Muscle Shoals, AL Colbert County, AL Lauderdale County, AL Fond du Lac, WI Fond du Lac County, WI Fort Collins-Loveland, CO Larimer County, CO 22744 ...... Fmt 4701 Sfmt 4702 22900 ...... 23020 ...... 23060 ...... 23104 ...... 23420 ...... 23460 ...... 23540 ...... 23580 ...... 23844 ...... 24020 ...... 24140 ...... 24220 ...... 24300 ...... 24340 ...... 24500 ...... 24540 ...... 24580 ...... 24660 ...... 24780 ...... 24860 ...... E:\FR\FM\30APP2.SGM Urban area (constituent counties) 1 Fort Lauderdale-Pompano Beach-Deerfield Beach, FL Broward County, FL Fort Smith, AR-OK Crawford County, AR Franklin County, AR Sebastian County, AR Le Flore County, OK Sequoyah County, OK Fort Walton Beach-CrestviewDestin, FL Okaloosa County, FL Fort Wayne, IN Allen County, IN Wells County, IN Whitley County, IN 1 Fort Worth-Arlington, TX Johnson County, TX Parker County, TX Tarrant County, TX Wise County, TX Fresno, CA Fresno County, CA Gadsden, AL Etowah County, AL Gainesville, FL Alachua County, FL Gilchrist County, FL Gainesville, GA Hall County, GA Gary, IN Jasper County, IN Lake County, IN Newton County, IN Porter County, IN Glens Falls, NY Warren County, NY Washington County, NY Goldsboro, NC Wayne County, NC Grand Forks, ND-MN Polk County, MN Grand Forks County, ND Grand Junction, CO Mesa County, CO Grand Rapids-Wyoming, MI Barry County, MI Ionia County, MI Kent County, MI Newaygo County, MI Great Falls, MT Cascade County, MT Greeley, CO Weld County, CO Green Bay, WI Brown County, WI Kewaunee County, WI Oconto County, WI Greensboro-High Point, NC Guilford County, NC Randolph County, NC Rockingham County, NC Greenville, NC Greene County, NC Pitt County, NC Greenville-Mauldin-Easley, SC Greenville County, SC Laurens County, SC Pickens County, SC 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code Urban area (constituent counties) 25020 ...... Guayama, PR Arroyo Municipio, PR Guayama Municipio, PR Patillas Municipio, PR Gulfport-Biloxi, MS Hancock County, MS Harrison County, MS Stone County, MS Hagerstown-Martinsburg, MDWV Washington County, MD Berkeley County, WV Morgan County, WV Hanford-Corcoran, CA Kings County, CA Harrisburg-Carlisle, PA Cumberland County, PA Dauphin County, PA Perry County, PA Harrisonburg, VA Rockingham County, VA Harrisonburg City, VA 1 Hartford-West Hartford-East Hartford, CT Hartford County, CT Middlesex County, CT Tolland County, CT Hattiesburg, MS Forrest County, MS Lamar County, MS Perry County, MS Hickory-Lenoir-Morganton, NC Alexander County, NC Burke County, NC Caldwell County, NC Catawba County, NC Hinesville-Fort Stewart, GA Liberty County, GA Long County, GA Holland-Grand Haven, MI Ottawa County, MI Honolulu, HI Honolulu County, HI Hot Springs, AR Garland County, AR Houma-Bayou Cane-Thibodaux, LA Lafourche Parish, LA Terrebonne Parish, LA 1 Houston-Sugar Land-Baytown, TX Austin County, TX Brazoria County, TX Chambers County, TX Fort Bend County, TX Galveston County, TX Harris County, TX Liberty County, TX Montgomery County, TX San Jacinto County, TX Waller County, TX Huntington-Ashland, WV-KY-OH Boyd County, KY Greenup County, KY Lawrence County, OH Cabell County, WV Wayne County, WV Huntsville, AL Limestone County, AL 25060 ...... 25180 ...... 25260 ...... 25420 ...... 25500 ...... 25540 ...... 25620 ...... 25860 ...... 25980 ...... 26100 ...... 26180 ...... 26300 ...... 26380 ...... 26420 ...... jlentini on PROD1PC65 with PROPOSALS2 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued 26580 ...... 26620 ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 CBSA code 26820 ...... 26900 ...... 26980 ...... 27060 ...... 27100 ...... 27140 ...... 27180 ...... 27260 ...... 27340 ...... 27500 ...... 27620 ...... 27740 ...... 27780 ...... 27860 ...... 27900 ...... 28020 ...... 28100 ...... 28140 ...... PO 00000 Frm 00279 Urban area (constituent counties) Madison County, AL Idaho Falls, ID Bonneville County, ID Jefferson County, ID 1 Indianapolis-Carmel, IN Boone County, IN Brown County, IN Hamilton County, IN Hancock County, IN Hendricks County, IN Johnson County, IN Marion County, IN Morgan County, IN Putnam County, IN Shelby County, IN Iowa City, IA Johnson County, IA Washington County, IA Ithaca, NY Tompkins County, NY Jackson, MI Jackson County, MI Jackson, MS Copiah County, MS Hinds County, MS Madison County, MS Rankin County, MS Simpson County, MS Jackson, TN Chester County, TN Madison County, TN 1 Jacksonville, FL Baker County, FL Clay County, FL Duval County, FL Nassau County, FL St. Johns County, FL Jacksonville, NC Onslow County, NC Janesville, WI Rock County, WI Jefferson City, MO Callaway County, MO Cole County, MO Moniteau County, MO Osage County, MO Johnson City, TN Carter County, TN Unicoi County, TN Washington County, TN Johnstown, PA Cambria County, PA Jonesboro, AR Craighead County, AR Poinsett County, AR Joplin, MO Jasper County, MO Newton County, MO Kalamazoo-Portage, MI Kalamazoo County, MI Van Buren County, MI Kankakee-Bradley, IL Kankakee County, IL 1 Kansas City, MO-KS Franklin County, KS Johnson County, KS Leavenworth County, KS Linn County, KS Miami County, KS Fmt 4701 Sfmt 4702 23805 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 28420 ...... 28660 ...... 28700 ...... 28740 ...... 28940 ...... 29020 ...... 29100 ...... 29140 ...... 29180 ...... 29340 ...... 29404 ...... 29420 ...... 29460 ...... 29540 ...... 29620 ...... 29700 ...... 29740 ...... 29820 ...... 29940 ...... E:\FR\FM\30APP2.SGM Urban area (constituent counties) Wyandotte County, KS Bates County, MO Caldwell County, MO Cass County, MO Clay County, MO Clinton County, MO Jackson County, MO Lafayette County, MO Platte County, MO Ray County, MO Kennewick-Pasco-Richland, WA Benton County, WA Franklin County, WA Killeen-Temple-Fort Hood, TX Bell County, TX Coryell County, TX Lampasas County, TX Kingsport-Bristol-Bristol, TN-VA Hawkins County, TN Sullivan County, TN Bristol City, VA Scott County, VA Washington County, VA Kingston, NY Ulster County, NY Knoxville, TN Anderson County, TN Blount County, TN Knox County, TN Loudon County, TN Union County, TN Kokomo, IN Howard County, IN Tipton County, IN La Crosse, WI-MN Houston County, MN La Crosse County, WI Lafayette, IN Benton County, IN Carroll County, IN Tippecanoe County, IN Lafayette, LA Lafayette Parish, LA St. Martin Parish, LA Lake Charles, LA Calcasieu Parish, LA Cameron Parish, LA Lake County-Kenosha County, IL-WI Lake County, IL Kenosha County, WI Lake Havasu City-Kingman, AZ Mohave County, AZ Lakeland-Winter Haven, FL Polk County, FL Winter Haven County, FL Lancaster, PA Lancaster County, PA Lansing-East Lansing, MI Clinton County, MI Eaton County, MI Ingham County, MI Laredo, TX Webb County, TX Las Cruces, NM Dona Ana County, NM 1 Las Vegas-Paradise, NV Clark County, NV Lawrence, KS 30APP2 23806 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 30020 ...... 30140 ...... 30300 ...... 30340 ...... 30460 ...... 30620 ...... 30700 ...... 30780 ...... 30860 ...... 30980 ...... 31020 ...... 31084 ...... 31140 ...... 31180 ...... jlentini on PROD1PC65 with PROPOSALS2 31340 ...... 31420 ...... VerDate Aug<31>2005 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued Urban area (constituent counties) CBSA code Douglas County, KS Lawton, OK Comanche County, OK Lebanon, PA Lebanon County, PA Lewiston, ID-WA Nez Perce County, ID Asotin County, WA Lewiston-Auburn, ME Androscoggin County, ME Lexington-Fayette, KY Bourbon County, KY Clark County, KY Fayette County, KY Jessamine County, KY Scott County, KY Woodford County, KY Lima, OH Allen County, OH Lincoln, NE Lancaster County, NE Seward County, NE Little Rock-North Little RockConway, AR Faulkner County, AR Grant County, AR Lonoke County, AR Perry County, AR Pulaski County, AR Saline County, AR Logan, UT-ID Franklin County, ID Cache County, UT Longview, TX Gregg County, TX Rusk County, TX Upshur County, TX Longview, WA Cowlitz County, WA 1 Los Angeles-Long Beach-Glendale, CA Los Angeles County, CA 1 Louisville-Jefferson County, KY-IN Clark County, IN Floyd County, IN Harrison County, IN Washington County, IN Bullitt County, KY Henry County, KY Jefferson County, KY Meade County, KY Nelson County, KY Oldham County, KY Shelby County, KY Spencer County, KY Trimble County, KY Lubbock, TX Crosby County, TX Lubbock County, TX Lynchburg, VA Amherst County, VA Appomattox County, VA Bedford County, VA Campbell County, VA Bedford City, VA Lynchburg City, VA Macon, GA Bibb County, GA 19:42 Apr 29, 2008 Jkt 214001 31460 ...... 31540 ...... 31700 ...... 31900 ...... 32420 ...... 32580 ...... 32780 ...... 32820 ...... 32900 ...... 33124 ...... 33140 ...... 33260 ...... 33340 ...... 33460 ...... 33540 ...... 33660 ...... 33700 ...... 33740 ...... 33780 ...... PO 00000 Frm 00280 Urban area (constituent counties) Crawford County, GA Jones County, GA Monroe County, GA Twiggs County, GA Madera, CA Madera County, CA Madison, WI Columbia County, WI Dane County, WI Iowa County, WI Manchester-Nashua, NH Hillsborough County, NH Mansfield, OH Richland County, OH ¨ Mayaguez, PR Hormigueros Municipio, PR ¨ Mayaguez Municipio, PR McAllen-Edinburg-Mission, TX Hidalgo County, TX Medford, OR Jackson County, OR 1 Memphis, TN-MS-AR Crittenden County, AR DeSoto County, MS Marshall County, MS Tate County, MS Tunica County, MS Fayette County, TN Shelby County, TN Tipton County, TN Merced, CA Merced County, CA 1 Miami-Miami Beach-Kendall, FL Miami-Dade County, FL Michigan City-La Porte, IN LaPorte County, IN Midland, TX Midland County, TX 1 Milwaukee-Waukesha-West Allis, WI Milwaukee County, WI Ozaukee County, WI Washington County, WI Waukesha County, WI 1 Minneapolis-St. Paul-Bloomington, MN-WI Anoka County, MN Carver County, MN Chisago County, MN Dakota County, MN Hennepin County, MN Isanti County, MN Ramsey County, MN Scott County, MN Sherburne County, MN Washington County, MN Wright County, MN Pierce County, WI St. Croix County, WI Missoula, MT Missoula County, MT Mobile, AL Mobile County, AL Modesto, CA Stanislaus County, CA Monroe, LA Ouachita Parish, LA Union Parish, LA Monroe, MI Fmt 4701 Sfmt 4702 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 33860 ...... 34060 ...... 34100 ...... 34580 ...... 34620 ...... 34740 ...... 34820 ...... 34900 ...... 34940 ...... 34980 ...... 35004 ...... 35084 ...... 35300 ...... 35380 ...... 35644 ...... E:\FR\FM\30APP2.SGM Urban area (constituent counties) Monroe County, MI Montgomery, AL Autauga County, AL Elmore County, AL Lowndes County, AL Montgomery County, AL Morgantown, WV Monongalia County, WV Preston County, WV Morristown, TN Grainger County, TN Hamblen County, TN Jefferson County, TN Mount Vernon-Anacortes, WA Skagit County, WA Muncie, IN Delaware County, IN Muskegon-Norton Shores, MI Muskegon County, MI Myrtle Beach-North Myrtle Beach-Conway, SC Horry County, SC Napa, CA Napa County, CA Naples-Marco Island, FL Collier County, FL 1 Nashville-DavidsonMurfreesboro-Franklin, TN Cannon County, TN Cheatham County, TN Davidson County, TN Dickson County, TN Hickman County, TN Macon County, TN Robertson County, TN Rutherford County, TN Smith County, TN Sumner County, TN Trousdale County, TN Williamson County, TN Wilson County, TN 1 Nassau-Suffolk, NY Nassau County, NY Suffolk County, NY 1 Newark-Union, NJ-PA Essex County, NJ Hunterdon County, NJ Morris County, NJ Sussex County, NJ Union County, NJ Pike County, PA New Haven-Milford, CT New Haven County, CT 1 New Orleans-Metairie-Kenner, LA Jefferson Parish, LA Orleans Parish, LA Plaquemines Parish, LA St. Bernard Parish, LA St. Charles Parish, LA St. John the Baptist Parish, LA St. Tammany Parish, LA 1 New York-White Plains-Wayne, NY-NJ Bergen County, NJ Hudson County, NJ Passaic County, NJ Bronx County, NY Kings County, NY 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 35660 ...... 35980 ...... 36084 ...... 36100 ...... 36140 ...... 36220 ...... 36260 ...... 36420 ...... 36500 ...... 36540 ...... 36740 ...... 36780 ...... 36980 ...... 37100 ...... 37340 ...... jlentini on PROD1PC65 with PROPOSALS2 37380 ...... 37460 ...... 37620 ...... VerDate Aug<31>2005 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued Urban area (constituent counties) CBSA code Urban area (constituent counties) New York County, NY Putnam County, NY Queens County, NY Richmond County, NY Rockland County, NY Westchester County, NY Niles-Benton Harbor, MI Berrien County, MI Norwich-New London, CT New London County, CT 1 Oakland-Fremont-Hayward, CA Alameda County, CA Contra Costa County, CA Ocala, FL Marion County, FL Ocean City, NJ Cape May County, NJ Odessa, TX Ector County, TX Ogden-Clearfield, UT Davis County, UT Morgan County, UT Weber County, UT 1 Oklahoma City, OK Canadian County, OK Cleveland County, OK Grady County, OK Lincoln County, OK Logan County, OK McClain County, OK Oklahoma County, OK Olympia, WA Thurston County, WA Omaha-Council Bluffs, NE-IA Harrison County, IA Mills County, IA Pottawattamie County, IA Cass County, NE Douglas County, NE Sarpy County, NE Saunders County, NE Washington County, NE 1 Orlando-Kissimmee, FL Lake County, FL Orange County, FL Osceola County, FL Seminole County, FL Oshkosh-Neenah, WI Winnebago County, WI Owensboro, KY Daviess County, KY Hancock County, KY McLean County, KY Oxnard-Thousand Oaks-Ventura, CA Ventura County, CA Palm Bay-Melbourne-Titusville, FL Brevard County, FL Palm Coast, FL Flager County, FL Panama City-Lynn Haven, FL Bay County, FL Parkersburg-Marietta-Vienna, WV-OH Washington County, OH Pleasants County, WV Wirt County, WV Wood County, WV 37700 ...... Pascagoula, MS George County, MS Jackson County, MS Peabody, MA Essex County, MA Pensacola-Ferry Pass-Brent, FL Escambia County, FL Santa Rosa County, FL Peoria, IL Marshall County, IL Peoria County, IL Stark County, IL Tazewell County, IL Woodford County, IL 1 Philadelphia, PA Bucks County, PA Chester County, PA Delaware County, PA Montgomery County, PA Philadelphia County, PA 1 Phoenix-Mesa-Scottsdale, AZ Maricopa County, AZ Pinal County, AZ Pine Bluff, AR Cleveland County, AR Jefferson County, AR Lincoln County, AR 1 Pittsburgh, PA Allegheny County, PA Armstrong County, PA Beaver County, PA Butler County, PA Fayette County, PA Washington County, PA Westmoreland County, PA Pittsfield, MA Berkshire County, MA Pocatello, ID Bannock County, ID Power County, ID Ponce, PR ´ Juana Dıaz Municipio, PR Ponce Municipio, PR Villalba Municipio, PR Portland-South Portland-Biddeford, ME Cumberland County, ME Sagadahoc County, ME York County, ME 1 Portland-Vancouver-Beaverton, OR-WA Clackamas County, OR Columbia County, OR Multnomah County, OR Washington County, OR Yamhill County, OR Clark County, WA Skamania County, WA Port St. Lucie, FL Martin County, FL St. Lucie County, FL Poughkeepsie-Newburgh-Middletown, NY Dutchess County, NY Orange County, NY Prescott, AZ Yavapai County, AZ 1 Providence-New Bedford-Fall River, RI-MA 19:42 Apr 29, 2008 Jkt 214001 37764 ...... 37860 ...... 37900 ...... 37964 ...... 38060 ...... 38220 ...... 38300 ...... 38340 ...... 38540 ...... 38660 ...... 38860 ...... 38900 ...... 38940 ...... 39100 ...... 39140 ...... 39300 ...... PO 00000 Frm 00281 Fmt 4701 Sfmt 4702 23807 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 39340 ...... 39380 ...... 39460 ...... 39540 ...... 39580 ...... 39660 ...... 39740 ...... 39820 ...... 39900 ...... 40060 ...... 40140 ...... 40220 ...... 40340 ...... 40380 ...... E:\FR\FM\30APP2.SGM Urban area (constituent counties) Bristol County, MA Bristol County, RI Kent County, RI Newport County, RI Providence County, RI Washington County, RI Provo-Orem, UT Juab County, UT Utah County, UT Pueblo, CO Pueblo County, CO Punta Gorda, FL Charlotte County, FL Racine, WI Racine County, WI Raleigh-Cary, NC Franklin County, NC Johnston County, NC Wake County, NC Rapid City, SD Meade County, SD Pennington County, SD Reading, PA Berks County, PA Redding, CA Shasta County, CA Reno-Sparks, NV Storey County, NV Washoe County, NV 1 Richmond, VA Amelia County, VA Caroline County, VA Charles City County, VA Chesterfield County, VA Cumberland County, VA Dinwiddie County, VA Goochland County, VA Hanover County, VA Henrico County, VA King and Queen County, VA King William County, VA Louisa County, VA New Kent County, VA Powhatan County, VA Prince George County, VA Sussex County, VA Colonial Heights City, VA Hopewell City, VA Petersburg City, VA Richmond City, VA 1 Riverside-San Bernardino-Ontario, CA Riverside County, CA San Bernardino County, CA Roanoke, VA Botetourt County, VA Craig County, VA Franklin County, VA Roanoke County, VA Roanoke City, VA Salem City, VA Rochester, MN Dodge County, MN Olmsted County, MN Wabasha County, MN 1 Rochester, NY Livingston County, NY Monroe County, NY Ontario County, NY 30APP2 23808 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code 40420 ...... 40484 ...... 40580 ...... 40660 ...... 40900 ...... 40980 ...... 41060 ...... 41100 ...... 41140 ...... 41180 ...... 41420 ...... 41500 ...... 41540 ...... jlentini on PROD1PC65 with PROPOSALS2 41620 ...... 41660 ...... 41700 ...... VerDate Aug<31>2005 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued Urban area (constituent counties) CBSA code Orleans County, NY Wayne County, NY Rockford, IL Boone County, IL Winnebago County, IL Rockingham County-Strafford County, NH Rockingham County, NH Strafford County, NH Rocky Mount, NC Edgecombe County, NC Nash County, NC Rome, GA Floyd County, GA 1 Sacramento—Arden-Arcade— Roseville, CA El Dorado County, CA Placer County, CA Sacramento County, CA Yolo County, CA Saginaw-Saginaw Township North, MI Saginaw County, MI St. Cloud, MN Benton County, MN Stearns County, MN St. George, UT Washington County, UT St. Joseph, MO-KS Doniphan County, KS Andrew County, MO Buchanan County, MO DeKalb County, MO 1 St. Louis, MO-IL Bond County, IL Calhoun County, IL Clinton County, IL Jersey County, IL Macoupin County, IL Madison County, IL Monroe County, IL St. Clair County, IL Crawford County, MO Franklin County, MO Jefferson County, MO Lincoln County, MO St. Charles County, MO St. Louis County, MO Warren County, MO Washington County, MO St. Louis City, MO Salem, OR Marion County, OR Polk County, OR Salinas, CA Monterey County, CA Salisbury, MD Somerset County, MD Wicomico County, MD Salt Lake City, UT Salt Lake County, UT Summit County, UT Tooele County, UT San Angelo, TX Irion County, TX Tom Green County, TX 1 San Antonio, TX Atascosa County, TX Bandera County, TX 19:42 Apr 29, 2008 Jkt 214001 41740 ...... 41780 ...... 41884 ...... 41900 ...... 41940 ...... 41980 ...... PO 00000 Frm 00282 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued Urban area (constituent counties) CBSA code Urban area (constituent counties) Bexar County, TX Comal County, TX Guadalupe County, TX Kendall County, TX Medina County, TX Wilson County, TX 1 San Diego-Carlsbad-San Marcos, CA San Diego County, CA Sandusky, OH Erie County, OH 1 San Francisco-San Mateo-Redwood City, CA Marin County, CA San Francisco County, CA San Mateo County, CA ´ San German-Cabo Rojo, PR Cabo Rojo Municipio, PR Lajas Municipio, PR Sabana Grande Municipio, PR ´ San German Municipio, PR 1 San Jose-Sunnyvale-Santa Clara, CA San Benito County, CA Santa Clara County, CA 1 San Juan-Caguas-Guaynabo, PR 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 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 San Luis Obispo County, CA 1 Santa Ana-Anaheim-Irvine, CA Orange County, CA Santa Barbara-Santa MariaGoleta, CA Santa Barbara County, CA Santa Cruz-Watsonville, CA Santa Cruz County, CA Santa Fe, NM Santa Fe County, NM Santa Rosa-Petaluma, CA Sonoma County, CA Savannah, GA Bryan County, GA Chatham County, GA Effingham County, GA Scranton—Wilkes-Barre, PA Lackawanna County, PA Luzerne County, PA Wyoming County, PA 1 Seattle-Bellevue-Everett, WA King County, WA Snohomish County, WA Sebastian-Vero Beach, FL Indian River County, FL Sheboygan, WI Sheboygan County, WI Sherman-Denison, TX Grayson County, TX Shreveport-Bossier City, LA Bossier Parish, LA Caddo Parish, LA De Soto Parish, LA Sioux City, IA-NE-SD Woodbury County, IA Dakota County, NE Dixon County, NE Union County, SD Sioux Falls, SD Lincoln County, SD McCook County, SD Minnehaha County, SD Turner County, SD South Bend-Mishawaka, IN-MI St. Joseph County, IN Cass County, MI Spartanburg, SC Spartanburg County, SC Spokane, WA Spokane County, WA Springfield, IL Menard County, IL Sangamon County, IL Springfield, MA Franklin County, MA Hampden County, MA Hampshire County, MA Springfield, MO Christian County, MO Dallas County, MO Greene County, MO Polk County, MO Webster County, MO Springfield, OH Clark County, OH State College, PA Centre County, PA Fmt 4701 Sfmt 4702 42044 ...... 42060 ...... 42100 ...... 42140 ...... 42220 ...... 42340 ...... 42540 ...... 42644 ...... 42680 ...... 43100 ...... 43300 ...... 43340 ...... 43580 ...... 43620 ...... 43780 ...... 43900 ...... 44060 ...... 44100 ...... 44140 ...... 44180 ...... 44220 ...... 44300 ...... E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code Urban area (constituent counties) CBSA code Urban area (constituent counties) 44700 ...... Stockton, CA San Joaquin County, CA Sumter, SC Sumter County, SC Syracuse, NY Madison County, NY Onondaga County, NY Oswego County, NY Tacoma, WA Pierce County, WA Tallahassee, FL Gadsden County, FL Jefferson County, FL Leon County, FL Wakulla County, FL 1 Tampa-St. Petersburg-Clearwater, FL Hernando County, FL Hillsborough County, FL Pasco County, FL Pinellas County, FL Terre Haute, IN Clay County, IN Sullivan County, IN Vermillion County, IN Vigo County, IN Texarkana, TX-Texarkana, AR Miller County, AR Bowie County, TX Toledo, OH Fulton County, OH Lucas County, OH Ottawa County, OH Wood County, OH Topeka, KS Jackson County, KS Jefferson County, KS Osage County, KS Shawnee County, KS Wabaunsee County, KS Trenton-Ewing, NJ Mercer County, NJ Tucson, AZ Pima County, AZ Tulsa, OK Creek County, OK Okmulgee County, OK Osage County, OK Pawnee County, OK Rogers County, OK Tulsa County, OK Wagoner County, OK Tuscaloosa, AL Greene County, AL Hale County, AL Tuscaloosa County, AL Tyler, TX Smith County, TX Utica-Rome, NY Herkimer County, NY Oneida County, NY Valdosta, GA Brooks County, GA Echols County, GA Lanier County, GA Lowndes County, GA 46700 ...... Vallejo-Fairfield, CA Solano County, CA Victoria, TX Calhoun County, TX Goliad County, TX Victoria County, TX Vineland-Millville-Bridgeton, NJ Cumberland County, NJ 1 Virginia Beach-Norfolk-Newport News, VA-NC Currituck County, NC Gloucester County, VA Isle of Wight County, VA James City County, VA Mathews County, VA Surry County, VA York County, VA Chesapeake City, VA Hampton City, VA Newport News City, VA Norfolk City, VA Poquoson City, VA Portsmouth City, VA Suffolk City, VA Virginia Beach City, VA Williamsburg City, VA Visalia-Porterville, CA Tulare County, CA Waco, TX McLennan County, TX Warner Robins, GA Houston County, GA 1 Warren-Troy-Farmington Hills, MI Lapeer County, MI Livingston County, MI Macomb County, MI Oakland County, MI St. Clair County, MI 1 Washington-Arlington-Alexandria, DC-VA-MD-WV District of Columbia, DC Calvert County, MD Charles County, MD Prince George’s County, MD Arlington County, VA Clarke County, VA Fairfax County, VA Fauquier County, VA Loudoun County, VA Prince William County, VA Spotsylvania County, VA Stafford County, VA Warren County, VA Alexandria City, VA Fairfax City, VA Falls Church City, VA Fredericksburg City, VA Manassas City, VA Manassas Park City, VA Jefferson County, WV Waterloo-Cedar Falls, IA Black Hawk County, IA Bremer County, IA Grundy County, IA Wausau, WI 44940 ...... 45060 ...... 45104 ...... 45220 ...... 45300 ...... 45460 ...... 45500 ...... 45780 ...... 45820 ...... 45940 ...... 46060 ...... 46140 ...... 46220 ...... 46340 ...... jlentini on PROD1PC65 with PROPOSALS2 46540 ...... 46660 ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 47020 ...... 47220 ...... 47260 ...... 47300 ...... 47380 ...... 47580 ...... 47644 ...... 47894 ...... 47940 ...... 48140 ...... PO 00000 Frm 00283 Fmt 4701 Sfmt 4702 23809 TABLE 4E.—URBAN CBSAS AND CONSTITUENT COUNTIES—FY 2009— Continued CBSA code Urban area (constituent counties) 48260 ...... 48300 ...... 48424 ...... 48540 ...... 48620 ...... 48660 ...... 48700 ...... 48864 ...... 48900 ...... 49020 ...... 49180 ...... 49340 ...... 49420 ...... 49500 ...... 49620 ...... 49660 ...... 49700 ...... 49740 ...... 1 Large E:\FR\FM\30APP2.SGM Marathon County, WI Weirton-Steubenville, WV-OH Jefferson County, OH Brooke County, WV Hancock County, WV Wenatchee, WA Chelan County, WA Douglas County, WA 1 West Palm Beach-Boca RatonBoynton Beach, FL Palm Beach County, FL Wheeling, WV-OH Belmont County, OH Marshall County, WV Ohio County, WV Wichita, KS Butler County, KS Harvey County, KS Sedgwick County, KS Sumner County, KS Wichita Falls, TX Archer County, TX Clay County, TX Wichita County, TX Williamsport, PA Lycoming County, PA Wilmington, DE-MD-NJ New Castle County, DE Cecil County, MD Salem County, NJ Wilmington, NC Brunswick County, NC New Hanover County, NC Pender County, NC Winchester, VA-WV Frederick County, VA Winchester City, VA Hampshire County, WV Winston-Salem, NC Davie County, NC Forsyth County, NC Stokes County, NC Yadkin County, NC Worcester, MA Worcester County, MA Yakima, WA Yakima County, WA Yauco, PR ´ Guanica Municipio, PR Guayanilla Municipio, PR ˜ Penuelas Municipio, PR Yauco Municipio, PR York-Hanover, PA York County, PA Youngstown-Warren-Boardman, OH-PA Mahoning County, OH Trumbull County, OH Mercer County, PA Yuba City, CA Sutter County, CA Yuba County, CA Yuma, AZ Yuma County, AZ urban area. 30APP2 23810 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4F.—PUERTO RICO WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT FACTOR (GAF) BY CBSA—FY 2009 [Note: The rural floor budget neutrality adjustment is not applicable to the Puerto Rico-specific wage index.] CBSA code 10380 21940 25020 32420 38660 41900 41980 49500 ....... ....... ....... ....... ....... ....... ....... ....... Area Wage index ´ Aguadilla-Isabela-San Sebastian, PR ....................................................... Fajardo, PR ............................................................................................... Guayama, PR ............................................................................................ ¨ Mayaguez, PR ........................................................................................... Ponce, PR ................................................................................................. ´ San German-Cabo Rojo, PR .................................................................... San Juan-Caguas-Guaynabo, PR ............................................................. Yauco, PR ................................................................................................. The following list represents all hospitals that are eligible to have their wage index increased by the out-migration adjustment listed in this table. Hospitals cannot receive the out-migration adjustment if they are reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8)(B) of the Act. Hospitals that have already been reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8)(B) of the Act are designated with an asterisk. We will automatically assume that hospitals that have already been reclassified under section 0.7845 0.9572 0.7472 0.9236 0.9757 1.0864 1.0348 0.7969 1886(d)(10) of the Act or redesignated under section 1886(d)(8)(B) of the Act wish to retain their reclassification/redesignation status and waive the application of the out-migration adjustment. Section 1886(d)(10) hospitals that wish to receive the out-migration adjustment, rather than their reclassification, should follow the termination/withdrawal procedures specified in 42 CFR 412.273 and section III.I.3. of the preamble of this proposed rule. Otherwise, they will be deemed to have waived the out-migration adjustment. Hospitals redesignated under section 1886(d)(8)(B) of the Act will be GAF 0.8469 0.9705 0.8191 0.9470 0.9833 1.0584 1.0237 0.8560 Wage index—reclassified hospitals GAF—reclassified hospitals .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... deemed to have waived the out-migration adjustment, unless they explicitly notify CMS that they elected to receive the outmigration adjustment instead within 45 days from the publication of this proposed rule. These notifications should be sent to the following address: Centers for Medicare and Medicaid Services, Center for Medicare Management, Attn.: Wage Index Adjustment Waivers, Division of Acute Care, Room C4– 08–06, 7500 Security Boulevard, Baltimore, MD 21244–1850. TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009 Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 010005 010008 010009 010010 010012 010015 010021 010022 010025 010027 010029 010032 010035 010038 010040 010045 010046 010047 010049 010052 010054 010059 010061 010065 010078 010083 010085 010091 010100 010101 010109 010110 010125 010128 010129 010138 010143 010146 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment * ................... ..................... * ................... * ................... * ................... ..................... ..................... * ................... * ................... ..................... * ................... ..................... * ................... ..................... ..................... ..................... ..................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... ..................... * ................... * ................... ..................... ..................... ..................... ..................... ..................... ..................... * ................... ..................... 0.0296 0.0174 0.0092 0.0296 0.0186 0.0046 0.0030 0.1128 0.0235 0.0015 0.0289 0.0325 0.0254 0.0047 0.0061 0.0222 0.0061 0.0127 0.0015 0.0103 0.0092 0.0069 0.0542 0.0103 0.0047 0.0134 0.0092 0.0046 0.0134 0.0211 0.0451 0.0215 0.0476 0.0046 0.0134 0.0066 0.0254 0.0047 PO 00000 Frm 00284 Fmt 4701 Qualifying county name MARSHALL ..................................................... CRENSHAW .................................................... MORGAN ......................................................... MARSHALL ..................................................... DE KALB ......................................................... CLARKE .......................................................... DALE ............................................................... CHEROKEE ..................................................... CHAMBERS .................................................... COFFEE .......................................................... LEE .................................................................. RANDOLPH ..................................................... CULLMAN ........................................................ CALHOUN ....................................................... ETOWAH ......................................................... FAYETTE ......................................................... ETOWAH ......................................................... BUTLER ........................................................... COFFEE .......................................................... TALLAPOOSA ................................................. MORGAN ......................................................... LAWRENCE .................................................... JACKSON ........................................................ TALLAPOOSA ................................................. CALHOUN ....................................................... BALDWIN ........................................................ MORGAN ......................................................... CLARKE .......................................................... BALDWIN ........................................................ TALLADEGA .................................................... PICKENS ......................................................... BULLOCK ........................................................ WINSTON ........................................................ CLARKE .......................................................... BALDWIN ........................................................ SUMTER .......................................................... CULLMAN ........................................................ CALHOUN ....................................................... Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 01470 01200 01510 01470 01240 01120 01220 01090 01080 01150 01400 01550 01210 01070 01270 01280 01270 01060 01150 01610 01510 01390 01350 01610 01070 01010 01510 01120 01010 01600 01530 01050 01660 01120 01010 01590 01210 01070 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23811 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 010150 010158 010164 030067 040014 040019 040039 040047 040067 040071 040076 040081 050002 050007 050008 050009 050013 050014 050016 050042 050043 050047 050055 050069 050070 050073 050075 050076 050084 050089 050090 050099 050101 050113 050118 050122 050129 050133 050136 050140 050150 050152 050167 050168 050173 050174 050193 050194 050195 050197 050211 050224 050226 050228 050230 050232 050242 050245 050264 050272 050279 050283 050289 050291 050298 050300 050305 050313 050320 050325 050327 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment * ................... * ................... * ................... ..................... * ................... * ................... * ................... ..................... ..................... * ................... * ................... ..................... ..................... ..................... ..................... * ................... * ................... * ................... ..................... * ................... ..................... ..................... ..................... * ................... ..................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... ..................... * ................... * ................... ..................... ..................... * ................... ..................... * ................... ..................... ..................... ..................... ..................... * ................... 0.0127 0.0023 0.0211 0.0298 0.0199 0.0258 0.0172 0.0117 0.0007 0.0149 0.1000 0.0357 0.0010 0.0146 0.0026 0.0180 0.0180 0.0139 0.0103 0.0162 0.0010 0.0026 0.0026 0.0020 0.0146 0.0171 0.0010 0.0026 0.0132 0.0017 0.0058 0.0017 0.0171 0.0146 0.0132 0.0132 0.0017 0.0178 0.0058 0.0017 0.0342 0.0026 0.0132 0.0020 0.0020 0.0058 0.0020 0.0052 0.0010 0.0146 0.0010 0.0020 0.0020 0.0026 0.0020 0.0103 0.0052 0.0017 0.0010 0.0017 0.0017 0.0010 0.0146 0.0058 0.0017 0.0017 0.0010 0.0132 0.0010 0.0033 0.0017 PO 00000 Frm 00285 Fmt 4701 Qualifying county name BUTLER ........................................................... FRANKLIN ....................................................... TALLADEGA .................................................... LAPAZ ............................................................. WHITE ............................................................. ST. FRANCIS .................................................. GREENE .......................................................... RANDOLPH ..................................................... COLUMBIA ...................................................... JEFFERSON ................................................... HOT SPRING .................................................. PIKE ................................................................. ALAMEDA ........................................................ SAN MATEO ................................................... SAN FRANCISCO ........................................... NAPA ............................................................... NAPA ............................................................... AMADOR ......................................................... SAN LUIS OBISPO ......................................... TEHAMA .......................................................... ALAMEDA ........................................................ SAN FRANCISCO ........................................... SAN FRANCISCO ........................................... ORANGE ......................................................... SAN MATEO ................................................... SOLANO .......................................................... ALAMEDA ........................................................ SAN FRANCISCO ........................................... SAN JOAQUIN ................................................ SAN BERNARDINO ........................................ SONOMA ......................................................... SAN BERNARDINO ........................................ SOLANO .......................................................... SAN MATEO ................................................... SAN JOAQUIN ................................................ SAN JOAQUIN ................................................ SAN BERNARDINO ........................................ YUBA ............................................................... SONOMA ......................................................... SAN BERNARDINO ........................................ NEVADA .......................................................... SAN FRANCISCO ........................................... SAN JOAQUIN ................................................ ORANGE ......................................................... ORANGE ......................................................... SONOMA ......................................................... ORANGE ......................................................... SANTA CRUZ .................................................. ALAMEDA ........................................................ SAN MATEO ................................................... ALAMEDA ........................................................ ORANGE ......................................................... ORANGE ......................................................... SAN FRANCISCO ........................................... ORANGE ......................................................... SAN LUIS OBISPO ......................................... SANTA CRUZ .................................................. SAN BERNARDINO ........................................ ALAMEDA ........................................................ SAN BERNARDINO ........................................ SAN BERNARDINO ........................................ ALAMEDA ........................................................ SAN MATEO ................................................... SONOMA ......................................................... SAN BERNARDINO ........................................ SAN BERNARDINO ........................................ ALAMEDA ........................................................ SAN JOAQUIN ................................................ ALAMEDA ........................................................ TUOLUMNE ..................................................... SAN BERNARDINO ........................................ Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 01060 01290 01600 03055 04720 04610 04270 04600 04130 04340 04290 04540 05000 05510 05480 05380 05380 05020 05500 05620 05000 05480 05480 05400 05510 05580 05000 05480 05490 05460 05590 05460 05580 05510 05490 05490 05460 05680 05590 05460 05390 05480 05490 05400 05400 05590 05400 05540 05000 05510 05000 05400 05400 05480 05400 05500 05540 05460 05000 05460 05460 05000 05510 05590 05460 05460 05000 05490 05000 05650 05460 23812 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050335 050336 050348 050366 050367 050385 050407 050426 050444 050454 050457 050476 050488 050494 050506 050512 050517 050526 050528 050541 050543 050547 050548 050551 050567 050570 050580 050584 050586 050589 050603 050609 050618 050633 050667 050668 050678 050680 050690 050693 050714 050720 050744 050745 050746 050747 050748 050754 050758 060001 060003 060010 060027 060030 060103 060116 060119 070006 070010 070018 070028 070033 070034 080001 080003 100014 100017 100045 100047 100068 100072 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment * ................... ..................... * ................... ..................... * ................... * ................... ..................... * ................... ..................... ..................... ..................... * ................... ..................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... * ................... ..................... * ................... ..................... * ................... ..................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... 0.0033 0.0132 0.0020 0.0015 0.0171 0.0058 0.0026 0.0020 0.0233 0.0026 0.0026 0.0278 0.0010 0.0342 0.0103 0.0010 0.0017 0.0020 0.0233 0.0146 0.0020 0.0058 0.0020 0.0020 0.0020 0.0020 0.0020 0.0017 0.0017 0.0020 0.0020 0.0020 0.0017 0.0103 0.0180 0.0026 0.0020 0.0171 0.0058 0.0020 0.0052 0.0020 0.0020 0.0020 0.0020 0.0020 0.0132 0.0146 0.0017 0.0042 0.0069 0.0153 0.0069 0.0153 0.0069 0.0069 0.0153 0.0045 0.0045 0.0045 0.0045 0.0045 0.0045 0.0063 0.0063 0.0047 0.0047 0.0047 0.0028 0.0047 0.0047 PO 00000 Frm 00286 Fmt 4701 Qualifying county name TUOLUMNE ..................................................... SAN JOAQUIN ................................................ ORANGE ......................................................... CALAVERAS ................................................... SOLANO .......................................................... SONOMA ......................................................... SAN FRANCISCO ........................................... ORANGE ......................................................... MERCED ......................................................... SAN FRANCISCO ........................................... SAN FRANCISCO ........................................... LAKE ................................................................ ALAMEDA ........................................................ NEVADA .......................................................... SAN LUIS OBISPO ......................................... ALAMEDA ........................................................ SAN BERNARDINO ........................................ ORANGE ......................................................... MERCED ......................................................... SAN MATEO ................................................... ORANGE ......................................................... SONOMA ......................................................... ORANGE ......................................................... ORANGE ......................................................... ORANGE ......................................................... ORANGE ......................................................... ORANGE ......................................................... SAN BERNARDINO ........................................ SAN BERNARDINO ........................................ ORANGE ......................................................... ORANGE ......................................................... ORANGE ......................................................... SAN BERNARDINO ........................................ SAN LUIS OBISPO ......................................... NAPA ............................................................... SAN FRANCISCO ........................................... ORANGE ......................................................... SOLANO .......................................................... SONOMA ......................................................... ORANGE ......................................................... SANTA CRUZ .................................................. ORANGE ......................................................... ORANGE ......................................................... ORANGE ......................................................... ORANGE ......................................................... ORANGE ......................................................... SAN JOAQUIN ................................................ SAN MATEO ................................................... SAN BERNARDINO ........................................ WELD .............................................................. BOULDER ....................................................... LARIMER ......................................................... BOULDER ....................................................... LARIMER ......................................................... BOULDER ....................................................... BOULDER ....................................................... LARIMER ......................................................... FAIRFIELD ...................................................... FAIRFIELD ...................................................... FAIRFIELD ...................................................... FAIRFIELD ...................................................... FAIRFIELD ...................................................... FAIRFIELD ...................................................... NEW CASTLE ................................................. NEW CASTLE ................................................. VOLUSIA ......................................................... VOLUSIA ......................................................... VOLUSIA ......................................................... CHARLOTTE ................................................... VOLUSIA ......................................................... VOLUSIA ......................................................... Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 05650 05490 05400 05040 05580 05590 05480 05400 05340 05480 05480 05160 05000 05390 05500 05000 05460 05400 05340 05510 05400 05590 05400 05400 05400 05400 05400 05460 05460 05400 05400 05400 05460 05500 05380 05480 05400 05580 05590 05400 05540 05400 05400 05400 05400 05400 05490 05510 05460 06610 06060 06340 06060 06340 06060 06060 06340 07000 07000 07000 07000 07000 07000 08010 08010 10630 10630 10630 10070 10630 10630 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23813 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 100077 100081 100102 100118 100156 100232 100236 100252 100290 100292 110023 110029 110040 110041 110100 110101 110142 110146 110150 110187 110189 110190 110205 130003 130024 130049 130066 130067 140001 140026 140043 140058 140110 140116 140160 140161 140167 140176 140234 150006 150015 150022 150030 150072 150076 150088 150091 150102 150113 150133 150146 160013 160030 160032 160080 170137 170150 180012 180017 180049 180064 180066 180070 180079 190003 190015 190017 190034 190044 190050 190053 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... * ................... * ................... * ................... ..................... ..................... * ................... ..................... * ................... ..................... * ................... ..................... ..................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... ..................... ..................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... * ................... ..................... * ................... * ................... * ................... ..................... * ................... ..................... ..................... * ................... * ................... * ................... ..................... ..................... ..................... ..................... 0.0028 0.0022 0.0125 0.0177 0.0125 0.0054 0.0028 0.0151 0.0582 0.0022 0.0416 0.0052 0.1455 0.0623 0.0790 0.0067 0.0185 0.0805 0.0227 0.0643 0.0066 0.0241 0.0507 0.0235 0.0675 0.0319 0.0319 0.0725 0.0369 0.0315 0.0056 0.0126 0.0315 0.0007 0.0332 0.0168 0.0632 0.0007 0.0315 0.0113 0.0113 0.0158 0.0192 0.0105 0.0215 0.0111 0.0050 0.0108 0.0111 0.0193 0.0319 0.0179 0.0040 0.0235 0.0066 0.0336 0.0166 0.0080 0.0035 0.0488 0.0314 0.0439 0.0240 0.0259 0.0085 0.0243 0.0187 0.0189 0.0261 0.0044 0.0101 PO 00000 Frm 00287 Fmt 4701 Qualifying county name CHARLOTTE ................................................... WALTON ......................................................... COLUMBIA ...................................................... FLAGLER ........................................................ COLUMBIA ...................................................... PUTNAM .......................................................... CHARLOTTE ................................................... OKEECHOBEE ................................................ SUMTER .......................................................... WALTON ......................................................... GORDON ......................................................... HALL ................................................................ JACKSON ........................................................ HABERSHAM .................................................. JEFFERSON ................................................... COOK .............................................................. EVANS ............................................................. CAMDEN ......................................................... BALDWIN ........................................................ LUMPKIN ......................................................... FANNIN ........................................................... MACON ........................................................... GILMER ........................................................... NEZ PERCE .................................................... BONNER ......................................................... KOOTENAI ...................................................... KOOTENAI ...................................................... BINGHAM ........................................................ FULTON .......................................................... LA SALLE ........................................................ WHITESIDE ..................................................... MORGAN ......................................................... LA SALLE ........................................................ MC HENRY ..................................................... STEPHENSON ................................................ LIVINGSTON ................................................... IROQUOIS ....................................................... MC HENRY ..................................................... LA SALLE ........................................................ LA PORTE ....................................................... LA PORTE ....................................................... MONTGOMERY .............................................. HENRY ............................................................ CASS ............................................................... MARSHALL ..................................................... MADISON ........................................................ HUNTINGTON ................................................. STARKE .......................................................... MADISON ........................................................ KOSCIUSKO ................................................... NOBLE ............................................................. MUSCATINE .................................................... STORY ............................................................ JASPER ........................................................... CLINTON ......................................................... DOUGLAS ....................................................... COWLEY ......................................................... HARDIN ........................................................... BARREN .......................................................... MADISON ........................................................ MONTGOMERY .............................................. LOGAN ............................................................ GRAYSON ....................................................... HARRISON ...................................................... IBERIA ............................................................. TANGIPAHOA ................................................. ST. LANDRY ................................................... VERMILION ..................................................... ACADIA ........................................................... BEAUREGARD ................................................ JEFFERSON DAVIS ....................................... Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 10070 10650 10110 10170 10110 10530 10070 10460 10590 10650 11500 11550 11610 11540 11620 11311 11441 11170 11030 11701 11450 11710 11471 13340 13080 13270 13270 13050 14370 14580 14988 14770 14580 14640 14970 14610 14460 14640 14580 15450 15450 15530 15320 15080 15490 15470 15340 15740 15470 15420 15560 16690 16840 16490 16220 17220 17170 18460 18040 18750 18860 18700 18420 18480 19220 19520 19480 19560 19000 19050 19260 23814 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 190054 190078 190086 190088 190099 190106 190116 190133 190140 190144 190145 190184 190190 190191 190246 190257 190277 200024 200032 200034 200050 210001 210023 210028 210043 210061 220001 220002 220010 220011 220019 220025 220029 220033 220035 220049 220058 220062 220063 220070 220080 220082 220084 220090 220095 220098 220101 220105 220163 220171 220174 220176 230003 230005 230013 230015 230019 230021 230022 230029 230035 230037 230047 230069 230071 230072 230075 230078 230092 230093 230096 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment ..................... ..................... * ................... * ................... ..................... * ................... ..................... ..................... ..................... * ................... ..................... * ................... ..................... * ................... ..................... * ................... ..................... * ................... ..................... * ................... * ................... ..................... ..................... ..................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... ..................... * ................... 0.0085 0.0187 0.0061 0.0387 0.0189 0.0102 0.0085 0.0102 0.0035 0.0387 0.0090 0.0161 0.0161 0.0187 0.0161 0.0061 0.0387 0.0094 0.0466 0.0094 0.0227 0.0187 0.0079 0.0512 0.0079 0.0188 0.0067 0.0271 0.0355 0.0271 0.0067 0.0067 0.0355 0.0355 0.0355 0.0271 0.0067 0.0067 0.0271 0.0271 0.0355 0.0271 0.0271 0.0067 0.0067 0.0271 0.0271 0.0271 0.0067 0.0271 0.0355 0.0067 0.0220 0.0473 0.0025 0.0295 0.0025 0.0101 0.0212 0.0025 0.0095 0.0210 0.0021 0.0210 0.0025 0.0220 0.0047 0.0101 0.0223 0.0058 0.0295 PO 00000 Frm 00288 Fmt 4701 Qualifying county name IBERIA ............................................................. ST. LANDRY ................................................... LINCOLN ......................................................... WEBSTER ....................................................... AVOYELLES .................................................... ALLEN ............................................................. MOREHOUSE ................................................. ALLEN ............................................................. FRANKLIN ....................................................... WEBSTER ....................................................... LA SALLE ........................................................ CALDWELL ..................................................... CALDWELL ..................................................... ST. LANDRY ................................................... CALDWELL ..................................................... LINCOLN ......................................................... WEBSTER ....................................................... ANDROSCOGGIN ........................................... OXFORD ......................................................... ANDROSCOGGIN ........................................... HANCOCK ....................................................... WASHINGTON ................................................ ANNE ARUNDEL ............................................ ST. MARYS ..................................................... ANNE ARUNDEL ............................................ WORCESTER ................................................. WORCESTER ................................................. MIDDLESEX .................................................... ESSEX ............................................................. MIDDLESEX .................................................... WORCESTER ................................................. WORCESTER ................................................. ESSEX ............................................................. ESSEX ............................................................. ESSEX ............................................................. MIDDLESEX .................................................... WORCESTER ................................................. WORCESTER ................................................. MIDDLESEX .................................................... MIDDLESEX .................................................... ESSEX ............................................................. MIDDLESEX .................................................... MIDDLESEX .................................................... WORCESTER ................................................. WORCESTER ................................................. MIDDLESEX .................................................... MIDDLESEX .................................................... MIDDLESEX .................................................... WORCESTER ................................................. MIDDLESEX .................................................... ESSEX ............................................................. WORCESTER ................................................. OTTAWA ......................................................... LENAWEE ....................................................... OAKLAND ........................................................ ST. JOSEPH .................................................... OAKLAND ........................................................ BERRIEN ......................................................... BRANCH .......................................................... OAKLAND ........................................................ MONTCALM .................................................... HILLSDALE ..................................................... MACOMB ......................................................... LIVINGSTON ................................................... OAKLAND ........................................................ OTTAWA ......................................................... CALHOUN ....................................................... BERRIEN ......................................................... JACKSON ........................................................ MECOSTA ....................................................... ST. JOSEPH .................................................... Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 19220 19480 19300 19590 19040 19010 19330 19010 19200 19590 19290 19100 19100 19480 19100 19300 19590 20000 20080 20000 20040 21210 21010 21180 21010 21230 22170 22090 22040 22090 22170 22170 22040 22040 22040 22090 22170 22170 22090 22090 22040 22090 22090 22170 22170 22090 22090 22090 22170 22090 22040 22170 23690 23450 23620 23740 23620 23100 23110 23620 23580 23290 23490 23460 23620 23690 23120 23100 23370 23530 23740 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23815 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 230099 230121 230130 230151 230174 230195 230204 230207 230208 230217 230222 230223 230227 230254 230257 230264 230269 230277 230279 230301 240018 240044 240064 240069 240071 240117 240211 250023 250040 250117 250128 250162 260059 260064 260097 260116 260163 280077 280123 290002 300011 300012 300017 300020 300023 300029 300034 310002 310009 310010 310011 310015 310017 310018 310021 310031 310038 310039 310044 310050 310054 310057 310061 310069 310070 310076 310083 310091 310092 310093 310096 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... * ................... * ................... * ................... ..................... ..................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... ..................... * ................... ..................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... 0.0231 0.0678 0.0025 0.0025 0.0220 0.0021 0.0021 0.0025 0.0095 0.0047 0.0035 0.0025 0.0021 0.0025 0.0021 0.0021 0.0025 0.0025 0.0210 0.0025 0.0805 0.0625 0.0134 0.0267 0.0385 0.0527 0.0812 0.0541 0.0021 0.0541 0.0446 0.0014 0.0077 0.0089 0.0300 0.0087 0.0087 0.0080 0.0123 0.0277 0.0069 0.0069 0.0102 0.0069 0.0102 0.0102 0.0069 0.0268 0.0268 0.0092 0.0115 0.0203 0.0203 0.0268 0.0092 0.0153 0.0209 0.0209 0.0092 0.0203 0.0268 0.0153 0.0153 0.0096 0.0209 0.0268 0.0268 0.0096 0.0092 0.0268 0.0268 PO 00000 Frm 00289 Fmt 4701 Qualifying county name MONROE ......................................................... SHIAWASSEE ................................................. OAKLAND ........................................................ OAKLAND ........................................................ OTTAWA ......................................................... MACOMB ......................................................... MACOMB ......................................................... OAKLAND ........................................................ MONTCALM .................................................... CALHOUN ....................................................... MIDLAND ......................................................... OAKLAND ........................................................ MACOMB ......................................................... OAKLAND ........................................................ MACOMB ......................................................... MACOMB ......................................................... OAKLAND ........................................................ OAKLAND ........................................................ LIVINGSTON ................................................... OAKLAND ........................................................ GOODHUE ...................................................... WINONA .......................................................... ITASCA ............................................................ STEELE ........................................................... RICE ................................................................ MOWER ........................................................... PINE ................................................................ PEARL RIVER ................................................. JACKSON ........................................................ PEARL RIVER ................................................. PANOLA .......................................................... HANCOCK ....................................................... LACLEDE ........................................................ AUDRAIN ......................................................... JOHNSON ....................................................... ST. FRANCOIS ............................................... ST. FRANCOIS ............................................... DODGE ............................................................ GAGE .............................................................. LYON ............................................................... HILLSBOROUGH ............................................ HILLSBOROUGH ............................................ ROCKINGHAM ................................................ HILLSBOROUGH ............................................ ROCKINGHAM ................................................ ROCKINGHAM ................................................ HILLSBOROUGH ............................................ ESSEX ............................................................. ESSEX ............................................................. MERCER ......................................................... CAPE MAY ...................................................... MORRIS .......................................................... MORRIS .......................................................... ESSEX ............................................................. MERCER ......................................................... BURLINGTON ................................................. MIDDLESEX .................................................... MIDDLESEX .................................................... MERCER ......................................................... MORRIS .......................................................... ESSEX ............................................................. BURLINGTON ................................................. BURLINGTON ................................................. SALEM ............................................................. MIDDLESEX .................................................... ESSEX ............................................................. ESSEX ............................................................. SALEM ............................................................. MERCER ......................................................... ESSEX ............................................................. ESSEX ............................................................. Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 23570 23770 23620 23620 23690 23490 23490 23620 23580 23120 23550 23620 23490 23620 23490 23490 23620 23620 23460 23620 24240 24840 24300 24730 24650 24490 24570 25540 25290 25540 25530 25220 26520 26030 26500 26930 26930 28260 28330 29090 30050 30050 30070 30050 30070 30070 30050 31200 31200 31260 31180 31300 31300 31200 31260 31150 31270 31270 31260 31300 31200 31150 31150 31340 31270 31200 31200 31340 31260 31200 31200 23816 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 310108 310110 310119 320003 320011 320018 320085 330004 330008 330010 330027 330033 330047 330073 330094 330103 330106 330126 330132 330135 330144 330151 330167 330175 330181 330182 330191 330198 330205 330224 330225 330235 330259 330264 330276 330277 330331 330332 330372 330386 340020 340021 340024 340027 340037 340038 340039 340068 340069 340070 340071 340073 340085 340096 340104 340114 340126 340129 340133 340138 340144 340145 340151 340173 360002 360010 360013 360025 360036 360040 360044 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment * ................... ..................... * ................... * ................... ..................... ..................... ..................... * ................... * ................... ..................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... ..................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... ..................... 0.0209 0.0092 0.0268 0.0629 0.0442 0.0024 0.0024 0.0633 0.0126 0.0067 0.0123 0.0223 0.0067 0.0151 0.0503 0.0131 0.0123 0.0642 0.0131 0.0642 0.0054 0.0054 0.0123 0.0260 0.0123 0.0123 0.0017 0.0123 0.0642 0.0633 0.0123 0.0306 0.0123 0.0642 0.0036 0.0054 0.0123 0.0123 0.0123 0.0745 0.0156 0.0162 0.0177 0.0128 0.0162 0.0253 0.0101 0.0087 0.0015 0.0395 0.0226 0.0015 0.0250 0.0250 0.0162 0.0015 0.0100 0.0101 0.0308 0.0015 0.0101 0.0336 0.0052 0.0015 0.0141 0.0074 0.0135 0.0077 0.0126 0.0387 0.0127 PO 00000 Frm 00290 Fmt 4701 Qualifying county name MIDDLESEX .................................................... MERCER ......................................................... ESSEX ............................................................. SAN MIGUEL .................................................. RIO ARRIBA .................................................... DONA ANA ...................................................... DONA ANA ...................................................... ULSTER ........................................................... WYOMING ....................................................... MONTGOMERY .............................................. NASSAU .......................................................... CHENANGO .................................................... MONTGOMERY .............................................. GENESEE ....................................................... COLUMBIA ...................................................... CATTARAUGUS .............................................. NASSAU .......................................................... ORANGE ......................................................... CATTARAUGUS .............................................. ORANGE ......................................................... STEUBEN ........................................................ STEUBEN ........................................................ NASSAU .......................................................... CORTLAND ..................................................... NASSAU .......................................................... NASSAU .......................................................... WARREN ......................................................... NASSAU .......................................................... ORANGE ......................................................... ULSTER ........................................................... NASSAU .......................................................... CAYUGA .......................................................... NASSAU .......................................................... ORANGE ......................................................... FULTON .......................................................... STEUBEN ........................................................ NASSAU .......................................................... NASSAU .......................................................... NASSAU .......................................................... SULLIVAN ....................................................... LEE .................................................................. CLEVELAND ................................................... SAMPSON ....................................................... LENOIR ........................................................... CLEVELAND ................................................... BEAUFORT ..................................................... IREDELL .......................................................... COLUMBUS .................................................... WAKE .............................................................. ALAMANCE ..................................................... HARNETT ........................................................ WAKE .............................................................. DAVIDSON ...................................................... DAVIDSON ...................................................... CLEVELAND ................................................... WAKE .............................................................. WILSON ........................................................... IREDELL .......................................................... MARTIN ........................................................... WAKE .............................................................. IREDELL .......................................................... LINCOLN ......................................................... HALIFAX .......................................................... WAKE .............................................................. ASHLAND ........................................................ TUSCARAWAS ............................................... SHELBY ........................................................... ERIE ................................................................ WAYNE ............................................................ KNOX ............................................................... DARKE ............................................................ Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 31270 31260 31200 32230 32190 32060 32060 33740 33900 33380 33400 33080 33380 33290 33200 33040 33400 33540 33040 33540 33690 33690 33400 33210 33400 33400 33750 33400 33540 33740 33400 33050 33400 33540 33280 33690 33400 33400 33400 33710 34520 34220 34810 34530 34220 34060 34480 34230 34910 34000 34420 34910 34280 34280 34220 34910 34970 34480 34580 34910 34480 34540 34410 34910 36020 36800 36760 36220 36860 36430 36190 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23817 TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 360065 360071 360086 360096 360107 360125 360156 360175 360185 360187 360245 370014 370015 370023 370065 370072 370083 370100 370149 370156 370169 370172 370214 380022 380029 380051 380056 390008 390016 390030 390031 390044 390052 390056 390065 390066 390079 390086 390096 390110 390113 390117 390122 390125 390130 390138 390146 390150 390151 390162 390183 390201 390236 390313 390316 420002 420007 420009 420019 420020 420027 420030 420036 420039 420043 420053 420054 420062 420068 420069 420070 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment * ................... ..................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... ..................... ..................... * ................... ..................... ..................... ..................... ..................... * ................... ..................... * ................... ..................... ..................... * ................... ..................... * ................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... ..................... * ................... ..................... ..................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... * ................... * ................... * ................... 0.0075 0.0035 0.0186 0.0071 0.0119 0.0133 0.0119 0.0183 0.0071 0.0186 0.0133 0.0361 0.0366 0.0090 0.0096 0.0258 0.0051 0.0100 0.0302 0.0121 0.0163 0.0258 0.0121 0.0067 0.0075 0.0075 0.0075 0.0060 0.0060 0.0284 0.0284 0.0191 0.0047 0.0036 0.0532 0.0372 0.0003 0.0047 0.0191 0.0003 0.0053 0.0002 0.0053 0.0022 0.0003 0.0218 0.0022 0.0031 0.0218 0.0200 0.0284 0.1170 0.0003 0.0284 0.0191 0.0004 0.0027 0.0113 0.0158 0.0007 0.0108 0.0069 0.0064 0.0153 0.0157 0.0035 0.0003 0.0109 0.0027 0.0052 0.0052 PO 00000 Frm 00291 Fmt 4701 Qualifying county name HURON ............................................................ VAN WERT ...................................................... CLARK ............................................................. COLUMBIANA ................................................. SANDUSKY ..................................................... ASHTABULA ................................................... SANDUSKY ..................................................... CLINTON ......................................................... COLUMBIANA ................................................. CLARK ............................................................. ASHTABULA ................................................... BRYAN ............................................................ MAYES ............................................................ STEPHENS ..................................................... CRAIG ............................................................. LATIMER ......................................................... PUSHMATAHA ................................................ CHOCTAW ...................................................... POTTAWATOMIE ............................................ GARVIN ........................................................... MCINTOSH ...................................................... LATIMER ......................................................... GARVIN ........................................................... LINN ................................................................. MARION .......................................................... MARION .......................................................... MARION .......................................................... LAWRENCE .................................................... LAWRENCE .................................................... SCHUYLKILL ................................................... SCHUYLKILL ................................................... BERKS ............................................................. CLEARFIELD ................................................... HUNTINGDON ................................................ ADAMS ............................................................ LEBANON ........................................................ BRADFORD ..................................................... CLEARFIELD ................................................... BERKS ............................................................. CAMBRIA ........................................................ CRAWFORD .................................................... BEDFORD ....................................................... CRAWFORD .................................................... WAYNE ............................................................ CAMBRIA ........................................................ FRANKLIN ....................................................... WARREN ......................................................... GREENE .......................................................... FRANKLIN ....................................................... NORTHAMPTON ............................................. SCHUYLKILL ................................................... MONROE ......................................................... BRADFORD ..................................................... SCHUYLKILL ................................................... BERKS ............................................................. YORK ............................................................... SPARTANBURG ............................................. OCONEE ......................................................... CHESTER ........................................................ GEORGETOWN .............................................. ANDERSON .................................................... COLLETON ..................................................... LANCASTER ................................................... UNION ............................................................. CHEROKEE ..................................................... NEWBERRY .................................................... MARLBORO .................................................... CHESTERFIELD ............................................. ORANGEBURG ............................................... CLARENDON .................................................. SUMTER .......................................................... Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 36400 36820 36110 36140 36730 36030 36730 36130 36140 36110 36030 37060 37480 37680 37170 37380 37630 37110 37620 37240 37450 37380 37240 38210 38230 38230 38230 39450 39450 39650 39650 39110 39230 39380 39000 39460 39130 39230 39110 39160 39260 39100 39260 39760 39160 39350 39740 39370 39350 39590 39650 39550 39130 39650 39110 42450 42410 42360 42110 42210 42030 42140 42280 42430 42100 42350 42340 42120 42370 42130 42420 23818 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 jlentini on PROD1PC65 with PROPOSALS2 Provider No. 420082 420083 420098 430008 430048 430094 440007 440008 440012 440016 440017 440024 440025 440030 440031 440033 440035 440047 440050 440051 440057 440060 440067 440070 440081 440084 440109 440115 440137 440144 440148 440153 440174 440176 440180 440181 440182 440185 450032 450039 450052 450059 450064 450087 450090 450099 450135 450137 450144 450163 450192 450194 450210 450224 450236 450270 450283 450324 450347 450348 450370 450389 450393 450395 450419 450438 450451 450460 450469 450497 450539 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. 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............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Out-migration adjustment ..................... * ................... * ................... ..................... ..................... ..................... ..................... * ................... ..................... ..................... ..................... * ................... * ................... ..................... ..................... ..................... * ................... ..................... ..................... ..................... ..................... * ................... * ................... ..................... ..................... ..................... ..................... ..................... ..................... * ................... * ................... ..................... ..................... ..................... ..................... ..................... ..................... * ................... ..................... * ................... * ................... ..................... * ................... * ................... ..................... * ................... * ................... * ................... ..................... ..................... ..................... ..................... ..................... * ................... ..................... ..................... * ................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... ..................... ..................... 0.0008 0.0027 0.0007 0.0535 0.0129 0.0129 0.0219 0.0449 0.0007 0.0144 0.0007 0.0230 0.0007 0.0056 0.0019 0.0027 0.0301 0.0338 0.0007 0.0082 0.0021 0.0338 0.0056 0.0109 0.0052 0.0025 0.0070 0.0338 0.0738 0.0219 0.0296 0.0007 0.0312 0.0007 0.0027 0.0365 0.0144 0.0230 0.0254 0.0024 0.0276 0.0075 0.0024 0.0024 0.0650 0.0145 0.0024 0.0024 0.0559 0.0054 0.0271 0.0213 0.0151 0.0195 0.0389 0.0271 0.0653 0.0132 0.0370 0.0059 0.0235 0.0618 0.0132 0.0441 0.0024 0.0235 0.0536 0.0053 0.0132 0.0375 0.0067 PO 00000 Frm 00292 Fmt 4701 Qualifying county name AIKEN .............................................................. SPARTANBURG ............................................. GEORGETOWN .............................................. BROOKINGS ................................................... LAWRENCE .................................................... LAWRENCE .................................................... COFFEE .......................................................... HENDERSON .................................................. SULLIVAN ....................................................... CARROLL ........................................................ SULLIVAN ....................................................... BRADLEY ........................................................ GREENE .......................................................... HAMBLEN ....................................................... ROANE ............................................................ CAMPBELL ...................................................... MONTGOMERY .............................................. GIBSON ........................................................... GREENE .......................................................... MC NAIRY ....................................................... CLAIBORNE .................................................... GIBSON ........................................................... HAMBLEN ....................................................... DECATUR ....................................................... SEVIER ............................................................ MONROE ......................................................... HARDIN ........................................................... GIBSON ........................................................... BEDFORD ....................................................... COFFEE .......................................................... DE KALB ......................................................... COCKE ............................................................ HAYWOOD ...................................................... SULLIVAN ....................................................... CAMPBELL ...................................................... HARDEMAN .................................................... CARROLL ........................................................ BRADLEY ........................................................ HARRISON ...................................................... TARRANT ........................................................ BOSQUE ......................................................... COMAL ............................................................ TARRANT ........................................................ TARRANT ........................................................ COOKE ............................................................ GRAY ............................................................... TARRANT ........................................................ TARRANT ........................................................ ANDREWS ...................................................... KLEBERG ........................................................ HILL ................................................................. CHEROKEE ..................................................... PANOLA .......................................................... WOOD ............................................................. HOPKINS ......................................................... HILL ................................................................. VAN ZANDT .................................................... GRAYSON ....................................................... WALKER .......................................................... FALLS .............................................................. COLORADO .................................................... HENDERSON .................................................. GRAYSON ....................................................... POLK ............................................................... TARRANT ........................................................ COLORADO .................................................... SOMERVELL ................................................... TYLER ............................................................. GRAYSON ....................................................... MONTAGUE .................................................... HALE ............................................................... Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 County code 42010 42410 42210 43050 43400 43400 44150 44380 44810 44080 44810 44050 44290 44310 44720 44060 44620 44260 44290 44540 44120 44260 44310 44190 44770 44610 44350 44260 44010 44150 44200 44140 44370 44810 44060 44340 44080 44050 45620 45910 45160 45320 45910 45910 45340 45563 45910 45910 45010 45743 45651 45281 45842 45974 45654 45651 45947 45564 45949 45500 45312 45640 45564 45850 45910 45312 45893 45942 45564 45800 45582 23819 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 4J.—OUT-MIGRATION ADJUSTMENT—FY 2009—Continued Reclassified for FY 2009 Provider No. 450547 450563 450565 450573 450596 450615 450639 450641 450672 450675 450677 450698 450747 450755 450770 450779 450813 450838 450872 450880 450884 450886 450888 460001 460013 460017 460023 460039 460043 460052 460055 490019 490084 490110 500003 500007 500019 500039 500041 510012 510018 510047 510077 520028 520035 520044 520057 520059 520071 520076 520095 520096 520102 520116 670015 670023 ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. Out-migration adjustment * ................... * ................... * ................... ..................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... ..................... * ................... ..................... * ................... * ................... * ................... ..................... * ................... * ................... ..................... * ................... ..................... ..................... ..................... ..................... ..................... * ................... ..................... ..................... ..................... * ................... ..................... ..................... * ................... * ................... ..................... * ................... * ................... ..................... * ................... * ................... * ................... * ................... ..................... ..................... ..................... * ................... * ................... * ................... ..................... * ................... * ................... * ................... ..................... ..................... 0.0195 0.0024 0.0486 0.0126 0.0743 0.0032 0.0024 0.0375 0.0024 0.0024 0.0024 0.0127 0.0126 0.0276 0.0182 0.0024 0.0126 0.0126 0.0024 0.0024 0.0049 0.0024 0.0024 0.0023 0.0023 0.0383 0.0023 0.0383 0.0023 0.0023 0.0023 0.1088 0.0187 0.0185 0.0166 0.0166 0.0131 0.0094 0.0020 0.0124 0.0188 0.0269 0.0021 0.0286 0.0076 0.0076 0.0193 0.0195 0.0161 0.0146 0.0193 0.0195 0.0242 0.0161 0.0024 0.0024 Qualifying county name County code WOOD ............................................................. TARRANT ........................................................ PALO PINTO ................................................... JASPER ........................................................... HOOD .............................................................. CASS ............................................................... TARRANT ........................................................ MONTAGUE .................................................... TARRANT ........................................................ TARRANT ........................................................ TARRANT ........................................................ LAMB ............................................................... ANDERSON .................................................... HOCKLEY ........................................................ MILAM ............................................................. TARRANT ........................................................ ANDERSON .................................................... JASPER ........................................................... TARRANT ........................................................ TARRANT ........................................................ UPSHUR .......................................................... TARRANT ........................................................ TARRANT ........................................................ UTAH ............................................................... UTAH ............................................................... BOX ELDER .................................................... UTAH ............................................................... BOX ELDER .................................................... UTAH ............................................................... UTAH ............................................................... UTAH ............................................................... CULPEPER ..................................................... ESSEX ............................................................. MONTGOMERY .............................................. SKAGIT ............................................................ SKAGIT ............................................................ LEWIS .............................................................. KITSAP ............................................................ COWLITZ ......................................................... MASON ............................................................ JACKSON ........................................................ MARION .......................................................... MINGO ............................................................. GREEN ............................................................ SHEBOYGAN .................................................. SHEBOYGAN .................................................. SAUK ............................................................... RACINE ........................................................... JEFFERSON ................................................... DODGE ............................................................ SAUK ............................................................... RACINE ........................................................... WALWORTH ................................................... JEFFERSON ................................................... TARRANT ........................................................ TARRANT ........................................................ 45974 45910 45841 45690 45653 45260 45910 45800 45910 45910 45910 45751 45000 45652 45795 45910 45000 45690 45910 45910 45943 45910 45910 46240 46240 46010 46240 46010 46240 46240 46240 49230 49280 49600 50280 50280 50200 50170 50070 51260 51170 51240 51290 52220 52580 52580 52550 52500 52270 52130 52550 52500 52630 52270 45910 45910 jlentini on PROD1PC65 with PROPOSALS2 TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC Type MS–DRG title 001 ........... No ............ No ............ PRE SURG ...... 002 ........... No ............ No ............ PRE SURG ...... Heart transplant or implant of heart assist system w MCC. Heart transplant or implant of heart assist system w/o MCC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00293 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 23.4061 29.1 40.2 12.8956 18.4 24.7 30APP2 23820 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued FY 2009 proposed rule special pay DRG MDC Type MS–DRG title 003 ........... Yes .......... No ............ PRE SURG ...... 004 ........... Yes .......... No ............ PRE SURG ...... 005 ........... No ............ No ............ PRE SURG ...... 006 ........... 007 ........... 008 ........... No ............ No ............ No ............ No ............ No ............ No ............ PRE PRE PRE SURG ...... SURG ...... SURG ...... 009 ........... 010 ........... 011 ........... No ............ No ............ No ............ No ............ No ............ No ............ PRE PRE PRE SURG ...... SURG ...... SURG ...... 012 ........... No ............ No ............ PRE SURG ...... 013 ........... No ............ No ............ PRE SURG ...... 020 ........... No ............ No ............ 01 SURG ...... 021 ........... No ............ No ............ 01 SURG ...... 022 ........... No ............ No ............ 01 SURG ...... 023 ........... No ............ No ............ 01 SURG ...... 024 ........... No ............ No ............ 01 SURG ...... 025 ........... Yes .......... No ............ 01 SURG ...... 026 ........... Yes .......... No ............ 01 SURG ...... 027 ........... Yes .......... No ............ 01 SURG ...... 028 ........... 029 ........... Yes .......... Yes .......... Yes .......... Yes .......... 01 01 SURG ...... SURG ...... 030 031 032 033 Yes Yes Yes Yes .......... .......... .......... .......... Yes .......... No ............ No ............ No ............ 01 01 01 01 SURG SURG SURG SURG 034 ........... 035 ........... 036 ........... No ............ No ............ No ............ No ............ No ............ No ............ 01 01 01 SURG ...... SURG ...... SURG ...... 037 038 039 040 ........... ........... ........... ........... No ............ No ............ No ............ Yes .......... No ............ No ............ No ............ Yes .......... 01 01 01 01 SURG SURG SURG SURG 041 ........... Yes .......... Yes .......... 01 SURG ...... 042 ........... jlentini on PROD1PC65 with PROPOSALS2 MS–DRG FY 2009 proposed rule postacute DRG Yes .......... Yes .......... 01 SURG ...... 052 ........... 053 ........... No ............ No ............ No ............ No ............ 01 01 MED ......... MED ......... 054 ........... 055 ........... 056 ........... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ 01 01 01 MED ......... MED ......... MED ......... 057 ........... Yes .......... No ............ 01 MED ......... ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R. Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R.. Liver transplant w MCC or intestinal transplant. Liver transplant w/o MCC .................... Lung transplant .................................... Simultaneous pancreas/kidney transplant. Bone marrow transplant ...................... Pancreas transplant ............................ Tracheostomy for face,mouth & neck diagnoses w MCC. Tracheostomy for face,mouth & neck diagnoses w CC. Tracheostomy for face,mouth & neck diagnoses w/o CC/MCC. Intracranial vascular procedures w PDX hemorrhage w MCC. Intracranial vascular procedures w PDX hemorrhage w CC. Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC. Cranio w major dev impl/acute complex CNS PDX w MCC or chemo implant. Cranio w major dev impl/acute complex CNS PDX w/o MCC. Craniotomy & endovascular intracranial procedures w MCC. Craniotomy & endovascular intracranial procedures w CC. Craniotomy & endovascular intracranial procedures w/o CC/ MCC. Spinal procedures w MCC .................. Spinal procedures w CC or spinal neurostimulators. Spinal procedures w/o CC/MCC ......... Ventricular shunt procedures w MCC Ventricular shunt procedures w CC .... Ventricular shunt procedures w/o CC/ MCC. Carotid artery stent procedure w MCC Carotid artery stent procedure w CC .. Carotid artery stent procedure w/o CC/MCC. Extracranial procedures w MCC ......... Extracranial procedures w CC ............ Extracranial procedures w/o CC/MCC Periph/cranial nerve & other nerv syst proc w MCC. Periph/cranial nerve & other nerv syst proc w CC or periph neurostim. Periph/cranial nerve & other nerv syst proc w/o CC/MCC. Spinal disorders & injuries w CC/MCC Spinal disorders & injuries w/o CC/ MCC. Nervous system neoplasms w MCC ... Nervous system neoplasms w/o MCC Degenerative nervous system disorders w MCC. Degenerative nervous system disorders w/o MCC. ........... ........... ........... ........... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ...... ...... ...... ...... ...... ...... ...... ...... Frm 00294 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 18.3635 32.5 39.6 11.1684 23.5 28.8 10.7436 15.9 21.2 4.8292 9.7325 4.8917 8.9 15.9 10.1 10.2 19.7 11.9 6.6398 3.7508 4.8900 18.2 9.1 13.1 21.9 10.8 16.7 3.0563 8.9 10.7 1.9057 5.9 6.9 8.3276 14.8 18.4 6.3534 13.7 15.4 4.2072 7.6 9.4 5.0763 8.9 12.7 3.4757 6.3 9.0 5.0324 9.9 13.0 3.0107 6.5 8.2 2.1083 3.5 4.5 5.1853 2.7949 10.7 5.1 14.3 7.1 1.5395 4.3899 1.9471 1.3334 2.8 9.4 4.0 2.3 3.7 13.1 6.0 3.0 3.2182 2.0258 1.5706 4.6 2.1 1.3 7.2 3.3 1.6 3.0208 1.5585 1.0057 3.9691 5.9 2.5 1.5 9.7 8.5 3.8 1.8 13.3 2.1517 5.3 7.2 1.6771 2.5 3.6 1.6271 0.8617 4.9 3.2 6.7 4.0 1.5844 1.0781 1.6311 5.2 3.8 5.7 7.0 5.1 7.8 0.8755 3.9 5.0 30APP2 23821 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 058 ........... No ............ No ............ 059 ........... No ............ 060 ........... Type MS–DRG title 01 MED ......... No ............ 01 MED ......... No ............ No ............ 01 MED ......... 061 ........... No ............ No ............ 01 MED ......... 062 ........... No ............ No ............ 01 MED ......... 063 ........... No ............ No ............ 01 MED ......... 064 ........... Yes .......... No ............ 01 MED ......... 065 ........... Yes .......... No ............ 01 MED ......... 066 ........... Yes .......... No ............ 01 MED ......... 067 ........... No ............ No ............ 01 MED ......... 068 ........... No ............ No ............ 01 MED ......... 069 ........... 070 ........... No ............ Yes .......... No ............ No ............ 01 01 MED ......... MED ......... 071 ........... Yes .......... No ............ 01 MED ......... 072 ........... Yes .......... No ............ 01 MED ......... 073 ........... No ............ No ............ 01 MED ......... 074 ........... No ............ No ............ 01 MED ......... 075 076 077 078 079 No No No No No No No No No No ............ ............ ............ ............ ............ 01 01 01 01 01 MED MED MED MED MED Multiple sclerosis & cerebellar ataxia w MCC. Multiple sclerosis & cerebellar ataxia w CC. Multiple sclerosis & cerebellar ataxia w/o CC/MCC. Acute ischemic stroke w use of thrombolytic agent w MCC. Acute ischemic stroke w use of thrombolytic agent w CC. Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC. Intracranial hemorrhage or cerebral infarction w MCC. Intracranial hemorrhage or cerebral infarction w CC. Intracranial hemorrhage or cerebral infarction w/o CC/MCC. Nonspecific cva & precerebral occlusion w/o infarct w MCC. Nonspecific cva & precerebral occlusion w/o infarct w/o MCC. Transient ischemia .............................. Nonspecific cerebrovascular disorders w MCC. Nonspecific cerebrovascular disorders w CC. Nonspecific cerebrovascular disorders w/o CC/MCC. Cranial & peripheral nerve disorders w MCC. Cranial & peripheral nerve disorders w/o MCC. Viral meningitis w CC/MCC ................. Viral meningitis w/o CC/MCC .............. Hypertensive encephalopathy w MCC Hypertensive encephalopathy w CC ... Hypertensive encephalopathy w/o CC/ MCC. Nontraumatic stupor & coma w MCC Nontraumatic stupor & coma w/o MCC. Traumatic stupor & coma, coma >1 hr w MCC. Traumatic stupor & coma, coma >1 hr w CC. Traumatic stupor & coma, coma >1 hr w/o CC/MCC. Traumatic stupor & coma, coma <1 hr w MCC. Traumatic stupor & coma, coma <1 hr w CC. Traumatic stupor & coma, coma <1 hr w/o CC/MCC. Concussion w MCC ............................. Concussion w CC ................................ Concussion w/o CC/MCC ................... Other disorders of nervous system w MCC. Other disorders of nervous system w CC. Other disorders of nervous system w/ o CC/MCC. Bacterial & tuberculous infections of nervous system w MCC. Bacterial & tuberculous infections of nervous system w CC. ........... ........... ........... ........... ........... ............ ............ ............ ............ ............ ......... ......... ......... ......... ......... No ............ No ............ No ............ No ............ 01 01 MED ......... MED ......... 082 ........... No ............ No ............ 01 MED ......... 083 ........... No ............ No ............ 01 MED ......... 084 ........... No ............ No ............ 01 MED ......... 085 ........... Yes .......... No ............ 01 MED ......... 086 ........... Yes .......... No ............ 01 MED ......... 087 ........... Yes .......... No ............ 01 MED ......... 088 089 090 091 jlentini on PROD1PC65 with PROPOSALS2 080 ........... 081 ........... ........... ........... ........... ........... No ............ No ............ No ............ Yes .......... No No No No ............ ............ ............ ............ 01 01 01 01 MED MED MED MED 092 ........... Yes .......... No ............ 01 MED ......... 093 ........... Yes .......... No ............ 01 MED ......... 094 ........... No ............ No ............ 01 MED ......... 095 ........... No ............ No ............ 01 MED ......... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ......... ......... ......... ......... Frm 00295 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.5373 5.7 7.6 0.9404 4.2 5.1 0.6978 3.4 4.0 2.8759 6.8 8.9 1.9505 5.3 6.3 1.5168 3.9 4.5 1.8446 5.5 7.5 1.1748 4.3 5.2 0.8426 3.1 3.7 1.3899 4.4 5.8 0.8449 2.7 3.4 0.7143 1.8241 2.4 6.0 3.0 7.9 1.1307 4.4 5.6 0.7629 2.8 3.5 1.3037 4.7 6.2 0.8406 3.4 4.3 1.6738 0.8544 1.6225 1.0050 0.7377 5.7 3.4 5.2 3.6 2.8 7.3 4.1 6.7 4.4 3.4 1.1007 0.7094 3.8 2.7 5.1 3.5 2.0177 3.7 6.4 1.3027 3.7 5.0 0.8720 2.4 3.1 2.0942 5.5 7.6 1.2049 3.9 5.0 0.8008 2.6 3.3 1.5774 0.9162 0.6736 1.5641 4.2 3.0 2.0 4.6 5.9 3.8 2.5 6.4 0.9195 3.5 4.5 0.6753 2.6 3.2 3.3477 9.2 11.9 2.1934 6.9 8.6 30APP2 23822 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 096 ........... No ............ No ............ 097 ........... No ............ 098 ........... Type MS–DRG title 01 MED ......... No ............ 01 MED ......... No ............ No ............ 01 MED ......... 099 ........... No ............ No ............ 01 MED ......... 100 101 102 103 113 114 115 116 117 121 122 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... Yes .......... Yes .......... No ............ No ............ No ............ No ............ No ............ No ............ No ............ No ............ No ............ No No No No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ 01 01 01 01 02 02 02 02 02 02 02 MED ......... MED ......... MED ......... MED ......... SURG ...... SURG ...... SURG ...... SURG ...... SURG ...... MED ......... MED ......... 123 124 125 129 ........... ........... ........... ........... No No No No No No No No ............ ............ ............ ............ 02 02 02 03 MED ......... MED ......... MED ......... SURG ...... Bacterial & tuberculous infections of nervous system w/o CC/MCC. Non-bacterial infect of nervous sys exc viral meningitis w MCC. Non-bacterial infect of nervous sys exc viral meningitis w CC. Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC. Seizures w MCC ................................. Seizures w/o MCC .............................. Headaches w MCC ............................. Headaches w/o MCC .......................... Orbital procedures w CC/MCC ........... Orbital procedures w/o CC/MCC ........ Extraocular procedures except orbit ... Intraocular procedures w CC/MCC ..... Intraocular procedures w/o CC/MCC .. Acute major eye infections w CC/MCC Acute major eye infections w/o CC/ MCC. Neurological eye disorders .................. Other disorders of the eye w MCC ..... Other disorders of the eye w/o MCC .. Major head & neck procedures w CC/ MCC or major device. Major head & neck procedures w/o CC/MCC. Cranial/facial procedures w CC/MCC Cranial/facial procedures w/o CC/ MCC. Other ear, nose, mouth & throat O.R. procedures w CC/MCC. Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC. Sinus & mastoid procedures w CC/ MCC. Sinus & mastoid procedures w/o CC/ MCC. Mouth procedures w CC/MCC ............ Mouth procedures w/o CC/MCC ......... Salivary gland procedures ................... Ear, nose, mouth & throat malignancy w MCC. Ear, nose, mouth & throat malignancy w CC. Ear, nose, mouth & throat malignancy w/o CC/MCC. Dysequilibrium ..................................... Epistaxis w MCC ................................. Epistaxis w/o MCC .............................. Otitis media & URI w MCC ................. Otitis media & URI w/o MCC .............. Other ear, nose, mouth & throat diagnoses w MCC. Other ear, nose, mouth & throat diagnoses w CC. Other ear, nose, mouth & throat diagnoses w/o CC/MCC. Dental & oral diseases w MCC ........... Dental & oral diseases w CC .............. Dental & oral diseases w/o CC/MCC .. Major chest procedures w MCC ......... Major chest procedures w CC ............ Major chest procedures w/o CC/MCC Other resp system O.R. procedures w MCC. ............ ............ ............ ............ 130 ........... No ............ No ............ 03 SURG ...... 131 ........... 132 ........... No ............ No ............ No ............ No ............ 03 03 SURG ...... SURG ...... 133 ........... No ............ No ............ 03 SURG ...... 134 ........... No ............ No ............ 03 SURG ...... 135 ........... No ............ No ............ 03 SURG ...... 136 ........... No ............ No ............ 03 SURG ...... 137 138 139 146 No No No No No No No No ............ ............ ............ ............ 03 03 03 03 SURG ...... SURG ...... SURG ...... MED ......... ........... ........... ........... ........... ............ ............ ............ ............ 147 ........... No ............ No ............ 03 MED ......... 148 ........... No ............ No ............ 03 MED ......... 149 150 151 152 153 154 No No No No No No No No No No No No ............ ............ ............ ............ ............ ............ 03 03 03 03 03 03 MED MED MED MED MED MED ........... ........... ........... ........... ........... ........... ............ ............ ............ ............ ............ ............ ......... ......... ......... ......... ......... ......... No ............ No ............ 03 MED ......... 156 ........... jlentini on PROD1PC65 with PROPOSALS2 155 ........... No ............ No ............ 03 MED ......... 157 158 159 163 164 165 166 No ............ No ............ No ............ Yes .......... Yes .......... Yes .......... Yes .......... No No No No No No No 03 03 03 04 04 04 04 MED ......... MED ......... MED ......... SURG ...... SURG ...... SURG ...... SURG ...... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 19:42 Apr 29, 2008 ............ ............ ............ ............ ............ ............ ............ Jkt 214001 PO 00000 Frm 00296 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.8297 5.0 6.2 3.2101 9.9 12.6 1.8564 6.8 8.4 1.2533 4.6 5.9 1.5064 0.7594 0.9594 0.6224 1.5656 0.8313 1.0625 1.1338 0.6699 0.9556 0.6127 4.7 2.9 3.3 2.5 3.8 1.9 3.3 2.6 1.6 4.4 3.4 6.4 3.7 4.5 3.1 5.6 2.6 4.3 4.1 2.2 5.5 4.0 0.6840 1.0620 0.6660 2.0147 2.3 3.9 2.8 3.7 2.9 5.3 3.5 5.2 1.1588 2.4 2.9 1.9768 1.1041 4.0 2.1 5.7 2.7 1.5491 3.6 5.3 0.8243 1.7 2.2 1.6842 3.8 5.8 0.9023 1.7 2.3 1.2668 0.7368 0.8176 2.0489 3.8 1.9 1.4 6.7 5.4 2.5 1.8 9.4 1.2486 4.3 6.1 0.8181 2.7 3.8 0.6086 1.2243 0.6018 0.8976 0.5948 1.3768 2.2 3.7 2.3 3.4 2.6 4.6 2.7 5.2 2.9 4.5 3.2 6.3 0.8779 3.5 4.4 0.6306 2.5 3.2 1.4793 0.8615 0.5952 4.9951 2.5982 1.8086 3.6865 4.7 3.4 2.4 12.2 6.7 4.3 10.0 6.7 4.5 3.1 14.9 8.1 5.1 12.9 30APP2 23823 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 167 ........... Yes .......... No ............ 168 ........... Yes .......... 175 ........... 176 ........... 177 ........... MS–DRG title 04 SURG ...... No ............ 04 SURG ...... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ 04 04 04 MED ......... MED ......... MED ......... 178 ........... Yes .......... No ............ 04 MED ......... 179 ........... Yes .......... No ............ 04 MED ......... 180 181 182 183 184 185 186 187 188 189 190 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... No ............ No ............ No ............ No ............ No ............ No ............ Yes .......... Yes .......... Yes .......... No ............ Yes .......... No No No No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ 04 04 04 04 04 04 04 04 04 04 04 MED MED MED MED MED MED MED MED MED MED MED 191 ........... Yes .......... No ............ 04 MED ......... 192 ........... Yes .......... No ............ 04 MED ......... 193 ........... 194 ........... 195 ........... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ 04 04 04 MED ......... MED ......... MED ......... 196 197 198 199 200 201 202 203 204 205 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ No ............ No ............ No ............ Yes .......... No No No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ 04 04 04 04 04 04 04 04 04 04 MED MED MED MED MED MED MED MED MED MED 206 ........... Yes .......... No ............ 04 MED ......... 207 ........... Yes .......... No ............ 04 MED ......... 208 ........... No ............ No ............ 04 MED ......... 215 ........... 216 ........... No ............ Yes .......... No ............ No ............ 05 05 SURG ...... SURG ...... 217 ........... Yes .......... No ............ 05 SURG ...... 218 ........... jlentini on PROD1PC65 with PROPOSALS2 Type Yes .......... No ............ 05 SURG ...... 219 ........... Yes .......... Yes .......... 05 SURG ...... 220 ........... Yes .......... Yes .......... 05 SURG ...... Other resp system O.R. procedures w CC. Other resp system O.R. procedures w/o CC/MCC. Pulmonary embolism w MCC .............. Pulmonary embolism w/o MCC ........... Respiratory infections & inflammations w MCC. Respiratory infections & inflammations w CC. Respiratory infections & inflammations w/o CC/MCC. Respiratory neoplasms w MCC .......... Respiratory neoplasms w CC ............. Respiratory neoplasms w/o CC/MCC Major chest trauma w MCC ................ Major chest trauma w CC ................... Major chest trauma w/o CC/MCC ....... Pleural effusion w MCC ...................... Pleural effusion w CC ......................... Pleural effusion w/o CC/MCC ............. Pulmonary edema & respiratory failure Chronic obstructive pulmonary disease w MCC. Chronic obstructive pulmonary disease w CC. Chronic obstructive pulmonary disease w/o CC/MCC. Simple pneumonia & pleurisy w MCC Simple pneumonia & pleurisy w CC ... Simple pneumonia & pleurisy w/o CC/ MCC. Interstitial lung disease w MCC .......... Interstitial lung disease w CC ............. Interstitial lung disease w/o CC/MCC Pneumothorax w MCC ........................ Pneumothorax w CC ........................... Pneumothorax w/o CC/MCC ............... Bronchitis & asthma w CC/MCC ......... Bronchitis & asthma w/o CC/MCC ...... Respiratory signs & symptoms ........... Other respiratory system diagnoses w MCC. Other respiratory system diagnoses w/ o MCC. Respiratory system diagnosis w ventilator support 96+ hours. Respiratory system diagnosis w ventilator support <96 hours. Other heart assist system implant ...... Cardiac valve & oth maj cardiothoracic proc w card cath w MCC. Cardiac valve & oth maj cardiothoracic proc w card cath w CC. Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC. Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC. Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... Frm 00297 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 2.0256 6.3 8.0 1.3443 3.9 5.3 1.5777 1.0696 2.0391 6.0 4.6 7.2 7.3 5.3 9.1 1.4979 6.0 7.4 1.0409 4.6 5.6 1.6938 1.2293 0.8712 1.5304 0.9405 0.6755 1.6200 1.0940 0.8121 1.3473 1.3004 6.0 4.5 3.2 5.8 3.8 2.9 5.7 4.1 3.1 4.8 5.0 7.9 5.9 4.2 7.2 4.6 3.4 7.4 5.3 4.0 6.1 6.3 0.9734 4.1 5.0 0.7239 3.3 4.0 1.4303 1.0041 0.7301 5.4 4.4 3.5 6.8 5.3 4.1 1.6006 1.0973 0.8158 1.7383 1.0118 0.7399 0.8135 0.5938 0.6533 1.2427 5.9 4.4 3.3 6.4 3.9 3.1 3.5 2.8 2.2 4.0 7.4 5.4 4.1 8.3 5.1 4.1 4.4 3.4 2.9 5.5 0.7266 2.7 3.4 5.1153 12.8 15.1 2.1827 5.2 7.2 12.3351 1..1072 7.8 15.7 14.2 18.4 7.0028 10.9 12.3 5.4355 8.4 9.1 8.0764 11.5 14.0 5.3066 7.7 8.6 30APP2 23824 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 221 ........... Yes .......... Yes .......... 222 ........... No ............ 223 ........... MS–DRG title 05 SURG ...... No ............ 05 SURG ...... No ............ No ............ 05 SURG ...... 224 ........... No ............ No ............ 05 SURG ...... 225 ........... No ............ No ............ 05 SURG ...... 226 ........... No ............ No ............ 05 SURG ...... 227 ........... No ............ No ............ 05 SURG ...... 228 ........... Yes .......... No ............ 05 SURG ...... 229 ........... 230 ........... Yes .......... Yes .......... No ............ No ............ 05 05 SURG ...... SURG ...... 231 ........... 232 ........... 233 ........... No ............ No ............ Yes .......... No ............ No ............ No ............ 05 05 05 SURG ...... SURG ...... SURG ...... 234 ........... Yes .......... No ............ 05 SURG ...... 235 ........... Yes .......... No ............ 05 SURG ...... 236 ........... Yes .......... No ............ 05 SURG ...... 237 ........... No ............ No ............ 05 SURG ...... 238 ........... No ............ No ............ 05 SURG ...... 239 ........... Yes .......... No ............ 05 SURG ...... 240 ........... Yes .......... No ............ 05 SURG ...... 241 ........... Yes .......... No ............ 05 SURG ...... 242 ........... Yes .......... No ............ 05 SURG ...... 243 ........... Yes .......... No ............ 05 SURG ...... 244 ........... Yes .......... No ............ 05 SURG ...... 245 ........... 246 ........... No ............ No ............ No ............ No ............ 05 05 SURG ...... SURG ...... 247 ........... No ............ No ............ 05 SURG ...... 248 ........... No ............ No ............ 05 SURG ...... 249 ........... No ............ No ............ 05 SURG ...... 250 ........... jlentini on PROD1PC65 with PROPOSALS2 Type No ............ No ............ 05 SURG ...... 251 ........... No ............ No ............ 05 SURG ...... 252 ........... 253 ........... 254 ........... No ............ No ............ No ............ No ............ No ............ No ............ 05 05 05 SURG ...... SURG ...... SURG ...... 255 ........... Yes .......... No ............ 05 SURG ...... Cardiac valve & oth maj cardiothoracic proc w/o card cath w/ o CC/MCC. Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC. Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC. Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC. Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC. Cardiac defibrillator implant w/o cardiac cath w MCC. Cardiac defibrillator implant w/o cardiac cath w/o MCC. Other cardiothoracic procedures w MCC. Other cardiothoracic procedures w CC Other cardiothoracic procedures w/o CC/MCC. Coronary bypass w PTCA w MCC ..... Coronary bypass w PTCA w/o MCC .. Coronary bypass w cardiac cath w MCC. Coronary bypass w cardiac cath w/o MCC. Coronary bypass w/o cardiac cath w MCC. Coronary bypass w/o cardiac cath w/o MCC. Major cardiovasc procedures w MCC or thoracic aortic aneurysm repair. Major cardiovasc procedures w/o MCC. Amputation for circ sys disorders exc upper limb & toe w MCC. Amputation for circ sys disorders exc upper limb & toe w CC. Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC. Permanent cardiac pacemaker implant w MCC. Permanent cardiac pacemaker implant w CC. Permanent cardiac pacemaker implant w/o CC/MCC. AICD generator procedures ................ Perc cardiovasc proc w drug-eluting stent w MCC or 4+ vessels/stents. Perc cardiovasc proc w drug-eluting stent w/o MCC. Perc cardiovasc proc w non-drugeluting stent w MCC or 4+ ves/ stents. Perc cardiovasc proc w non-drugeluting stent w/o MCC. Perc cardiovasc proc w/o coronary artery stent w MCC. Perc cardiovasc proc w/o coronary artery stent w/o MCC. Other vascular procedures w MCC ..... Other vascular procedures w CC ........ Other vascular procedures w/o CC/ MCC. Upper limb & toe amputation for circ system disorders w MCC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00298 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 4.4089 6.0 6.4 8.6586 10.7 13.1 6.3035 4.6 6.3 7.9767 9.2 11.4 5.9123 4.5 5.6 6.7278 6.2 9.3 5.0145 1.8 2.8 7.8191 12.1 14.7 5.0358 4.0677 7.9 5.6 9.1 6.5 7.6801 5.5460 7.0378 11.2 8.3 12.4 13.3 9.2 14.2 4.6193 8.3 8.9 5.6992 9.5 11.2 3.6122 6.1 6.6 5.0881 7.5 10.8 2.8962 3.2 4.6 4.4798 12.0 15.3 2.6706 8.3 10.4 1.5740 5.6 6.8 3.7041 6.7 8.8 2.5934 3.8 5.1 2.0098 2.2 2.9 4.0022 3.1498 2.1 3.6 3.2 5.3 1.9134 1.7 2.2 2.8065 4.2 6.0 1.6397 1.9 2.5 2.9923 5.4 7.8 1.6023 2.1 2.8 2.9526 2.2593 1.5485 5.5 4.2 2.0 8.5 6.0 2.7 2.4040 7.1 9.7 30APP2 23825 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 256 ........... Yes .......... No ............ 257 ........... Yes .......... 258 ........... MS–DRG title 05 SURG ...... No ............ 05 SURG ...... No ............ No ............ 05 SURG ...... 259 ........... No ............ No ............ 05 SURG ...... 260 ........... No ............ No ............ 05 SURG ...... 261 ........... No ............ No ............ 05 SURG ...... 262 ........... No ............ No ............ 05 SURG ...... 263 ........... 264 ........... No ............ Yes .......... No ............ No ............ 05 05 SURG ...... SURG ...... 265 ........... 280 ........... No ............ Yes .......... No ............ No ............ 05 05 SURG ...... MED ......... 281 ........... Yes .......... No ............ 05 MED ......... 282 ........... Yes .......... No ............ 05 MED ......... 283 ........... No ............ No ............ 05 MED ......... 284 ........... No ............ No ............ 05 MED ......... 285 ........... No ............ No ............ 05 MED ......... 286 ........... No ............ No ............ 05 MED ......... 287 ........... No ............ No ............ 05 MED ......... 288 ........... Yes .......... No ............ 05 MED ......... 289 ........... 290 ........... Yes .......... Yes .......... No ............ No ............ 05 05 MED ......... MED ......... 291 292 293 294 ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... No ............ No No No No ............ ............ ............ ............ 05 05 05 05 MED MED MED MED 295 ........... No ............ No ............ 05 MED ......... 296 ........... 297 ........... 298 ........... No ............ No ............ No ............ No ............ No ............ No ............ 05 05 05 MED ......... MED ......... MED ......... 299 ........... 300 ........... 301 ........... jlentini on PROD1PC65 with PROPOSALS2 Type Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ 05 05 05 MED ......... MED ......... MED ......... 302 303 304 305 306 No No No No No No No No No No ............ ............ ............ ............ ............ 05 05 05 05 05 MED MED MED MED MED Upper limb & toe amputation for circ system disorders w CC. Upper limb & toe amputation for circ system disorders w/o CC/MCC. Cardiac pacemaker device replacement w MCC. Cardiac pacemaker device replacement w/o MCC. Cardiac pacemaker revision except device replacement w MCC. Cardiac pacemaker revision except device replacement w CC. Cardiac pacemaker revision except device replacement w/o CC/MCC. Vein ligation & stripping ...................... Other circulatory system O.R. procedures. AICD lead procedures ......................... Acute myocardial infarction, discharged alive w MCC. Acute myocardial infarction, discharged alive w CC. Acute myocardial infarction, discharged alive w/o CC/MCC. Acute myocardial infarction, expired w MCC. Acute myocardial infarction, expired w CC. Acute myocardial infarction, expired w/o CC/MCC. Circulatory disorders except AMI, w card cath w MCC. Circulatory disorders except AMI, w card cath w/o MCC. Acute & subacute endocarditis w MCC. Acute & subacute endocarditis w CC Acute & subacute endocarditis w/o CC/MCC. Heart failure & shock w MCC ............. Heart failure & shock w CC ................ Heart failure & shock w/o CC/MCC .... Deep vein thrombophlebitis w CC/ MCC. Deep vein thrombophlebitis w/o CC/ MCC. Cardiac arrest, unexplained w MCC ... Cardiac arrest, unexplained w CC ...... Cardiac arrest, unexplained w/o CC/ MCC. Peripheral vascular disorders w MCC Peripheral vascular disorders w CC ... Peripheral vascular disorders w/o CC/ MCC. Atherosclerosis w MCC ....................... Atherosclerosis w/o MCC .................... Hypertension w MCC .......................... Hypertension w/o MCC ....................... Cardiac congenital & valvular disorders w MCC. Cardiac congenital & valvular disorders w/o MCC. Cardiac arrhythmia & conduction disorders w MCC. Cardiac arrhythmia & conduction disorders w CC. ........... ........... ........... ........... ........... ............ ............ ............ ............ ............ ......... ......... ......... ......... ......... ......... ......... ......... ......... 307 ........... No ............ No ............ 05 MED ......... 308 ........... No ............ No ............ 05 MED ......... 309 ........... No ............ No ............ 05 MED ......... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00299 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.5895 5.8 7.5 1.0216 3.6 4.8 2.8434 5.4 7.4 1.6944 2.0 2.8 3.4221 8.1 11.2 1.4398 3.0 4.2 1.0173 2.0 2.6 1.5392 2.5265 3.4 5.8 5.4 8.9 2.2140 1.9395 2.2 5.8 3.5 7.3 1.2210 3.9 4.8 0.8698 2.6 3.2 1.6979 3.4 5.5 0.9130 2.2 3.2 0.6059 1.7 2.2 1.9745 5.2 6.9 1.0225 2.4 3.1 3.0720 9.2 11.8 1.9524 1.4507 7.0 5.2 8.7 6.5 1.4576 1.0053 0.7205 0.9564 5.0 4.1 3.1 4.6 6.5 5.0 3.7 5.5 0.6347 3.7 4.3 1.1910 0.6502 0.4438 1.9 1.4 1.1 3.0 1.8 1.3 1.4326 0.9245 0.6580 5.0 4.1 3.0 6.7 5.0 3.7 1.0307 0.5666 1.0808 0.5900 1.5655 3.2 2.0 3.9 2.3 4.4 4.4 2.5 5.2 2.9 6.3 0.7476 2.7 3.4 1.2981 4.1 5.5 0.8320 3.1 3.9 30APP2 23826 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 310 ........... No ............ No ............ 311 312 313 314 ........... ........... ........... ........... No ............ No ............ No ............ Yes .......... No No No No 315 ........... MS–DRG title 05 MED ......... ............ ............ ............ ............ 05 05 05 05 MED MED MED MED Yes .......... No ............ 05 MED ......... 316 ........... Yes .......... No ............ 05 MED ......... 326 ........... Yes .......... No ............ 06 SURG ...... 327 ........... Yes .......... No ............ 06 SURG ...... 328 ........... Yes .......... No ............ 06 SURG ...... 329 ........... Yes .......... No ............ 06 SURG ...... 330 ........... Yes .......... No ............ 06 SURG ...... 331 ........... Yes .......... No ............ 06 SURG ...... 332 333 334 335 336 337 338 ........... ........... ........... ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... Yes .......... Yes .......... Yes .......... No ............ No No No No No No No ............ ............ ............ ............ ............ ............ ............ 06 06 06 06 06 06 06 SURG SURG SURG SURG SURG SURG SURG 339 ........... No ............ No ............ 06 SURG ...... 340 ........... No ............ No ............ 06 SURG ...... 341 ........... No ............ No ............ 06 SURG ...... 342 ........... No ............ No ............ 06 SURG ...... 343 ........... No ............ No ............ 06 SURG ...... 344 ........... No ............ No ............ 06 SURG ...... 345 ........... No ............ No ............ 06 SURG ...... 346 ........... No ............ No ............ 06 SURG ...... 347 ........... 348 ........... 349 ........... No ............ No ............ No ............ No ............ No ............ No ............ 06 06 06 SURG ...... SURG ...... SURG ...... 350 ........... No ............ No ............ 06 SURG ...... 351 ........... No ............ No ............ 06 SURG ...... 352 ........... No ............ No ............ 06 SURG ...... 353 ........... jlentini on PROD1PC65 with PROPOSALS2 Type No ............ No ............ 06 SURG ...... 354 ........... No ............ No ............ 06 SURG ...... 355 ........... No ............ No ............ 06 SURG ...... 356 ........... Yes .......... No ............ 06 SURG ...... 357 ........... Yes .......... No ............ 06 SURG ...... Cardiac arrhythmia & conduction disorders w/o CC/MCC. Angina pectoris .................................... Syncope & collapse ............................. Chest pain ........................................... Other circulatory system diagnoses w MCC. Other circulatory system diagnoses w CC. Other circulatory system diagnoses w/ o CC/MCC. Stomach, esophageal & duodenal proc w MCC. Stomach, esophageal & duodenal proc w CC. Stomach, esophageal & duodenal proc w/o CC/MCC. Major small & large bowel procedures w MCC. Major small & large bowel procedures w CC. Major small & large bowel procedures w/o CC/MCC. Rectal resection w MCC ..................... Rectal resection w CC ........................ Rectal resection w/o CC/MCC ............ Peritoneal adhesiolysis w MCC .......... Peritoneal adhesiolysis w CC ............. Peritoneal adhesiolysis w/o CC/MCC Appendectomy w complicated principal diag w MCC. Appendectomy w complicated principal diag w CC. Appendectomy w complicated principal diag w/o CC/MCC. Appendectomy w/o complicated principal diag w MCC. Appendectomy w/o complicated principal diag w CC. Appendectomy w/o complicated principal diag w/o CC/MCC. Minor small & large bowel procedures w MCC. Minor small & large bowel procedures w CC. Minor small & large bowel procedures w/o CC/MCC. Anal & stomal procedures w MCC ...... Anal & stomal procedures w CC ......... Anal & stomal procedures w/o CC/ MCC. Inguinal & femoral hernia procedures w MCC. Inguinal & femoral hernia procedures w CC. Inguinal & femoral hernia procedures w/o CC/MCC. Hernia procedures except inguinal & femoral w MCC. Hernia procedures except inguinal & femoral w CC. Hernia procedures except inguinal & femoral w/o CC/MCC. Other digestive system O.R. procedures w MCC. Other digestive system O.R. procedures w CC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ......... ......... ......... ......... ...... ...... ...... ...... ...... ...... ...... Frm 00300 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 0.5829 2.3 2.8 0.4969 0.7082 0.5312 1.7517 1.9 2.5 1.7 5.0 2.3 3.1 2.1 7.0 0.9922 3.5 4.6 0.6513 2.4 3.0 5.8025 13.2 17.1 2.8389 7.8 10.1 1.4576 3.2 4.4 5.1793 12.8 16.0 2.5644 8.3 9.7 1.6250 5.2 5.9 4.5358 2.4487 1.6247 4.0903 2.2387 1.4519 3.1787 12.0 7.7 4.7 11.6 7.5 4.4 8.8 14.3 8.8 5.5 14.1 9.1 5.6 10.7 1.8625 6.0 7.0 1.2267 3.5 4.2 2.1659 5.3 7.1 1.3154 3.2 4.1 0.9067 1.8 2.2 3.0822 9.2 11.8 1.6391 6.2 7.2 1.1869 4.4 4.9 2.1823 1.2860 0.7681 6.4 4.4 2.4 8.8 5.7 3.1 2.2486 5.8 8.0 1.2638 3.4 4.6 0.8131 2.0 2.5 2.4935 6.4 8.4 1.4046 4.0 5.1 0.9675 2.4 2.9 3.8574 9.5 12.9 2.1703 6.2 8.1 30APP2 23827 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 358 ........... Yes .......... No ............ 368 ........... 369 ........... 370 ........... No ............ No ............ No ............ 371 ........... MS–DRG title 06 SURG ...... No ............ No ............ No ............ 06 06 06 MED ......... MED ......... MED ......... Yes .......... No ............ 06 MED ......... 372 ........... Yes .......... No ............ 06 MED ......... 373 ........... Yes .......... No ............ 06 MED ......... 374 375 376 377 378 379 380 381 382 383 384 385 386 387 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... Yes .......... Yes .......... Yes .......... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ No ............ No ............ No No No No No No No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ 06 06 06 06 06 06 06 06 06 06 06 06 06 06 MED MED MED MED MED MED MED MED MED MED MED MED MED MED ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... 388 389 390 391 ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... No ............ No No No No ............ ............ ............ ............ 06 06 06 06 MED MED MED MED ......... ......... ......... ......... 392 ........... No ............ No ............ 06 MED ......... 393 ........... No ............ No ............ 06 MED ......... 394 ........... No ............ No ............ 06 MED ......... 395 ........... No ............ No ............ 06 MED ......... 405 ........... Yes .......... No ............ 07 SURG ...... 406 ........... Yes .......... No ............ 07 SURG ...... 407 ........... Yes .......... No ............ 07 SURG ...... 408 ........... No ............ No ............ 07 SURG ...... 409 ........... No ............ No ............ 07 SURG ...... 410 ........... No ............ No ............ 07 SURG ...... 411 ........... 412 ........... 413 ........... No ............ No ............ No ............ No ............ No ............ No ............ 07 07 07 SURG ...... SURG ...... SURG ...... 414 ........... Yes .......... No ............ 07 SURG ...... 415 ........... jlentini on PROD1PC65 with PROPOSALS2 Type Yes .......... No ............ 07 SURG ...... 416 ........... Yes .......... No ............ 07 SURG ...... 417 ........... No ............ No ............ 07 SURG ...... 418 ........... No ............ No ............ 07 SURG ...... Other digestive system O.R. procedures w/o CC/MCC. Major esophageal disorders w MCC ... Major esophageal disorders w CC ...... Major esophageal disorders w/o CC/ MCC. Major gastrointestinal disorders & peritoneal infections w MCC. Major gastrointestinal disorders & peritoneal infections w CC. Major gastrointestinal disorders & peritoneal infections w/o CC/MCC. Digestive malignancy w MCC ............. Digestive malignancy w CC ................ Digestive malignancy w/o CC/MCC .... G.I. hemorrhage w MCC ..................... G.I. hemorrhage w CC ........................ G.I. hemorrhage w/o CC/MCC ............ Complicated peptic ulcer w MCC ........ Complicated peptic ulcer w CC ........... Complicated peptic ulcer w/o CC/MCC Uncomplicated peptic ulcer w MCC .... Uncomplicated peptic ulcer w/o MCC Inflammatory bowel disease w MCC .. Inflammatory bowel disease w CC ..... Inflammatory bowel disease w/o CC/ MCC. G.I. obstruction w MCC ....................... G.I. obstruction w CC .......................... G.I. obstruction w/o CC/MCC .............. Esophagitis, gastroent & misc digest disorders w MCC. Esophagitis, gastroent & misc digest disorders w/o MCC. Other digestive system diagnoses w MCC. Other digestive system diagnoses w CC. Other digestive system diagnoses w/o CC/MCC. Pancreas, liver & shunt procedures w MCC. Pancreas, liver & shunt procedures w CC. Pancreas, liver & shunt procedures w/ o CC/MCC. Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC. Biliary tract proc except only cholecyst w or w/o c.d.e. w CC. Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC. Cholecystectomy w c.d.e. w MCC ...... Cholecystectomy w c.d.e. w CC ......... Cholecystectomy w c.d.e. w/o CC/ MCC. Cholecystectomy except by laparoscope w/o c.d.e. w MCC. Cholecystectomy except by laparoscope w/o c.d.e. w CC. Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/ MCC. Laparoscopic cholecystectomy w/o c.d.e. w MCC. Laparoscopic cholecystectomy w/o c.d.e. w CC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00301 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.3493 3.3 4.5 1.6184 1.0703 0.7835 5.1 3.8 2.8 6.6 4.7 3.4 1.9062 6.7 8.7 1.3025 5.6 6.9 0.8646 4.2 4.9 1.9057 1.2523 0.8820 1.6069 1.0048 0.7567 1.7995 1.1138 0.8208 1.1789 0.7818 1.8541 1.0601 0.7746 6.3 4.6 3.2 4.9 3.7 2.9 5.6 4.2 3.1 4.4 3.1 6.5 4.5 3.5 8.6 6.0 4.2 6.4 4.4 3.4 7.3 5.2 3.7 5.5 3.7 8.8 5.7 4.3 1.5392 0.9244 0.6333 1.0810 5.5 4.0 3.0 3.9 7.3 5.0 3.6 5.2 0.6685 2.8 3.5 1.5367 4.9 6.9 0.9489 3.8 4.8 0.6745 2.6 3.3 5.6481 12.4 17.0 2.7895 7.0 9.2 1.8411 4.2 5.5 4.2539 12.1 15.0 2.5819 8.3 9.8 1.6374 5.4 6.5 3.7602 2.3633 1.6896 10.4 7.5 5.0 12.4 8.6 5.9 3.5777 9.7 11.7 2.0372 6.5 7.6 1.3290 4.1 4.8 2.4851 6.5 8.4 1.6541 4.5 5.6 30APP2 23828 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 419 ........... No ............ No ............ 420 ........... No ............ 421 ........... MS–DRG title 07 SURG ...... No ............ 07 SURG ...... No ............ No ............ 07 SURG ...... 422 ........... No ............ No ............ 07 SURG ...... 423 ........... No ............ No ............ 07 SURG ...... 424 ........... No ............ No ............ 07 SURG ...... 425 ........... No ............ No ............ 07 SURG ...... 432 ........... 433 ........... 434 ........... No ............ No ............ No ............ No ............ No ............ No ............ 07 07 07 MED ......... MED ......... MED ......... 435 ........... No ............ No ............ 07 MED ......... 436 ........... No ............ No ............ 07 MED ......... 437 ........... No ............ No ............ 07 MED ......... 438 ........... No ............ No ............ 07 MED ......... 439 ........... No ............ No ............ 07 MED ......... 440 ........... No ............ No ............ 07 MED ......... 441 ........... Yes .......... No ............ 07 MED ......... 442 ........... Yes .......... No ............ 07 MED ......... 443 ........... Yes .......... No ............ 07 MED ......... 444 ........... 445 ........... 446 ........... No ............ No ............ No ............ No ............ No ............ No ............ 07 07 07 MED ......... MED ......... MED ......... 453 ........... No ............ No ............ 08 SURG ...... 454 ........... No ............ No ............ 08 SURG ...... 455 ........... No ............ No ............ 08 SURG ...... 456 ........... No ............ No ............ 08 SURG ...... 457 ........... No ............ No ............ 08 SURG ...... 458 ........... No ............ No ............ 08 SURG ...... 459 ........... 460 ........... 461 ........... Yes .......... Yes .......... No ............ No ............ No ............ No ............ 08 08 08 SURG ...... SURG ...... SURG ...... 462 ........... jlentini on PROD1PC65 with PROPOSALS2 Type No ............ No ............ 08 SURG ...... 463 ........... Yes .......... No ............ 08 SURG ...... 464 ........... Yes .......... No ............ 08 SURG ...... 465 ........... Yes .......... No ............ 08 SURG ...... 466 ........... Yes .......... No ............ 08 SURG ...... Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC. Hepatobiliary diagnostic procedures w MCC. Hepatobiliary diagnostic procedures w CC. Hepatobiliary diagnostic procedures w/o CC/MCC. Other hepatobiliary or pancreas O.R. procedures w MCC. Other hepatobiliary or pancreas O.R. procedures w CC. Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC. Cirrhosis & alcoholic hepatitis w MCC Cirrhosis & alcoholic hepatitis w CC ... Cirrhosis & alcoholic hepatitis w/o CC/ MCC. Malignancy of hepatobiliary system or pancreas w MCC. Malignancy of hepatobiliary system or pancreas w CC. Malignancy of hepatobiliary system or pancreas w/o CC/MCC. Disorders of pancreas except malignancy w MCC. Disorders of pancreas except malignancy w CC. Disorders of pancreas except malignancy w/o CC/MCC. Disorders of liver except malig, cirr, alc hepa w MCC. Disorders of liver except malig, cirr, alc hepa w CC. Disorders of liver except malig, cirr, alc hepa w/o CC/MCC. Disorders of the biliary tract w MCC ... Disorders of the biliary tract w CC ...... Disorders of the biliary tract w/o CC/ MCC. Combined anterior/posterior spinal fusion w MCC. Combined anterior/posterior spinal fusion w CC. Combined anterior/posterior spinal fusion w/o CC/MCC. Spinal fus exc cerv w spinal curv/ malig/infec or 9+ fus w MCC. Spinal fus exc cerv w spinal curv/ malig/infec or 9+ fus w CC. Spinal fus exc cerv w spinal curv/ malig/infec or 9+ fus w/o CC/MCC. Spinal fusion except cervical w MCC Spinal fusion except cervical w/o MCC Bilateral or multiple major joint procs of lower extremity w MCC. Bilateral or multiple major joint procs of lower extremity w/o MCC. Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w MCC. Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w CC. Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC. Revision of hip or knee replacement w MCC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00302 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.1296 2.5 3.2 4.0976 9.9 13.7 1.8978 5.6 7.7 1.2275 3.2 4.4 4.5535 11.8 15.9 2.5159 7.9 10.4 1.3760 4.0 5.4 1.6776 0.9378 0.6551 5.2 3.8 2.9 7.0 4.9 3.7 1.7117 5.7 7.6 1.1892 4.5 5.8 0.9506 3.2 4.3 1.6992 5.5 7.5 1.0223 4.2 5.3 0.6963 3.2 3.8 1.6580 5.1 7.0 0.9825 3.9 5.1 0.6945 3.0 3.8 1.5579 1.0375 0.7225 5.0 3.8 2.6 6.6 4.7 3.3 9.8724 12.0 15.7 7.0370 6.5 8.0 5.1744 3.7 4.4 8.5225 11.6 14.7 5.6672 6.2 7.5 4.7056 4.0 4.5 5.9847 3.5746 4.5636 7.6 3.6 6.8 9.4 4.2 8.4 3.1564 3.9 4.2 4.6669 12.0 16.6 2.6117 7.7 10.2 1.4955 4.4 5.9 4.5564 7.4 9.2 30APP2 23829 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 467 ........... Yes .......... No ............ 468 ........... Yes .......... 469 ........... MS–DRG title 08 SURG ...... No ............ 08 SURG ...... Yes .......... No ............ 08 SURG ...... 470 ........... Yes .......... No ............ 08 SURG ...... 471 472 473 474 ........... ........... ........... ........... No ............ No ............ No ............ Yes .......... No No No No ............ ............ ............ ............ 08 08 08 08 SURG SURG SURG SURG 475 ........... Yes .......... No ............ 08 SURG ...... 476 ........... Yes .......... No ............ 08 SURG ...... 477 ........... Yes .......... Yes .......... 08 SURG ...... 478 ........... Yes .......... Yes .......... 08 SURG ...... 479 ........... Yes .......... Yes .......... 08 SURG ...... 480 ........... Yes .......... Yes .......... 08 SURG ...... 481 ........... Yes .......... Yes .......... 08 SURG ...... 482 ........... Yes .......... Yes .......... 08 SURG ...... 483 ........... Yes .......... No ............ 08 SURG ...... 484 ........... Yes .......... No ............ 08 SURG ...... 485 ........... No ............ No ............ 08 SURG ...... 486 ........... No ............ No ............ 08 SURG ...... 487 ........... No ............ No ............ 08 SURG ...... 488 ........... Yes .......... No ............ 08 SURG ...... 489 ........... Yes .......... No ............ 08 SURG ...... 490 ........... No ............ No ............ 08 SURG ...... 491 ........... No ............ No ............ 08 SURG ...... 492 ........... Yes .......... Yes .......... 08 SURG ...... 493 ........... Yes .......... Yes .......... 08 SURG ...... 494 ........... Yes .......... Yes .......... 08 SURG ...... 495 ........... Yes .......... No ............ 08 SURG ...... 496 ........... Yes .......... No ............ 08 SURG ...... 497 ........... jlentini on PROD1PC65 with PROPOSALS2 Type Yes .......... No ............ 08 SURG ...... 498 ........... No ............ No ............ 08 SURG ...... 499 ........... No ............ No ............ 08 SURG ...... 500 501 502 503 Yes .......... Yes .......... Yes .......... No ............ Yes .......... Yes .......... Yes .......... No ............ 08 08 08 08 SURG SURG SURG SURG Revision of hip or knee replacement w CC. Revision of hip or knee replacement w/o CC/MCC. Major joint replacement or reattachment of lower extremity w MCC. Major joint replacement or reattachment of lower extremity w/o MCC. Cervical spinal fusion w MCC ............. Cervical spinal fusion w CC ................ Cervical spinal fusion w/o CC/MCC .... Amputation for musculoskeletal sys & conn tissue dis w MCC. Amputation for musculoskeletal sys & conn tissue dis w CC. Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC. Biopsies of musculoskeletal system & connective tissue w MCC. Biopsies of musculoskeletal system & connective tissue w CC. Biopsies of musculoskeletal system & connective tissue w/o CC/MCC. Hip & femur procedures except major joint w MCC. Hip & femur procedures except major joint w CC. Hip & femur procedures except major joint w/o CC/MCC. Major joint & limb reattachment proc of upper extremity w CC/MCC. Major joint & limb reattachment proc of upper extremity w/o CC/MCC. Knee procedures w pdx of infection w MCC. Knee procedures w pdx of infection w CC. Knee procedures w pdx of infection w/ o CC/MCC. Knee procedures w/o pdx of infection w CC/MCC. Knee procedures w/o pdx of infection w/o CC/MCC. Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim. Back & neck proc exc spinal fusion w/ o CC/MCC. Lower extrem & humer proc except hip,foot,femur w MCC. Lower extrem & humer proc except hip,foot,femur w CC. Lower extrem & humer proc except hip,foot,femur w/o CC/MCC. Local excision & removal int fix devices exc hip & femur w MCC. Local excision & removal int fix devices exc hip & femur w CC. Local excision & removal int fix devices exc hip & femur w/o CC/MCC. Local excision & removal int fix devices of hip & femur w CC/MCC. Local excision & removal int fix devices of hip & femur w/o CC/MCC. Soft tissue procedures w MCC ........... Soft tissue procedures w CC .............. Soft tissue procedures w/o CC/MCC .. Foot procedures w MCC ..................... ........... ........... ........... ........... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ...... ...... ...... ...... ...... ...... ...... ...... Frm 00303 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 3.0720 4.8 5.5 2.4597 3.6 3.9 3.2979 6.9 8.2 2.0144 3.6 3.9 4.4277 2.6200 1.9213 3.4435 7.0 2.8 1.6 9.5 9.8 4.1 2.0 12.6 1.9768 6.5 8.4 1.1001 3.7 4.8 3.2545 8.9 11.9 2.1266 4.6 6.6 1.4779 1.9 2.8 2.9050 7.8 9.3 1.8204 5.4 5.9 1.4976 4.5 4.8 2.2601 3.4 4.2 1.7535 2.1 2.4 3.3033 9.8 12.1 2.1664 6.8 8.0 1.5507 4.9 5.7 1.6836 4.1 5.2 1.1604 2.6 3.0 1.7221 3.0 4.3 0.9413 1.8 2.2 2.7705 6.8 8.5 1.7631 4.3 5.3 1.2385 2.8 3.4 3.1782 8.1 11.0 1.7775 4.6 6.0 1.1277 2.3 3.0 2.0274 5.5 7.9 0.9097 2.3 3.0 2.8423 1.4718 0.9585 2.3059 7.8 4.5 2.3 7.2 10.8 6.0 2.9 9.5 30APP2 23830 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG 504 505 506 507 ........... ........... ........... ........... FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG No No No No No No No No ............ ............ ............ ............ MDC Type ............ ............ ............ ............ 08 08 08 08 SURG SURG SURG SURG ...... ...... ...... ...... 508 ........... No ............ No ............ 08 SURG ...... 509 ........... 510 ........... No ............ Yes .......... No ............ No ............ 08 08 SURG ...... SURG ...... 511 ........... Yes .......... No ............ 08 SURG ...... 512 ........... Yes .......... No ............ 08 SURG ...... 513 ........... No ............ No ............ 08 SURG ...... 514 ........... No ............ No ............ 08 SURG ...... 515 ........... Yes .......... Yes .......... 08 SURG ...... 516 ........... Yes .......... Yes .......... 08 SURG ...... 517 ........... Yes .......... Yes .......... 08 SURG ...... 533 534 535 536 537 ........... ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... Yes .......... No ............ No No No No No ............ ............ ............ ............ ............ 08 08 08 08 08 MED MED MED MED MED 538 ........... No ............ No ............ 08 MED ......... 539 540 541 542 Yes Yes Yes Yes No No No No ............ ............ ............ ............ 08 08 08 08 MED MED MED MED ........... ........... ........... ........... .......... .......... .......... .......... ......... ......... ......... ......... ......... ......... ......... ......... ......... Yes .......... No ............ 08 MED ......... 544 ........... Yes .......... No ............ 08 MED ......... 545 ........... 546 ........... 547 ........... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ 08 08 08 MED ......... MED ......... MED ......... 548 549 550 551 552 553 ........... ........... ........... ........... ........... ........... No ............ No ............ No ............ Yes .......... Yes .......... No ............ No No No No No No ............ ............ ............ ............ ............ ............ 08 08 08 08 08 08 MED MED MED MED MED MED 554 ........... No ............ No ............ 08 MED ......... 555 ........... jlentini on PROD1PC65 with PROPOSALS2 543 ........... No ............ No ............ 08 MED ......... 556 ........... No ............ No ............ 08 MED ......... 557 ........... 558 ........... Yes .......... Yes .......... No ............ No ............ 08 08 MED ......... MED ......... 559 ........... Yes .......... No ............ 08 MED ......... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ......... ......... ......... ......... ......... ......... MS–DRG title Foot procedures w CC ........................ Foot procedures w/o CC/MCC ............ Major thumb or joint procedures ......... Major shoulder or elbow joint procedures w CC/MCC. Major shoulder or elbow joint procedures w/o CC/MCC. Arthroscopy ......................................... Shoulder,elbow or forearm proc, exc major joint proc w MCC. Shoulder,elbow or forearm proc, exc major joint proc w CC. Shoulder,elbow or forearm proc, exc major joint proc w/o CC/MCC. Hand or wrist proc, except major thumb or joint proc w CC/MCC. Hand or wrist proc, except major thumb or joint proc w/o CC/MCC. Other musculoskelet sys & conn tiss O.R. proc w MCC. Other musculoskelet sys & conn tiss O.R. proc w CC. Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC. Fractures of femur w MCC .................. Fractures of femur w/o MCC ............... Fractures of hip & pelvis w MCC ........ Fractures of hip & pelvis w/o MCC ..... Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC. Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC. Osteomyelitis w MCC .......................... Osteomyelitis w CC ............................. Osteomyelitis w/o CC/MCC ................. Pathological fractures & musculoskelet & conn tiss malig w MCC. Pathological fractures & musculoskelet & conn tiss malig w CC. Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC. Connective tissue disorders w MCC ... Connective tissue disorders w CC ...... Connective tissue disorders w/o CC/ MCC. Septic arthritis w MCC ........................ Septic arthritis w CC ........................... Septic arthritis w/o CC/MCC ............... Medical back problems w MCC .......... Medical back problems w/o MCC ....... Bone diseases & arthropathies w MCC. Bone diseases & arthropathies w/o MCC. Signs & symptoms of musculoskeletal system & conn tissue w MCC. Signs & symptoms of musculoskeletal system & conn tissue w/o MCC. Tendonitis, myositis & bursitis w MCC Tendonitis, myositis & bursitis w/o MCC. Aftercare, musculoskeletal system & connective tissue w MCC. Frm 00304 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.4725 0.9882 1.0286 1.7188 5.1 2.6 2.5 3.7 6.5 3.4 3.4 5.1 1.1156 1.7 2.1 1.1762 1.9973 2.0 4.9 3.1 6.4 1.3434 3.2 4.0 0.9533 1.8 2.2 1.2813 3.6 5.0 0.8067 2.1 2.8 3.0601 7.9 10.4 1.8073 4.5 6.0 1.3326 2.1 3.0 1.4207 0.7318 1.3327 0.6934 0.8871 4.8 3.3 4.8 3.4 3.6 6.7 4.0 6.2 3.9 4.5 0.5787 2.7 3.2 2.0097 1.3457 0.9285 1.8953 7.5 5.7 4.2 6.7 9.7 7.1 5.4 8.8 1.1263 4.8 5.9 0.7672 3.7 4.4 2.3477 1.0951 0.7224 6.5 4.4 3.1 9.1 5.5 3.8 1.8776 1.1590 0.8006 1.5261 0.7623 1.0978 6.7 5.1 3.7 5.4 3.4 4.7 8.9 6.4 4.5 7.1 4.1 6.0 0.6305 3.0 3.7 1.0014 3.6 4.8 0.5738 2.5 3.1 1.4264 0.8009 5.2 3.5 6.6 4.3 1.7085 5.3 7.6 30APP2 23831 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 560 ........... Yes .......... No ............ 561 ........... Yes .......... 562 ........... MS–DRG title 08 MED ......... No ............ 08 MED ......... Yes .......... No ............ 08 MED ......... 563 ........... Yes .......... No ............ 08 MED ......... 564 ........... No ............ No ............ 08 MED ......... 565 ........... No ............ No ............ 08 MED ......... 566 ........... No ............ No ............ 08 MED ......... 573 ........... Yes .......... No ............ 09 SURG ...... 574 ........... Yes .......... No ............ 09 SURG ...... 575 ........... Yes .......... No ............ 09 SURG ...... 576 ........... No ............ No ............ 09 SURG ...... 577 ........... No ............ No ............ 09 SURG ...... 578 ........... No ............ No ............ 09 SURG ...... 579 ........... Yes .......... No ............ 09 SURG ...... 580 ........... Yes .......... No ............ 09 SURG ...... 581 ........... Yes .......... No ............ 09 SURG ...... 582 ........... No ............ No ............ 09 SURG ...... 583 ........... No ............ No ............ 09 SURG ...... 584 ........... No ............ No ............ 09 SURG ...... 585 ........... No ............ No ............ 09 SURG ...... 592 593 594 595 596 597 598 599 ........... ........... ........... ........... ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ No ............ No ............ No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ 09 09 09 09 09 09 09 09 MED MED MED MED MED MED MED MED 600 ........... No ............ No ............ 09 MED ......... 601 ........... No ............ No ............ 09 MED ......... 602 ........... 603 ........... 604 ........... Yes .......... Yes .......... No ............ No ............ No ............ No ............ 09 09 09 MED ......... MED ......... MED ......... 605 ........... jlentini on PROD1PC65 with PROPOSALS2 Type No ............ No ............ 09 MED ......... 606 ........... 607 ........... 614 ........... No ............ No ............ No ............ No ............ No ............ No ............ 09 09 10 MED ......... MED ......... SURG ...... 615 ........... No ............ No ............ 10 SURG ...... 616 ........... Yes .......... No ............ 10 SURG ...... Aftercare, musculoskeletal system & connective tissue w CC. Aftercare, musculoskeletal system & connective tissue w/o CC/MCC. Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC. Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC. Other musculoskeletal sys & connective tissue diagnoses w MCC. Other musculoskeletal sys & connective tissue diagnoses w CC. Other musculoskeletal sys & connective tissue diagnoses w/o CC/MCC. Skin graft &/or debrid for skn ulcer or cellulitis w MCC. Skin graft &/or debrid for skn ulcer or cellulitis w CC. Skin graft &/or debrid for skn ulcer or cellulitis w/o CC/MCC. Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC. Skin graft &/or debrid exc for skin ulcer or cellulitis w CC. Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC. Other skin, subcut tiss & breast proc w MCC. Other skin, subcut tiss & breast proc w CC. Other skin, subcut tiss & breast proc w/o CC/MCC. Mastectomy for malignancy w CC/ MCC. Mastectomy for malignancy w/o CC/ MCC. Breast biopsy, local excision & other breast procedures w CC/MCC. Breast biopsy, local excision & other breast procedures w/o CC/MCC. Skin ulcers w MCC .............................. Skin ulcers w CC ................................. Skin ulcers w/o CC/MCC .................... Major skin disorders w MCC ............... Major skin disorders w/o MCC ............ Malignant breast disorders w MCC ..... Malignant breast disorders w CC ........ Malignant breast disorders w/o CC/ MCC. Non-malignant breast disorders w CC/ MCC. Non-malignant breast disorders w/o CC/MCC. Cellulitis w MCC .................................. Cellulitis w/o MCC ............................... Trauma to the skin, subcut tiss & breast w MCC. Trauma to the skin, subcut tiss & breast w/o MCC. Minor skin disorders w MCC ............... Minor skin disorders w/o MCC ............ Adrenal & pituitary procedures w CC/ MCC. Adrenal & pituitary procedures w/o CC/MCC. Amputat of lower limb for endocrine, nutrit, & metabol dis w MCC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ......... ......... ......... ......... ......... ......... ......... ......... Frm 00305 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 0.9491 3.6 4.7 0.5794 2.1 2.8 1.3933 4.9 6.4 0.6749 3.1 3.7 1.4053 5.2 7.0 0.8848 3.9 5.0 0.6673 3.0 3.7 3.1703 9.6 13.1 1.9362 7.1 9.3 1.1176 4.7 5.9 3.4522 8.4 13.0 1.5788 4.2 6.1 0.9803 2.4 3.3 2.7821 7.8 10.7 1.4093 3.7 5.5 0.8606 1.9 2.6 0.9682 2.1 2.8 0.7498 1.6 1.8 1.4344 4.0 6.0 0.7995 1.7 2.2 1.7469 1.1021 0.7871 1.8159 0.8200 1.6001 1.0812 0.7309 6.6 5.2 4.1 6.2 3.8 5.9 4.3 2.7 8.9 6.4 5.1 8.3 4.8 8.2 5.7 3.7 0.9433 4.1 5.1 0.6539 3.1 3.9 1.3980 0.7988 1.1875 5.5 3.9 4.3 7.0 4.7 5.7 0.6739 2.8 3.5 1.2415 0.6434 2.5046 4.4 2.9 5.1 6.3 3.8 7.0 1.3782 2.7 3.2 4.6284 13.3 16.9 30APP2 23832 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 617 ........... Yes .......... No ............ 618 ........... Yes .......... 619 ........... 620 ........... 621 ........... Type MS–DRG title 10 SURG ...... No ............ 10 SURG ...... No ............ No ............ No ............ No ............ No ............ No ............ 10 10 10 SURG ...... SURG ...... SURG ...... 622 ........... Yes .......... No ............ 10 SURG ...... 623 ........... Yes .......... No ............ 10 SURG ...... 624 ........... Yes .......... No ............ 10 SURG ...... 625 ........... No ............ No ............ 10 SURG ...... 626 ........... No ............ No ............ 10 SURG ...... 627 ........... No ............ No ............ 10 SURG ...... 628 ........... Yes .......... No ............ 10 SURG ...... 629 ........... Yes .......... No ............ 10 SURG ...... 630 ........... Yes .......... No ............ 10 SURG ...... 637 638 639 640 Yes Yes Yes Yes No No No No ............ ............ ............ ............ 10 10 10 10 MED MED MED MED Amputat of lower limb for endocrine, nutrit, & metabol dis w CC. Amputat of lower limb for endocrine, nutrit, & metabol dis w/o CC/MCC. O.R. procedures for obesity w MCC ... O.R. procedures for obesity w CC ...... O.R. procedures for obesity w/o CC/ MCC. Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC. Skin grafts & wound debrid for endoc, nutrit & metab dis w CC. Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC. Thyroid, parathyroid & thyroglossal procedures w MCC. Thyroid, parathyroid & thyroglossal procedures w CC. Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC. Other endocrine, nutrit & metab O.R. proc w MCC. Other endocrine, nutrit & metab O.R. proc w CC. Other endocrine, nutrit & metab O.R. proc w/o CC/MCC. Diabetes w MCC ................................. Diabetes w CC .................................... Diabetes w/o CC/MCC ........................ Nutritional & misc metabolic disorders w MCC. Nutritional & misc metabolic disorders w/o MCC. Inborn errors of metabolism ................ Endocrine disorders w MCC ............... Endocrine disorders w CC .................. Endocrine disorders w/o CC/MCC ...... Kidney transplant ................................. Major bladder procedures w MCC ...... Major bladder procedures w CC ......... Major bladder procedures w/o CC/ MCC. Kidney & ureter procedures for neoplasm w MCC. Kidney & ureter procedures for neoplasm w CC. Kidney & ureter procedures for neoplasm w/o CC/MCC. Kidney & ureter procedures for nonneoplasm w MCC. Kidney & ureter procedures for nonneoplasm w CC. Kidney & ureter procedures for nonneoplasm w/o CC/MCC. Minor bladder procedures w MCC ...... Minor bladder procedures w CC ......... Minor bladder procedures w/o CC/ MCC. Prostatectomy w MCC ........................ Prostatectomy w CC ........................... Prostatectomy w/o CC/MCC ............... Transurethral procedures w MCC ....... Transurethral procedures w CC .......... Transurethral procedures w/o CC/ MCC. Urethral procedures w CC/MCC ......... Urethral procedures w/o CC/MCC ...... ........... ........... ........... ........... .......... .......... .......... .......... ......... ......... ......... ......... Yes .......... No ............ 10 MED ......... 642 643 644 645 652 653 654 655 ........... ........... ........... ........... ........... ........... ........... ........... No ............ Yes .......... Yes .......... Yes .......... No ............ Yes .......... Yes .......... Yes .......... No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ 10 10 10 10 11 11 11 11 MED ......... MED ......... MED ......... MED ......... SURG ...... SURG ...... SURG ...... SURG ...... 656 ........... No ............ No ............ 11 SURG ...... 657 ........... No ............ No ............ 11 SURG ...... 658 ........... No ............ No ............ 11 SURG ...... 659 ........... Yes .......... No ............ 11 SURG ...... 660 ........... Yes .......... No ............ 11 SURG ...... 661 ........... Yes .......... No ............ 11 SURG ...... 662 ........... 663 ........... 664 ........... jlentini on PROD1PC65 with PROPOSALS2 641 ........... No ............ No ............ No ............ No ............ No ............ No ............ 11 11 11 SURG ...... SURG ...... SURG ...... 665 666 667 668 669 670 No No No No No No No No No No No No ............ ............ ............ ............ ............ ............ 11 11 11 11 11 11 SURG SURG SURG SURG SURG SURG No ............ No ............ 11 11 SURG ...... SURG ...... ........... ........... ........... ........... ........... ........... 671 ........... 672 ........... VerDate Aug<31>2005 ............ ............ ............ ............ ............ ............ No ............ No ............ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ...... ...... ...... ...... ...... ...... Frm 00306 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 2.0940 7.0 8.8 1.3234 5.1 6.4 3.3383 1.8739 1.4269 5.2 2.9 1.9 8.2 3.7 2.2 3.1268 9.4 13.2 1.8728 6.7 8.6 1.0877 4.8 6.0 2.1260 4.7 7.1 1.1284 2.1 3.1 0.7378 1.3 1.5 3.2732 7.5 11.2 2.2931 6.9 8.7 1.5069 4.0 5.5 1.3538 0.8135 0.5577 1.1105 4.5 3.4 2.5 3.9 6.1 4.3 3.0 5.4 0.6798 3.1 3.8 1.0169 1.6408 1.0437 0.7164 2.9787 5.8091 2.9531 2.0241 3.7 5.8 4.4 3.1 6.6 13.6 8.7 5.7 5.2 7.6 5.5 3.9 7.8 16.9 9.9 6.5 3.2762 8.0 10.1 1.8655 5.0 6.0 1.3790 3.3 3.7 3.3225 8.0 11.2 1.8913 4.8 6.5 1.2600 2.6 3.3 2.7078 1.4443 0.9940 7.4 3.7 1.6 10.3 5.3 2.1 2.5635 1.5553 0.8259 2.2348 1.2049 0.7672 8.2 4.3 2.1 6.2 3.1 1.9 11.1 6.4 2.9 8.5 4.4 2.5 1.4136 0.7962 4.1 1.9 5.9 2.5 30APP2 23833 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 673 ........... No ............ No ............ 674 ........... No ............ 675 ........... 682 683 684 685 686 Type MS–DRG title 11 SURG ...... No ............ 11 SURG ...... No ............ No ............ 11 SURG ...... ........... ........... ........... ........... ........... Yes .......... Yes .......... Yes .......... No ............ No ............ No No No No No ............ ............ ............ ............ ............ 11 11 11 11 11 MED MED MED MED MED 687 ........... No ............ No ............ 11 MED ......... 688 ........... No ............ No ............ 11 MED ......... 689 ........... Yes .......... No ............ 11 MED ......... 690 ........... Yes .......... No ............ 11 MED ......... 691 ........... No ............ No ............ 11 MED ......... 692 ........... No ............ No ............ 11 MED ......... 693 ........... No ............ No ............ 11 MED ......... 694 ........... No ............ No ............ 11 MED ......... 695 ........... No ............ No ............ 11 MED ......... 696 ........... No ............ No ............ 11 MED ......... 697 ........... 698 ........... No ............ Yes .......... No ............ No ............ 11 11 MED ......... MED ......... 699 ........... Yes .......... No ............ 11 MED ......... 700 ........... Yes .......... No ............ 11 MED ......... 707 ........... No ............ No ............ 12 SURG ...... 708 ........... No ............ No ............ 12 SURG ...... 709 710 711 712 713 No No No No No No No No No No ............ ............ ............ ............ ............ 12 12 12 12 12 SURG SURG SURG SURG SURG Other kidney & urinary tract procedures w MCC. Other kidney & urinary tract procedures w CC. Other kidney & urinary tract procedures w/o CC/MCC. Renal failure w MCC ........................... Renal failure w CC .............................. Renal failure w/o CC/MCC .................. Admit for renal dialysis ........................ Kidney & urinary tract neoplasms w MCC. Kidney & urinary tract neoplasms w CC. Kidney & urinary tract neoplasms w/o CC/MCC. Kidney & urinary tract infections w MCC. Kidney & urinary tract infections w/o MCC. Urinary stones w esw lithotripsy w CC/MCC. Urinary stones w esw lithotripsy w/o CC/MCC. Urinary stones w/o esw lithotripsy w MCC. Urinary stones w/o esw lithotripsy w/o MCC. Kidney & urinary tract signs & symptoms w MCC. Kidney & urinary tract signs & symptoms w/o MCC. Urethral stricture .................................. Other kidney & urinary tract diagnoses w MCC. Other kidney & urinary tract diagnoses w CC. Other kidney & urinary tract diagnoses w/o CC/MCC. Major male pelvic procedures w CC/ MCC. Major male pelvic procedures w/o CC/ MCC. Penis procedures w CC/MCC ............. Penis procedures w/o CC/MCC .......... Testes procedures w CC/MCC ........... Testes procedures w/o CC/MCC ........ Transurethral prostatectomy w CC/ MCC. Transurethral prostatectomy w/o CC/ MCC. Other male reproductive system O.R. proc for malignancy w CC/MCC. Other male reproductive system O.R. proc for malignancy w/o CC/MCC. Other male reproductive system O.R. proc exc malignancy w CC/MCC. Other male reproductive system O.R. proc exc malignancy w/o CC/MCC. Malignancy, male reproductive system w MCC. Malignancy, male reproductive system w CC. Malignancy, male reproductive system w/o CC/MCC. Benign prostatic hypertrophy w MCC ........... ........... ........... ........... ........... ............ ............ ............ ............ ............ ......... ......... ......... ......... ......... ...... ...... ...... ...... ...... No ............ No ............ 12 SURG ...... 715 ........... No ............ No ............ 12 SURG ...... 716 ........... No ............ No ............ 12 SURG ...... 717 ........... No ............ No ............ 12 SURG ...... 718 ........... jlentini on PROD1PC65 with PROPOSALS2 714 ........... No ............ No ............ 12 SURG ...... 722 ........... No ............ No ............ 12 MED ......... 723 ........... No ............ No ............ 12 MED ......... 724 ........... No ............ No ............ 12 MED ......... 725 ........... No ............ No ............ 12 MED ......... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00307 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 2.7645 5.8 9.7 2.1527 4.6 7.2 1.3137 1.5 2.1 1.6374 1.1270 0.7278 0.8578 1.6240 5.2 4.5 3.2 2.5 5.6 7.2 5.7 3.9 3.5 7.6 1.0719 4.1 5.4 0.6816 2.5 3.3 1.2271 4.9 6.2 0.7559 3.5 4.2 1.4503 2.9 4.0 1.1528 1.9 2.4 1.1915 3.6 4.8 0.6573 2.0 2.6 1.1723 4.2 5.5 0.6308 2.6 3.3 0.6938 1.4719 2.4 5.0 3.1 6.7 0.9700 3.7 4.8 0.6813 2.8 3.6 1.6265 3.4 4.4 1.1839 1.8 2.1 1.8803 1.2586 2.0318 0.8077 1.1188 3.8 1.4 5.5 2.2 2.9 6.5 1.8 8.2 3.0 4.2 0.6333 1.7 1.9 1.7120 3.9 6.3 0.9713 1.2 1.4 1.8091 5.1 7.2 0.7849 2.2 2.8 1.5588 5.7 7.6 0.9901 4.1 5.3 0.6006 2.4 3.2 1.0462 4.2 5.5 30APP2 23834 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 726 ........... No ............ No ............ 727 ........... No ............ 728 ........... MS–DRG title 12 MED ......... No ............ 12 MED ......... No ............ No ............ 12 MED ......... 729 ........... No ............ No ............ 12 MED ......... 730 ........... No ............ No ............ 12 MED ......... 734 ........... No ............ No ............ 13 SURG ...... 735 ........... No ............ No ............ 13 SURG ...... 736 ........... No ............ No ............ 13 SURG ...... 737 ........... No ............ No ............ 13 SURG ...... 738 ........... No ............ No ............ 13 SURG ...... 739 ........... No ............ No ............ 13 SURG ...... 740 ........... No ............ No ............ 13 SURG ...... 741 ........... No ............ No ............ 13 SURG ...... 742 ........... No ............ No ............ 13 SURG ...... 743 ........... No ............ No ............ 13 SURG ...... 744 ........... No ............ No ............ 13 SURG ...... 745 ........... No ............ No ............ 13 SURG ...... 746 ........... No ............ No ............ 13 SURG ...... 747 ........... No ............ No ............ 13 SURG ...... 748 ........... No ............ No ............ 13 SURG ...... 749 ........... No ............ No ............ 13 SURG ...... 750 ........... No ............ No ............ 13 SURG ...... 754 ........... No ............ No ............ 13 MED ......... 755 ........... No ............ No ............ 13 MED ......... 756 ........... No ............ No ............ 13 MED ......... 757 ........... No ............ No ............ 13 MED ......... 758 ........... No ............ No ............ 13 MED ......... 759 ........... No ............ No ............ 13 MED ......... 760 ........... jlentini on PROD1PC65 with PROPOSALS2 Type No ............ No ............ 13 MED ......... 761 ........... No ............ No ............ 13 MED ......... 765 ........... 766 ........... 767 ........... No ............ No ............ No ............ No ............ No ............ No ............ 14 14 14 SURG ...... SURG ...... SURG ...... 768 ........... No ............ No ............ 14 SURG ...... Benign prostatic hypertrophy w/o MCC. Inflammation of the male reproductive system w MCC. Inflammation of the male reproductive system w/o MCC. Other male reproductive system diagnoses w CC/MCC. Other male reproductive system diagnoses w/o CC/MCC. Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC. Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC. Uterine & adnexa proc for ovarian or adnexal malignancy w MCC. Uterine & adnexa proc for ovarian or adnexal malignancy w CC. Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC. Uterine, adnexa proc for non-ovarian/ adnexal malig w MCC. Uterine, adnexa proc for non-ovarian/ adnexal malig w CC. Uterine, adnexa proc for non-ovarian/ adnexal malig w/o CC/MCC. Uterine & adnexa proc for non-malignancy w CC/MCC. Uterine & adnexa proc for non-malignancy w/o CC/MCC. D&C, conization, laparoscopy & tubal interruption w CC/MCC. D&C, conization, laparoscopy & tubal interruption w/o CC/MCC. Vagina, cervix & vulva procedures w CC/MCC. Vagina, cervix & vulva procedures w/o CC/MCC. Female reproductive system reconstructive procedures. Other female reproductive system O.R. procedures w CC/MCC. Other female reproductive system O.R. procedures w/o CC/MCC. Malignancy, female reproductive system w MCC. Malignancy, female reproductive system w CC. Malignancy, female reproductive system w/o CC/MCC. Infections, female reproductive system w MCC. Infections, female reproductive system w CC. Infections, female reproductive system w/o CC/MCC. Menstrual & other female reproductive system disorders w CC/MCC. Menstrual & other female reproductive system disorders w/o CC/MCC. Cesarean section w CC/MCC ............. Cesarean section w/o CC/MCC .......... Vaginal delivery w sterilization &/or D&C. Vaginal delivery w O.R. proc except steril &/or D&C. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00308 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 0.6675 2.7 3.5 1.3016 5.0 6.4 0.6911 3.3 4.0 1.0993 4.0 5.6 0.5963 2.4 3.1 2.3505 6.0 8.0 1.1311 2.9 3.4 4.1736 11.2 13.8 1.9577 6.0 7.2 1.1577 3.5 3.9 3.0131 7.8 10.2 1.4661 4.3 5.2 1.0021 2.7 3.0 1.3433 3.5 4.5 0.8469 2.0 2.3 1.3918 4.1 5.8 0.7460 2.1 2.6 1.2662 3.0 4.2 0.8403 1.6 1.9 0.8193 1.5 1.7 2.4919 6.7 9.3 0.9660 2.5 3.1 1.7520 6.2 8.3 1.0769 4.3 5.7 0.6327 2.5 3.1 1.5775 6.5 8.1 1.0621 4.9 6.1 0.7646 3.6 4.5 0.7917 3.0 4.0 0.5008 1.9 2.4 1.0606 0.7486 0.9741 4.0 3.0 2.6 5.0 3.2 3.4 1.7321 0.0 0.0 30APP2 23835 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 769 ........... No ............ No ............ 770 ........... No ............ 774 ........... Type MS–DRG title 14 SURG ...... No ............ 14 SURG ...... No ............ No ............ 14 MED ......... 775 ........... No ............ No ............ 14 MED ......... 776 ........... No ............ No ............ 14 MED ......... 777 778 779 780 781 No No No No No No No No No No ............ ............ ............ ............ ............ 14 14 14 14 14 MED MED MED MED MED Postpartum & post abortion diagnoses w O.R. procedure. Abortion w D&C, aspiration curettage or hysterotomy. Vaginal delivery w complicating diagnoses. Vaginal delivery w/o complicating diagnoses. Postpartum & post abortion diagnoses w/o O.R. procedure. Ectopic pregnancy ............................... Threatened abortion ............................ Abortion w/o D&C ................................ False labor ........................................... Other antepartum diagnoses w medical complications. Other antepartum diagnoses w/o medical complications. Neonates, died or transferred to another acute care facility. Extreme immaturity or respiratory distress syndrome, neonate. Prematurity w major problems ............ Prematurity w/o major problems ......... Full term neonate w major problems .. Neonate w other significant problems Normal newborn .................................. Splenectomy w MCC ........................... Splenectomy w CC .............................. Splenectomy w/o CC/MCC ................. Other O.R. proc of the blood & blood forming organs w MCC. Other O.R. proc of the blood & blood forming organs w CC. Other O.R. proc of the blood & blood forming organs w/o CC/MCC. Major hematol/immun diag exc sickle cell crisis & coagul w MCC. Major hematol/immun diag exc sickle cell crisis & coagul w CC. Major hematol/immun diag exc sickle cell crisis & coagul w/o CC/MCC. Red blood cell disorders w MCC ........ Red blood cell disorders w/o MCC ..... Coagulation disorders ......................... Reticuloendothelial & immunity disorders w MCC. Reticuloendothelial & immunity disorders w CC. Reticuloendothelial & immunity disorders w/o CC/MCC. Lymphoma & leukemia w major O.R. procedure w MCC. Lymphoma & leukemia w major O.R. procedure w CC. Lymphoma & leukemia w major O.R. procedure w/o CC/MCC. Lymphoma & non-acute leukemia w other O.R. proc w MCC. Lymphoma & non-acute leukemia w other O.R. proc w CC. Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC. Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC. Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC. ........... ........... ........... ........... ........... ............ ............ ............ ............ ............ ......... ......... ......... ......... ......... 782 ........... No ............ No ............ 14 MED ......... 789 ........... No ............ No ............ 15 MED ......... 790 ........... No ............ No ............ 15 MED ......... 791 792 793 794 795 799 800 801 802 No No No No No No No No No No No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ ............ 15 15 15 15 15 16 16 16 16 MED ......... MED ......... MED ......... MED ......... MED ......... SURG ...... SURG ...... SURG ...... SURG ...... ........... ........... ........... ........... ........... ........... ........... ........... ........... ............ ............ ............ ............ ............ ............ ............ ............ ............ 803 ........... No ............ No ............ 16 SURG ...... 804 ........... No ............ No ............ 16 SURG ...... 808 ........... No ............ No ............ 16 MED ......... 809 ........... No ............ No ............ 16 MED ......... 810 ........... No ............ No ............ 16 MED ......... 811 812 813 814 No No No No No No No No ............ ............ ............ ............ 16 16 16 16 MED MED MED MED ........... ........... ........... ........... ............ ............ ............ ............ ......... ......... ......... ......... No ............ No ............ 16 MED ......... 816 ........... No ............ No ............ 16 MED ......... 820 ........... No ............ No ............ 17 SURG ...... 821 ........... No ............ No ............ 17 SURG ...... 822 ........... No ............ No ............ 17 SURG ...... 823 ........... jlentini on PROD1PC65 with PROPOSALS2 815 ........... No ............ No ............ 17 SURG ...... 824 ........... No ............ No ............ 17 SURG ...... 825 ........... No ............ No ............ 17 SURG ...... 826 ........... No ............ No ............ 17 SURG ...... 827 ........... No ............ No ............ 17 SURG ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00309 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.2935 3.2 4.6 0.6677 1.6 2.2 0.6571 2.6 3.2 0.4830 2.0 2.2 0.6192 2.5 3.3 0.7721 0.4373 0.4871 0.1962 0.6154 1.9 2.0 1.6 1.3 2.6 2.2 3.0 2.1 1.5 3.8 0.3926 1.7 2.5 1.4227 0.0 0.0 4.6916 0.0 0.0 3.2042 1.9334 3.2914 1.1650 0.1577 4.7602 2.5819 1.6484 3.3539 0.0 0.0 0.0 0.0 0.0 10.8 6.2 3.8 8.9 0.0 0.0 0.0 0.0 0.0 14.1 7.9 4.9 12.2 1.7689 4.7 6.7 1.0613 2.5 3.4 1.9850 6.3 8.2 1.1737 4.2 5.3 0.8957 3.2 4.0 1.2742 0.7629 1.3556 1.4932 4.0 2.8 3.7 5.0 5.7 3.7 5.1 6.7 0.9973 3.8 5.0 0.6989 2.8 3.5 5.6401 13.3 17.7 2.2489 5.5 7.9 1.2399 2.6 3.5 4.0990 12.1 15.4 2.1791 6.6 8.7 1.2059 3.0 4.3 4.6385 11.1 15.0 2.2759 5.9 8.0 30APP2 23836 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 828 ........... No ............ No ............ 829 ........... No ............ 830 ........... MS–DRG title 17 SURG ...... No ............ 17 SURG ...... No ............ No ............ 17 SURG ...... 834 ........... No ............ No ............ 17 MED ......... 835 ........... No ............ No ............ 17 MED ......... 836 ........... No ............ No ............ 17 MED ......... 837 ........... No ............ No ............ 17 MED ......... 838 ........... No ............ No ............ 17 MED ......... 839 ........... No ............ No ............ 17 MED ......... 840 ........... Yes .......... No ............ 17 MED ......... 841 ........... Yes .......... No ............ 17 MED ......... 842 ........... Yes .......... No ............ 17 MED ......... 843 ........... No ............ No ............ 17 MED ......... 844 ........... No ............ No ............ 17 MED ......... 845 ........... No ............ No ............ 17 MED ......... 846 ........... No ............ No ............ 17 MED ......... 847 ........... No ............ No ............ 17 MED ......... 848 ........... No ............ No ............ 17 MED ......... 849 ........... 853 ........... No ............ Yes .......... No ............ No ............ 17 18 MED ......... SURG ...... 854 ........... Yes .......... No ............ 18 SURG ...... 855 ........... Yes .......... No ............ 18 SURG ...... 856 ........... Yes .......... No ............ 18 SURG ...... 857 ........... Yes .......... No ............ 18 SURG ...... 858 ........... Yes .......... No ............ 18 SURG ...... 862 ........... Yes .......... No ............ 18 MED ......... 863 ........... Yes .......... No ............ 18 MED ......... 864 865 866 867 jlentini on PROD1PC65 with PROPOSALS2 Type ........... ........... ........... ........... No ............ No ............ No ............ Yes .......... No No No No ............ ............ ............ ............ 18 18 18 18 MED MED MED MED 868 ........... Yes .......... No ............ 18 MED ......... 869 ........... Yes .......... No ............ 18 MED ......... 870 ........... Yes .......... No ............ 18 MED ......... 871 ........... Yes .......... No ............ 18 MED ......... Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC. Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC. Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC. Acute leukemia w/o major O.R. procedure w MCC. Acute leukemia w/o major O.R. procedure w CC. Acute leukemia w/o major O.R. procedure w/o CC/MCC. Chemo w acute leukemia as sdx or w high dose chemo agent w MCC. Chemo w acute leukemia as sdx w CC or high dose chemo agent. Chemo w acute leukemia as sdx w/o CC/MCC. Lymphoma & non-acute leukemia w MCC. Lymphoma & non-acute leukemia w CC. Lymphoma & non-acute leukemia w/o CC/MCC. Other myeloprolif dis or poorly diff neopl diag w MCC. Other myeloprolif dis or poorly diff neopl diag w CC. Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC. Chemotherapy w/o acute leukemia as secondary diagnosis w MCC. Chemotherapy w/o acute leukemia as secondary diagnosis w CC. Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC. Radiotherapy ....................................... Infectious & parasitic diseases w O.R. procedure w MCC. Infectious & parasitic diseases w O.R. procedure w CC. Infectious & parasitic diseases w O.R. procedure w/o CC/MCC. Postoperative or post-traumatic infections w O.R. proc w MCC. Postoperative or post-traumatic infections w O.R. proc w CC. Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC. Postoperative & post-traumatic infections w MCC. Postoperative & post-traumatic infections w/o MCC. Fever of unknown origin ...................... Viral illness w MCC ............................. Viral illness w/o MCC .......................... Other infectious & parasitic diseases diagnoses w MCC. Other infectious & parasitic diseases diagnoses w CC. Other infectious & parasitic diseases diagnoses w/o CC/MCC. Septicemia or severe sepsis w MV 96+ hours. Septicemia or severe sepsis w/o MV 96+ hours w MCC. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ......... ......... ......... ......... Frm 00310 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.3050 3.0 3.8 2.8972 7.0 10.7 1.0802 2.5 3.7 4.5854 9.5 15.5 2.5840 6.2 10.4 1.2085 3.4 5.2 6.4047 17.6 23.1 2.9669 7.9 12.3 1.4181 5.0 6.4 2.6031 7.7 10.4 1.5529 5.2 6.9 1.0261 3.4 4.6 1.8203 6.1 8.5 1.2030 4.6 6.1 0.8143 3.3 4.3 2.1299 5.8 8.4 0.9436 2.7 3.4 0.7995 2.5 3.1 1.2021 5.4286 4.4 12.7 6.0 16.7 2.9171 9.1 11.1 1.8093 5.6 7.0 4.7315 11.5 15.4 2.0472 6.6 8.5 1.3563 4.5 5.7 1.9123 6.1 8.2 0.9575 4.2 5.2 0.8224 1.4950 0.6673 2.3423 3.2 4.7 2.8 7.0 4.1 6.7 3.5 9.6 1.0761 4.5 5.8 0.7628 3.5 4.3 5.7422 12.9 15.5 1.8211 5.5 7.5 30APP2 23837 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 872 ........... Yes .......... No ............ 876 ........... No ............ 880 ........... Type MS–DRG title 18 MED ......... No ............ 19 SURG ...... No ............ No ............ 19 MED ......... 881 ........... 882 ........... 883 ........... No ............ No ............ No ............ No ............ No ............ No ............ 19 19 19 MED ......... MED ......... MED ......... 884 ........... Yes .......... No ............ 19 MED ......... 885 886 887 894 No No No No No No No No ............ ............ ............ ............ 19 19 19 20 MED MED MED MED Septicemia or severe sepsis w/o MV 96+ hours w/o MCC. O.R. procedure w principal diagnoses of mental illness. Acute adjustment reaction & psychosocial dysfunction. Depressive neuroses ........................... Neuroses except depressive ............... Disorders of personality & impulse control. Organic disturbances & mental retardation. Psychoses ........................................... Behavioral & developmental disorders Other mental disorder diagnoses ........ Alcohol/drug abuse or dependence, left ama. Alcohol/drug abuse or dependence w rehabilitation therapy. Alcohol/drug abuse or dependence w/ o rehabilitation therapy w MCC. Alcohol/drug abuse or dependence w/ o rehabilitation therapy w/o MCC. Wound debridements for injuries w MCC. Wound debridements for injuries w CC. Wound debridements for injuries w/o CC/MCC. Skin grafts for injuries w CC/MCC ...... Skin grafts for injuries w/o CC/MCC ... Hand procedures for injuries ............... Other O.R. procedures for injuries w MCC. Other O.R. procedures for injuries w CC. Other O.R. procedures for injuries w/o CC/MCC. Traumatic injury w MCC ...................... Traumatic injury w/o MCC ................... Allergic reactions w MCC .................... Allergic reactions w/o MCC ................. Poisoning & toxic effects of drugs w MCC. Poisoning & toxic effects of drugs w/o MCC. Complications of treatment w MCC .... Complications of treatment w CC ....... Complications of treatment w/o CC/ MCC. Other injury, poisoning & toxic effect diag w MCC. Other injury, poisoning & toxic effect diag w/o MCC. Extensive burns or full thickness burns w MV 96+ hrs w skin graft. Full thickness burn w skin graft or inhal inj w CC/MCC. Full thickness burn w skin graft or inhal inj w/o CC/MCC. Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft. Full thickness burn w/o skin grft or inhal inj. Non-extensive burns ........................... O.R. proc w diagnoses of other contact w health services w MCC. ........... ........... ........... ........... ............ ............ ............ ............ ......... ......... ......... ......... No ............ No ............ 20 MED ......... 896 ........... Yes .......... No ............ 20 MED ......... 897 ........... Yes .......... No ............ 20 MED ......... 901 ........... No ............ No ............ 21 SURG ...... 902 ........... No ............ No ............ 21 SURG ...... 903 ........... No ............ No ............ 21 SURG ...... 904 905 906 907 ........... ........... ........... ........... No ............ No ............ No ............ Yes .......... No No No No ............ ............ ............ ............ 21 21 21 21 SURG SURG SURG SURG 908 ........... Yes .......... No ............ 21 SURG ...... 909 ........... Yes .......... No ............ 21 SURG ...... 913 914 915 916 917 ........... ........... ........... ........... ........... No ............ No ............ No ............ No ............ Yes .......... No No No No No ............ ............ ............ ............ ............ 21 21 21 21 21 MED MED MED MED MED 918 ........... Yes .......... No ............ 21 MED ......... 919 ........... 920 ........... 921 ........... No ............ No ............ No ............ No ............ No ............ No ............ 21 21 21 MED ......... MED ......... MED ......... 922 ........... No ............ No ............ 21 MED ......... 923 ........... No ............ No ............ 21 MED ......... 927 ........... No ............ No ............ 22 SURG ...... 928 ........... No ............ No ............ 22 SURG ...... 929 ........... jlentini on PROD1PC65 with PROPOSALS2 895 ........... No ............ No ............ 22 SURG ...... 933 ........... No ............ No ............ 22 MED ......... 934 ........... No ............ No ............ 22 MED ......... 935 ........... 939 ........... No ............ No ............ No ............ No ............ 22 23 MED ......... SURG ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 ...... ...... ...... ...... ......... ......... ......... ......... ......... Frm 00311 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Weights Geometric mean LOS Arithmetic mean LOS 1.1188 4.7 5.7 2.4279 7.8 11.9 0.5867 2.4 3.2 0.5784 0.6086 1.0102 3.1 3.1 4.4 4.2 4.4 7.4 0.8923 4.1 5.5 0.8380 0.7479 0.7275 0.3842 5.5 4.0 3.0 2.1 7.6 6.1 4.6 3.0 0.8727 8.1 10.5 1.3787 4.8 6.6 0.6152 3.3 4.1 3.8708 9.9 15.1 1.6889 5.5 7.7 0.9976 3.4 4.6 2.9204 1.1156 0.9941 3.6871 7.0 3.4 2.1 8.0 11.2 4.7 3.1 11.6 1.9162 4.9 6.8 1.1372 2.7 3.6 1.2246 0.6625 1.2354 0.4409 1.4143 4.2 2.7 3.3 1.7 3.7 5.7 3.4 4.7 2.1 5.2 0.5809 2.1 2.7 1.5200 0.9220 0.6097 4.5 3.3 2.3 6.4 4.4 3.0 1.3580 4.1 6.0 0.6142 2.4 3.2 14.0060 23.4 31.1 5.0621 11.7 16.0 2.1574 5.3 7.7 2.1246 2.3 4.3 1.2949 4.4 6.2 1.2209 2.6570 3.6 6.6 5.4 10.1 30APP2 23838 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS–DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—Continued MS–DRG FY 2009 proposed rule postacute DRG FY 2009 proposed rule special pay DRG MDC 940 ........... No ............ No ............ 941 ........... No ............ 945 946 947 948 949 950 951 955 ........... ........... ........... ........... ........... ........... ........... ........... MS–DRG title 23 SURG ...... No ............ 23 SURG ...... Yes .......... Yes .......... Yes .......... Yes .......... No ............ No ............ No ............ No ............ No No No No No No No No ............ ............ ............ ............ ............ ............ ............ ............ 23 23 23 23 23 23 23 24 MED ......... MED ......... MED ......... MED ......... MED ......... MED ......... MED ......... SURG ...... 956 ........... Yes .......... No ............ 24 SURG ...... 957 ........... No ............ No ............ 24 SURG ...... 958 ........... No ............ No ............ 24 SURG ...... 959 ........... No ............ No ............ 24 SURG ...... 963 ........... No ............ No ............ 24 MED ......... 964 ........... No ............ No ............ 24 MED ......... 965 ........... No ............ No ............ 24 MED ......... 969 ........... No ............ No ............ 25 SURG ...... 970 ........... No ............ No ............ 25 SURG ...... 974 ........... 975 ........... 976 ........... No ............ No ............ No ............ No ............ No ............ No ............ 25 25 25 MED ......... MED ......... MED ......... 977 ........... 981 ........... No ............ Yes .......... No ............ No ............ 25 ........ MED ......... SURG ...... 982 ........... Yes .......... No ............ ........ SURG ...... 983 ........... Yes .......... No ............ ........ SURG ...... 984 ........... No ............ No ............ ........ SURG ...... 985 ........... No ............ No ............ ........ SURG ...... 986 ........... No ............ No ............ ........ SURG ...... 987 ........... Yes .......... No ............ ........ SURG ...... 988 ........... Yes .......... No ............ ........ SURG ...... 989 ........... Yes .......... No ............ ........ SURG ...... 998 ........... jlentini on PROD1PC65 with PROPOSALS2 Type No ............ No ............ ........ ** .............. 999 ........... No ............ No ............ ........ ** .............. O.R. proc w diagnoses of other contact w health services w CC. O.R. proc w diagnoses of other contact w health services w/o CC/MCC. Rehabilitation w CC/MCC ................... Rehabilitation w/o CC/MCC ................ Signs & symptoms w MCC ................. Signs & symptoms w/o MCC .............. Aftercare w CC/MCC ........................... Aftercare w/o CC/MCC ........................ Other factors influencing health status Craniotomy for multiple significant trauma. Limb reattachment, hip & femur proc for multiple significant trauma. Other O.R. procedures for multiple significant trauma w MCC. Other O.R. procedures for multiple significant trauma w CC. Other O.R. procedures for multiple significant trauma w/o CC/MCC. Other multiple significant trauma w MCC. Other multiple significant trauma w CC. Other multiple significant trauma w/o CC/MCC. HIV w extensive O.R. procedure w MCC. HIV w extensive O.R. procedure w/o MCC. HIV w major related condition w MCC HIV w major related condition w CC ... HIV w major related condition w/o CC/ MCC. HIV w or w/o other related condition .. Extensive O.R. procedure unrelated to principal diagnosis w MCC. Extensive O.R. procedure unrelated to principal diagnosis w CC. Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC. Prostatic O.R. procedure unrelated to principal diagnosis w MCC. Prostatic O.R. procedure unrelated to principal diagnosis w CC. Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC. Non-extensive O.R. proc unrelated to principal diagnosis w MCC. Non-extensive O.R. proc unrelated to principal diagnosis w CC. Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC. Principal diagnosis invalid as discharge diagnosis. Ungroupable ........................................ Weights Geometric mean LOS Arithmetic mean LOS 1.6379 3.6 5.4 1.0782 2.1 2.7 1.2869 1.0861 1.0525 0.6473 0.7925 0.5548 0.7442 5.0969 8.6 6.9 3.8 2.8 2.6 2.4 2.2 8.6 10.5 7.9 5.0 3.5 4.1 3.5 4.7 12.3 3.5263 7.6 9.3 6.0787 10.2 14.9 3.6129 8.0 10.4 2.3808 4.9 6.3 2.8713 6.7 9.5 1.6024 4.9 6.2 0.9832 3.4 4.1 5.3749 12.9 18.8 2.4892 6.5 9.8 2.5595 1.3571 0.8910 7.3 5.3 3.8 10.4 7.0 4.9 1.0965 5.0175 3.9 11.7 5.3 15.1 3.0780 7.5 9.7 1.9959 3.9 5.4 3.3256 11.8 14.6 2.2113 7.3 9.7 1.2767 3.5 5.3 3.4336 9.8 13.0 1.8752 5.8 7.8 1.1032 2.9 4.1 0.0000 0.0 0.0 0.0000 0.0 0.0 MS–DRGs 998 and 999 contain cases that could not be assigned to valid DRGs. NOTE: If there is no value in either the geometric mean length of stay or the arithmetic mean length of stay columns, the volume of cases is insufficient to obtain a meaningful computation of these statistics. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00312 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23839 TABLE 6A.—NEW DIAGNOSIS CODES Description CC 046.11 ...... 046.19 ...... 046.71 ...... Variant Creutzfeldt-Jakob disease .............................................................................................. Other and unspecified Creutzfeldt-Jakob disease ...................................................................... ¨ Gerstmann-Straussler-Scheinker syndrome ............................................................................... CC .... CC .... CC .... 046.72 ...... Fatal familial insomnia ................................................................................................................. CC .... 046.79 ...... Other and unspecified prion disease of central nervous system ................................................ CC .... 051.01 ...... 051.02 ...... 059.00 ...... 059.01 ...... 059.09 ...... 059.10 ...... 059.11 ...... 059.12 ...... 059.19 ...... 059.21 ...... 059.22 ...... 059.29 ...... 059.8 ........ 059.9 ........ 078.12 ...... 136.21 ...... 136.29 ...... 199.2 ........ 203.02 ...... Cowpox ........................................................................................................................................ Vaccinia not from vaccination ..................................................................................................... Orthopoxvirus infection, unspecified ........................................................................................... Monkeypox .................................................................................................................................. Other orthopoxvirus infections ..................................................................................................... Parapoxvirus infection, unspecified ............................................................................................. Bovine stomatitis ......................................................................................................................... Sealpox ........................................................................................................................................ Other parapoxvirus infections ...................................................................................................... Tanapox ....................................................................................................................................... Yaba monkey tumor virus ........................................................................................................... Yatapoxvirus infection, unspecified ............................................................................................. Other poxvirus infections ............................................................................................................. Poxvirus infections, unspecified .................................................................................................. Plantar wart ................................................................................................................................. Specific infection due to acanthamoeba ..................................................................................... Other specific infections by free-living amebae .......................................................................... Malignant neoplasm associated with transplant organ ............................................................... Multiple myeloma, in relapse ....................................................................................................... N ....... N ....... N ....... CC .... N ....... N ....... N ....... N ....... N ....... CC .... N ....... N ....... N ....... N ....... N ....... N ....... CC .... CC .... CC .... 01 01 01 25 01 25 01 25 18 18 18 18 18 18 18 18 18 18 18 18 18 18 09 18 18 17 17 203.12 ...... Plasma cell leukemia, in relapse ................................................................................................. CC .... 17 203.82 ...... Other immunoproliferative neoplasms, in relapse ....................................................................... CC .... 17 204.02 ...... Acute lymphoid leukemia, in relapse .......................................................................................... CC .... 17 204.12 ...... Chronic lymphoid leukemia, in relapse ....................................................................................... CC .... 17 204.22 ...... Subacute lymphoid leukemia, in relapse .................................................................................... CC .... 17 204.82 ...... Other lymphoid leukemia, in relapse ........................................................................................... CC .... 17 204.92 ...... Unspecified lymphoid leukemia, in relapse ................................................................................. CC .... 17 205.02 ...... Acute myeloid leukemia, in relapse ............................................................................................ CC .... 17 205.12 ...... Chronic myeloid leukemia, in relapse ......................................................................................... CC .... 17 205.22 ...... Subacute myeloid leukemia, in relapse ...................................................................................... CC .... 17 205.32 ...... jlentini on PROD1PC65 with PROPOSALS2 Diagnosis code Myeloid sarcoma, in relapse ....................................................................................................... CC .... 17 205.82 ...... Other myeloid leukemia, in relapse ............................................................................................. CC .... 17 205.92 ...... Unspecified myeloid leukemia, in relapse ................................................................................... CC .... 17 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00313 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 MDC MS–DRG 056, 057 056, 057 056, 057 974, 975, 976 056, 057 974, 975, 976 056, 057 974, 975, 976 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 865, 866 606, 607 867, 868, 869 867, 868, 869 843, 844, 845 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 23840 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 6A.—NEW DIAGNOSIS CODES—Continued Description CC 206.02 ...... Acute monocytic leukemia, in relapse ......................................................................................... CC .... 17 206.12 ...... Chronic monocytic leukemia, in relapse ..................................................................................... CC .... 17 206.22 ...... Subacute monocytic leukemia, in relapse ................................................................................... CC .... 17 206.82 ...... Other monocytic leukemia, in relapse ......................................................................................... CC .... 17 206.92 ...... Unspecified monocytic leukemia, in relapse ............................................................................... CC .... 17 207.02 ...... Acute erythremia and erythroleukemia, in relapse ..................................................................... CC .... 17 207.12 ...... Chronic erythremia, in relapse .................................................................................................... CC .... 17 207.22 ...... Megakaryocytic leukemia, in relapse .......................................................................................... CC .... 17 207.82 ...... Other specified leukemia, in relapse ........................................................................................... CC .... 17 208.02 ...... Acute leukemia of unspecified cell type, in relapse .................................................................... CC .... 17 208.12 ...... Chronic leukemia of unspecified cell type, in relapse ................................................................. CC .... 17 208.22 ...... Subacute leukemia of unspecified cell type, in relapse .............................................................. CC .... 17 208.82 ...... Other leukemia of unspecified cell type, in relapse .................................................................... CC .... 17 208.92 ...... Unspecified leukemia, in relapse ................................................................................................ CC .... 17 209.00 209.01 209.02 209.03 209.10 209.11 ...... ...... ...... ...... ...... ...... Malignant Malignant Malignant Malignant Malignant Malignant carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid tumor tumor tumor tumor tumor tumor of of of of of of the the the the the the small intestine, unspecified portion ........................................ duodenum ............................................................................... jejunum ................................................................................... ileum ....................................................................................... large intestine, unspecified portion ........................................ appendix ................................................................................. CC CC CC CC CC CC .... .... .... .... .... .... 06 06 06 06 06 06 209.12 209.13 209.14 209.15 209.16 209.17 209.20 209.21 209.22 209.23 209.24 jlentini on PROD1PC65 with PROPOSALS2 Diagnosis code ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... Malignant Malignant Malignant Malignant Malignant Malignant Malignant Malignant Malignant Malignant Malignant carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor of of of of of of of of of of of the cecum ..................................................................................... the ascending colon ..................................................................... the transverse colon ..................................................................... the descending colon ................................................................... the sigmoid colon ......................................................................... the rectum ..................................................................................... unknown primary site ................................................................... the bronchus and lung .................................................................. the thymus .................................................................................... the stomach .................................................................................. the kidney ..................................................................................... CC CC CC CC CC CC CC CC CC CC CC .... .... .... .... .... .... .... .... .... .... .... 06 06 06 06 06 06 17 04 17 06 11 209.25 209.26 209.27 209.29 209.30 209.40 209.41 ...... ...... ...... ...... ...... ...... ...... Malignant carcinoid tumor of foregut, not otherwise specified ................................................... Malignant carcinoid tumor of midgut, not otherwise specified .................................................... Malignant carcinoid tumor of hindgut, not otherwise specified ................................................... Malignant carcinoid tumor of other sites ..................................................................................... Malignant poorly differentiated neuroendocrine carcinoma, any site ......................................... Benign carcinoid tumor of the small intestine, unspecified portion ............................................ Benign carcinoid tumor of the duodenum ................................................................................... CC .... CC .... CC .... CC .... CC .... N ....... N ....... 06 06 06 17 17 06 06 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00314 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 MDC MS–DRG 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 374, 375, 376 374, 375, 376 374, 375, 376 374, 375, 376 374, 375, 376 338, 339, 340, 374, 375, 376 374, 375, 376 374, 375, 376 374, 375, 376 374, 375, 376 374, 375, 376 374, 375, 376 843, 844, 845 180, 181, 182 843, 844, 845 374, 375, 376 656, 657, 658, 686, 687, 688 374, 375, 376 374, 375, 376 374, 375, 376 843, 844, 845 843, 844, 845 393, 394, 395 393, 394, 395 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23841 TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis code Description 209.42 209.43 209.50 209.51 209.52 209.53 209.54 209.55 209.56 209.57 209.60 209.61 209.62 209.63 209.64 ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... Benign Benign Benign Benign Benign Benign Benign Benign Benign Benign Benign Benign Benign Benign Benign 209.65 209.66 209.67 209.69 238.77 249.00 ...... ...... ...... ...... ...... ...... 06 06 06 06 06 06 06 06 06 06 17 04 16 06 11 N ....... N ....... N ....... N ....... CC .... N ....... 249.01 ...... Benign carcinoid tumor of foregut, not otherwise specified ........................................................ Benign carcinoid tumor of midgut, not otherwise specified ........................................................ Benign carcinoid tumor of hindgut, not otherwise specified ....................................................... Benign carcinoid tumor of other sites ......................................................................................... Post-transplant lymphoproliferative disorder (PTLD) .................................................................. Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus without mention of complication, uncontrolled .............................. 249.10 ...... Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified ...... MCC 249.11 ...... Secondary diabetes mellitus with ketoacidosis, uncontrolled ..................................................... MCC 249.20 ...... Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified MCC 249.21 ...... Secondary diabetes mellitus with hyperosmolarity, uncontrolled ............................................... MCC 249.30 ...... Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified ........ MCC 249.31 ...... Secondary diabetes mellitus with other coma, uncontrolled ....................................................... MCC 249.40 ...... Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with renal manifestations, uncontrolled ........................................ N ....... Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled ............................... N ....... Secondary diabetes mellitus with neurological manifestations, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with neurological manifestations, uncontrolled ............................. N ....... Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled ....................... N ....... Secondary diabetes mellitus with other specified manifestations, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with other specified manifestations, uncontrolled ......................... N ....... N ....... 249.91 ...... Secondary diabetes mellitus with unspecified complication, not stated as uncontrolled, or unspecified. Secondary diabetes mellitus with unspecified complication, uncontrolled ................................. 259.50 ...... 259.51 ...... 259.52 ...... 275.5 ........ 279.50 ...... 279.51 ...... 279.52 ...... 279.53 ...... 289.84 ...... Androgen insensitivity, unspecified ............................................................................................. Androgen insensitivity syndrome ................................................................................................. Partial androgen insensitivity ....................................................................................................... Hungry bone syndrome ............................................................................................................... Graft-versus-host disease, unspecified ....................................................................................... Acute graft-versus-host disease .................................................................................................. Chronic graft-versus-host disease ............................................................................................... Acute on chronic graft-versus-host disease ................................................................................ Heparin-induced thrombocytopenia (HIT) ................................................................................... N ....... N ....... N ....... N ....... CC .... CC .... CC .... CC .... N ....... 06 06 06 17 21 PRE 10 PRE 10 PRE 10 PRE 10 PRE 10 PRE 10 PRE 10 PRE 10 PRE 11 PRE 11 PRE 02 PRE 02 PRE 01 PRE 01 PRE 05 PRE 05 PRE 10 PRE 10 PRE 10 PRE 10 10 10 10 10 16 16 16 16 15 16 249.50 ...... 249.51 ...... 249.60 ...... 249.61 ...... 249.70 ...... 249.71 ...... 249.80 ...... 249.81 ...... jlentini on PROD1PC65 with PROPOSALS2 249.90 ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor tumor of of of of of of of of of of of of of of of the jejunum ....................................................................................... the ileum ........................................................................................... the large intestine, unspecified portion ............................................. the appendix ..................................................................................... the cecum ......................................................................................... the ascending colon .......................................................................... the transverse colon ......................................................................... the descending colon ........................................................................ the sigmoid colon .............................................................................. the rectum ......................................................................................... unknown primary site ........................................................................ the bronchus and lung ...................................................................... the thymus ........................................................................................ the stomach ...................................................................................... the kidney .......................................................................................... Jkt 214001 PO 00000 Frm 00315 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM N N N N N N N N N N N N N N N MDC ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... 249.41 ...... carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid carcinoid CC N ....... N ....... N ....... N ....... N ....... N ....... N ....... 30APP2 MS–DRG 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 843, 844, 845 180, 181, 182 814, 815, 816 393, 394, 395 656, 657, 658, 686, 687, 688 393, 394, 395 393, 394, 395 393, 394, 395 843, 844, 845 919, 920, 921 008, 010 637, 638, 639 008, 010 637, 638, 639 008, 010 637, 638, 639 008, 010 637, 638, 639, 008, 010 637, 638, 639 008, 010 637, 638, 639 008, 010 637, 638, 639 008, 010 637, 638, 639 008, 010 698, 699, 700 008, 010 698, 699, 700 008, 010 124, 125 008, 010 124, 125 008, 010 073, 074 008, 010 073, 074 008, 010 299, 300, 301 008, 010 299, 300, 301 008, 010 637, 638, 639 008, 010 637, 638, 639 008, 010 637, 638, 639 008, 010 637, 638, 639 643, 644, 645 643, 644, 645 643, 644, 645 640, 641 808, 809, 810 808, 809, 810 808, 809, 810 808, 809, 810 791 2, 793 2 813 23842 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis code Description 337.00 ...... 337.01 ...... 337.09 ...... 339.00 ...... 339.01 ...... 339.02 ...... 339.03 ...... 339.04 ...... 339.05 ...... 339.09 ...... 339.10 ...... 339.11 ...... 339.12 ...... 339.20 ...... 339.21 ...... 339.22 ...... 339.3 ........ 339.41 ...... 339.42 ...... 339.43 ...... 339.44 ...... 339.81 ...... 339.82 ...... 339.83 ...... 339.84 ...... 339.85 ...... 339.89 ...... 346.02 ...... 346.03 ...... 346.12 ...... 346.13 ...... 346.22 ...... Idiopathic peripheral autonomic neuropathy, unspecified ........................................................... Carotid sinus syndrome ............................................................................................................... Other idiopathic peripheral autonomic neuropathy ..................................................................... Cluster headache syndrome, unspecified ................................................................................... Episodic cluster headache .......................................................................................................... Chronic cluster headache ............................................................................................................ Episodic paroxysmal hemicrania ................................................................................................. Chronic paroxysmal hemicrania .................................................................................................. Short lasting unilateral neuralgiform headache with conjunctival injection and tearing ............. Other trigeminal autonomic cephalgias ....................................................................................... Tension type headache, unspecified ........................................................................................... Episodic tension type headache ................................................................................................. Chronic tension type headache ................................................................................................... Post-traumatic headache, unspecified ........................................................................................ Acute post-traumatic headache ................................................................................................... Chronic post-traumatic headache ............................................................................................... Drug induced headache, not elsewhere classified ..................................................................... Hemicrania continua .................................................................................................................... New daily persistent headache ................................................................................................... Primary thunderclap headache ................................................................................................... Other complicated headache syndrome ..................................................................................... Hypnic headache ......................................................................................................................... Headache associated with sexual activity ................................................................................... Primary cough headache ............................................................................................................ Primary exertional headache ....................................................................................................... Primary stabbing headache ......................................................................................................... Other headache syndromes ........................................................................................................ Migraine with aura, without mention of intractable migraine with status migrainosus ............... Migraine with aura, with intractable migraine, so stated, with status migrainosus ..................... Migraine without aura, without mention of intractable migraine with status migrainosus .......... Migraine without aura, with intractable migraine, so stated, with status migrainosus ................ Variants of migraine, not elsewhere classified, without mention of intractable migraine with status migrainosus. Variants of migraine, not elsewhere classified, with intractable migraine, so stated, with status migrainosus. Hemiplegic migraine, without mention of intractable migraine without mention of status migrainosus. Hemiplegic migraine, with intractable migraine, so stated, without mention of status migrainosus. Hemiplegic migraine, without mention of intractable migraine with status migrainosus ............ Hemiplegic migraine, with intractable migraine, so stated, with status migrainosus .................. Menstrual migraine, without mention of intractable migraine without mention of status migrainosus. Menstrual migraine, with intractable migraine, so stated, without mention of status migrainosus. Menstrual migraine, without mention of intractable migraine with status migrainosus .............. Menstrual migraine, with intractable migraine, so stated, with status migrainosus .................... Persistent migraine aura without cerebral infarction, without mention of intractable migraine without mention of status migrainosus. Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus. Persistent migraine aura without cerebral infarction, without mention of intractable migraine with status migrainosus. Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, with status migrainosus. Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status migrainosus. Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus. Persistent migraine aura with cerebral infarction, without mention of intractable migraine with status migrainosus. Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with status migrainosus. Chronic migraine without aura, without mention of intractable migraine without mention of status migrainosus. Chronic migraine without aura, with intractable migraine, so stated, without mention of status migrainosus. Chronic migraine without aura, without mention of intractable migraine with status migrainosus. Chronic migraine without aura, with intractable migraine, so stated, with status migrainosus .. 346.23 ...... 346.30 ...... 346.31 ...... 346.32 ...... 346.33 ...... 346.40 ...... 346.41 ...... 346.42 ...... 346.43 ...... 346.50 ...... 346.51 ...... 346.52 ...... 346.53 ...... 346.60 ...... 346.61 ...... 346.62 ...... jlentini on PROD1PC65 with PROPOSALS2 346.63 ...... 346.70 ...... 346.71 ...... 346.72 ...... 346.73 ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00316 Fmt 4701 CC Sfmt 4702 E:\FR\FM\30APP2.SGM MDC MS–DRG ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... 25 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 977 073, 073, 073, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, 102, N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... N ....... N ....... 01 01 01 102, 103 102, 103 102, 103 N ....... 01 102, 103 N ....... N ....... N ....... 01 01 01 102, 103 102, 103 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 CC .... 01 102, 103 CC .... 01 102, 103 CC .... 01 102, 103 CC .... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N 30APP2 074 074 074 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 103 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23843 TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis code Description CC 346.82 ...... 346.83 ...... 362.20 ...... 362.22 ...... 362.23 ...... 362.24 ...... 362.25 ...... 362.26 ...... 362.27 ...... 364.82 ...... 372.34 ...... 414.3 ........ 511.81 ...... 511.89 ...... Other forms of migraine, without mention of intractable migraine with status migrainosus ....... Other forms of migraine, with intractable migraine, so stated, with status migrainosus ............ Retinopathy of prematurity, unspecified ...................................................................................... Retinopathy of prematurity, stage 0 ............................................................................................ Retinopathy of prematurity, stage 1 ............................................................................................ Retinopathy of prematurity, stage 2 ............................................................................................ Retinopathy of prematurity, stage 3 ............................................................................................ Retinopathy of prematurity, stage 4 ............................................................................................ Retinopathy of prematurity, stage 5 ............................................................................................ Plateau iris syndrome .................................................................................................................. Pingueculitis ................................................................................................................................. Coronary atherosclerosis due to lipid rich plaque ....................................................................... Malignant pleural effusion ........................................................................................................... Other specified forms of effusion, except tuberculous ................................................................ N ....... N ....... N ....... N ....... N ....... N ....... N ....... N ....... N ....... N ....... N ....... N ....... CC .... CC .... 569.44 ...... 571.42 ...... 599.70 ...... Dysplasia of anus ........................................................................................................................ Autoimmune hepatitis .................................................................................................................. Hematuria, unspecified ................................................................................................................ N ....... N ....... N ....... 599.71 ...... Gross hematuria .......................................................................................................................... N ....... 599.72 ...... Microscopic hematuria ................................................................................................................. N ....... 611.81 ...... 611.82 ...... 611.83 ...... 611.89 ...... 612.0 ........ 612.1 ........ 625.70 ...... Ptosis of breast ............................................................................................................................ Hypoplasia of breast .................................................................................................................... Capsular contracture of breast implant ....................................................................................... Other specified disorders of breast ............................................................................................. Deformity of reconstructed breast ............................................................................................... Disproportion of reconstructed breast ......................................................................................... Vulvodynia, unspecified ............................................................................................................... N N N N N N N ....... ....... ....... ....... ....... ....... ....... 01 01 02 02 02 02 02 02 02 02 02 05 04 04 15 06 07 11 15 11 15 11 15 09 09 09 09 09 09 13 625.71 ...... Vulvar vestibulitis ......................................................................................................................... N ....... 13 625.79 ...... Other vulvodynia .......................................................................................................................... N ....... 13 649.70 ...... 649.71 ...... Cervical shortening, unspecified as to episode of care or not applicable .................................. Cervical shortening, delivered, with or without mention of antepartum condition ...................... CC .... CC .... 14 14 649.73 ...... 678.00 ...... 678.01 ...... Cervical shortening, antepartum condition or complication ........................................................ Fetal hematologic conditions, unspecified as to episode of care or not applicable ................... Fetal hematologic conditions, delivered, with or without mention of antepartum condition ....... CC .... N ....... N ....... 14 14 14 678.03 ...... 678.10 ...... 678.11 ...... Fetal hematologic conditions, antepartum condition or complication ......................................... Fetal conjoined twins, unspecified as to episode of care or not applicable ............................... Fetal conjoined twins, delivered, with or without mention of antepartum condition ................... N ....... N ....... N ....... 14 14 14 678.13 ...... 679.00 ...... Fetal conjoined twins, antepartum condition or complication ..................................................... Maternal complications from in utero procedure, unspecified as to episode of care or not applicable. Maternal complications from in utero procedure, delivered, with or without mention of antepartum condition. Maternal complications from in utero procedure, delivered, with mention of postpartum complication. Maternal complications from in utero procedure, antepartum condition or complication ........... Maternal complications from in utero procedure, postpartum condition or complication ........... Fetal complications from in utero procedures, unspecified as to episode of care or not applicable. Fetal complications from in utero procedures, delivered, with or without mention of antepartum condition. Fetal complications from in utero procedures, delivered, with mention of postpartum complication. Fetal complications from in utero procedures, antepartum condition or complication ............... Fetal complications from in utero procedures, postpartum condition or complication ............... Erythema multiforme, unspecified ............................................................................................... Erythema multiforme minor ......................................................................................................... Erythema multiforme major ......................................................................................................... Stevens-Johnson syndrome ........................................................................................................ Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome ............................... Toxic epidermal necrolysis .......................................................................................................... Other erythema multiforme .......................................................................................................... Exfoliation due to erythematous condition involving less than 10 percent of body surface ....... N ....... N ....... 14 14 N ....... 14 N ....... 14 N ....... N ....... N ....... 14 14 14 N ....... 14 N ....... 14 N ....... N ....... N ....... N ....... CC .... CC .... CC .... CC .... N ....... N ....... 14 14 09 09 09 09 09 09 09 09 679.01 ...... 679.02 ...... 679.03 ...... 679.04 ...... 679.10 ...... 679.11 ...... jlentini on PROD1PC65 with PROPOSALS2 679.12 ...... 679.13 679.14 695.10 695.11 695.12 695.13 695.14 695.15 695.19 695.50 ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00317 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 MDC MS–DRG 102, 103 102, 103 124, 125 124, 125 124, 125 124, 125 124, 125 124, 125 124, 125 124, 125 124, 125 302, 303 180, 181, 182 186, 187, 188 791 2, 793 2 393, 394, 395 441, 442, 443 695, 696 791 2, 793 2 695, 696 791 2, 793 2 695, 696 791 2, 793 2 600, 601 600, 601 600, 601 600, 601 600, 601 600, 601 742, 743, 760, 761 742, 743, 757, 758, 759 742, 743, 760, 761 998 765, 766, 767, 768, 774, 775 781, 782 998 765, 766, 767, 768, 774, 775 781, 782 998 765, 766, 767, 768, 774, 775 781, 782 765, 766, 767, 768, 774, 775 765, 766, 767, 768, 774 765, 766, 767, 768, 774 781, 782 769, 776 998 765, 766, 767, 768, 774, 775 765, 766, 767, 768, 774, 775 781, 782 769, 776 595, 596 595, 596 595, 596 595, 596 595, 596 595, 596 595, 596 606, 607 23844 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis code Description CC ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... Exfoliation due to erythematous condition involving 10–19 percent of body surface ................ Exfoliation due to erythematous condition involving 20–29 percent of body surface ................ Exfoliation due to erythematous condition involving 30–39 percent of body surface ................ Exfoliation due to erythematous condition involving 40–49 percent of body surface ................ Exfoliation due to erythematous condition involving 50–59 percent of body surface ................ Exfoliation due to erythematous condition involving 60–69 percent of body surface ................ Exfoliation due to erythematous condition involving 70–79 percent of body surface ................ Exfoliation due to erythematous condition involving 80–89 percent of body surface ................ Exfoliation due to erythematous condition involving 90 percent or more of body surface ......... Pressure ulcer, unspecified stage ............................................................................................... N ....... N ....... CC .... CC .... CC .... CC .... CC .... CC .... CC .... N ....... 09 09 09 09 09 09 09 09 09 09 707.21 ...... Pressure ulcer, stage I ................................................................................................................ N ....... 09 707.22 ...... Pressure ulcer, stage II ............................................................................................................... N ....... 09 707.23 ...... Pressure ulcer, stage III .............................................................................................................. MCC 3 09 707.24 ...... Pressure ulcer, stage IV .............................................................................................................. MCC 3 09 729.90 729.91 729.92 729.99 760.61 760.62 760.63 760.64 777.50 777.51 777.52 777.53 780.72 788.91 788.99 795.07 ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... Disorders of soft tissue, unspecified ........................................................................................... Post-traumatic seroma ................................................................................................................ Nontraumatic hematoma of soft tissue ....................................................................................... Other disorders of soft tissue ...................................................................................................... Newborn affected by amniocentesis ........................................................................................... Newborn affected by other in utero procedure ........................................................................... Newborn affected by other surgical operations on mother during pregnancy ............................ Newborn affected by previous surgical procedure on mother not associated with pregnancy .. Necrotizing enterocolitis in newborn, unspecified ....................................................................... Stage I necrotizing enterocolitis in newborn ............................................................................... Stage II necrotizing enterocolitis in newborn .............................................................................. Stage III necrotizing enterocolitis in newborn ............................................................................. Functional quadriplegia ............................................................................................................... Functional urinary incontinence ................................................................................................... Other symptoms involving urinary system .................................................................................. Satisfactory cervical smear but lacking transformation zone ...................................................... N ....... N ....... N ....... N ....... N ....... N ....... N ....... N ....... MCC MCC MCC MCC MCC N ....... N ....... N ....... 08 08 08 08 15 15 15 15 15 15 15 15 01 11 11 13 795.10 ...... Abnormal glandular Papanicolaou smear of vagina ................................................................... N ....... 13 795.11 ...... N ....... 13 N ....... 13 795.13 ...... Papanicolaou smear of vagina with atypical squamous cells of undetermined significance (ASC–US). Papanicolaou smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC–H). Papanicolaou smear of vagina with low grade squamous intraepithelial lesion (LGSIL) ........... N ....... 13 795.14 ...... Papanicolaou smear of vagina with high grade squamous intraepithelial lesion (HGSIL) ......... N ....... 13 795.15 ...... Vaginal high risk human papillomavirus (HPV) DNA test positive ............................................. N ....... 13 795.16 ...... Papanicolaou smear of vagina with cytologic evidence of malignancy ...................................... N ....... 13 795.18 ...... Unsatisfactory vaginal cytology smear ........................................................................................ N ....... 13 795.19 ...... Other abnormal Papanicolaou smear of vagina and vaginal HPV ............................................. N ....... 13 796.70 ...... 796.71 ...... N ....... N ....... 06 06 N ....... 06 393, 394, 395 ...... ...... ...... ...... ...... ...... ...... ...... Abnormal glandular Papanicolaou smear of anus ...................................................................... Papanicolaou smear of anus with atypical squamous cells of undetermined significance (ASC–US). Papanicolaou smear of anus with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC–H). Papanicolaou smear of anus with low grade squamous intraepithelial lesion (LGSIL) ............. Papanicolaou smear of anus with high grade squamous intraepithelial lesion (HGSIL) ........... Anal high risk human papillomavirus (HPV) DNA test positive .................................................. Papanicolaou smear of anus with cytologic evidence of malignancy ......................................... Satisfactory anal smear but lacking transformation zone ........................................................... Unsatisfactory anal cytology smear ............................................................................................ Other abnormal Papanicolaou smear of anus and anal HPV .................................................... Ventilator associated pneumonia ................................................................................................ 606, 607 606, 607 606, 607 606, 607 606, 607 606, 607 606, 607 606, 607 606, 607 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 555, 556 555, 556 555, 556 555, 556 794 794 794 794 791 4, 793 4 791 4, 793 4 791 4, 793 4 791 4, 793 4 052, 053 695, 696 695, 696 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 393, 394, 395 393, 394, 395 N ....... N ....... N ....... N ....... N ....... N ....... N ....... CC .... 997.39 ...... Other respiratory complications ................................................................................................... CC .... 998.30 ...... Disruption of wound, unspecified ................................................................................................ CC .... 06 06 06 06 06 06 06 04 15 04 15 21 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 393, 394, 395 205, 206 791 2, 793 2 205, 206 791 2, 793 2 919, 920, 921 695.51 695.52 695.53 695.54 695.55 695.56 695.57 695.58 695.59 707.20 795.12 ...... jlentini on PROD1PC65 with PROPOSALS2 796.72 ...... 796.73 796.74 796.75 796.76 796.77 796.78 796.79 997.31 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00318 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 MDC MS–DRG Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23845 TABLE 6A.—NEW DIAGNOSIS CODES—Continued Diagnosis code Description CC 998.33 ...... 999.81 ...... Disruption of traumatic wound repair .......................................................................................... Extravasation of vesicant chemotherapy .................................................................................... CC .... CC .... 999.82 ...... Extravasation of other vesicant agent ......................................................................................... CC .... 999.88 ...... Other infusion reaction ................................................................................................................ N ....... 999.89 ...... Other transfusion reaction ........................................................................................................... N ....... V07.51 ...... V07.52 ...... V07.59 ...... V13.51 ...... V13.52 ...... V13.59 ...... V15.21 ...... V15.22 ...... V15.29 ...... V15.51 ...... V15.59 ...... V23.85 ...... V23.86 ...... V28.81 ...... V28.82 ...... V28.89 ...... V45.11 ...... V45.12 ...... V45.87 ...... V46.3 ........ V51.0 ........ V51.8 ........ V87.01 ...... V87.09 ...... V87.11 ...... V87.12 ...... V87.19 ...... V87.2 ........ V87.31 ...... V87.39 ...... V87.41 ...... V87.42 ...... V87.49 ...... V88.01 ...... Prophylactic use of selective estrogen receptor modulators (SERMs) ...................................... Prophylactic use of aromatase inhibitors .................................................................................... Prophylactic use of other agents affecting estrogen receptors and estrogen levels .................. Personal history of pathologic fracture ........................................................................................ Personal history of stress fracture .............................................................................................. Personal history of other musculoskeletal disorders .................................................................. Personal history of undergoing in utero procedure during pregnancy ....................................... Personal history of undergoing in utero procedure while a fetus ............................................... Personal history of surgery to other organs ................................................................................ Personal history of traumatic fracture ......................................................................................... Personal history of other injury ................................................................................................... Pregnancy resulting from assisted reproductive technology ...................................................... Pregnancy with history of in utero procedure during previous pregnancy ................................. Encounter for fetal anatomic survey ........................................................................................... Encounter for screening for risk of pre-term labor ...................................................................... Other specified antenatal screening ............................................................................................ Renal dialysis status .................................................................................................................... Noncompliance with renal dialysis .............................................................................................. Transplanted organ removal status ............................................................................................. Wheelchair dependence .............................................................................................................. Encounter for breast reconstruction following mastectomy ........................................................ Other aftercare involving the use of plastic surgery ................................................................... Contact with and (suspected) exposure to arsenic ..................................................................... Contact with and (suspected) exposure to other hazardous metals .......................................... Contact with and (suspected) exposure to aromatic amines ...................................................... Contact with and (suspected) exposure to benzene .................................................................. Contact with and (suspected) exposure to other hazardous aromatic compounds ................... Contact with and (suspected) exposure to other potentially hazardous chemicals ................... Contact with and (suspected) exposure to mold ........................................................................ Contact with and (suspected) exposure to other potentially hazardous substances ................. Personal history of antineoplastic chemotherapy ....................................................................... Personal history of monoclonal drug therapy ............................................................................. Personal history of other drug therapy ........................................................................................ Acquired absence of both cervix and uterus .............................................................................. N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... 21 05 15 05 15 05 15 15 16 23 23 23 23 23 23 23 23 23 23 23 14 14 23 23 23 23 23 23 23 09 09 23 23 23 23 23 23 23 23 23 23 23 13 V88.02 ...... Acquired absence of uterus with remaining cervical stump ....................................................... N ....... 13 V88.03 ...... Acquired absence of cervix with remaining uterus ..................................................................... N ....... 13 V89.01 V89.02 V89.03 V89.04 V89.05 V89.09 Suspected problem with amniotic cavity and membrane not found ........................................... Suspected placental problem not found ...................................................................................... Suspected fetal anomaly not found ............................................................................................. Suspected problem with fetal growth not found .......................................................................... Suspected cervical shortening not found .................................................................................... Other suspected maternal and fetal condition not found ............................................................ N N N N N N 23 23 23 23 23 23 ...... ...... ...... ...... ...... ...... ....... ....... ....... ....... ....... ....... MDC MS–DRG 919, 920, 921 314, 315, 316 791 2, 793 2 314, 315, 316 791 2, 793 2 314, 315, 316 791 2, 793 2 791 2, 793 2 811, 812 951 951 951 951 951 951 951 951 951 951 951 998 998 951 951 951 951 951 951 951 606, 607 606, 607 951 951 951 951 951 951 951 951 949, 950 949, 950 949, 950 742, 743, 760, 761 742, 743, 760, 761 742, 743, 760, 761 951 951 951 951 951 951 1 Secondary diagnosis of acute leukemia diagnosis of major problem. pressure ulcer site specific codes (707.00–707.09) will be non-CCs. The pressure ulcer stage III and IV codes will be classified as 2 Secondary 3 The MCCs. 4 Principal or secondary diagnosis of major problem. jlentini on PROD1PC65 with PROPOSALS2 TABLE 6B.—NEW PROCEDURE CODES Procedure code 00.49 00.58 00.59 00.67 00.68 00.69 ........ ........ ........ ........ ........ ........ VerDate Aug<31>2005 Description O.R. SuperSaturated oxygen therapy .................................................................................................. Insertion of intra-aneurysm sac pressure monitoring device (intraoperative) ............................. Intravascular pressure measurement of coronary arteries ......................................................... Intravascular pressure measurement of intrathoracic arteries .................................................... Intravascular pressure measurement of peripheral arteries ....................................................... Intravascular pressure measurement, other specified and unspecified vessels ........................ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00319 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM N. N. N. N. N. N. 30APP2 MDC MS–DRG 23846 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 6B.—NEW PROCEDURE CODES—Continued Procedure code 17.11 17.12 17.13 17.21 17.22 17.23 ........ ........ ........ ........ ........ ........ 17.24 ........ 17.31 ........ Description Laparoscopic Laparoscopic Laparoscopic Laparoscopic Laparoscopic Laparoscopic prosthesis. Laparoscopic fied. Laparoscopic O.R. Y Y Y Y Y Y ....... ....... ....... ....... ....... ....... 06 06 06 06 06 06 350, 350, 350, 350, 350, 350, bilateral repair of inguinal hernia with graft or prosthesis, not otherwise speci- Y ....... 06 350, 351, 352 multiple segmental resection of large intestine .................................................... Y ....... 06 17 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 628, 629, 630 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 Laparoscopic cecectomy ............................................................................................................. Y ....... 17.33 ........ Laparoscopic right hemicolectomy .............................................................................................. Y ....... 17.35 ........ 17.36 ........ 17.39 ........ Laparoscopic resection of transverse colon ................................................................................ Laparoscopic left hemicolectomy ................................................................................................ Laparoscopic sigmoidectomy ...................................................................................................... Other laparoscopic partial excision of large intestine ................................................................. 21 24 05 06 21 24 05 06 17 Y ....... 21 24 05 06 17 Y ....... 21 24 05 06 10 17 Y ....... 21 24 06 17 Y ....... 21 24 05 06 17 21 24 37.36 ........ 37.55 ........ Excision or destruction of left atrial appendage (LAA) ............................................................... Removal of internal biventricular heart replacement system ...................................................... N. Y ....... 38.23 ........ 45.81 ........ Intravascular spectroscopy .......................................................................................................... Laparoscopic total intra-abdominal colectomy ............................................................................ N. Y ....... jlentini on PROD1PC65 with PROPOSALS2 45.82 ........ 45.83 ........ 48.40 ........ VerDate Aug<31>2005 MS–DRG repair of direct inguinal hernia with graft or prosthesis ........................................ repair of indirect inguinal hernia with graft or prosthesis ..................................... repair of inguinal hernia with graft or prosthesis, not otherwise specified ........... bilateral repair of direct inguinal hernia with graft or prosthesis .......................... bilateral repair of indirect inguinal hernia with graft or prosthesis ....................... bilateral repair of inguinal hernia, one direct and one indirect, with graft or 17.32 ........ 17.34 ........ MDC Open total intra-abdominal colectomy ......................................................................................... Other and unspecified total intra-abdominal colectomy .............................................................. Pull-through resection of rectum, not otherwise specified .......................................................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00320 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM PRE 05 05 06 17 Y ....... 21 24 05 06 17 Y ....... 21 24 05 06 17 Y ....... 30APP2 21 24 06 351, 351, 351, 351, 351, 351, 352 352 352 352 352 352 001, 002 237, 238 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23847 TABLE 6B.—NEW PROCEDURE CODES—Continued Procedure code Description O.R. MDC 17 48.42 ........ 48.43 ........ 48.50 ........ 48.51 ........ 48.52 ........ 48.59 ........ Laparoscopic pull-through resection of rectum ........................................................................... Open pull-through resection of rectum ........................................................................................ Abdominoperineal resection of the rectum, not otherwise specified .......................................... Laparoscopic abdominoperineal resection of the rectum ........................................................... Open abdominoperineal resection of the rectum ........................................................................ Other abdominoperineal resection of the rectum ........................................................................ Y ....... 21 24 06 17 Y ....... 21 24 06 17 Y ....... 21 24 06 17 Y ....... 21 24 06 17 Y ....... 21 24 06 17 Y ....... 21 24 06 17 Laparoscopic repair of umbilical hernia with graft or prosthesis ................................................ Other laparoscopic umbilical herniorrhaphy ................................................................................ Y ....... Y ....... 53.62 ........ Laparoscopic incisional hernia repair with graft or prosthesis .................................................... Y ....... 53.63 ........ 53.71 ........ Other laparoscopic repair of other hernia of anterior abdominal wall with graft or prosthesis .. Laparoscopic repair of diaphragmatic hernia, abdominal approach ........................................... Y ....... Y ....... 53.72 ........ Other and open repair of diaphragmatic hernia, abdominal approach ....................................... Y ....... 53.75 ........ Repair of diaphragmatic hernia, abdominal approach, not otherwise specified ......................... Y ....... 53.83 ........ Laparoscopic repair of diaphragmatic hernia, with thoracic approach ....................................... Y ....... 53.84 ........ Other and open repair of diaphragmatic hernia, with thoracic approach ................................... Y ....... 80.53 ........ jlentini on PROD1PC65 with PROPOSALS2 53.42 ........ 53.43 ........ Repair of the anulus fibrosus with graft or prosthesis ................................................................ Y ....... 80.54 ........ VerDate Aug<31>2005 Other and unspecified repair of the anulus fibrosus ................................................................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00321 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM Y ....... 30APP2 21 24 06 06 21 24 06 21 24 06 04 06 21 24 04 06 21 24 04 06 21 24 04 06 21 24 04 06 21 24 01 08 17 21 24 01 08 17 MS–DRG 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 353, 354, 355 353, 354, 355 907, 908, 909 957, 958, 959 353, 354, 355 907, 908, 909 957, 958, 959 353, 354, 355 163, 164, 165 326, 327, 328 907, 908, 909 957, 958, 959 163, 164, 165 326, 327, 328 907, 908, 909 957, 958, 959 163, 164, 165 326, 327, 328 907, 908, 909 957, 958, 959 163, 164, 165 326, 327, 328 907, 908, 909 957, 958, 959 163, 164, 165 326, 327, 328 907, 908, 909 957, 958, 959 028, 029, 030 490, 491 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 028, 029, 030 490, 491 820, 821, 822, 826, 827, 828 23848 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 6B.—NEW PROCEDURE CODES—Continued Procedure code Description O.R. MDC 21 24 MS–DRG 907, 908, 909 957, 958, 959 TABLE 6C.—INVALID DIAGNOSIS CODES Diagnosis code Description CC ........ ........ ........ ........ ........ ........ Jakob-Creutzfeldt disease ........................................................................................................... Cowpox ........................................................................................................................................ Specific infections by free-living amebae .................................................................................... Androgen insensitivity syndrome ................................................................................................. Idiopathic peripheral autonomic neuropathy ............................................................................... Other specified forms of pleural effusion, except tuberculous .................................................... CC .... N ....... MCC N ....... CC .... MCC 599.7 ........ Hematuria .................................................................................................................................... N ....... 611.8 695.1 729.9 760.6 777.5 788.9 795.1 997.3 ........ ........ ........ ........ ........ ........ ........ ........ Other specified disorders of breast ............................................................................................. Erythema multiforme ................................................................................................................... Other and unspecified disorders of soft tissue ........................................................................... Surgical operation on mother ...................................................................................................... Necrotizing enterocolitis in fetus or newborn .............................................................................. Other symptoms involving urinary system .................................................................................. Nonspecific abnormal Papanicolaou smear of other site ........................................................... Respiratory complications ........................................................................................................... N ....... CC .... N ....... N ....... MCC N ....... N ....... CC .... 999.8 ........ Other transfusion reaction ........................................................................................................... CC .... V13.5 ........ V15.2 ........ V15.5 ........ V28.8 ........ V45.1 ........ V51 ........... Personal history of other musculoskeletal disorders .................................................................. Personal history of surgery to other major organs ..................................................................... Personal history of injury ............................................................................................................. Encounter for other specified antenatal screening ..................................................................... Renal dialysis status .................................................................................................................... Aftercare involving the use of plastic surgery ............................................................................. N N N N N N 046.1 051.0 136.2 259.5 337.0 511.8 1 2 ....... ....... ....... ....... ....... ....... MDC 01 18 18 10 01 04 15 11 15 09 09 08 15 15 11 04 04 15 15 16 23 23 23 23 23 09 MS–DRG 056, 057 865, 866 867, 868, 869 643, 644, 645 073, 074 186, 187, 188 791 1, 793 1 695, 696 791 1, 793 1 600, 601 595, 596 555, 556 794 791 2, 793 2 695, 696 180, 181, 182 205, 206 791 1, 793 1 791 1, 793 1 811, 812 951 951 951 951 951 606, 607 Principal or secondary diagnosis of major problem. Principal or secondary diagnosis of major problem. TABLE 6D.—INVALID PROCEDURE CODES Procedure code Description O.R. MDC 45.8 .......... Total intra-abdominal colectomy ................................................................................................. Y ....... ............ 05 06 17 Y ....... 21 24 06 17 Y ....... 21 24 04 06 21 24 48.5 .......... jlentini on PROD1PC65 with PROPOSALS2 53.7 .......... Abdominoperineal resection of rectum ........................................................................................ Repair of diaphragmatic hernia, abdominal approach ................................................................ MS–DRG 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 332, 333, 334 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 163, 164, 165 326, 327, 328 907, 908, 909 957, 958, 959 TABLE 6E.—REVISED DIAGNOSIS CODE TITLES Diagnosis code Description CC 203.00 ...... Multiple myeloma, without mention of having achieved remission ............................................. CC .... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00322 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 MDC 17 MS–DRG 820, 821, 822, 823, 824, 825, 840, 841, 842 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23849 TABLE 6E.—REVISED DIAGNOSIS CODE TITLES—Continued Description CC 203.10 ...... Plasma cell leukemia, without mention of having achieved remission ....................................... CC .... 17 203.80 ...... Other immunoproliferative neoplasms, without mention of having achieved remission ............. CC .... 17 204.00 ...... Acute lymphoid leukemia, without mention of having achieved remission ................................. CC .... 17 204.10 ...... Chronic lymphoid leukemia, without mention of having achieved remission ............................. CC .... 17 204.20 ...... Subacute lymphoid leukemia, without mention of having achieved remission ........................... CC .... 17 204.80 ...... Other lymphoid leukemia, without mention of having achieved remission ................................. CC .... 17 204.90 ...... Unspecified lymphoid leukemia, without mention of having achieved remission ....................... CC .... 17 205.00 ...... Acute myeloid leukemia, without mention of having achieved remission ................................... CC .... 17 205.10 ...... Chronic myeloid leukemia, without mention of having achieved remission ............................... CC .... 17 205.20 ...... Subacute myeloid leukemia, without mention of having achieved remission ............................. CC .... 17 205.30 ...... Myeloid sarcoma, without mention of having achieved remission .............................................. CC .... 17 205.80 ...... Other myeloid leukemia, without mention of having achieved remission ................................... CC .... 17 205.90 ...... Unspecified myeloid leukemia, without mention of having achieved remission ......................... CC .... 17 206.00 ...... Acute monocytic leukemia, without mention of having achieved remission ............................... CC .... 17 206.10 ...... Chronic monocytic leukemia, without mention of having achieved remission ............................ CC .... 17 206.20 ...... Subacute monocytic leukemia, without mention of having achieved remission ......................... CC .... 17 206.80 ...... Other monocytic leukemia, without mention of having achieved remission ............................... CC .... 17 206.90 ...... Unspecified monocytic leukemia, without mention of having achieved remission ..................... CC .... 17 207.00 ...... Acute erythremia and erythroleukemia, without mention of having achieved remission ............ CC .... 17 207.10 ...... jlentini on PROD1PC65 with PROPOSALS2 Diagnosis code Chronic erythremia, without mention of having achieved remission .......................................... CC .... 17 207.20 ...... Megakaryocytic leukemia, without mention of having achieved remission ................................ CC .... 17 207.80 ...... Other specified leukemia, without mention of having achieved remission ................................. CC .... 17 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00323 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 MDC MS–DRG 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 23850 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 6E.—REVISED DIAGNOSIS CODE TITLES—Continued Diagnosis code Description CC 208.00 ...... Acute leukemia of unspecified cell type, without mention of having achieved remission .......... CC .... 17 208.10 ...... Chronic leukemia of unspecified cell type, without mention of having achieved remission ....... CC .... 17 208.20 ...... Subacute leukemia of unspecified cell type, without mention of having achieved remission .... CC .... 17 208.80 ...... Other leukemia of unspecified cell type, without mention of having achieved remission .......... CC .... 17 208.90 ...... Unspecified leukemia, without mention of having achieved remission ....................................... CC .... 17 346.00 ...... N ....... 01 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 N ....... 01 102, 103 ...... ...... ...... ...... ...... ...... Migraine with aura, without mention of intractable migraine without mention of status migrainosus. Migraine with aura, with intractable migraine, so stated, without mention of status migrainosus. Migraine without aura, without mention of intractable migraine without mention of status migrainosus. Migraine without aura, with intractable migraine, so stated, without mention of status migrainosus. Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus. Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without mention of status migrainosus. Other forms of migraine, without mention of intractable migraine without mention of status migrainosus. Other forms of migraine, with intractable migraine, so stated, without mention of status migrainosus. ´ ` Meniere’s disease, unspecified ................................................................................................... ´ ` Active Meniere’s disease, cochleovestibular ............................................................................... ´ ` Active Meniere’s disease, cochlear ............................................................................................. ´ ` Active Meniere’s disease, vestibular ........................................................................................... ´ ` Inactive Meniere’s disease .......................................................................................................... Pressure ulcer, unspecified site .................................................................................................. 820, 821, 822, 834, 835, 836, 837 1, 838 1, 839 1 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 820, 821, 822, 823, 824, 825, 840, 841, 842 102, 103 N ....... N ....... N ....... N ....... N ....... N 2 ..... 03 03 03 03 03 09 707.01 ...... Pressure ulcer, elbow .................................................................................................................. N 2 ..... 09 707.02 ...... Pressure ulcer, upper back ......................................................................................................... N 2 ..... 09 707.03 ...... Pressure ulcer, lower back .......................................................................................................... N 2 ..... 09 707.04 ...... Pressure ulcer, hip ...................................................................................................................... N 2 ..... 09 707.05 ...... Pressure ulcer, buttock ................................................................................................................ N 2 ..... 09 707.06 ...... Pressure ulcer, ankle ................................................................................................................... N 2 ..... 09 707.07 ...... Pressure ulcer, heel .................................................................................................................... N 2 ..... 09 707.09 ...... Pressure ulcer, other site ............................................................................................................ N 2 ..... 09 776.9 ........ 795.08 ...... Unspecified hematological disorder specific to newborn ............................................................ Unsatisfactory cervical cytology smear ....................................................................................... N ....... N ....... 15 13 998.31 ...... V28.3 ........ V45.71 ...... Disruption of internal operation (surgical) wound ....................................................................... Encounter for routine screening for malformation using ultrasonics .......................................... Acquired absence of breast and nipple ...................................................................................... CC .... N ....... N ....... 21 23 23 149 149 149 149 149 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 573, 574, 575, 592, 593, 594 794 742, 743, 760, 761 919, 920, 921 951 951 346.01 ...... 346.10 ...... 346.11 ...... 346.20 ...... 346.21 ...... 346.80 ...... 346.81 ...... jlentini on PROD1PC65 with PROPOSALS2 386.00 386.01 386.02 386.03 386.04 707.00 1 MDC MS–DRG Secondary diagnosis of acute leukemia. The pressure ulcer site specific codes (707.00–707.09) will be non-CCs. The pressure ulcer stage III and IV codes will be classified as MCCs. 2 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00324 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23851 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 6F.—REVISED PROCEDURE CODE TITLES Procedure code 37.52 37.53 37.54 45.71 ........ ........ ........ ........ Description O.R. Implantation of internal biventricular heart replacement system ................................................ Replacement or repair of thoracic unit of (total) replacement heart system .............................. Replacement or repair of other implantable component of (total) replacement heart system ... Open and other multiple segmental resection of large intestine ................................................ Y Y Y Y ....... ....... ....... ....... 45.72 ........ Open and other cecectomy ......................................................................................................... Y ....... 45.73 ........ Open and other right hemicolectomy .......................................................................................... Y ....... 45.74 ........ 45.75 ........ 45.76 ........ 45.79 ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ Open and other left hemicolectomy ............................................................................................ Open and other sigmoidectomy .................................................................................................. Other and unspecified partial excision of large intestine ............................................................ Y ....... 21 24 05 06 17 Other open incisional hernia repair with graft or prosthesis ....................................................... Y ....... 53.69 ........ 81.65 ........ Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis ....... Percutaneous vertebroplasty ....................................................................................................... Y ....... Y ....... 81.66 ........ Percutaneous vertebral augmentation ........................................................................................ Y ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... Y ....... Y ....... MS–DRG change. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00325 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 353, 353, 907, 957, 353, 907, 957, 353, 515, 907, 957, 515, 907, 957, Y ....... 21 24 06 17 53.61 ........ VerDate Aug<31>2005 06 06 21 24 06 21 24 06 08 21 24 08 21 24 Y ....... 21 24 05 06 10 17 Y Y Y Y Y Y Y Y Y Y 1 Note 21 24 06 06 06 06 06 06 06 06 06 06 21 24 05 06 21 24 05 06 17 Y ....... Other and open repair of direct inguinal hernia .......................................................................... Other and open repair of indirect inguinal hernia ....................................................................... Other and open repair of direct inguinal hernia with graft or prosthesis .................................... Other and open repair of indirect inguinal hernia with graft or prosthesis ................................. Other and open bilateral repair of direct inguinal hernia ............................................................ Other and open bilateral repair of indirect inguinal hernia ......................................................... Other and open bilateral repair of inguinal hernia, one direct and one indirect ......................... Other and open bilateral repair of direct inguinal hernia with graft or prosthesis ...................... Other and open bilateral repair of indirect inguinal hernia with graft or prosthesis ................... Other and open bilateral repair of inguinal hernia, one direct and one indirect, with graft or prosthesis. Other and open repair of umbilical hernia with graft or prosthesis ............................................ Other open umbilical herniorrhaphy ............................................................................................ 30APP2 MS–DRG 001 1, 002 1 215 215 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 628, 629, 630 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 264 329, 330, 331 820, 821, 822, 826, 827, 828 907, 908, 909 957, 958, 959 350, 351, 352 350, 351, 352 350, 351, 352 350, 351, 352 350, 351, 352 350, 351, 352 350, 351, 352 350, 351, 352 350, 351, 352 350, 351, 352 PRE 05 05 06 17 21 24 05 06 17 53.41 ........ 53.49 ........ jlentini on PROD1PC65 with PROPOSALS2 53.01 53.02 53.03 53.04 53.11 53.12 53.13 53.14 53.15 53.16 Open and other resection of transverse colon ............................................................................ MDC 354, 354, 908, 958, 354, 908, 958, 354, 516, 908, 958, 516, 908, 958, 355 355 909 959 355 909 959 355 517 909 959 517 909 959 23852 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 1 ............................................................... 2 ............................................................... 3 ............................................................... 4 ............................................................... 5 ............................................................... 6 ............................................................... 7 ............................................................... 8 ............................................................... 9 ............................................................... 10 ............................................................. 11 ............................................................. 12 ............................................................. 13 ............................................................. 20 ............................................................. 21 ............................................................. 22 ............................................................. 23 ............................................................. 24 ............................................................. 25 ............................................................. 26 ............................................................. 27 ............................................................. 28 ............................................................. 29 ............................................................. 30 ............................................................. 31 ............................................................. 32 ............................................................. 33 ............................................................. 34 ............................................................. 35 ............................................................. 36 ............................................................. 37 ............................................................. 38 ............................................................. 39 ............................................................. 40 ............................................................. 41 ............................................................. 42 ............................................................. 52 ............................................................. 53 ............................................................. 54 ............................................................. 55 ............................................................. 56 ............................................................. 57 ............................................................. 58 ............................................................. 59 ............................................................. 60 ............................................................. 61 ............................................................. 62 ............................................................. 63 ............................................................. 64 ............................................................. 65 ............................................................. 66 ............................................................. 67 ............................................................. 68 ............................................................. 69 ............................................................. 70 ............................................................. 71 ............................................................. 72 ............................................................. 73 ............................................................. 74 ............................................................. 75 ............................................................. 76 ............................................................. 77 ............................................................. 78 ............................................................. 79 ............................................................. 80 ............................................................. 81 ............................................................. 82 ............................................................. 83 ............................................................. 84 ............................................................. 85 ............................................................. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 655 287 23,205 21,267 635 229 356 483 1,346 163 1,264 1,907 1,268 885 530 212 3,730 2,092 8,697 11,781 13,695 1,666 3,070 3,398 1,024 2,780 3,623 765 2,239 6,947 4,841 14,146 51,927 4,766 7,573 4,859 1,163 587 5,240 16,289 8,250 47,224 736 2,752 4,068 1,586 2,464 1,323 55,734 105,000 89,325 1,397 11,402 101,817 7,341 9,526 5,739 9,223 31,500 1,238 873 1,211 1,405 931 1,861 7,124 1,757 2,049 2,769 5,879 PO 00000 Frm 00326 10th percentile 40.2107 24.7456 39.6406 28.8412 21.1717 10.2576 19.6517 11.9337 21.9725 10.7791 16.7302 10.6754 6.9267 18.3525 15.4472 9.3726 12.6794 9.0263 13.0331 8.2206 4.5403 14.3055 7.1091 3.7310 13.1377 5.9781 3.0395 7.2261 3.2823 1.5949 8.5478 3.7666 1.8278 13.3479 7.2006 3.6300 6.7395 4.0102 6.9504 5.0708 7.7668 4.9743 7.5978 5.1432 3.9668 8.9426 6.2683 4.5110 7.4669 5.2179 3.7141 5.8232 3.4467 2.9920 7.8574 5.5568 3.5389 6.2394 4.3070 7.3021 4.1340 6.6821 4.4157 3.3845 5.1016 3.5267 6.4087 4.9551 3.1268 7.6399 Fmt 4701 12 9 16 11 7 6 8 6 8 6 6 4 3 6 8 2 2 1 4 2 1 4 1 1 3 1 1 1 1 1 2 1 1 3 1 1 2 1 2 1 2 2 2 2 2 2 3 2 2 2 1 2 1 1 2 2 1 2 1 2 2 2 2 1 1 1 1 1 1 2 Sfmt 4702 25th percentile 50th percentile 17 12 22 17 10 7 10 7 16 7 9 6 4 10 11 6 5 4 6 4 2 7 3 1 6 2 1 2 1 1 3 1 1 6 3 1 3 2 3 2 3 3 4 3 2 4 4 3 3 3 2 3 2 2 4 3 2 3 2 4 2 3 2 2 2 2 1 2 1 3 E:\FR\FM\30APP2.SGM 31 17 32 24 15 9 15 9 20 8 13 9 6 17 14 9 10 8 10 7 4 11 6 3 10 4 2 5 2 1 7 2 1 10 6 2 5 3 5 4 6 4 6 4 4 7 5 4 6 4 3 5 3 2 6 4 3 5 3 6 4 5 4 3 4 3 4 4 2 6 30APP2 75th percentile 51 28 48 35 26 12 22 13 25 11 20 13 8 24 19 12 17 12 17 11 6 18 9 5 18 8 4 9 4 2 11 5 2 17 9 5 8 5 9 6 9 6 9 6 5 11 8 6 10 6 5 7 4 4 10 7 4 8 5 9 5 9 6 4 6 4 9 7 4 10 90th percentile 83 48 68 49 42 17 38 20 35 19 30 18 11 32 25 15 25 18 25 15 9 27 14 7 27 14 6 15 8 3 17 9 3 25 14 8 14 7 14 10 14 9 15 9 7 17 11 8 15 9 7 11 6 5 15 10 7 12 8 14 7 12 8 6 10 6 15 10 6 15 23853 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 86 ............................................................. 87 ............................................................. 88 ............................................................. 89 ............................................................. 90 ............................................................. 91 ............................................................. 92 ............................................................. 93 ............................................................. 94 ............................................................. 95 ............................................................. 96 ............................................................. 97 ............................................................. 98 ............................................................. 99 ............................................................. 100 ........................................................... 101 ........................................................... 102 ........................................................... 103 ........................................................... 113 ........................................................... 114 ........................................................... 115 ........................................................... 116 ........................................................... 117 ........................................................... 121 ........................................................... 122 ........................................................... 123 ........................................................... 124 ........................................................... 125 ........................................................... 129 ........................................................... 130 ........................................................... 131 ........................................................... 132 ........................................................... 133 ........................................................... 134 ........................................................... 135 ........................................................... 136 ........................................................... 137 ........................................................... 138 ........................................................... 139 ........................................................... 146 ........................................................... 147 ........................................................... 148 ........................................................... 149 ........................................................... 150 ........................................................... 151 ........................................................... 152 ........................................................... 153 ........................................................... 154 ........................................................... 155 ........................................................... 156 ........................................................... 157 ........................................................... 158 ........................................................... 159 ........................................................... 163 ........................................................... 164 ........................................................... 165 ........................................................... 166 ........................................................... 167 ........................................................... 168 ........................................................... 175 ........................................................... 176 ........................................................... 177 ........................................................... 178 ........................................................... 179 ........................................................... 180 ........................................................... 181 ........................................................... 182 ........................................................... 183 ........................................................... 184 ........................................................... 185 ........................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 11,469 12,958 711 2,733 3,089 7,605 16,265 16,121 1,473 1,030 757 1,192 1,005 641 16,989 56,991 1,080 13,735 525 555 1,046 546 996 542 617 2,785 749 4,661 1,353 1,073 929 886 1,981 3,362 352 472 773 886 1,490 674 1,364 847 38,817 949 6,810 1,726 11,433 1,899 4,471 4,819 1,044 3,219 2,355 13,614 17,887 13,805 20,549 20,520 5,467 12,682 41,338 63,750 70,831 26,087 22,324 30,220 5,446 1,856 4,320 2,506 PO 00000 Frm 00327 10th percentile 5.0021 3.2740 5.8748 3.7603 2.5494 6.3657 4.4647 3.2188 11.8547 8.6359 6.1744 12.6023 8.3522 5.8752 6.3526 3.6950 4.5306 3.1270 5.5981 2.6090 4.3222 4.0678 2.1596 5.4576 4.0454 2.8747 5.2697 3.5134 5.1803 2.9385 5.7492 2.6501 5.3296 2.2329 5.8295 2.3305 5.4062 2.5237 1.8456 9.4466 6.1320 3.8040 2.7185 5.1981 2.8921 4.4571 3.2168 6.3381 4.4187 3.1731 6.6542 4.5281 3.0522 14.9476 8.0977 5.1442 12.9161 7.9756 5.2532 7.2650 5.3283 9.1032 7.3794 5.5654 7.9001 5.9078 4.1761 7.2338 4.5829 3.4066 Fmt 4701 25th percentile 1 1 1 1 1 2 1 1 4 3 2 4 3 2 2 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 5 3 2 4 2 1 3 2 3 3 2 2 2 1 2 2 1 Sfmt 4702 50th percentile 3 2 3 2 1 3 2 2 6 5 4 7 5 3 3 2 2 2 2 1 2 1 1 3 2 2 2 2 2 1 2 1 2 1 2 1 2 1 1 4 2 1 1 2 1 2 2 3 2 2 3 2 1 8 5 3 7 4 2 4 3 5 4 3 4 3 2 4 3 2 E:\FR\FM\30APP2.SGM 4 3 4 3 2 5 4 3 10 7 6 11 7 5 5 3 3 2 4 2 4 2 1 4 3 2 4 3 4 2 4 2 4 1 4 1 4 2 1 7 4 3 2 4 2 3 3 5 4 3 5 3 2 13 7 5 10 7 4 6 5 7 6 5 6 5 3 6 4 3 30APP2 75th percentile 6 4 7 5 3 8 6 4 15 11 8 16 10 8 8 5 6 4 8 3 5 5 2 7 5 4 7 4 6 4 8 3 7 3 8 3 7 3 2 12 8 5 3 6 4 5 4 8 6 4 8 6 4 19 10 6 16 10 7 9 7 12 9 7 10 8 5 9 6 4 90th percentile 9 6 12 7 5 13 8 6 22 15 11 23 15 11 12 7 9 6 12 5 7 8 3 10 7 5 10 7 11 6 12 5 11 4 12 5 11 5 3 19 12 8 5 10 5 8 6 12 8 6 14 9 6 27 15 9 24 15 10 12 9 17 13 10 15 11 8 13 8 6 23854 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 9,239 10,028 5,014 113,067 58,781 118,162 184,764 87,315 253,950 133,231 5,388 6,796 4,616 3,208 8,382 3,467 29,252 36,870 25,669 5,848 21,532 39,505 76,444 141 8,616 7,236 2,554 10,525 13,928 7,032 2,771 5,080 1,911 5,076 7,064 42,807 2,974 3,596 1,566 1,446 1,515 16,254 34,309 9,629 30,065 22,384 42,226 13,307 11,658 2,680 17,519 36,074 62,706 5,887 28,818 188,884 13,847 69,978 6,762 41,707 45,567 44,910 53,360 2,521 3,425 705 686 7,302 1,549 3,522 PO 00000 Frm 00328 10th percentile 7.4006 5.3216 3.9928 6.1459 6.2972 5.0156 3.9705 6.7517 5.2660 4.0792 7.3537 5.3899 4.0804 8.3030 5.0894 4.0580 4.3530 3.3859 2.8746 5.5050 3.4393 15.0709 7.2241 14.1844 18.3713 12.3046 9.0568 13.9944 8.5619 6.4428 13.0949 6.2701 11.3673 5.6420 9.3342 2.8263 14.7078 9.1096 6.4757 13.3811 9.1868 14.1787 8.9262 11.2185 6.6177 10.8073 4.6444 15.3499 10.3695 6.7634 8.7738 5.0924 2.9268 3.3061 5.3370 2.1674 5.9831 2.4966 7.7798 2.8343 8.5378 6.0144 2.7299 9.6942 7.4762 4.8482 7.3761 2.8020 11.2214 4.2127 Fmt 4701 25th percentile 2 2 1 2 2 2 1 2 2 2 3 2 1 2 1 1 1 1 1 1 1 6 1 1 8 6 5 6 5 4 5 1 4 2 1 1 6 4 3 6 5 7 5 5 4 2 1 5 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 2 1 3 1 Sfmt 4702 50th percentile 4 3 2 3 3 3 2 4 3 2 4 3 2 4 2 2 2 2 1 2 2 9 3 3 11 8 6 8 6 5 7 3 6 3 3 1 8 6 4 8 7 9 6 7 5 5 2 8 5 4 4 2 1 1 2 1 2 1 3 1 3 2 1 4 4 2 3 1 5 1 E:\FR\FM\30APP2.SGM 6 4 3 5 5 4 3 6 4 4 6 4 3 7 4 3 4 3 2 4 3 13 6 9 16 11 8 11 7 6 11 5 9 5 7 1 13 8 6 11 8 12 8 9 6 9 3 12 8 6 7 4 2 2 4 1 4 2 6 2 6 5 2 8 6 4 6 2 8 3 30APP2 75th percentile 9 7 5 8 8 6 5 8 7 5 9 7 5 11 7 5 5 4 4 7 4 18 10 17 23 15 11 17 10 7 17 8 14 7 12 3 18 11 8 17 11 17 11 14 8 14 6 19 13 8 11 7 4 4 7 3 8 3 10 4 11 8 3 12 9 7 9 4 14 6 90th percentile 14 10 8 11 12 9 7 12 9 7 14 10 7 16 10 8 8 6 5 10 6 25 14 31 31 20 14 26 14 10 23 12 21 10 19 7 26 15 11 24 14 24 13 20 10 21 9 29 19 12 17 10 6 7 12 4 12 5 16 6 18 13 6 18 13 10 14 6 22 9 23855 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 262 263 264 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 3,531 652 28,273 63,593 53,704 54,305 14,888 4,139 2,803 23,695 158,158 2,953 1,357 473 187,597 204,514 196,441 1,415 1,343 1,917 791 602 17,750 44,551 36,994 7,587 70,544 2,086 35,079 1,515 6,344 35,699 79,311 158,556 21,034 165,835 211,391 61,613 29,960 17,966 11,226 10,457 8,865 48,110 63,624 28,171 1,823 5,922 3,719 7,182 12,448 8,570 1,501 3,163 3,558 878 2,544 6,975 936 2,914 2,759 1,625 4,164 5,155 1,756 4,287 8,183 3,165 8,420 15,316 PO 00000 Frm 00329 10th percentile 2.5902 5.4126 8.8998 7.3381 4.8075 3.2480 5.4547 3.2341 2.2112 6.9333 3.1457 11.7541 8.6610 6.4947 6.4926 4.9936 3.6816 5.5611 4.3291 3.0303 1.8217 1.3040 6.6518 5.0493 3.6992 4.3756 2.5315 5.1942 2.8628 6.2964 3.4455 5.5438 3.9373 2.7530 2.3089 3.1053 2.1067 7.0205 4.6041 2.9978 17.1201 10.0519 4.3610 15.9561 9.7138 5.8793 14.3489 8.8349 5.5052 14.0778 9.0917 5.5883 10.7082 7.0452 4.1521 7.1287 4.1395 2.1792 11.7575 7.2447 4.9467 8.8166 5.7366 3.0795 7.9897 4.5573 2.4793 8.4051 5.0816 2.8995 Fmt 4701 25th percentile 1 1 1 2 2 1 1 1 1 2 1 4 3 2 2 2 1 2 2 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 6 3 1 6 4 3 6 4 2 5 3 1 4 3 2 2 1 1 4 3 2 2 2 1 2 1 1 2 2 1 Sfmt 4702 50th percentile 1 1 3 4 3 2 1 1 1 3 1 6 5 4 3 3 2 3 3 1 1 1 3 3 2 2 1 2 1 3 2 2 2 1 1 2 1 3 2 1 9 5 2 9 6 4 8 6 4 8 5 3 6 4 2 3 2 1 6 4 3 4 3 1 3 2 1 4 3 1 E:\FR\FM\30APP2.SGM 2 3 6 6 4 3 3 2 1 5 2 9 7 5 5 4 3 5 4 1 1 1 5 4 3 3 2 4 2 4 3 4 3 2 2 2 2 5 4 2 14 8 3 13 8 5 12 8 5 12 8 5 9 6 4 5 3 2 9 6 5 7 5 2 6 4 2 7 4 2 30APP2 75th percentile 3 7 11 9 6 4 7 4 3 9 4 14 11 8 8 6 5 7 6 3 2 1 8 6 5 5 3 7 4 8 4 7 5 4 3 4 3 9 6 4 21 13 6 20 12 7 18 10 7 18 11 8 13 9 5 9 5 3 15 9 6 11 7 4 10 6 3 11 6 4 90th percentile 6 13 19 13 9 6 13 7 5 14 6 22 15 11 12 9 6 9 7 7 3 2 12 9 7 8 5 10 5 12 6 11 7 5 4 6 4 14 9 6 32 18 9 29 17 9 25 15 9 25 16 10 19 12 7 14 8 4 22 12 8 17 11 6 16 9 5 16 9 5 23856 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 356 357 358 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 453 454 455 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 8,335 7,801 2,477 3,566 5,248 3,554 24,371 27,061 15,249 9,039 18,945 4,279 51,556 110,340 92,136 3,020 5,293 4,492 1,223 8,080 1,996 7,126 5,033 18,540 45,795 46,426 44,299 282,071 23,253 45,853 24,740 3,963 5,300 2,115 1,548 1,737 598 956 955 756 5,241 6,127 5,328 16,444 27,075 35,887 766 1,054 327 1,542 894 125 15,140 9,672 877 12,111 13,158 3,887 14,063 24,364 25,670 13,335 14,144 6,544 12,898 16,794 15,932 948 1,771 1,969 PO 00000 Frm 00330 10th percentile 12.9146 8.1406 4.4719 6.5979 4.7487 3.3995 8.7488 6.8532 4.9382 8.5759 6.0287 4.1837 6.3806 4.4472 3.4088 7.2738 5.1734 3.6814 5.5200 3.7490 8.8191 5.6996 4.2935 7.3159 5.0160 3.5522 5.2367 3.4889 6.8917 4.8196 3.3344 17.0056 9.1566 5.4851 14.9961 9.8290 6.5033 12.4069 8.5696 5.9272 11.7296 7.6236 4.8281 8.3803 5.6341 3.1911 13.6606 7.6879 4.3609 15.8599 10.4172 5.3760 6.9542 4.8719 3.6933 7.5614 5.8396 4.2529 7.5128 5.3275 3.8103 7.0467 5.1103 3.7796 6.6243 4.7264 3.2658 15.6561 8.0237 4.4307 Fmt 4701 25th percentile 3 2 1 2 2 1 3 3 2 2 2 1 2 2 1 2 2 1 2 1 3 2 1 2 2 1 1 1 2 1 1 5 2 1 6 4 2 5 4 2 5 3 2 3 2 1 3 2 1 4 3 1 2 1 1 2 2 1 2 2 1 2 2 1 2 1 1 5 3 1 Sfmt 4702 50th percentile 6 4 2 3 3 2 4 4 3 4 3 2 3 3 2 3 3 2 3 2 4 3 2 3 3 2 2 2 3 2 2 8 5 3 8 6 4 7 6 4 7 5 3 4 3 1 6 3 2 7 5 2 3 2 2 3 3 2 3 3 2 3 2 2 3 2 2 7 4 3 E:\FR\FM\30APP2.SGM 10 6 4 5 4 3 7 6 4 7 5 3 5 4 3 6 4 3 4 3 6 5 4 6 4 3 4 3 5 4 3 13 7 5 12 8 6 10 8 5 10 7 4 7 5 3 10 6 4 12 8 4 5 4 3 6 5 3 5 4 3 5 4 3 5 4 3 12 6 4 30APP2 75th percentile 16 10 6 8 6 4 11 8 6 11 8 5 8 5 4 9 6 5 7 5 11 7 5 9 6 4 6 4 8 6 4 21 11 7 18 12 8 15 11 7 14 9 6 10 7 4 17 10 6 20 14 7 9 6 5 10 8 6 9 7 5 9 6 5 8 6 4 19 10 5 90th percentile 25 16 9 13 9 6 17 12 8 16 12 8 12 8 6 14 9 7 10 7 18 10 8 14 9 6 10 6 14 9 6 34 18 10 28 18 11 22 14 10 21 13 8 16 10 6 26 16 8 32 20 10 14 9 6 15 11 8 15 10 7 14 9 7 13 9 6 29 14 7 23857 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 533 534 535 536 537 538 539 540 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 946 2,413 1,609 3,508 51,883 1,018 13,194 5,054 5,839 2,398 4,072 14,331 21,133 30,532 405,204 2,283 6,954 22,875 2,918 3,277 1,589 2,582 8,562 11,424 26,724 72,123 48,111 7,100 17,842 1,183 2,186 1,312 2,495 5,763 22,971 52,406 5,217 16,900 29,166 1,970 5,555 6,632 1,163 1,110 1,503 3,873 6,452 833 2,162 3,004 810 836 2,481 627 973 3,926 10,961 1,052 1,006 3,818 11,280 17,523 822 3,392 6,990 33,661 665 1,056 3,417 4,016 PO 00000 Frm 00331 10th percentile 14.7061 7.4836 4.5438 9.4478 4.2180 8.4342 4.2178 16.5693 10.2197 5.8661 9.1717 5.4882 3.9306 8.2006 3.9281 9.7946 4.0913 1.9623 12.6453 8.3946 4.7885 11.8548 6.6119 2.8188 9.2958 5.9291 4.8427 4.2093 2.4311 12.1116 8.0425 5.6715 5.2236 3.0465 4.3437 2.2104 8.5338 5.2509 3.3992 10.9609 5.9802 3.0054 7.8865 2.9757 10.8283 5.9700 2.9416 9.4586 6.4510 3.3832 3.4074 5.1459 2.0512 3.1100 6.4070 3.9758 2.1581 5.0266 2.8191 10.4445 5.9870 3.0079 6.6861 4.0292 6.2365 3.9328 4.4722 3.2197 9.7085 7.1257 Fmt 4701 25th percentile 5 3 2 4 2 3 3 5 3 1 3 3 2 3 3 2 1 1 4 3 1 3 1 1 4 3 3 2 1 4 3 3 2 1 1 1 3 2 1 3 2 1 2 1 3 2 1 3 2 1 1 1 1 1 2 1 1 1 1 3 1 1 2 1 2 2 2 1 3 3 Sfmt 4702 50th percentile 7 4 3 5 3 5 3 7 5 3 5 3 3 5 3 4 1 1 6 4 2 6 3 1 5 4 4 2 2 6 5 3 3 2 1 1 5 3 2 5 3 1 3 1 5 3 1 5 3 2 1 2 1 1 3 2 1 2 1 5 3 1 3 2 3 3 3 2 5 4 E:\FR\FM\30APP2.SGM 11 6 4 7 4 6 4 12 8 5 7 4 3 7 3 7 3 1 10 7 4 9 6 1 8 5 4 3 2 10 7 5 4 3 3 2 7 4 3 8 5 2 6 2 8 5 2 7 6 3 2 4 1 2 5 3 2 4 2 8 5 2 5 3 5 3 4 3 8 6 30APP2 75th percentile 19 9 6 11 5 9 5 20 12 7 11 6 4 10 4 13 5 2 15 11 6 15 9 4 11 7 6 5 3 15 10 7 6 4 5 3 11 6 4 14 7 4 10 4 14 8 4 11 8 4 4 6 2 3 8 5 3 6 3 13 8 4 8 5 8 5 5 4 12 8 90th percentile 28 13 7 17 7 14 6 33 20 11 16 9 6 14 6 20 9 4 24 15 9 22 13 7 16 9 7 8 4 22 14 9 10 5 9 4 15 9 6 21 11 6 16 6 21 12 6 17 12 6 7 10 3 7 12 7 4 10 6 20 11 7 12 7 12 7 8 6 17 13 23858 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 573 574 575 576 577 578 579 580 581 582 583 584 585 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 1,618 5,709 17,012 10,798 4,079 5,577 4,533 580 1,110 858 10,066 85,179 3,076 19,173 2,013 18,639 3,646 15,089 1,815 4,319 7,107 5,458 36,267 1,661 3,311 2,624 5,477 11,123 5,462 547 2,228 3,054 3,511 10,711 12,142 5,337 8,748 668 1,469 4,178 12,304 2,751 1,112 5,308 458 1,400 306 682 884 22,088 130,121 2,660 22,097 1,350 7,168 1,457 1,546 1,091 6,718 258 696 2,186 7,848 1,112 3,077 383 1,274 2,538 14,026 3,366 PO 00000 Frm 00332 10th percentile 5.3745 8.7758 5.9463 4.4077 9.0924 5.5338 3.8083 8.9379 6.3874 4.4545 7.1058 4.1225 5.9620 3.6913 4.8405 3.1089 6.6100 4.2586 7.5444 4.7217 2.7680 6.3674 3.7016 6.9934 4.9795 3.6825 13.0933 9.3248 5.8521 12.9506 6.1104 3.3062 10.6830 5.5084 2.6146 2.8943 1.8056 5.9850 2.2321 8.8712 6.4415 5.0593 8.3327 4.7600 8.2009 5.7243 3.7320 5.0513 3.8541 7.0278 4.7073 5.6590 3.4622 6.3422 3.7913 7.0336 3.1572 16.9432 8.7904 6.3605 8.2011 3.6780 2.1617 13.1574 8.5707 6.0261 7.0879 3.1233 1.5172 11.1851 Fmt 4701 25th percentile 2 3 2 2 2 2 1 3 2 2 2 1 2 1 1 1 2 2 2 1 1 2 1 2 2 1 4 3 2 2 1 1 3 1 1 1 1 1 1 3 2 2 2 1 2 2 1 2 1 2 2 1 1 1 1 2 1 6 3 2 2 1 1 3 3 2 1 1 1 2 Sfmt 4702 50th percentile 3 4 3 3 4 3 2 4 3 2 3 2 3 2 2 2 3 2 3 2 1 3 2 3 3 2 6 5 3 4 2 1 5 2 1 1 1 2 1 4 3 3 4 2 3 3 1 3 2 4 3 3 2 3 2 3 2 9 5 3 3 2 1 6 4 3 2 1 1 4 E:\FR\FM\30APP2.SGM 4 7 5 4 6 4 3 7 5 4 6 3 5 3 4 3 5 4 6 4 2 5 3 5 4 3 9 7 5 9 4 2 8 4 2 2 1 4 1 7 5 4 6 4 6 4 3 4 3 6 4 4 3 4 3 5 3 13 7 6 5 3 2 9 7 5 5 2 1 8 30APP2 75th percentile 7 11 7 5 11 7 5 11 8 6 9 5 7 5 6 4 8 5 9 6 3 8 4 9 6 5 16 11 7 17 8 4 14 7 3 3 2 8 2 10 8 6 10 6 10 7 4 7 5 9 6 7 4 7 5 8 4 20 11 8 9 4 3 16 10 7 9 3 2 14 90th percentile 9 17 11 8 19 10 7 17 12 8 14 7 11 7 9 6 12 7 15 9 5 12 6 13 9 7 26 17 11 28 13 7 21 12 6 5 3 13 4 16 11 9 16 8 16 11 6 9 7 13 8 11 6 12 7 14 5 31 15 11 18 7 4 24 15 10 15 7 2 23 23859 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 629 630 637 638 639 640 641 642 643 644 645 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 707 708 709 710 711 712 713 714 715 716 717 718 722 723 724 725 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 4,160 534 17,104 42,581 38,312 60,806 201,324 1,492 5,176 11,788 8,179 10,067 1,697 3,452 1,633 3,918 7,422 8,271 4,658 7,594 4,260 949 2,054 4,390 654 2,092 3,616 3,833 12,746 11,687 808 943 12,542 11,715 7,824 82,091 132,320 44,932 2,331 1,597 3,261 1,073 55,995 198,101 821 491 2,429 18,000 975 10,518 592 23,320 24,207 12,279 5,979 18,063 762 1,831 790 705 10,252 28,797 531 1,273 703 589 745 1,949 578 755 PO 00000 Frm 00333 10th percentile 8.7418 5.5281 6.0581 4.2659 3.0382 5.4332 3.8256 5.1810 7.6103 5.4597 3.8912 7.7888 16.8981 9.8624 6.5150 10.1146 5.9603 3.7356 11.2003 6.5146 3.2758 10.2740 5.2639 2.1223 11.0627 6.3595 2.8695 8.5265 4.4236 2.5131 5.9468 2.5302 9.7323 7.1905 2.0675 7.1569 5.6544 3.8913 3.4822 7.5717 5.3502 3.2591 6.2004 4.2356 3.9586 2.3992 4.8345 2.5778 5.5251 3.2901 3.1115 6.6546 4.8302 3.5497 4.4131 2.1475 6.5341 1.7739 8.1684 3.0496 4.1916 1.9430 6.2806 1.4289 7.2319 2.7640 7.5852 5.2678 3.1522 5.5007 Fmt 4701 25th percentile 3 1 2 1 1 1 1 1 2 2 1 4 7 5 3 4 3 2 3 2 1 2 1 1 3 1 1 2 1 1 1 1 1 1 1 2 2 1 1 2 1 1 2 2 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 1 2 Sfmt 4702 50th percentile 5 2 3 2 2 2 2 2 4 3 2 5 9 7 5 5 4 2 5 3 2 4 2 1 5 2 1 4 2 1 2 1 3 2 1 3 3 2 1 3 3 1 3 2 2 1 2 1 3 2 1 3 2 2 2 1 2 1 3 1 2 1 2 1 3 1 3 3 1 3 E:\FR\FM\30APP2.SGM 7 4 5 3 2 4 3 4 6 4 3 6 13 8 7 8 5 3 8 5 3 8 4 1 9 4 2 7 3 2 4 2 7 5 1 5 5 3 2 6 4 2 5 4 3 2 4 2 4 3 2 5 4 3 3 2 4 1 6 2 3 2 4 1 5 2 6 4 2 4 30APP2 75th percentile 11 7 7 5 4 7 5 6 9 7 5 9 21 11 8 12 7 5 14 8 4 14 7 2 14 9 3 11 6 3 8 3 13 9 2 9 7 5 4 9 7 4 8 5 5 3 6 3 7 4 4 8 6 4 5 3 8 2 10 4 5 2 8 1 9 3 10 7 4 7 90th percentile 16 11 12 8 5 11 7 9 14 10 7 13 31 16 10 19 10 6 22 13 6 20 11 4 21 14 6 16 9 5 12 5 21 15 4 14 10 7 7 15 10 6 11 7 8 5 10 5 11 6 6 13 9 7 8 4 15 3 16 7 9 3 13 2 14 5 14 10 6 10 23860 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 726 727 728 729 730 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 754 755 756 757 758 759 760 761 765 766 767 768 769 770 774 775 776 777 778 779 780 781 782 790 799 800 801 802 803 804 808 809 810 811 812 813 814 815 816 820 821 822 823 824 825 826 827 828 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 3,716 1,294 6,158 591 471 1,362 1,130 854 3,293 863 1,013 4,326 6,014 10,950 32,325 1,520 1,694 2,634 10,409 19,857 982 435 978 2,933 677 1,393 1,605 1,239 1,700 1,749 2,754 2,686 132 6 98 202 1,506 5,768 511 206 474 110 40 3,017 171 1 566 705 557 765 1,070 987 6,088 12,869 2,786 21,404 89,951 14,232 1,554 3,297 2,147 1,299 2,474 1,893 2,178 2,974 1,748 524 1,254 799 PO 00000 Frm 00334 10th percentile 3.4739 6.3995 4.0404 5.5736 3.0786 7.9941 3.3602 13.7752 7.1786 3.8714 10.1955 5.2305 2.9940 4.5175 2.2608 5.8355 2.5738 4.2134 1.8856 1.7358 9.3401 3.1103 8.3395 5.6870 3.1359 8.1436 6.0536 4.4722 3.9594 2.4351 5.0359 3.1601 3.3712 3.5000 4.6224 2.2277 3.1886 2.2394 3.3112 2.2136 3.0127 2.1182 1.4500 3.7630 2.4971 25.0000 14.0583 7.8610 4.9336 12.2706 6.6738 3.4215 8.2467 5.3247 4.0337 5.6912 3.7401 5.1669 6.7368 4.9706 3.5198 17.7229 7.8646 3.5288 15.4385 8.7492 4.3084 15.0401 7.9793 3.7722 Fmt 4701 1 2 1 1 1 3 1 5 3 2 3 2 1 2 1 1 1 1 1 1 2 1 2 2 1 3 2 2 1 1 2 2 2 1 1 1 2 1 1 1 1 1 1 1 1 125 5 3 2 3 1 1 3 2 1 1 1 1 2 1 1 5 1 1 5 2 1 4 2 1 Sfmt 4702 25th percentile 2 3 2 2 1 4 2 7 4 3 5 3 2 2 2 2 1 2 1 1 4 1 4 3 1 4 3 2 2 1 3 2 2 2 2 1 2 2 2 1 1 1 1 1 1 125 7 4 2 5 3 1 4 3 2 2 2 2 3 2 2 8 3 1 8 4 1 7 4 2 E:\FR\FM\30APP2.SGM 50th percentile 3 5 3 4 2 6 3 11 6 3 8 4 3 3 2 4 2 3 2 1 7 2 7 4 2 6 5 4 3 2 4 3 2 3 3 1 2 2 2 2 2 1 1 2 1 125 11 6 4 9 5 3 6 4 3 4 3 4 5 4 3 14 6 3 12 7 3 11 6 3 30APP2 75th percentile 4 8 5 7 4 9 4 17 8 5 12 6 4 5 3 7 3 5 2 2 12 4 11 7 4 10 7 5 5 3 5 4 3 6 6 2 3 3 4 3 3 2 1 4 2 125 18 9 6 15 8 4 10 7 5 7 5 6 8 6 4 23 10 4 20 11 6 19 10 5 90th percentile 6 12 7 10 6 15 5 25 13 6 20 9 5 8 3 12 5 8 3 3 19 6 16 11 6 16 11 8 8 5 7 4 5 6 11 5 5 3 7 4 5 3 3 7 4 125 26 15 9 25 14 6 16 10 7 11 7 10 13 9 7 34 16 7 29 17 9 29 16 7 23861 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS-DRG 829 830 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 853 854 855 856 857 858 862 863 864 865 866 867 868 869 870 871 872 876 880 881 882 883 884 885 886 887 894 895 896 897 901 902 903 904 905 906 907 908 909 913 914 915 916 917 918 919 920 921 922 923 927 928 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 1,171 521 4,028 2,703 1,622 1,043 1,320 1,467 9,659 10,035 5,310 1,350 2,412 804 2,113 23,862 1,723 1,477 34,852 6,643 459 5,892 9,614 3,246 7,929 21,420 18,946 1,705 8,182 5,062 2,641 1,103 21,199 216,384 90,892 857 9,282 4,623 1,556 757 19,006 80,806 404 393 4,369 6,958 5,490 36,053 924 2,031 1,500 1,047 811 712 8,462 8,319 5,447 804 6,609 1,078 5,508 15,775 35,653 11,089 13,970 9,423 1,047 3,952 211 818 PO 00000 Frm 00335 10th percentile 10.6576 3.7179 15.4615 10.4351 5.1843 23.1419 12.2629 6.4104 10.4408 6.9221 4.5563 8.5222 6.0987 4.3022 8.4179 3.3508 3.1294 5.9709 16.6669 11.1072 7.0261 15.3839 8.4628 5.6741 8.1778 5.1976 4.0639 6.7009 3.5351 9.6254 5.7819 4.3128 15.4758 7.4839 5.7138 11.9498 3.1518 4.1888 4.4274 7.3725 5.4936 7.6211 6.0767 4.6209 2.9528 10.4997 6.6087 4.0582 15.0693 7.7371 4.5680 11.2178 4.6523 3.1657 11.6494 6.7682 3.6367 5.6629 3.4330 4.7356 2.1044 5.1645 2.7260 6.3723 4.3608 2.9687 5.9933 3.2338 31.1374 15.9694 Fmt 4701 25th percentile 2 1 2 2 1 5 3 3 3 2 1 2 2 1 2 1 1 2 5 4 2 4 3 2 2 2 1 2 1 2 2 2 6 2 2 2 1 1 1 1 2 2 1 1 1 3 2 1 3 2 1 2 1 1 2 2 1 1 1 1 1 1 1 2 1 1 1 1 7 4 Sfmt 4702 50th percentile 4 1 4 3 2 10 4 4 5 3 2 4 3 2 3 2 1 3 8 6 4 7 4 3 4 3 2 3 2 4 3 2 9 3 3 5 1 2 2 2 3 3 2 2 1 4 3 2 6 3 2 4 2 1 5 3 1 3 2 2 1 2 1 3 2 1 2 1 15 7 E:\FR\FM\30APP2.SGM 7 2 10 6 3 23 6 5 8 5 4 6 5 3 5 3 3 5 13 9 6 12 7 5 6 4 3 4 3 7 4 4 13 6 5 9 2 3 3 4 4 6 4 3 2 6 5 3 10 6 4 7 4 2 8 5 3 4 3 3 2 4 2 5 3 2 4 2 26 12 30APP2 75th percentile 13 4 23 12 6 31 21 6 13 9 6 10 8 6 10 4 4 6 21 14 9 19 10 7 10 7 5 8 4 12 7 5 19 10 7 14 4 5 6 8 6 9 7 5 3 7 8 5 18 9 6 13 6 4 14 8 5 7 4 6 3 6 3 8 5 4 7 4 41 21 90th percentile 22 8 36 28 10 42 29 10 21 13 9 17 12 8 18 6 5 12 30 20 13 30 16 10 16 9 7 14 7 19 11 7 27 14 10 24 6 8 9 15 10 14 12 8 4 9 13 6 30 16 9 23 8 6 23 13 7 12 6 9 4 11 5 13 8 6 12 6 60 31 23862 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V25.0 MS–DRGS—Continued Number of discharges MS-DRG 929 933 934 935 939 940 941 945 946 947 948 949 950 951 955 956 957 958 959 963 964 965 969 970 974 975 976 977 981 982 983 984 985 986 987 988 989 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... Arithmetic mean LOS 438 139 659 2,201 671 1,320 1,707 6,244 3,055 9,715 47,722 632 387 940 443 3,975 1,311 1,146 286 1,586 2,573 1,071 639 136 5,920 4,674 2,617 4,565 25,479 18,329 6,112 671 903 731 8,240 11,583 5,796 10th percentile 7.6872 4.3453 6.1988 5.4330 10.0611 5.4220 2.7299 10.4947 7.8628 5.0101 3.4806 4.1092 3.4858 4.6436 12.2822 9.2896 14.8795 10.4031 6.2413 9.5214 6.2274 4.1391 18.8279 9.8309 10.3723 7.0148 4.9308 5.2931 15.1488 9.7455 5.3613 14.6811 9.6512 5.3338 13.0089 7.8090 4.1046 25th percentile 1 1 1 1 2 1 1 4 3 1 1 1 1 1 2 4 2 3 2 2 2 1 4 2 2 2 2 1 5 3 1 5 2 1 4 2 1 50th percentile 3 1 3 2 4 2 1 6 5 2 2 1 1 1 5 5 7 6 3 4 3 2 8 3 4 3 2 2 8 5 2 8 5 2 6 3 1 6 1 5 4 7 4 2 8 6 4 3 2 2 2 10 7 12 8 5 8 5 3 14 7 8 5 4 4 12 8 4 13 8 3 10 6 3 75th percentile 10 4 8 7 13 7 3 12 7 6 4 4 4 3 16 11 19 13 8 13 8 5 22 12 13 9 6 6 19 12 7 18 13 7 16 10 6 90th percentile 16 8 12 11 20 12 5 15 8 10 6 6 5 6 26 17 28 19 11 19 11 7 36 17 21 13 8 10 28 18 11 25 18 12 24 15 9 11,387,276 TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 1 ............................................................... 2 ............................................................... 3 ............................................................... 4 ............................................................... 5 ............................................................... 6 ............................................................... 7 ............................................................... 8 ............................................................... 9 ............................................................... 10 ............................................................. 11 ............................................................. 12 ............................................................. 13 ............................................................. 20 ............................................................. 21 ............................................................. 22 ............................................................. 23 ............................................................. 24 ............................................................. 25 ............................................................. 26 ............................................................. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 655 287 23,205 21,267 635 229 356 483 1,346 163 1,264 1,907 1,268 885 530 212 3,730 2,092 8,697 11,781 PO 00000 Frm 00336 10th percentile 40.2107 24.7456 39.6406 28.8412 21.1717 10.2576 19.6517 11.9337 21.9725 10.7791 16.7302 10.6754 6.9267 18.3525 15.4472 9.3726 12.6794 9.0263 13.0331 8.2206 Fmt 4701 12 9 16 11 7 6 8 6 8 6 6 4 3 6 8 2 2 1 4 2 Sfmt 4702 25th percentile 50th percentile 17 12 22 17 10 7 10 7 16 7 9 6 4 10 11 6 5 4 6 4 E:\FR\FM\30APP2.SGM 31 17 32 24 15 9 15 9 20 8 13 9 6 17 14 9 10 8 10 7 30APP2 75th percentile 51 28 48 35 26 12 22 13 25 11 20 13 8 24 19 12 17 12 17 11 90th percentile 83 48 68 49 42 17 38 20 35 19 30 18 11 32 25 15 25 18 25 15 23863 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 27 ............................................................. 28 ............................................................. 29 ............................................................. 30 ............................................................. 31 ............................................................. 32 ............................................................. 33 ............................................................. 34 ............................................................. 35 ............................................................. 36 ............................................................. 37 ............................................................. 38 ............................................................. 39 ............................................................. 40 ............................................................. 41 ............................................................. 42 ............................................................. 52 ............................................................. 53 ............................................................. 54 ............................................................. 55 ............................................................. 56 ............................................................. 57 ............................................................. 58 ............................................................. 59 ............................................................. 60 ............................................................. 61 ............................................................. 62 ............................................................. 63 ............................................................. 64 ............................................................. 65 ............................................................. 66 ............................................................. 67 ............................................................. 68 ............................................................. 69 ............................................................. 70 ............................................................. 71 ............................................................. 72 ............................................................. 73 ............................................................. 74 ............................................................. 75 ............................................................. 76 ............................................................. 77 ............................................................. 78 ............................................................. 79 ............................................................. 80 ............................................................. 81 ............................................................. 82 ............................................................. 83 ............................................................. 84 ............................................................. 85 ............................................................. 86 ............................................................. 87 ............................................................. 88 ............................................................. 89 ............................................................. 90 ............................................................. 91 ............................................................. 92 ............................................................. 93 ............................................................. 94 ............................................................. 95 ............................................................. 96 ............................................................. 97 ............................................................. 98 ............................................................. 99 ............................................................. 100 ........................................................... 101 ........................................................... 102 ........................................................... 103 ........................................................... 113 ........................................................... 114 ........................................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 13,695 1,666 3,070 3,398 1,024 2,780 3,623 765 2,239 6,947 4,841 14,146 51,927 4,765 7,573 4,859 1,163 587 5,240 16,289 8,250 47,224 736 2,752 4,068 1,586 2,464 1,323 55,734 105,000 89,325 1,397 11,402 101,817 7,341 9,526 5,739 9,223 31,500 1,238 873 1,211 1,405 931 1,861 7,124 1,757 2,049 2,769 5,879 11,468 12,958 711 2,733 3,089 7,605 16,265 16,121 1,473 1,030 757 1,192 1,005 641 16,989 56,991 1,080 13,735 525 555 PO 00000 Frm 00337 10th percentile 4.5403 14.3055 7.1091 3.7310 13.1377 5.9781 3.0395 7.2261 3.2823 1.5949 8.5478 3.7666 1.8278 13.3490 7.2006 3.6300 6.7395 4.0102 6.9504 5.0708 7.7668 4.9743 7.5978 5.1432 3.9668 8.9426 6.2683 4.5110 7.4669 5.2179 3.7141 5.8232 3.4467 2.9920 7.8574 5.5568 3.5389 6.2394 4.3070 7.3021 4.1340 6.6821 4.4157 3.3845 5.1016 3.5267 6.4087 4.9551 3.1268 7.6399 5.0024 3.2740 5.8748 3.7603 2.5494 6.3657 4.4647 3.2188 11.8547 8.6359 6.1744 12.6023 8.3522 5.8752 6.3526 3.6950 4.5306 3.1270 5.5981 2.6090 Fmt 4701 25th percentile 1 4 1 1 3 1 1 1 1 1 2 1 1 3 1 1 2 1 2 1 2 2 2 2 2 2 3 2 2 2 1 2 1 1 2 2 1 2 1 2 2 2 2 1 1 1 1 1 1 2 1 1 1 1 1 2 1 1 4 3 2 4 3 2 2 1 1 1 1 1 Sfmt 4702 50th percentile 2 7 3 1 6 2 1 2 1 1 3 1 1 6 3 1 3 2 3 2 3 3 4 3 2 4 4 3 3 3 2 3 2 2 4 3 2 3 2 4 2 3 2 2 2 2 1 2 1 3 3 2 3 2 1 3 2 2 6 5 4 7 5 3 3 2 2 2 2 1 E:\FR\FM\30APP2.SGM 4 11 6 3 10 4 2 5 2 1 7 2 1 10 6 2 5 3 5 4 6 4 6 4 4 7 5 4 6 4 3 5 3 2 6 4 3 5 3 6 4 5 4 3 4 3 4 4 2 6 4 3 4 3 2 5 4 3 10 7 6 11 7 5 5 3 3 2 4 2 30APP2 75th percentile 6 18 9 5 18 8 4 9 4 2 11 5 2 17 9 5 8 5 9 6 9 6 9 6 5 11 8 6 10 6 5 7 4 4 10 7 4 8 5 9 5 9 6 4 6 4 9 7 4 10 6 4 7 5 3 8 6 4 15 11 8 16 10 8 8 5 6 4 8 3 90th percentile 9 27 14 7 27 14 6 15 8 3 17 9 3 25 14 8 14 7 14 10 14 9 15 9 7 17 11 8 15 9 7 11 6 5 15 10 7 12 8 14 7 12 8 6 10 6 15 10 6 15 9 6 12 7 5 13 8 6 22 15 11 23 15 11 12 7 9 6 12 5 23864 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 115 116 117 121 122 123 124 125 129 130 131 132 133 134 135 136 137 138 139 146 147 148 149 150 151 152 153 154 155 156 157 158 159 163 164 165 166 167 168 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 1,046 546 996 542 617 2,785 749 4,661 1,353 1,073 929 886 1,981 3,362 352 472 773 886 1,490 674 1,364 847 38,817 949 6,810 1,726 11,433 1,899 4,471 4,819 1,044 3,219 2,355 13,614 17,887 13,805 20,549 20,520 5,467 12,682 41,338 63,750 70,831 26,087 22,324 30,220 5,446 1,856 4,320 2,506 9,239 10,028 5,014 113,067 58,781 118,162 184,764 87,315 253,950 133,231 5,388 6,796 4,616 3,208 8,382 3,467 29,252 36,870 25,669 5,848 PO 00000 Frm 00338 10th percentile 4.3222 4.0678 2.1596 5.4576 4.0454 2.8747 5.2697 3.5134 5.1803 2.9385 5.7492 2.6501 5.3296 2.2329 5.8295 2.3305 5.4062 2.5237 1.8456 9.4466 6.1320 3.8040 2.7185 5.1981 2.8921 4.4571 3.2168 6.3381 4.4187 3.1731 6.6542 4.5281 3.0522 14.9476 8.0977 5.1442 12.9161 7.9756 5.2532 7.2650 5.3283 9.1032 7.3794 5.5654 7.9001 5.9078 4.1761 7.2338 4.5829 3.4066 7.4006 5.3216 3.9928 6.1459 6.2972 5.0156 3.9705 6.7517 5.2660 4.0792 7.3537 5.3899 4.0804 8.3030 5.0894 4.0580 4.3530 3.3859 2.8746 5.5050 Fmt 4701 25th percentile 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 5 3 2 4 2 1 3 2 3 3 2 2 2 1 2 2 1 2 2 1 2 2 2 1 2 2 2 3 2 1 2 1 1 1 1 1 1 Sfmt 4702 50th percentile 2 1 1 3 2 2 2 2 2 1 2 1 2 1 2 1 2 1 1 4 2 1 1 2 1 2 2 3 2 2 3 2 1 8 5 3 7 4 2 4 3 5 4 3 4 3 2 4 3 2 4 3 2 3 3 3 2 4 3 2 4 3 2 4 2 2 2 2 1 2 E:\FR\FM\30APP2.SGM 4 2 1 4 3 2 4 3 4 2 4 2 4 1 4 1 4 2 1 7 4 3 2 4 2 3 3 5 4 3 5 3 2 13 7 5 10 7 4 6 5 7 6 5 6 5 3 6 4 3 6 4 3 5 5 4 3 6 4 4 6 4 3 7 4 3 4 3 2 4 30APP2 75th percentile 5 5 2 7 5 4 7 4 6 4 8 3 7 3 8 3 7 3 2 12 8 5 3 6 4 5 4 8 6 4 8 6 4 19 10 6 16 10 7 9 7 12 9 7 10 8 5 9 6 4 9 7 5 8 8 6 5 8 7 5 9 7 5 11 7 5 5 4 4 7 90th percentile 7 8 3 10 7 5 10 7 11 6 12 5 11 4 12 5 11 5 3 19 12 8 5 10 5 8 6 12 8 6 14 9 6 27 15 9 24 15 10 12 9 17 13 10 15 11 8 13 8 6 14 10 8 11 12 9 7 12 9 7 14 10 7 16 10 8 8 6 5 10 23865 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 206 207 208 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 21,532 39,505 76,444 141 8,616 7,236 2,554 10,525 13,928 7,032 2,771 5,080 1,911 5,076 7,064 42,807 2,974 3,596 1,566 1,446 1,515 16,254 34,309 9,629 30,065 22,384 42,226 13,307 11,658 2,680 17,519 36,074 62,706 3,930 28,818 188,884 13,847 69,978 6,762 41,707 45,567 44,910 53,360 2,521 3,425 705 686 7,302 1,549 3,522 3,531 652 28,273 1,957 63,593 53,704 54,305 14,888 4,139 2,803 23,695 158,158 2,953 1,357 473 187,597 204,514 196,441 1,415 1,343 PO 00000 Frm 00339 10th percentile 3.4393 15.0709 7.2241 14.1844 18.3713 12.3046 9.0568 13.9944 8.5619 6.4428 13.0949 6.2701 11.3673 5.6420 9.3342 2.8263 14.7078 9.1096 6.4757 13.3811 9.1868 14.1787 8.9262 11.2185 6.6177 10.8073 4.6444 15.3499 10.3695 6.7634 8.7738 5.0924 2.9268 3.2237 5.3370 2.1674 5.9831 2.4966 7.7798 2.8343 8.5378 6.0144 2.7299 9.6942 7.4762 4.8482 7.3761 2.8020 11.2214 4.2127 2.5902 5.4126 8.8998 3.4716 7.3381 4.8075 3.2480 5.4547 3.2341 2.2112 6.9333 3.1457 11.7541 8.6610 6.4947 6.4926 4.9936 3.6816 5.5611 4.3291 Fmt 4701 25th percentile 1 6 1 1 8 6 5 6 5 4 5 1 4 2 1 1 6 4 3 6 5 7 5 5 4 2 1 5 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 2 1 3 1 1 1 1 1 2 2 1 1 1 1 2 1 4 3 2 2 2 1 2 2 Sfmt 4702 50th percentile 2 9 3 3 11 8 6 8 6 5 7 3 6 3 3 1 8 6 4 8 7 9 6 7 5 5 2 8 5 4 4 2 1 1 2 1 2 1 3 1 3 2 1 4 4 2 3 1 5 1 1 1 3 1 4 3 2 1 1 1 3 1 6 5 4 3 3 2 3 3 E:\FR\FM\30APP2.SGM 3 13 6 9 16 11 8 11 7 6 11 5 9 5 7 1 13 8 6 11 8 12 8 9 6 9 3 12 8 6 7 4 2 2 4 1 4 2 6 2 6 5 2 8 6 4 6 2 8 3 2 3 6 2 6 4 3 3 2 1 5 2 9 7 5 5 4 3 5 4 30APP2 75th percentile 4 18 10 17 23 15 11 17 10 7 17 8 14 7 12 3 18 11 8 17 11 17 11 14 8 14 6 19 13 8 11 7 4 4 7 3 8 3 10 4 11 8 3 12 9 7 9 4 14 6 3 7 11 4 9 6 4 7 4 3 9 4 14 11 8 8 6 5 7 6 90th percentile 6 25 14 31 31 20 14 26 14 10 23 12 21 10 19 7 26 15 11 24 14 24 13 20 10 21 9 29 19 12 17 10 6 7 12 4 12 5 16 6 18 13 6 18 13 10 14 6 22 9 6 13 19 8 13 9 6 13 7 5 14 6 22 15 11 12 9 6 9 7 23866 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 1,917 791 602 17,750 44,551 36,994 7,587 70,544 2,086 35,079 1,515 6,344 35,699 79,311 158,556 21,034 165,835 211,391 61,613 29,960 17,966 11,226 10,457 8,865 48,110 63,624 28,171 1,823 5,922 3,719 7,182 12,448 8,570 1,501 3,163 3,558 878 2,544 6,975 936 2,914 2,759 1,625 4,164 5,155 1,756 4,287 8,183 3,165 8,420 15,316 8,334 7,801 2,477 3,566 5,248 3,554 24,371 27,061 15,249 9,039 18,945 4,279 51,556 110,340 92,136 3,020 5,293 4,492 1,223 PO 00000 Frm 00340 10th percentile 3.0303 1.8217 1.3040 6.6518 5.0493 3.6992 4.3756 2.5315 5.1942 2.8628 6.2964 3.4455 5.5438 3.9373 2.7530 2.3089 3.1053 2.1067 7.0205 4.6041 2.9978 17.1201 10.0519 4.3610 15.9561 9.7138 5.8793 14.3489 8.8349 5.5052 14.0778 9.0917 5.5883 10.7082 7.0452 4.1521 7.1287 4.1395 2.1792 11.7575 7.2447 4.9467 8.8166 5.7366 3.0795 7.9897 4.5573 2.4793 8.4051 5.0816 2.8995 12.9144 8.1406 4.4719 6.5979 4.7487 3.3995 8.7488 6.8532 4.9382 8.5759 6.0287 4.1837 6.3806 4.4472 3.4088 7.2738 5.1734 3.6814 5.5200 Fmt 4701 25th percentile 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 6 3 1 6 4 3 6 4 2 5 3 1 4 3 2 2 1 1 4 3 2 2 2 1 2 1 1 2 2 1 3 2 1 2 2 1 3 3 2 2 2 1 2 2 1 2 2 1 2 Sfmt 4702 50th percentile 1 1 1 3 3 2 2 1 2 1 3 2 2 2 1 1 2 1 3 2 1 9 5 2 9 6 4 8 6 4 8 5 3 6 4 2 3 2 1 6 4 3 4 3 1 3 2 1 4 3 1 6 4 2 3 3 2 4 4 3 4 3 2 3 3 2 3 3 2 3 E:\FR\FM\30APP2.SGM 1 1 1 5 4 3 3 2 4 2 4 3 4 3 2 2 2 2 5 4 2 14 8 3 13 8 5 12 8 5 12 8 5 9 6 4 5 3 2 9 6 5 7 5 2 6 4 2 7 4 2 10 6 4 5 4 3 7 6 4 7 5 3 5 4 3 6 4 3 4 30APP2 75th percentile 3 2 1 8 6 5 5 3 7 4 8 4 7 5 4 3 4 3 9 6 4 21 13 6 20 12 7 18 10 7 18 11 8 13 9 5 9 5 3 15 9 6 11 7 4 10 6 3 11 6 4 16 10 6 8 6 4 11 8 6 11 8 5 8 5 4 9 6 5 7 90th percentile 7 3 2 12 9 7 8 5 10 5 12 6 11 7 5 4 6 4 14 9 6 32 18 9 29 17 9 25 15 9 25 16 10 19 12 7 14 8 4 22 12 8 17 11 6 16 9 5 16 9 5 25 16 9 13 9 6 17 12 8 16 12 8 12 8 6 14 9 7 10 23867 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 384 385 386 387 388 389 390 391 392 393 394 395 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 8,080 1,996 7,126 5,033 18,540 45,795 46,426 44,299 282,071 23,253 45,853 24,740 3,963 5,300 2,115 1,548 1,737 598 956 955 756 5,241 6,127 5,328 16,444 27,075 35,887 766 1,054 327 1,542 894 125 15,140 9,672 877 12,111 13,158 3,887 14,063 24,364 25,670 13,335 14,144 6,544 12,898 16,794 15,932 948 1,771 1,969 946 2,413 1,609 3,508 51,883 1,018 13,194 5,052 5,838 2,398 4,072 14,331 21,133 30,531 405,204 2,283 6,954 22,875 2,918 PO 00000 Frm 00341 10th percentile 3.7490 8.8191 5.6996 4.2935 7.3159 5.0160 3.5522 5.2367 3.4889 6.8917 4.8196 3.3344 17.0056 9.1566 5.4851 14.9961 9.8290 6.5033 12.4069 8.5696 5.9272 11.7296 7.6236 4.8281 8.3803 5.6341 3.1911 13.6606 7.6879 4.3609 15.8599 10.4172 5.3760 6.9542 4.8719 3.6933 7.5614 5.8396 4.2529 7.5128 5.3275 3.8103 7.0467 5.1103 3.7796 6.6243 4.7264 3.2658 15.6561 8.0237 4.4307 14.7061 7.4836 4.5438 9.4478 4.2180 8.4342 4.2178 16.5713 10.2205 5.8661 9.1717 5.4882 3.9306 8.2004 3.9281 9.7946 4.0913 1.9623 12.6453 Fmt 4701 25th percentile 1 3 2 1 2 2 1 1 1 2 1 1 5 2 1 6 4 2 5 4 2 5 3 2 3 2 1 3 2 1 4 3 1 2 1 1 2 2 1 2 2 1 2 2 1 2 1 1 5 3 1 5 3 2 4 2 3 3 5 3 1 3 3 2 3 3 2 1 1 4 Sfmt 4702 50th percentile 2 4 3 2 3 3 2 2 2 3 2 2 8 5 3 8 6 4 7 6 4 7 5 3 4 3 1 6 3 2 7 5 2 3 2 2 3 3 2 3 3 2 3 2 2 3 2 2 7 4 3 7 4 3 5 3 5 3 7 5 3 5 3 3 5 3 4 1 1 6 E:\FR\FM\30APP2.SGM 3 6 5 4 6 4 3 4 3 5 4 3 13 7 5 12 8 6 10 8 5 10 7 4 7 5 3 10 6 4 12 8 4 5 4 3 6 5 3 5 4 3 5 4 3 5 4 3 12 6 4 11 6 4 7 4 6 4 12 8 5 7 4 3 7 3 7 3 1 10 30APP2 75th percentile 5 11 7 5 9 6 4 6 4 8 6 4 21 11 7 18 12 8 15 11 7 14 9 6 10 7 4 17 10 6 20 14 7 9 6 5 10 8 6 9 7 5 9 6 5 8 6 4 19 10 5 19 9 6 11 5 9 5 20 12 7 11 6 4 10 4 13 5 2 15 90th percentile 7 18 10 8 14 9 6 10 6 14 9 6 34 18 10 28 18 11 22 14 10 21 13 8 16 10 6 26 16 8 32 20 10 14 9 6 15 11 8 15 10 7 14 9 7 13 9 6 29 14 7 28 13 7 17 7 14 6 33 20 11 16 9 6 14 6 20 9 4 24 23868 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 3,277 1,589 2,582 8,562 11,424 26,724 72,123 48,111 7,100 17,842 1,183 2,186 1,312 2,495 5,763 22,971 52,406 5,216 16,899 29,166 1,970 5,555 6,632 1,163 1,110 1,502 3,872 6,452 833 2,162 3,004 810 836 2,481 627 973 3,926 10,961 1,052 1,006 3,818 11,280 17,523 822 3,392 6,990 33,661 665 1,056 3,417 4,016 1,618 5,709 17,012 10,798 4,079 5,577 4,533 580 1,110 858 10,066 85,179 3,076 19,173 2,013 18,639 3,646 15,089 1,815 PO 00000 Frm 00342 10th percentile 8.3946 4.7885 11.8548 6.6119 2.8188 9.2958 5.9291 4.8427 4.2093 2.4311 12.1116 8.0425 5.6715 5.2236 3.0465 4.3437 2.2104 8.5299 5.2510 3.3992 10.9609 5.9802 3.0054 7.8865 2.9757 10.8309 5.9698 2.9416 9.4586 6.4510 3.3832 3.4074 5.1459 2.0512 3.1100 6.4070 3.9758 2.1581 5.0266 2.8191 10.4445 5.9870 3.0079 6.6861 4.0292 6.2365 3.9328 4.4722 3.2197 9.7085 7.1257 5.3745 8.7758 5.9463 4.4077 9.0924 5.5338 3.8083 8.9379 6.3874 4.4545 7.1058 4.1225 5.9620 3.6913 4.8405 3.1089 6.6100 4.2586 7.5444 Fmt 4701 25th percentile 3 1 3 1 1 4 3 3 2 1 4 3 3 2 1 1 1 3 2 1 3 2 1 2 1 3 2 1 3 2 1 1 1 1 1 2 1 1 1 1 3 1 1 2 1 2 2 2 1 3 3 2 3 2 2 2 2 1 3 2 2 2 1 2 1 1 1 2 2 2 Sfmt 4702 50th percentile 4 2 6 3 1 5 4 4 2 2 6 5 3 3 2 1 1 5 3 2 5 3 1 3 1 5 3 1 5 3 2 1 2 1 1 3 2 1 2 1 5 3 1 3 2 3 3 3 2 5 4 3 4 3 3 4 3 2 4 3 2 3 2 3 2 2 2 3 2 3 E:\FR\FM\30APP2.SGM 7 4 9 6 1 8 5 4 3 2 10 7 5 4 3 3 2 7 4 3 8 5 2 6 2 8 5 2 7 6 3 2 4 1 2 5 3 2 4 2 8 5 2 5 3 5 3 4 3 8 6 4 7 5 4 6 4 3 7 5 4 6 3 5 3 4 3 5 4 6 30APP2 75th percentile 11 6 15 9 4 11 7 6 5 3 15 10 7 6 4 5 3 11 6 4 14 7 4 10 4 14 8 4 11 8 4 4 6 2 3 8 5 3 6 3 13 8 4 8 5 8 5 5 4 12 8 7 11 7 5 11 7 5 11 8 6 9 5 7 5 6 4 8 5 9 90th percentile 15 9 22 13 7 16 9 7 8 4 22 14 9 10 5 9 4 15 9 6 21 11 6 16 6 21 12 6 17 12 6 7 10 3 7 12 7 4 10 6 20 11 7 12 7 12 7 8 6 17 13 9 17 11 8 19 10 7 17 12 8 14 7 11 7 9 6 12 7 15 23869 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 560 561 562 563 564 565 566 573 574 575 576 577 578 579 580 581 582 583 584 585 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 637 638 639 640 641 642 643 644 645 652 653 654 655 656 657 658 659 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 4,319 7,107 5,458 36,267 1,661 3,311 2,624 5,477 11,123 5,462 547 2,228 3,054 3,511 10,711 12,142 5,337 8,748 668 1,469 4,178 12,304 2,751 1,112 5,308 458 1,400 306 682 884 22,088 130,121 2,660 22,097 1,350 7,168 1,457 1,546 1,091 6,718 258 696 2,186 7,848 1,112 3,077 383 1,274 2,538 14,026 3,366 4,160 534 17,104 42,581 38,312 60,806 201,324 1,492 5,176 11,788 8,179 10,067 1,697 3,452 1,633 3,918 7,422 8,271 4,658 PO 00000 Frm 00343 10th percentile 4.7217 2.7680 6.3674 3.7016 6.9934 4.9795 3.6825 13.0933 9.3248 5.8521 12.9506 6.1104 3.3062 10.6830 5.5084 2.6146 2.8943 1.8056 5.9850 2.2321 8.8712 6.4415 5.0593 8.3327 4.7600 8.2009 5.7243 3.7320 5.0513 3.8541 7.0278 4.7073 5.6590 3.4622 6.3422 3.7913 7.0336 3.1572 16.9432 8.7904 6.3605 8.2011 3.6780 2.1617 13.1574 8.5707 6.0261 7.0879 3.1233 1.5172 11.1851 8.7418 5.5281 6.0581 4.2659 3.0382 5.4332 3.8256 5.1810 7.6103 5.4597 3.8912 7.7888 16.8981 9.8624 6.5150 10.1146 5.9603 3.7356 11.2003 Fmt 4701 25th percentile 1 1 2 1 2 2 1 4 3 2 2 1 1 3 1 1 1 1 1 1 3 2 2 2 1 2 2 1 2 1 2 2 1 1 1 1 2 1 6 3 2 2 1 1 3 3 2 1 1 1 2 3 1 2 1 1 1 1 1 2 2 1 4 7 5 3 4 3 2 3 Sfmt 4702 50th percentile 2 1 3 2 3 3 2 6 5 3 4 2 1 5 2 1 1 1 2 1 4 3 3 4 2 3 3 1 3 2 4 3 3 2 3 2 3 2 9 5 3 3 2 1 6 4 3 2 1 1 4 5 2 3 2 2 2 2 2 4 3 2 5 9 7 5 5 4 2 5 E:\FR\FM\30APP2.SGM 4 2 5 3 5 4 3 9 7 5 9 4 2 8 4 2 2 1 4 1 7 5 4 6 4 6 4 3 4 3 6 4 4 3 4 3 5 3 13 7 6 5 3 2 9 7 5 5 2 1 8 7 4 5 3 2 4 3 4 6 4 3 6 13 8 7 8 5 3 8 30APP2 75th percentile 6 3 8 4 9 6 5 16 11 7 17 8 4 14 7 3 3 2 8 2 10 8 6 10 6 10 7 4 7 5 9 6 7 4 7 5 8 4 20 11 8 9 4 3 16 10 7 9 3 2 14 11 7 7 5 4 7 5 6 9 7 5 9 21 11 8 12 7 5 14 90th percentile 9 5 12 6 13 9 7 26 17 11 28 13 7 21 12 6 5 3 13 4 16 11 9 16 8 16 11 6 9 7 13 8 11 6 12 7 14 5 31 15 11 18 7 4 24 15 10 15 7 2 23 16 11 12 8 5 11 7 9 14 10 7 13 31 16 10 19 10 6 22 23870 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 707 708 709 710 711 712 713 714 715 716 717 718 722 723 724 725 726 727 728 729 730 734 735 736 737 738 739 740 741 742 743 744 745 746 747 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 7,594 4,260 949 2,054 4,390 654 2,092 3,616 3,833 12,746 11,687 808 943 12,542 11,715 7,824 82,091 132,320 44,932 2,331 1,597 3,261 1,073 55,995 198,101 821 491 2,429 18,000 975 10,518 592 23,320 24,207 12,279 5,979 18,063 762 1,831 790 705 10,252 28,797 531 1,273 703 589 745 1,949 578 755 3,716 1,294 6,158 591 471 1,362 1,130 854 3,293 863 1,013 4,326 6,014 10,950 32,325 1,520 1,694 2,634 10,409 PO 00000 Frm 00344 10th percentile 6.5146 3.2758 10.2740 5.2639 2.1223 11.0627 6.3595 2.8695 8.5265 4.4236 2.5131 5.9468 2.5302 9.7323 7.1905 2.0675 7.1569 5.6544 3.8913 3.4822 7.5717 5.3502 3.2591 6.2004 4.2356 3.9586 2.3992 4.8345 2.5778 5.5251 3.2901 3.1115 6.6546 4.8302 3.5497 4.4131 2.1475 6.5341 1.7739 8.1684 3.0496 4.1916 1.9430 6.2806 1.4289 7.2319 2.7640 7.5852 5.2678 3.1522 5.5007 3.4739 6.3995 4.0404 5.5736 3.0786 7.9941 3.3602 13.7752 7.1786 3.8714 10.1955 5.2305 2.9940 4.5175 2.2608 5.8355 2.5738 4.2134 1.8856 Fmt 4701 25th percentile 2 1 2 1 1 3 1 1 2 1 1 1 1 1 1 1 2 2 1 1 2 1 1 2 2 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 1 2 1 2 1 1 1 3 1 5 3 2 3 2 1 2 1 1 1 1 1 Sfmt 4702 50th percentile 3 2 4 2 1 5 2 1 4 2 1 2 1 3 2 1 3 3 2 1 3 3 1 3 2 2 1 2 1 3 2 1 3 2 2 2 1 2 1 3 1 2 1 2 1 3 1 3 3 1 3 2 3 2 2 1 4 2 7 4 3 5 3 2 2 2 2 1 2 1 E:\FR\FM\30APP2.SGM 5 3 8 4 1 9 4 2 7 3 2 4 2 7 5 1 5 5 3 2 6 4 2 5 4 3 2 4 2 4 3 2 5 4 3 3 2 4 1 6 2 3 2 4 1 5 2 6 4 2 4 3 5 3 4 2 6 3 11 6 3 8 4 3 3 2 4 2 3 2 30APP2 75th percentile 8 4 14 7 2 14 9 3 11 6 3 8 3 13 9 2 9 7 5 4 9 7 4 8 5 5 3 6 3 7 4 4 8 6 4 5 3 8 2 10 4 5 2 8 1 9 3 10 7 4 7 4 8 5 7 4 9 4 17 8 5 12 6 4 5 3 7 3 5 2 90th percentile 13 6 20 11 4 21 14 6 16 9 5 12 5 21 15 4 14 10 7 7 15 10 6 11 7 8 5 10 5 11 6 6 13 9 7 8 4 15 3 16 7 9 3 13 2 14 5 14 10 6 10 6 12 7 10 6 15 5 25 13 6 20 9 5 8 3 12 5 8 3 23871 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 748 749 750 754 755 756 757 758 759 760 761 765 766 767 768 769 770 774 775 776 777 778 779 780 781 782 790 799 800 801 802 803 804 808 809 810 811 812 813 814 815 816 820 821 822 823 824 825 826 827 828 829 830 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 853 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 19,857 982 435 978 2,933 677 1,393 1,605 1,239 1,700 1,749 2,754 2,686 132 6 98 202 1,506 5,768 511 206 474 110 40 3,017 171 1 566 705 557 765 1,070 987 6,088 12,869 2,786 21,404 89,951 14,232 1,554 3,297 2,147 1,299 2,474 1,893 2,178 2,974 1,748 524 1,254 799 1,171 521 4,028 2,703 1,622 1,043 1,320 1,467 9,659 10,035 5,310 1,350 2,412 804 2,113 23,862 1,723 1,477 34,852 PO 00000 Frm 00345 10th percentile 1.7358 9.3401 3.1103 8.3395 5.6870 3.1359 8.1436 6.0536 4.4722 3.9594 2.4351 5.0359 3.1601 3.3712 3.5000 4.6224 2.2277 3.1886 2.2394 3.3112 2.2136 3.0127 2.1182 1.4500 3.7630 2.4971 25.0000 14.0583 7.8610 4.9336 12.2706 6.6738 3.4215 8.2467 5.3247 4.0337 5.6912 3.7401 5.1669 6.7368 4.9706 3.5198 17.7229 7.8646 3.5288 15.4385 8.7492 4.3084 15.0401 7.9793 3.7722 10.6576 3.7179 15.4615 10.4351 5.1843 23.1419 12.2629 6.4104 10.4408 6.9221 4.5563 8.5222 6.0987 4.3022 8.4179 3.3508 3.1294 5.9709 16.6669 Fmt 4701 1 2 1 2 2 1 3 2 2 1 1 2 2 2 1 1 1 2 1 1 1 1 1 1 1 1 125 5 3 2 3 1 1 3 2 1 1 1 1 2 1 1 5 1 1 5 2 1 4 2 1 2 1 2 2 1 5 3 3 3 2 1 2 2 1 2 1 1 2 5 Sfmt 4702 25th percentile 1 4 1 4 3 1 4 3 2 2 1 3 2 2 2 2 1 2 2 2 1 1 1 1 1 1 125 7 4 2 5 3 1 4 3 2 2 2 2 3 2 2 8 3 1 8 4 1 7 4 2 4 1 4 3 2 10 4 4 5 3 2 4 3 2 3 2 1 3 8 E:\FR\FM\30APP2.SGM 50th percentile 1 7 2 7 4 2 6 5 4 3 2 4 3 2 3 3 1 2 2 2 2 2 1 1 2 1 125 11 6 4 9 5 3 6 4 3 4 3 4 5 4 3 14 6 3 12 7 3 11 6 3 7 2 10 6 3 23 6 5 8 5 4 6 5 3 5 3 3 5 13 30APP2 75th percentile 2 12 4 11 7 4 10 7 5 5 3 5 4 3 6 6 2 3 3 4 3 3 2 1 4 2 125 18 9 6 15 8 4 10 7 5 7 5 6 8 6 4 23 10 4 20 11 6 19 10 5 13 4 23 12 6 31 21 6 13 9 6 10 8 6 10 4 4 6 21 90th percentile 3 19 6 16 11 6 16 11 8 8 5 7 4 5 6 11 5 5 3 7 4 5 3 3 7 4 125 26 15 9 25 14 6 16 10 7 11 7 10 13 9 7 34 16 7 29 17 9 29 16 7 22 8 36 28 10 42 29 10 21 13 9 17 12 8 18 6 5 12 30 23872 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 854 855 856 857 858 862 863 864 865 866 867 868 869 870 871 872 876 880 881 882 883 884 885 886 887 894 895 896 897 901 902 903 904 905 906 907 908 909 913 914 915 916 917 918 919 920 921 922 923 927 928 929 933 934 935 939 940 941 945 946 947 948 949 950 951 955 956 957 958 959 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Arithmetic mean LOS 6,643 459 5,892 9,614 3,246 7,929 21,420 18,946 1,705 8,182 5,062 2,641 1,103 21,199 216,384 90,892 857 9,282 4,623 1,556 757 19,006 80,806 404 393 4,369 6,958 5,490 36,053 924 2,031 1,500 1,046 811 710 8,461 8,319 5,447 804 6,609 1,078 5,508 15,775 35,653 11,089 13,970 9,423 1,047 3,952 211 818 438 139 659 2,201 671 1,320 1,707 6,244 3,055 9,715 47,722 632 387 940 444 3,976 1,318 1,147 291 PO 00000 Frm 00346 10th percentile 11.1072 7.0261 15.3839 8.4628 5.6741 8.1778 5.1976 4.0639 6.7009 3.5351 9.6254 5.7819 4.3128 15.4758 7.4839 5.7138 11.9498 3.1518 4.1888 4.4274 7.3725 5.4936 7.6211 6.0767 4.6209 2.9528 10.4997 6.6087 4.0582 15.0693 7.7371 4.5680 11.2237 4.6523 3.1451 11.6506 6.7682 3.6367 5.6629 3.4330 4.7356 2.1044 5.1645 2.7260 6.3723 4.3608 2.9687 5.9933 3.2338 31.1374 15.9694 7.6872 4.3453 6.1988 5.4330 10.0611 5.4220 2.7299 10.4947 7.8628 5.0101 3.4806 4.1092 3.4858 4.6436 12.2658 9.2912 14.8566 10.4080 6.2921 Fmt 4701 25th percentile 4 2 4 3 2 2 2 1 2 1 2 2 2 6 2 2 2 1 1 1 1 2 2 1 1 1 3 2 1 3 2 1 2 1 1 2 2 1 1 1 1 1 1 1 2 1 1 1 1 7 4 1 1 1 1 2 1 1 4 3 1 1 1 1 1 2 4 2 3 2 Sfmt 4702 50th percentile 6 4 7 4 3 4 3 2 3 2 4 3 2 9 3 3 5 1 2 2 2 3 3 2 2 1 4 3 2 6 3 2 4 2 1 5 3 1 3 2 2 1 2 1 3 2 1 2 1 15 7 3 1 3 2 4 2 1 6 5 2 2 1 1 1 5 5 7 6 3 E:\FR\FM\30APP2.SGM 9 6 12 7 5 6 4 3 4 3 7 4 4 13 6 5 9 2 3 3 4 4 6 4 3 2 6 5 3 10 6 4 7 4 2 8 5 3 4 3 3 2 4 2 5 3 2 4 2 26 12 6 1 5 4 7 4 2 8 6 4 3 2 2 2 10 7 12 8 5 30APP2 75th percentile 14 9 19 10 7 10 7 5 8 4 12 7 5 19 10 7 14 4 5 6 8 6 9 7 5 3 7 8 5 18 9 6 13 6 4 14 8 5 7 4 6 3 6 3 8 5 4 7 4 41 21 10 4 8 7 13 7 3 12 7 6 4 4 4 3 16 11 19 13 8 90th percentile 20 13 30 16 10 16 9 7 14 7 19 11 7 27 14 10 24 6 8 9 15 10 14 12 8 4 9 13 6 30 16 9 23 8 6 23 13 7 12 6 9 4 11 5 13 8 6 12 6 60 31 16 8 12 11 20 12 5 15 8 10 6 6 5 6 26 17 28 19 11 23873 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY: FY 2007 MEDPAR UPDATE—DECEMBER 2007 GROUPER V26.0 MS–DRGS—Continued Number of discharges MS–DRG 963 964 965 969 970 974 975 976 977 981 982 983 984 985 986 987 988 989 ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... ........................................................... Arithmetic mean LOS 1,586 2,573 1,072 639 136 5,920 4,674 2,617 4,565 25,478 18,329 6,112 671 903 731 8,240 11,583 5,796 10th percentile 9.5214 6.2274 4.1371 18.8279 9.8309 10.3723 7.0148 4.9308 5.2931 15.1488 9.7455 5.3613 14.6811 9.6512 5.3338 13.0089 7.8090 4.1046 25th percentile 2 2 1 4 2 2 2 2 1 5 3 1 5 2 1 4 2 1 50th percentile 4 3 2 8 3 4 3 2 2 8 5 2 8 5 2 6 3 1 8 5 3 14 7 8 5 4 4 12 8 4 13 8 3 10 6 3 75th percentile 90th percentile 13 8 5 22 12 13 9 6 6 19 12 7 18 13 7 16 10 6 19 11 7 36 17 21 13 8 10 28 18 11 25 18 12 24 15 9 11,387,276 TABLE 8A.—PROPOSED STATEWIDE AVERAGE OPERATING COST-TOCHARGE RATIOS—MARCH 2008 jlentini on PROD1PC65 with PROPOSALS2 State Urban Alabama ................ Alaska ................... Arizona .................. Arkansas ............... California ............... Colorado ............... Connecticut ........... Delaware ............... District of Columbia * ................... Florida ................... Georgia ................. Hawaii ................... Idaho ..................... Illinois .................... Indiana .................. Iowa ...................... Kansas .................. Kentucky ............... Louisiana .............. Maine .................... Maryland ............... Massachusetts * .... Michigan ............... Minnesota ............. Mississippi ............ Missouri ................ Montana ................ Nebraska .............. Nevada ................. New Hampshire .... New Jersey * ......... New Mexico .......... New York .............. North Carolina ...... North Dakota ........ Ohio ...................... Oklahoma ............. Oregon .................. Pennsylvania ........ Puerto Rico * ......... Rhode Island * ...... VerDate Aug<31>2005 Rural 0.261 0.401 0.288 0.32 0.225 0.281 0.399 0.495 0.33 0.745 0.418 0.368 0.303 0.437 0.528 0.513 0.345 0.238 0.329 0.382 0.468 0.305 0.39 0.357 0.288 0.37 0.299 0.498 0.726 0.471 0.364 0.391 0.302 0.33 0.422 0.335 0.22 0.457 0.178 0.377 0.346 0.402 0.428 0.338 0.293 0.452 0.267 0.474 0.388 .................. 0.281 0.39 0.453 0.534 0.395 0.466 0.444 0.424 0.371 0.353 0.462 0.793 .................. 0.462 0.53 0.355 0.399 0.465 0.46 0.478 0.427 .................. 0.36 0.522 0.396 0.457 0.522 0.383 0.415 0.413 .................. .................. 19:42 Apr 29, 2008 TABLE 8A.—PROPOSED STATEWIDE AVERAGE OPERATING COST-TOCHARGE RATIOS—MARCH 2008— Continued Jkt 214001 State Urban South Carolina ...... South Dakota ........ Tennessee ............ Texas .................... Utah ...................... Vermont ................ Virginia .................. Washington ........... West Virginia ........ Wisconsin ............. Wyoming ............... 0.284 0.335 0.297 0.257 0.414 0.543 0.358 0.385 0.471 0.425 0.431 Rural 0.301 0.43 0.371 0.342 0.572 0.619 0.357 0.443 0.462 0.458 0.562 * All counties in the State or Territory are classified as urban, with the exception of Massachusetts, which has areas designated as rural. However, no short-term acute care IPPS hospitals are located in those areas as of March 2008. TABLE 8B.—PROPOSED STATEWIDE AVERAGE CAPITAL COST-TOCHARGE RATIOS—MARCH 2008 State Ratio Alabama ...................................... Alaska ......................................... Arizona ........................................ Arkansas ..................................... California ..................................... Colorado ..................................... Connecticut ................................. Delaware ..................................... District of Columbia .................... Florida ......................................... Georgia ....................................... Hawaii ......................................... Idaho ........................................... Illinois .......................................... Indiana ........................................ PO 00000 Frm 00347 Fmt 4701 Sfmt 4702 TABLE 8B.—PROPOSED STATEWIDE AVERAGE CAPITAL COST-TOCHARGE RATIOS—MARCH 2008— Continued 0.024 0.036 0.023 0.025 0.015 0.028 0.028 0.035 0.022 0.022 0.028 0.03 0.038 0.026 0.037 State Iowa ............................................ Kansas ........................................ Kentucky ..................................... Louisiana .................................... Maine .......................................... Maryland ..................................... Massachusetts ............................ Michigan ..................................... Minnesota ................................... Mississippi .................................. Missouri ...................................... Montana ...................................... Nebraska .................................... Nevada ....................................... New Hampshire .......................... New Jersey ................................. New Mexico ................................ New York .................................... North Carolina ............................ North Dakota .............................. Ohio ............................................ Oklahoma ................................... Oregon ........................................ Pennsylvania .............................. Puerto Rico ................................. Rhode Island .............................. South Carolina ............................ South Dakota .............................. Tennessee .................................. Texas .......................................... Utah ............................................ Vermont ...................................... Virginia ........................................ Washington ................................. West Virginia .............................. Wisconsin ................................... Wyoming ..................................... E:\FR\FM\30APP2.SGM 30APP2 Ratio 0.028 0.03 0.029 0.026 0.03 0.058 0.031 0.03 0.028 0.027 0.029 0.034 0.039 0.021 0.032 0.013 0.032 0.026 0.032 0.037 0.028 0.026 0.031 0.022 0.042 0.02 0.024 0.032 0.03 0.026 0.032 0.045 0.036 0.03 0.034 0.037 0.044 23874 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 8C.—PROPOSED STATEWIDE AVERAGE TOTAL COST-TO-CHARGE RATIOS FOR LTCHS—MARCH 2008 State Urban Alabama ................ Alaska ................... Arizona .................. Arkansas ............... California ............... Colorado ............... Connecticut ........... Delaware ............... District of Columbia * ................... Florida ................... Georgia ................. Hawaii ................... Idaho ..................... Illinois .................... Indiana .................. Iowa ...................... Kansas .................. Kentucky ............... Louisiana .............. Maine .................... Maryland *** .......... TABLE 8C.—PROPOSED STATEWIDE AVERAGE TOTAL COST-TO-CHARGE RATIOS FOR LTCHS—MARCH 2008—Continued Rural 0.279 0.432 0.311 0.343 0.238 0.307 0.426 0.529 0.36 0.806 0.448 0.401 0.322 0.479 0.576 0.551 0.368 0.259 0.355 0.411 0.506 0.33 0.426 0.381 0.314 0.398 0.325 0.529 0.34 .................. 0.311 0.424 0.487 0.576 0.427 0.507 0.483 0.463 0.401 0.38 0.49 0.434 State Urban Massachusetts ** .. Michigan ............... Minnesota ............. Mississippi ............ Missouri ................ Montana ................ Nebraska .............. Nevada ................. New Hampshire .... New Jersey ** ....... New Mexico .......... New York .............. North Carolina ...... North Dakota ........ Ohio ...................... Oklahoma ............. Oregon .................. Pennsylvania ........ Puerto Rico ** ....... Rhode Island ** ..... 0.502 0.393 0.418 0.328 0.357 0.453 0.371 0.24 0.489 0.19 0.408 0.372 0.434 0.461 0.365 0.318 0.484 0.287 0.514 0.408 TABLE 8C.—PROPOSED STATEWIDE AVERAGE TOTAL COST-TO-CHARGE RATIOS FOR LTCHS—MARCH 2008—Continued Rural State .................. 0.497 0.569 0.384 0.438 0.505 0.505 0.539 0.459 .................. 0.394 0.558 0.431 0.505 0.563 0.414 0.444 0.443 .................. .................. South Carolina ...... South Dakota ........ Tennessee ............ Texas .................... Utah ...................... Vermont ................ Virginia .................. Washington ........... West Virginia ........ Wisconsin ............. Wyoming ............... Urban Rural 0.308 0.365 0.326 0.282 0.445 0.594 0.393 0.414 0.505 0.462 0.467 0.327 0.466 0.406 0.374 0.622 0.657 0.398 0.473 0.496 0.497 0.616 * All counties in the State or Territory are classified as urban, with the exception of Massachusetts, which has areas designated as rural. However, no short-term acute care IPPS hospitals or LTCHs are located in those areas as of March 2008. ** National average IPPS total cost-to-charge ratios, as discussed in section VI.E. of this proposed rule. TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009 Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 010001 010005 010009 010010 010012 010022 010025 010029 010035 010052 010054 010055 010059 010061 010065 010083 010085 010090 010100 010101 010102 010118 010126 010143 010150 010158 010164 020008 030007 030033 030055 030069 030101 040014 040017 040019 040020 040027 040039 040041 040069 040071 ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00348 Fmt 4701 Sfmt 4702 Reclassified CBSA 20020 01 19460 01 01 01 01 12220 01 01 19460 20020 19460 01 01 01 19460 33660 01 01 01 01 01 01 01 01 01 02 39140 03 29420 29420 29420 04 04 04 27860 04 04 04 04 38220 E:\FR\FM\30APP2.SGM 30APP2 10500 26620 26620 13820 40660 12060 17980 17980 13820 33860 26620 37460 26620 16860 13820 37860 26620 37700 37860 13820 33860 33860 33860 26620 33860 22520 13820 11260 22380 22380 39140 40140 29820 30780 22220 32820 32820 44180 27860 30780 32820 30780 LUGAR LUGAR Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23875 TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 040076 040078 040080 040085 040088 040091 040119 050006 050009 050013 050014 050022 050038 050042 050046 050054 050069 050071 050073 050076 050082 050089 050090 050099 050101 050102 050118 050125 050129 050131 050133 050136 050140 050150 050153 050159 050168 050173 050174 050188 050193 050194 050197 050224 050226 050230 050236 050242 050243 050245 050272 050279 050291 050292 050300 050301 050308 050327 050329 050335 050348 050360 050367 050380 050385 050390 050394 050423 050426 050441 050476 ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00349 Fmt 4701 Sfmt 4702 Reclassified CBSA 04 26300 04 04 04 04 04 05 34900 34900 05 40140 41940 05 37100 40140 42044 41940 46700 41884 37100 40140 42220 40140 46700 40140 44700 41940 40140 41884 49700 42220 40140 05 41940 37100 42044 42044 42220 41940 42044 42100 41884 42044 42044 42044 37100 42100 40140 40140 40140 40140 42220 40140 40140 05 41940 40140 40140 05 42044 41884 46700 41940 42220 40140 37100 40140 42044 41940 05 E:\FR\FM\30APP2.SGM 30APP2 30780 30780 27860 32820 33740 45500 30780 39820 46700 46700 40900 42044 42100 39820 31084 42044 31084 42100 36084 36084 31084 31084 41884 31084 36084 42044 33700 42100 31084 36084 40900 41884 31084 40900 42100 31084 31084 31084 41884 42100 31084 41940 41940 31084 31084 31084 31084 41940 42044 31084 31084 31084 41884 42044 31084 42220 42100 31084 42044 33700 31084 36084 36084 42100 41884 42044 31084 42044 31084 42100 42220 LUGAR LUGAR 23876 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050494 050510 050517 050526 050534 050541 050543 050547 050548 050549 050551 050567 050570 050573 050580 050586 050589 050603 050604 050609 050616 050662 050667 050678 050680 050684 050686 050688 050690 050693 050694 050701 050709 050720 050744 050745 050746 050747 050749 050758 060003 060012 060023 060027 060031 060049 060075 060096 060103 060116 070001 070003 070004 070005 070006 070010 070011 070015 070016 070017 070018 070019 070022 070028 070031 070033 070034 070036 070038 070039 080001 ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00350 Fmt 4701 Sfmt 4702 Reclassified CBSA 05 41884 40140 42044 40140 41884 42044 42220 42044 37100 42044 42044 42044 40140 42044 40140 42044 42044 41940 42044 37100 41940 34900 42044 46700 40140 40140 41940 42220 42044 40140 40140 40140 42044 42044 42044 42044 42044 37100 40140 14500 39380 24300 14500 17820 06 06 06 14500 14500 35300 07 07 35300 14860 14860 07 07 35300 35300 14860 35300 35300 14860 35300 14860 14860 25540 35300 35300 48864 E:\FR\FM\30APP2.SGM 30APP2 40900 36084 31084 31084 42044 41940 31084 41884 31084 31084 31084 31084 31084 42044 31084 31084 31084 31084 42100 31084 31084 42100 46700 31084 36084 42044 42044 42100 41884 31084 42044 42044 31084 31084 31084 31084 31084 31084 31084 31084 19740 17820 19740 19740 19740 22660 24300 19740 19740 19740 35004 25540 25540 35004 35644 35644 25540 35644 35004 35004 35644 35004 35004 35644 35004 35644 35644 35300 35004 35004 37964 LUGAR LUGAR Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23877 TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 080003 080004 080006 080007 090001 090004 090011 100002 100014 100017 100022 100023 100024 100045 100047 100049 100068 100072 100077 100080 100081 100105 100109 100130 100139 100150 100156 100157 100160 100168 100176 100217 100232 100234 100236 100249 100252 100253 100258 100268 100269 100275 100287 100288 100292 110001 110002 110016 110023 110029 110038 110040 110041 110054 110069 110075 110095 110112 110121 110122 110125 110128 110146 110150 110153 110168 110187 110189 120028 130002 130003 ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00351 Fmt 4701 Sfmt 4702 Reclassified CBSA 48864 20100 08 08 47894 47894 47894 48424 19660 19660 33124 10 10 19660 39460 10 19660 19660 39460 48424 10 42680 10 48424 10 10 10 29460 10 48424 48424 42680 10 48424 39460 10 10 48424 48424 48424 48424 48424 48424 48424 10 19140 11 11 11 23580 11 11 11 40660 47580 11 11 11 11 46660 11 11 11 11 47580 40660 11 11 12 13 30300 E:\FR\FM\30APP2.SGM 30APP2 37964 48864 20100 36140 13644 13644 13644 22744 36740 36740 22744 36740 33124 36740 14600 29460 36740 36740 14600 22744 23020 38940 36740 22744 23540 33124 23540 45300 33124 22744 22744 38940 27260 22744 14600 45300 38940 22744 22744 22744 22744 22744 22744 22744 23020 16860 12060 17980 12060 12060 45220 12060 12060 12060 31420 42340 10500 10500 45220 45220 31420 42340 27260 12060 31420 12060 12060 12060 26180 14260 28420 LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR 23878 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 130049 130067 140012 140015 140032 140034 140040 140043 140046 140058 140064 140084 140100 140110 140130 140135 140143 140155 140160 140164 140186 140202 140291 150002 150004 150006 150008 150011 150015 150018 150023 150026 150030 150034 150042 150045 150048 150051 150065 150069 150076 150088 150090 150091 150102 150112 150113 150115 150125 150126 150133 150146 150147 160001 160016 160057 160064 160080 160089 160147 170006 170012 170013 170020 170023 170068 170120 170142 170175 170190 170193 ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00352 Fmt 4701 Sfmt 4702 Reclassified CBSA 17660 13 14 14 14 14 14 14 14 14 14 29404 29404 14 29404 19500 14 28100 14 14 28100 29404 29404 23844 23844 33140 23844 15 33140 21140 45460 21140 15 23844 15 15 15 14020 15 15 15 11300 23844 15 15 18020 11300 15 23844 23844 15 15 23844 16 16 16 16 16 16 16 17 17 17 17 17 17 17 17 17 17 17 E:\FR\FM\30APP2.SGM 30APP2 44060 26820 16974 41180 41180 41180 37900 19340 41180 41180 37900 16974 16974 16974 16974 16580 16974 16974 40420 41180 16974 16974 16974 16974 16974 43780 16974 26900 23844 43780 26900 43780 26900 16974 14020 23060 17140 26900 26900 17140 43780 26900 16974 23060 23844 26900 26900 21780 16974 16974 43780 21140 16974 11180 11180 26980 47940 19340 26980 11180 27900 48620 48620 48620 48620 11100 27900 45820 48620 45820 48620 LUGAR LUGAR LUGAR LUGAR Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23879 TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 180002 180005 180011 180012 180013 180017 180024 180027 180029 180043 180044 180048 180049 180050 180066 180069 180078 180080 180093 180102 180104 180116 180124 180127 180132 190003 190015 190017 190086 190088 190106 190144 190164 190167 190184 190191 190208 190218 190257 200020 200024 200034 200039 200050 220001 220002 220008 220010 220011 220019 220020 220025 220029 220033 220035 220049 220058 220062 220063 220070 220073 220074 220077 220080 220082 220084 220090 220095 220098 220101 220105 ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00353 Fmt 4701 Sfmt 4702 Reclassified CBSA 18 18 18 21060 14540 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 14540 18 18 19 19 19 19 19 19 19 19 19 19 19 19 19 19 38860 30340 30340 20 20 49340 15764 39300 37764 15764 49340 39300 49340 37764 37764 37764 15764 49340 49340 15764 15764 39300 39300 44140 37764 15764 15764 49340 49340 15764 15764 15764 E:\FR\FM\30APP2.SGM 30APP2 49 26580 30460 31140 34980 21060 31140 17300 30460 44 26580 31140 30460 28700 34980 26580 26580 28940 21780 17300 17300 14 34980 31140 30460 29180 35380 29180 33740 43340 10780 43340 10780 29180 33740 29180 04 43340 33740 40484 38860 38860 38860 12620 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 14484 25540 14484 14484 14484 14484 14484 14484 14484 14484 LUGAR 23880 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 220163 220171 220174 220175 220176 230002 230003 230013 230019 230020 230021 230022 230024 230029 230030 230035 230036 230037 230038 230047 230053 230054 230059 230069 230071 230072 230077 230080 230089 230092 230095 230096 230097 230099 230104 23B104 230105 230106 230119 230121 230130 230135 230142 230146 230151 230165 230174 230176 230195 230204 230207 230208 230222 230223 230227 230236 230244 230254 230257 230264 230269 230270 230273 230277 230279 230301 240030 240036 240064 240069 240071 ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00354 Fmt 4701 Sfmt 4702 Reclassified CBSA 49340 15764 37764 15764 49340 19804 26100 47644 47644 19804 35660 23 19804 47644 23 23 23 23 24340 47644 19804 23 24340 47644 47644 26100 40980 23 19804 27100 23 23 23 33780 19804 47644 23 24340 19804 23 47644 19804 19804 19804 47644 19804 26100 19804 47644 47644 47644 23 23 47644 47644 24340 19804 47644 47644 47644 47644 19804 19804 47644 47644 47644 24 41060 24 24 24 E:\FR\FM\30APP2.SGM 30APP2 14484 14484 14484 14484 14484 11460 34740 19804 19804 11460 28020 29620 11460 19804 40980 24340 13020 11460 34740 19804 11460 24580 34740 22420 19804 34740 22420 13020 11460 11460 13020 28020 24340 11460 11460 19804 13020 34740 11460 29620 19804 11460 11460 11460 19804 11460 34740 11460 19804 19804 19804 24340 13020 19804 19804 34740 11460 19804 19804 19804 19804 11460 11460 19804 22420 19804 41060 33460 20260 33460 33460 LUGAR LUGAR LUGAR LUGAR Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23881 TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 240075 240088 240093 240187 250002 250004 250006 250009 250023 250031 250034 250040 250042 250044 250069 250078 250081 250082 250094 250097 250099 250100 250104 250117 260009 260015 260017 260022 260025 260050 260064 260074 260094 260110 260113 260116 260119 260175 260183 260186 270003 270014 270017 270051 280009 280023 280032 280061 280065 280125 290002 290006 290008 290019 300001 300011 300012 300017 300019 300020 300023 300029 300034 310002 310009 310014 310015 310017 310018 310021 310022 ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00355 Fmt 4701 Sfmt 4702 Reclassified CBSA 24 24 24 24 25 25 25 25 25 25 25 37700 25 25 25 25620 25 25 25620 25 25 25 25 25 26 26 26 26 26 26 26 26 26 26 26 26 26 26 26 26 27 33540 27 27 28 28 28 28 28 28 29 29 29 16180 30 31700 31700 40484 30 31700 40484 40484 31700 35084 35084 15804 35084 35084 35084 45940 15804 E:\FR\FM\30APP2.SGM 30APP2 41060 41060 33460 33460 22520 32820 32820 27180 25060 27140 32820 25060 32820 22520 46220 25060 46220 38220 25060 12940 27140 46220 46220 25060 28140 27860 27620 16 41180 41140 17860 17860 44180 44180 14 14 27860 28140 41180 44180 24500 17660 33540 33540 30700 30700 30700 53 24540 43580 16180 39900 14260 39900 31700 49340 49340 37764 15764 49340 37764 37764 49340 35644 35644 37964 35644 35644 35644 35084 37964 LUGAR LUGAR LUGAR LUGAR 23882 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 310029 310031 310032 310038 310039 310048 310050 310054 310070 310076 310081 310083 310086 310093 310096 310108 310119 320003 320005 320006 320013 320033 320063 320065 330004 330008 330023 330027 330049 330067 330073 330085 330090 330094 330103 330106 330126 330136 330157 330167 330181 330182 330191 330198 330224 330225 330229 330235 330239 330250 330259 330277 330331 330332 330372 330386 340004 340008 340010 340013 340014 340015 340021 340023 340027 340039 340047 340050 340051 340068 340069 ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00356 Fmt 4701 Sfmt 4702 Reclassified CBSA 15804 15804 47220 20764 20764 20764 35084 35084 20764 35084 15804 35084 15804 35084 35084 20764 35084 32 22140 32 32 32 32 32 28740 33 39100 35004 39100 39100 33 33 21300 33 33 35004 39100 33 33 35004 35004 35004 24020 35004 28740 35004 33 33 33 33 35004 33 35004 35004 35004 33 24660 34 24140 34 49180 34 34 11700 34 34 49180 34 34 34 39580 E:\FR\FM\30APP2.SGM 30APP2 37964 20764 48864 35644 35644 35084 35644 35644 35644 35644 37964 35644 37964 35644 35644 35644 35644 42140 10740 10740 42140 42140 36220 36220 39100 15380 35644 35644 14860 14860 40380 45060 27060 38340 39 35644 35644 45060 45060 35644 35644 35644 10580 35644 39100 35644 21500 45060 21500 15540 35644 27060 35644 35644 35644 35084 49180 22180 39580 24860 24660 16740 16740 24860 24780 16740 24660 22180 25860 34820 20500 LUGAR LUGAR LUGAR LUGAR LUGAR Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23883 TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 340070 340071 340073 340091 340109 340114 340115 340126 340127 340129 340131 340138 340144 340145 340147 340148 340173 350003 350006 350009 360008 360010 360011 360013 360014 360019 360020 360025 360027 360036 360039 360054 360065 360078 360086 360095 360096 360107 360121 360150 360159 360175 360185 360187 360197 360211 360245 360253 370004 370006 370014 370015 370016 370018 370025 370026 370030 370047 370049 370113 370149 380001 380022 380027 380050 380051 380090 390006 390013 390016 390031 ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00357 Fmt 4701 Sfmt 4702 Reclassified CBSA 15500 34 39580 24660 34 39580 34 34 34 34 34 39580 34 34 40580 49180 39580 35 35 35 36 36 36 36 36 10420 10420 41780 10420 36 36 36 36 10420 44220 36 36 36 36 10420 36 36 36 44220 36 48260 36 19380 37 37 37 37 37 37 37 37 37 37 37 37 37 38 38 38 38 41420 38 39 39 39 39 E:\FR\FM\30APP2.SGM 30APP2 24660 39580 20500 49180 47260 20500 20500 39580 20500 16740 24780 20500 16740 16740 39580 24660 20500 13900 13900 22020 26580 10420 18140 30620 18140 17460 17460 45780 17460 17460 18140 26580 17460 17460 19380 45780 49660 45780 45780 17460 18140 18140 49660 19380 18140 38300 17460 17140 27900 48620 43300 46140 36420 46140 46140 36420 46140 36420 36420 22220 36420 38900 18700 21660 32780 38900 21660 25420 25420 49660 39740 LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR 23884 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 390044 390046 390048 390065 390066 390071 390079 390086 390091 390093 390096 390110 390113 390138 390150 390151 390162 390163 390185 390313 410001 410004 410005 410007 410010 410011 410012 410013 420007 420009 420020 420027 420030 420036 420039 420062 420067 420068 420069 420070 420071 420080 420083 420085 420098 430012 430013 430014 430077 440002 440008 440020 440024 440025 440035 440056 440059 440060 440067 440068 440072 440073 440144 440148 440151 440185 440192 450007 450039 450064 450080 ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00358 Fmt 4701 Sfmt 4702 Reclassified CBSA 39740 49620 39 39 30140 39 39 39 39 39 39740 27780 39 39 39 39 10900 38300 42540 39 39300 39300 39300 39300 39300 39300 39300 39300 43900 42 42 11340 42 42 42 42 42 42 42 44940 42 42 43900 34820 42 43 43 43 39660 27180 44 44 17420 44 17300 34100 44 44 34100 44 44 44 44 44 44 17420 44 45 23104 23104 45 E:\FR\FM\30APP2.SGM 30APP2 37964 29540 25420 13644 25420 48700 13780 27780 49660 49660 37964 38300 49660 25420 38300 13644 35084 49660 10900 39740 14484 14484 14484 14484 14484 14484 14484 35980 24860 24860 16700 24860 16700 16740 43900 16740 42340 16700 44940 17900 24860 42340 24860 48900 34820 43620 43620 22020 16220 32820 27180 26620 16860 34 34980 28940 34980 27180 28700 16860 32820 34980 34980 34980 34980 16860 34980 41700 19124 19124 30980 LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 23885 TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA jlentini on PROD1PC65 with PROPOSALS2 Provider No. 450087 450099 450133 450135 450137 450148 450178 450187 450196 450211 450214 450224 450283 450324 450347 450351 450389 450393 450395 450419 450447 450465 450469 450484 450508 450547 450563 450565 450596 450639 450656 450672 450675 450677 450747 450770 450779 450813 450830 450872 450880 450886 460004 460005 460007 460021 460026 460039 460041 460042 470001 470012 490004 490005 490013 490018 490019 490040 490042 490043 490048 490063 490079 490097 490101 490107 490122 500002 500003 500007 500016 ................................................................................................................................ ................................................................................................................................ 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VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00359 Fmt 4701 Sfmt 4702 Reclassified CBSA 23104 45 33260 23104 23104 23104 45 45 45 45 45 45 45 43300 45 45 45 43300 45 23104 45 45 43300 45 45 45 23104 45 45 23104 45 23104 23104 23104 45 45 23104 45 45 23104 23104 23104 36260 36260 46 41100 46 46 36260 36260 47 47 25500 49020 49 49 49 47894 13980 47894 40220 47894 49 49 47894 47894 47894 50 34580 34580 48300 E:\FR\FM\30APP2.SGM 30APP2 19124 11100 36220 19124 19124 19124 36220 26420 19124 30980 26420 46340 19124 19124 26420 23104 19124 19124 26420 19124 19124 26420 19124 30980 30980 19124 19124 23104 23104 19124 30980 19124 19124 19124 46340 12420 19124 41700 36220 19124 19124 19124 41620 41620 41100 29820 39340 30860 41620 41620 30 38340 16820 47894 20500 16820 47894 13644 40220 13644 31340 13644 24660 40060 13644 13644 13644 28420 42644 42644 42644 LUGAR LUGAR LUGAR LUGAR 23886 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 9A.—HOSPITAL RECLASSIFICATIONS AND REDESIGNATIONS—FY 2009—Continued Geographic CBSA Provider No. 500021 500031 500039 500041 500072 500079 500108 500129 510001 510002 510006 510018 510024 510046 510047 510050 510062 510070 510071 510077 520002 520013 520021 520028 520037 520059 520071 520076 520096 520102 520107 520113 520116 520189 530014 530015 ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 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................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 45104 50 14740 31020 50 45104 45104 45104 34060 51 51 51 34060 51 51 48540 51 51 51 51 52 20740 29404 52 52 39540 52 52 39540 52 52 52 52 29404 16940 53 TABLE 9C.—HOSPITALS REDESIGNATED AS RURAL UNDER SECTION 1886(D)(8)(E) OF THE ACT—FY TABLE 9C.—HOSPITALS REDESIGNATED AS RURAL UNDER SECTION 1886(D)(8)(E) OF THE ACT—FY 2009 2009—Continued jlentini on PROD1PC65 with PROPOSALS2 Provider No. 050192 050528 050618 100048 100118 100134 140167 170137 220051 230078 250017 260006 260047 260195 330268 360125 370054 380040 390130 390183 440135 450052 450078 450243 .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... VerDate Aug<31>2005 Geographic CBSA Redesignated rural area 23420 32900 40140 37860 37380 27260 14 29940 38340 35660 25 41140 27620 44180 10580 36 36420 13460 27780 39 34980 45 10180 10180 19:42 Apr 29, 2008 05 05 05 10 10 10 14 17 22 23 25 26 26 26 33 36 37 38 39 39 44 45 45 45 Jkt 214001 Geographic CBSA Provider No. 450348 .......... 490116 .......... 500148 .......... 45 13980 48300 Redesignated rural area 45 49 50 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1 Number of cases MS–DRG 1 ........................ 2 ........................ PO 00000 Frm 00360 Fmt 4701 655 287 Sfmt 4702 Reclassified CBSA Threshold $345,754 202,892 42644 36500 42644 38900 14740 42644 42644 42644 38300 40220 34060 16620 38300 13980 38300 38300 16620 16620 13980 26580 48140 33460 16974 31540 48140 33340 33340 31540 33340 33340 22540 24580 33340 16974 24540 26820 LUGAR LUGAR LUGAR LUGAR LUGAR LUGAR TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued MS–DRG 3 ........................ 4 ........................ 5 ........................ 6 ........................ 7 ........................ 8 ........................ 9 ........................ 10 ...................... 11 ...................... 12 ...................... 13 ...................... 20 ...................... 21 ...................... 22 ...................... 23 ...................... 24 ...................... E:\FR\FM\30APP2.SGM 30APP2 Number of cases 23,338 21,431 634 228 356 482 1,345 163 1,266 1,909 1,274 887 532 212 3,741 2,103 Threshold 258,756 156,815 172,190 95,919 167,452 96,343 104,341 77,500 77,654 55,617 39,624 149,490 115,973 81,500 88,473 62,851 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Number of cases jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... ...................... VerDate Aug<31>2005 8,713 11,796 13,711 1,670 3,085 3,425 1,024 2,785 3,621 764 2,238 6,915 4,842 14,152 51,945 4,769 7,588 4,869 1,167 593 5,257 16,334 8,269 47,422 742 2,761 4,080 1,591 2,466 1,327 55,842 105,150 89,467 1,406 11,458 102,005 7,347 9,531 5,746 9,230 31,583 1,240 874 1,214 1,405 931 1,870 7,158 1,764 2,056 2,784 5,896 11,488 13,005 712 2,740 3,094 7,628 16,286 19:42 Apr 29, 2008 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Threshold 82,504 56,523 44,491 80,242 50,231 32,616 67,618 38,809 31,322 60,605 44,518 38,592 55,045 35,529 25,865 62,151 41,971 36,094 32,407 22,313 31,973 26,860 29,873 19,707 29,625 22,941 17,346 55,734 44,297 38,685 35,590 28,434 21,616 31,006 23,218 18,938 34,967 27,718 20,092 28,411 21,471 35,756 23,183 34,334 25,703 19,435 26,205 17,937 36,630 30,149 22,390 37,019 27,925 19,836 31,870 23,572 17,953 30,627 22,388 Jkt 214001 Number of cases MS–DRG 93 ...................... 94 ...................... 95 ...................... 96 ...................... 97 ...................... 98 ...................... 99 ...................... 100 .................... 101 .................... 102 .................... 103 .................... 113 .................... 114 .................... 115 .................... 116 .................... 117 .................... 121 .................... 122 .................... 123 .................... 124 .................... 125 .................... 129 .................... 130 .................... 131 .................... 132 .................... 133 .................... 134 .................... 135 .................... 136 .................... 137 .................... 138 .................... 139 .................... 146 .................... 147 .................... 148 .................... 149 .................... 150 .................... 151 .................... 152 .................... 153 .................... 154 .................... 155 .................... 156 .................... 157 .................... 158 .................... 159 .................... 163 .................... 164 .................... 165 .................... 166 .................... 167 .................... 168 .................... 175 .................... 176 .................... 177 .................... 178 .................... 179 .................... 180 .................... 181 .................... PO 00000 Frm 00361 Fmt 4701 16,162 1,476 1,034 761 1,195 1,007 642 17,058 57,248 1,086 13,854 527 562 1,060 566 1,140 549 623 2,789 753 4,693 1,359 1,074 933 889 1,988 3,379 353 474 775 891 1,498 680 1,369 860 38,942 955 6,839 1,735 11,517 1,906 4,498 4,851 1,048 3,229 2,376 13,622 17,895 13,816 20,575 20,538 5,478 12,686 41,375 63,876 71,036 26,205 22,369 30,299 Sfmt 4702 Threshold 17,182 57,294 44,072 37,723 56,725 38,018 30,539 30,273 19,211 24,512 16,849 33,475 20,755 26,332 26,098 16,472 22,487 14,246 18,857 25,197 16,936 40,771 29,912 39,603 28,315 32,709 21,267 36,814 24,169 29,030 18,731 20,992 36,795 27,392 20,935 16,006 25,517 13,767 21,825 15,282 28,847 21,959 16,219 29,382 21,572 15,149 83,366 50,966 40,520 60,767 42,190 32,296 34,823 26,341 38,177 31,805 25,015 34,979 28,647 23887 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued MS–DRG 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... E:\FR\FM\30APP2.SGM 30APP2 Number of cases 5,485 1,858 4,329 2,521 9,254 10,047 5,031 113,197 58,935 118,443 185,468 87,659 254,760 134,022 5,396 6,822 4,650 3,215 8,396 3,475 29,397 37,161 25,777 5,872 21,625 39,614 76,655 143 8,640 7,240 2,557 10,538 13,938 7,039 2,772 5,081 1,912 5,074 7,067 42,758 2,975 3,599 1,568 1,445 1,516 16,267 34,348 9,634 30,093 22,441 42,307 13,331 11,688 2,679 17,530 36,091 62,665 3,943 28,838 Threshold 22,812 32,624 23,386 16,595 33,122 27,117 20,564 30,640 28,961 24,100 18,078 30,876 24,785 18,110 32,914 27,198 20,752 34,978 25,022 17,803 20,216 14,886 17,542 27,528 18,717 87,097 43,557 173,781 168,323 124,423 104,181 136,802 99,436 87,477 156,334 119,825 145,014 113,498 118,743 93,475 132,326 95,382 80,590 149,264 114,499 125,690 93,360 99,860 73,812 88,481 57,831 62,725 43,263 32,205 66,838 52,897 44,466 73,686 67,069 23888 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Number of cases jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 326 327 328 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... VerDate Aug<31>2005 188,816 13,859 70,027 6,790 41,777 45,667 44,988 53,543 2,525 3,453 707 688 7,314 1,553 3,525 3,531 656 28,327 1,959 63,744 53,825 54,438 14,927 4,145 2,811 23,714 158,325 2,964 1,357 480 188,057 205,085 197,247 1,417 1,346 1,917 793 603 17,830 44,700 37,174 7,607 70,815 2,098 35,311 1,521 6,371 35,795 79,510 158,993 21,229 166,359 212,358 61,733 30,052 18,076 11,247 10,467 8,878 19:42 Apr 29, 2008 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Threshold 48,746 60,786 44,038 59,714 41,857 51,697 46,446 37,335 40,724 31,694 23,510 53,299 38,081 56,280 31,484 25,624 30,621 41,945 42,694 37,477 29,595 22,672 32,787 24,166 16,215 42,608 29,592 50,314 37,277 31,429 30,477 23,997 17,506 22,037 14,125 28,779 17,798 12,266 29,028 21,461 15,572 24,792 14,928 25,698 15,266 29,058 18,574 28,398 20,681 14,833 13,279 18,189 14,841 32,156 24,173 16,573 90,510 52,332 34,042 Jkt 214001 Number of cases MS–DRG 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 405 PO 00000 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... Frm 00362 Fmt 4701 48,192 63,720 28,246 1,828 5,926 3,736 7,186 12,464 8,586 1,501 3,167 3,566 882 2,548 6,990 933 2,919 2,766 1,628 4,174 5,178 1,760 4,293 8,211 3,172 8,433 15,386 8,357 7,827 2,484 3,570 5,250 3,562 24,424 27,117 15,293 9,082 19,032 4,321 51,664 110,502 92,325 3,027 5,304 4,499 1,227 8,101 1,998 7,139 5,041 18,589 45,899 46,538 44,419 282,973 23,327 45,966 24,872 3,972 Sfmt 4702 Threshold 83,718 49,785 37,251 76,442 48,536 36,301 70,724 45,785 34,468 60,013 42,250 31,529 45,033 33,808 24,135 54,766 36,119 28,030 40,240 30,100 19,260 42,667 30,824 20,507 47,221 33,349 23,911 61,777 42,844 32,598 34,021 26,848 20,098 34,233 28,743 20,505 35,802 28,329 22,907 32,372 24,239 18,668 35,357 27,876 21,070 29,549 21,207 34,976 26,903 20,238 31,113 23,260 16,397 26,016 17,753 30,889 23,957 17,482 86,374 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued MS–DRG 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... E:\FR\FM\30APP2.SGM 30APP2 Number of cases 5,304 2,120 1,549 1,737 601 957 961 760 5,248 6,133 5,338 16,454 27,098 35,942 768 1,057 331 1,545 897 126 15,201 9,723 898 12,164 13,203 3,911 14,096 24,418 25,766 13,382 14,214 6,593 12,947 16,870 16,037 950 1,778 1,988 947 2,416 1,617 3,516 52,310 1,018 13,179 5,060 5,853 2,416 4,073 14,326 21,140 30,544 405,849 2,288 7,009 23,109 2,925 3,287 1,595 Threshold 52,360 39,348 71,677 50,663 36,877 69,221 51,066 39,922 62,853 43,331 32,604 49,649 39,258 29,790 66,342 39,447 31,257 71,874 47,509 32,981 33,045 23,926 17,085 34,878 28,443 25,366 33,587 26,852 18,781 31,516 24,098 17,782 33,108 27,464 19,832 165,424 121,032 93,297 144,023 98,535 82,249 97,638 66,514 82,048 63,047 60,604 43,476 31,714 74,467 57,869 49,618 59,370 44,493 77,861 52,304 42,971 51,927 37,186 25,620 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Number of cases jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... VerDate Aug<31>2005 2,589 8,575 11,457 26,755 72,188 48,187 7,107 17,896 1,183 2,189 1,312 2,501 5,791 23,080 52,938 5,221 16,933 29,231 1,974 5,569 6,672 1,167 1,113 1,503 3,878 6,482 833 2,172 3,036 815 838 2,506 627 974 3,932 11,002 1,053 1,014 3,820 11,287 17,603 825 3,414 7,007 33,727 667 1,059 3,448 4,046 1,658 5,723 17,041 10,817 4,093 5,587 4,571 585 1,120 865 19:42 Apr 29, 2008 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Threshold 58,272 45,067 35,879 53,624 40,303 34,632 47,684 40,860 60,074 44,942 36,049 35,530 27,889 37,310 23,744 51,439 38,816 29,960 52,628 37,148 28,169 38,115 22,378 47,316 32,847 23,489 42,531 32,702 24,287 25,704 37,099 27,713 28,236 40,828 32,904 23,803 30,121 20,124 54,024 39,608 32,537 27,647 16,259 27,756 15,479 21,443 13,756 35,081 28,706 21,628 34,804 26,766 18,081 36,357 26,110 17,948 33,933 26,761 18,763 Jkt 214001 Number of cases MS–DRG 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 573 574 575 576 577 578 579 580 581 582 583 584 585 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 614 615 616 617 618 619 620 621 622 623 624 625 626 627 PO 00000 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... Frm 00363 Fmt 4701 10,077 85,429 3,084 19,284 2,025 18,715 3,658 15,153 1,816 4,334 7,125 5,476 36,406 1,667 3,334 2,646 5,490 11,156 5,477 549 2,233 3,065 3,521 10,746 12,188 5,347 8,780 670 1,499 4,197 12,368 2,786 1,119 5,334 465 1,413 321 686 893 22,195 130,827 2,679 22,207 1,358 7,223 1,460 1,550 1,091 6,743 262 696 2,183 7,840 1,113 3,081 387 1,276 2,544 14,040 Sfmt 4702 Threshold 30,882 18,705 25,449 15,035 23,819 14,407 29,996 19,455 30,350 21,234 13,644 28,172 15,527 28,585 21,320 16,029 45,601 34,288 25,545 51,383 32,911 24,256 45,095 31,153 22,362 24,362 19,177 31,432 20,658 31,149 23,904 17,143 31,375 19,449 30,971 25,450 18,124 22,523 15,565 28,410 18,332 26,853 16,438 25,667 15,152 47,701 34,632 65,719 38,652 29,334 56,060 41,545 34,898 43,197 34,355 24,651 41,939 28,873 19,271 23889 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued MS–DRG 628 629 630 637 638 639 640 641 642 643 644 645 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 707 708 709 710 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... E:\FR\FM\30APP2.SGM 30APP2 Number of cases 3,371 4,183 539 17,173 42,846 38,599 61,027 202,068 1,522 5,194 11,834 8,221 10,083 1,697 3,458 1,633 3,922 7,428 8,291 4,668 7,609 4,273 952 2,064 4,406 656 2,094 3,632 3,838 12,767 11,721 809 945 12,591 11,735 7,841 82,356 132,588 45,085 2,328 1,603 3,266 1,084 56,256 198,999 819 492 2,431 18,046 981 10,563 594 23,391 24,279 12,340 5,984 18,084 765 1,845 Threshold 53,828 42,434 33,189 28,050 19,293 13,546 25,018 16,467 23,787 31,972 25,437 17,977 61,353 89,458 56,337 42,874 58,696 41,203 33,644 53,703 38,883 31,713 45,713 31,902 24,778 47,408 32,797 20,211 42,144 30,048 19,264 31,091 19,988 45,199 41,821 34,014 31,292 26,544 17,817 19,847 31,947 26,251 18,135 27,047 18,127 33,914 26,929 28,697 18,013 25,865 15,132 17,528 29,470 23,424 16,877 37,222 30,416 35,528 29,560 23890 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Number of cases jlentini on PROD1PC65 with PROPOSALS2 MS–DRG 711 712 713 714 715 716 717 718 722 723 724 725 726 727 728 729 730 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 754 755 756 757 758 759 760 761 765 766 767 769 770 774 775 776 777 778 779 780 781 782 799 800 801 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... VerDate Aug<31>2005 792 710 10,272 28,875 532 1,275 705 589 754 1,970 586 759 3,733 1,300 6,194 592 471 1,364 1,133 856 3,302 866 1,015 4,338 6,033 10,977 32,430 1,527 1,700 2,643 10,434 19,915 982 437 986 2,954 687 1,398 1,612 1,244 1,708 1,773 2,773 2,692 133 98 203 1,517 5,784 513 209 475 112 41 3,040 175 566 705 556 19:42 Apr 29, 2008 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Threshold 37,675 20,316 26,996 15,559 36,052 29,420 34,114 19,293 30,816 24,740 15,657 24,606 16,368 27,843 17,130 25,442 14,723 44,272 28,372 73,117 41,614 28,882 53,269 34,448 24,839 31,971 21,234 30,774 20,207 30,028 21,235 20,564 45,119 24,771 33,562 25,879 16,172 32,870 26,363 19,100 19,562 13,249 20,365 13,836 18,724 28,990 16,249 12,327 8,750 15,047 20,244 8,942 11,223 3,917 13,218 8,623 82,467 50,685 37,382 Jkt 214001 Number of cases MS–DRG 802 803 804 808 809 810 811 812 813 814 815 816 820 821 822 823 824 825 826 827 828 829 830 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 853 854 855 856 857 858 862 863 864 865 866 867 868 869 870 871 872 876 880 881 PO 00000 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... Frm 00364 Fmt 4701 764 1,071 995 6,092 12,879 2,801 21,482 90,369 14,238 1,564 3,315 2,154 1,301 2,478 1,894 2,182 2,976 1,756 524 1,256 802 1,175 524 4,031 2,707 1,623 1,044 1,321 1,466 9,683 10,060 5,341 1,354 2,414 811 2,117 23,925 1,725 1,478 34,961 6,662 459 5,904 9,631 3,258 7,955 21,482 19,034 1,707 8,201 5,076 2,659 1,139 21,356 216,894 91,026 860 9,304 4,658 Sfmt 4702 Threshold 53,613 36,134 27,223 37,130 27,509 22,786 26,846 18,397 27,095 30,406 25,805 18,432 89,835 43,777 30,581 69,584 44,341 30,652 76,715 44,122 32,076 47,921 28,158 58,295 37,287 25,573 96,925 47,431 30,443 43,346 32,240 25,445 34,538 27,673 21,496 38,966 26,844 23,146 29,110 80,838 52,593 38,661 65,124 37,513 30,272 34,329 22,129 20,781 29,217 17,149 38,916 25,425 18,507 94,830 35,333 27,030 42,167 15,133 12,046 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued MS–DRG 882 883 884 885 886 887 894 895 896 897 901 902 903 904 905 906 907 908 909 913 914 915 916 917 918 919 920 921 922 923 927 928 929 933 934 935 939 940 941 945 946 947 948 949 950 951 955 956 957 958 959 963 964 965 969 970 974 975 976 .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... E:\FR\FM\30APP2.SGM 30APP2 Number of cases 1,558 758 19,126 81,314 407 399 4,798 10,278 5,570 38,298 926 2,036 1,508 1,047 812 716 8,469 8,340 5,470 807 6,655 1,080 5,527 15,818 35,758 11,106 14,005 9,462 1,055 3,976 213 819 440 145 663 2,220 673 1,322 1,720 6,687 4,359 9,751 47,916 682 420 951 449 3,984 1,325 1,156 295 1,592 2,581 1,077 644 138 5,952 4,710 2,654 Threshold 12,634 17,971 19,197 15,242 13,905 16,694 7,599 12,773 26,933 13,086 54,456 33,188 23,579 43,056 26,185 24,257 56,134 36,960 27,977 27,237 16,360 26,134 10,518 29,720 14,390 30,394 22,313 14,923 28,288 15,419 182,484 65,145 37,218 31,568 24,756 22,937 46,257 33,961 26,932 20,290 15,730 24,756 15,920 18,328 12,682 15,279 87,860 57,503 101,860 67,071 47,759 50,127 34,357 25,020 78,213 45,746 41,989 29,607 22,430 23891 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Number of cases MS–DRG 977 981 982 983 984 .................... .................... .................... .................... .................... 4,633 25,506 18,355 6,144 671 TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Threshold 25,054 78,693 55,049 40,105 59,501 Number of cases MS–DRG 985 986 987 988 989 .................... .................... .................... .................... .................... TABLE 10.—GEOMETRIC MEAN PLUS THE LESSER OF .75 OF THE NATIONAL ADJUSTED OPERATING STANDARDIZED PAYMENT AMOUNT (INCREASED TO REFLECT THE DIFFERENCE BETWEEN COSTS AND CHARGES) OR .75 OF ONE STANDARD DEVIATION OF MEAN CHARGES BY MEDICARE SEVERITY DIAGNOSISRELATED GROUP (MS–DRG)— MARCH 2008 1—Continued Threshold 904 732 8,256 11,611 5,817 MS–DRG 42,990 29,607 55,744 37,995 27,744 999 .................... Number of cases 26 Threshold 15,387 1 Cases taken from the FY 2007 MedPAR file; MS–DRGs are from GROUPER Version 26.0. TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD Proposed base MS– LTC–DRG 1 ............... 2 ............... 1 ............... 1 ............... 3 ............... 3 ............... 4 ............... 4 ............... 5 ............... 6 ............... 7 ............... 8 ............... 9 ............... 10 ............. 11 ............. 12 ............. 13 ............. 5 ............... 5 ............... 7 ............... 8 ............... 9 ............... 10 ............ 11 ............ 11 ............ 11 ............ 20 ............. 20 ............ 21 ............. 20 ............ 22 ............. 20 ............ 23 ............. 23 ............ 24 ............. 23 ............ 25 ............. 25 ............ 26 ............. 27 ............. jlentini on PROD1PC65 with PROPOSALS2 Proposed MS–LTC– DRG 25 ............ 25 ............ 28 29 30 31 32 33 34 35 36 37 38 39 28 28 28 31 31 31 34 34 34 37 37 37 ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. VerDate Aug<31>2005 ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ FY 2007 LTCH cases Proposed MS–LTC–DRG title Heart transplant or implant of heart assist system w MCC Heart transplant or implant of heart assist system w/o MCC. ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R.. Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R.. Liver transplant w MCC or intestinal transplant .................. Liver transplant w/o MCC .................................................... Lung transplant .................................................................... Simultaneous pancreas/kidney transplant ........................... Bone marrow transplant ...................................................... Pancreas transplant ............................................................. Tracheostomy for face, mouth & neck diagnoses w MCC Tracheostomy for face, mouth & neck diagnoses w CC .... Tracheostomy for face, mouth & neck diagnoses w/o CC/ MCC. Intracranial vascular procedures w PDX hemorrhage w MCC. Intracranial vascular procedures w PDX hemorrhage w CC. Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC. Craniotomy w major device implant or acute complex CNS PDX w MCC*. Craniotomy w major device implant or acute complex CNS PDX w/o MCC*. Craniotomy & endovascular intracranial procedures w MCC. Craniotomy & endovascular intracranial procedures w CC Craniotomy & endovascular intracranial procedures w/o CC/MCC. Spinal procedures w MCC ................................................... Spinal procedures w CC ...................................................... Spinal procedures w/o CC/MCC ......................................... Ventricular shunt procedures w MCC ................................. Ventricular shunt procedures w CC .................................... Ventricular shunt procedures w/o CC/MCC ........................ Carotid artery stent procedure w MCC ............................... Carotid artery stent procedurew CC .................................... Carotid artery stent procedure w/o CC/MCC ...................... Extracranial procedures w MCC .......................................... Extracranial procedures w CC* ........................................... Extracranial procedures w/o CC/MCC ................................ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00365 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 0 0 0.0000 0.0000 0.0 0.0 0.0 0.0 286 4.5889 66.5 55.4 1,201 2.9992 44.4 37.0 0 0 0 0 0 0 1 1 0 0.0000 0.0000 0.0000 0.0000 1.2617 0.0000 1.7509 1.7509 1.7509 0.0 0.0 0.0 0.0 31.5 0.0 37.9 37.9 37.9 0.0 0.0 0.0 0.0 26.3 0.0 31.6 31.6 31.6 0 1.7509 37.9 31.6 0 1.7509 37.9 31.6 0 1.7509 37.9 31.6 2 1.2617 31.5 26.3 1 1.2617 31.5 26.3 1 1.7509 37.9 31.6 3 1 1.7509 0.8596 37.9 25.2 31.6 21.0 11 9 1 5 1 0 0 0 0 7 6 0 1.2617 1.2617 1.2617 1.7509 1.7509 1.7509 1.2617 1.2617 1.2617 1.2617 1.2617 1.2617 31.5 31.5 31.5 37.9 37.9 37.9 31.5 31.5 31.5 31.5 31.5 31.5 26.3 26.3 26.3 31.6 31.6 31.6 26.3 26.3 26.3 26.3 26.3 26.3 E:\FR\FM\30APP2.SGM 30APP2 23892 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 40 ............. 41 ............. 42 ............. 40 ............ 40 ............ 40 ............ 52 53 54 55 56 57 58 59 60 61 62 63 52 52 54 54 56 56 58 58 58 61 61 61 ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ 64 ............. 65 ............. 66 ............. 64 ............ 64 ............ 64 ............ 67 ............. 67 ............ 68 ............. 67 ............ 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 69 70 70 70 73 73 75 75 77 77 77 80 80 82 82 82 85 85 85 88 88 88 91 91 91 94 ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ ............ 94 ............ 96 ............. 94 ............ 97 ............. 97 ............ 98 ............. jlentini on PROD1PC65 with PROPOSALS2 95 ............. 97 ............ 99 ............. 97 ............ 100 101 102 103 113 100 100 102 102 113 ........... ........... ........... ........... ........... VerDate Aug<31>2005 ........... ........... ........... ........... ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Periph & cranial nerve & other nerv syst proc w MCC ....... Periph & cranial nerve & other nerv syst proc w CC .......... Periph & cranial nerve & other nerv syst proc w/o CC/ MCC*. Spinal disorders & injuries w CC/MCC ............................... Spinal disorders & injuries w/o CC/MCC ............................ Nervous system neoplasms w MCC ................................... Nervous system neoplasms w/o MCC ................................ Degenerative nervous system disorders w MCC ................ Degenerative nervous system disorders w/o MCC ............. Multiple sclerosis & cerebellar ataxia w MCC ..................... Multiple sclerosis & cerebellar ataxia w CC ........................ Multiple sclerosis & cerebellar ataxia w/o CC/MCC ............ Acute ischemic stroke w use of thrombolytic agent w MCC Acute ischemic stroke w use of thrombolytic agent w CC .. Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC. Intracranial hemorrhage or cerebral infarction w MCC ....... Intracranial hemorrhage or cerebral infarction w CC .......... Intracranial hemorrhage or cerebral infarction w/o CC/ MCC. Nonspecific cva & precerebral occlusion w/o infarct w MCC. Nonspecific cva & precerebral occlusion w/o infarct w/o MCC. Transient ischemia ............................................................... Nonspecific cerebrovascular disorders w MCC .................. Nonspecific cerebrovascular disorders w CC ..................... Nonspecific cerebrovascular disorders w/o CC/MCC ......... Cranial & peripheral nerve disorders w MCC ..................... Cranial & peripheral nerve disorders w/o MCC .................. Viral meningitis w CC/MCC ................................................. Viral meningitis w/o CC/MCC .............................................. Hypertensive encephalopathy w MCC ................................ Hypertensive encephalopathy w CC ................................... Hypertensive encephalopathy w/o CC/MCC ....................... Nontraumatic stupor & coma w MCC .................................. Nontraumatic stupor & coma w/o MCC ............................... Traumatic stupor & coma, coma >1 hr w MCC .................. Traumatic stupor & coma, coma >1 hr w CC ..................... Traumatic stupor & coma, coma >1 hr w/o CC/MCC ......... Traumatic stupor & coma, coma <1 hr w MCC .................. Traumatic stupor & coma, coma <1 hr w CC ..................... Traumatic stupor & coma, coma <1 hr w/o CC/MCC ......... Concussion w MCC ............................................................. Concussion w CC ................................................................ Concussion w/o CC/MCC .................................................... Other disorders of nervous system w MCC ........................ Other disorders of nervous system w CC ........................... Other disorders of nervous system w/o CC/MCC ............... Bacterial & tuberculous infections of nervous system w MCC. Bacterial & tuberculous infections of nervous system w CC. Bacterial & tuberculous infections of nervous system w/o CC/MCC. Non-bacterial infect of nervous sys exc viral meningitis w MCC. Non-bacterial infect of nervous sys exc viral meningitis w CC. Non-bacterial infect of nervous sys exc viral meningitis w/ o CC/MCC. Seizures w MCC .................................................................. Seizures w/o MCC ............................................................... Headaches w MCC .............................................................. Headaches w/o MCC ........................................................... Orbital procedures w CC/MCC ............................................ 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00366 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 143 87 6 1.2451 1.0890 1.0890 34.8 34.5 34.5 29.0 28.8 28.8 83 7 31 50 1,180 1,945 19 23 10 0 0 0 0.9943 0.8596 1.0109 0.6542 0.8022 0.6033 0.8596 0.6327 0.6327 0.8823 0.5770 0.4824 31.3 25.2 26.7 21.6 25.3 24.0 25.2 21.6 21.6 23.5 22.8 19.6 26.1 21.0 22.3 18.0 21.1 20.0 21.0 18.0 18.0 19.6 19.0 16.3 107 67 24 0.7831 0.6217 0.4824 24.5 24.0 19.6 20.4 20.0 16.3 4 0.4824 19.6 16.3 4 0.4824 19.6 16.3 13 87 52 8 116 173 15 0 4 1 1 47 110 9 12 3 78 81 15 0 1 0 218 138 43 203 0.4824 0.8823 0.5770 0.4824 0.8910 0.6057 0.6327 0.6327 1.2617 0.6327 0.4824 0.7859 0.7028 0.8596 0.6327 0.6327 0.8652 0.6630 0.4824 0.4824 0.4824 0.4824 0.9248 0.6661 0.6046 1.0466 19.6 23.5 22.8 19.6 24.6 23.1 21.6 21.6 31.5 21.6 19.6 29.2 28.2 25.2 21.6 21.6 26.1 24.1 19.6 19.6 19.6 19.6 25.9 25.0 22.0 29.2 16.3 19.6 19.0 16.3 20.5 19.3 18.0 18.0 26.3 18.0 16.3 24.3 23.5 21.0 18.0 18.0 21.8 20.1 16.3 16.3 16.3 16.3 21.6 20.8 18.3 24.3 106 0.9763 28.9 24.1 31 0.7559 27.6 23.0 48 1.0415 26.0 21.7 22 0.8596 25.2 21.0 6 0.6327 21.6 18.0 47 55 9 4 1 0.6380 0.6132 0.6327 0.6327 0.8596 21.8 25.4 21.6 21.6 25.2 18.2 21.2 18.0 18.0 21.0 E:\FR\FM\30APP2.SGM 30APP2 23893 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 114 115 116 117 121 122 123 124 125 129 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 113 115 116 116 121 121 123 124 124 129 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 130 131 132 133 ........... ........... ........... ........... 129 131 131 133 ........... ........... ........... ........... jlentini on PROD1PC65 with PROPOSALS2 134 ........... 133 ........... 135 136 137 138 139 146 147 148 149 150 151 152 153 154 155 156 157 158 159 163 164 165 166 167 168 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 135 135 137 137 139 146 146 146 149 150 150 152 152 154 154 154 157 157 157 163 163 163 166 166 166 175 175 177 177 177 180 180 180 183 183 183 186 186 186 189 190 190 190 193 193 193 196 196 196 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Orbital procedures w/o CC/MCC ......................................... Extraocular procedures except orbit .................................... Intraocular procedures w CC/MCC ..................................... Intraocular procedures w/o CC/MCC .................................. Acute major eye infections w CC/MCC ............................... Acute major eye infections w/o CC/MCC ............................ Neurological eye disorders .................................................. Other disorders of the eye w MCC ..................................... Other disorders of the eye w/o MCC .................................. Major head & neck procedures w CC/MCC or major device. Major head & neck procedures w/o CC/MCC ..................... Cranial/facial procedures w CC/MCC .................................. Cranial/facial procedures w/o CC/MCC ............................... Other ear, nose, mouth & throat O.R. procedures w CC/ MCC. Other ear, nose, mouth & throat O.R. procedures w/o CC/ MCC. Sinus & mastoid procedures w CC/MCC ............................ Sinus & mastoid procedures w/o CC/MCC* ........................ Mouth procedures w CC/MCC ............................................ Mouth procedures w/o CC/MCC ......................................... Salivary gland procedures ................................................... Ear, nose, mouth & throat malignancy w MCC ................... Ear, nose, mouth & throat malignancy w CC ...................... Ear, nose, mouth & throat malignancy w/o CC/MCC ......... Dysequilibrium ..................................................................... Epistaxis w MCC ................................................................. Epistaxis w/o MCC .............................................................. Otitis media & URI w MCC .................................................. Otitis media & URI w/o MCC ............................................... Nasal trauma & deformity w MCC ....................................... Nasal trauma & deformity w CC .......................................... Nasal trauma & deformity w/o CC/MCC ............................. Dental & Oral Diseases w MCC .......................................... Dental & Oral Diseases w CC ............................................. Dental & Oral Diseases w/o CC/MCC ................................. Major chest procedures w MCC .......................................... Major chest procedures w CC ............................................. Major chest procedures w/o CC/MCC ................................. Other resp system O.R. procedures w MCC ...................... Other resp system O.R. procedures w CC ......................... Other resp system O.R. procedures w/o CC/MCC ............. Pulmonary embolism w MCC .............................................. Pulmonary embolism w/o MCC ........................................... Respiratory infections & inflammations w MCC .................. Respiratory infections & inflammations w CC ..................... Respiratory infections & inflammations w/o CC/MCC ......... Respiratory neoplasms w MCC ........................................... Respiratory neoplasms w CC .............................................. Respiratory neoplasms w/o CC/MCC* ................................ Major chest trauma w MCC ................................................. Major chest trauma w CC .................................................... Major chest trauma w/o CC/MCC ....................................... Pleural effusion w MCC ....................................................... Pleural effusion w CC .......................................................... Pleural effusion w/o CC/MCC* ............................................ Pulmonary edema & respiratory failure ............................... Chronic obstructive pulmonary disease w MCC ................. Chronic obstructive pulmonary disease w CC .................... Chronic obstructive pulmonary disease w/o CC/MCC ........ Simple pneumonia & pleurisy w MCC ................................. Simple pneumonia & pleurisy w CC .................................... Simple pneumonia & pleurisy w/o CC/MCC ....................... Interstitial lung disease w MCC ........................................... Interstitial lung disease w CC .............................................. Interstitial lung disease w/o CC/MCC .................................. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00367 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 0 0 1 0 10 1 0 2 8 0 0.8596 0.4824 0.8596 0.4824 0.6327 0.6327 0.4824 0.6327 0.4824 1.3344 25.2 19.6 25.2 19.6 21.6 21.6 19.6 21.6 19.6 30.2 21.0 16.3 21.0 16.3 18.0 18.0 16.3 18.0 16.3 25.2 0 0 1 10 0.4824 1.7509 1.7509 1.2617 19.6 37.9 37.9 31.5 16.3 31.6 31.6 26.3 0 1.2617 31.5 26.3 2 1 1 0 0 40 26 6 11 0 0 9 23 50 47 13 12 21 5 45 6 1 1,506 211 8 128 139 3,181 2,334 394 149 109 11 1 2 1 121 60 15 6,586 1,652 1,343 764 1,805 2,026 382 110 85 40 0.4824 0.4824 1.7509 1.7509 1.7509 1.3344 0.9930 0.4824 0.4824 0.8596 0.6327 0.8596 0.6327 0.7707 0.7011 0.6327 0.6327 0.6327 0.4824 2.5063 1.2617 0.8596 2.4992 1.8587 0.8596 0.6640 0.5479 0.8784 0.7414 0.6225 0.7975 0.6255 0.6255 0.4824 0.4824 0.4824 0.7576 0.6176 0.6176 0.9608 0.7477 0.6220 0.5358 0.7698 0.6368 0.5374 0.7122 0.5716 0.5059 19.6 19.6 37.9 37.9 37.9 30.2 22.4 19.6 19.6 25.2 21.6 25.2 21.6 22.0 21.1 21.6 21.6 21.6 19.6 33.5 31.5 25.2 41.8 36.2 25.2 21.9 20.0 22.8 22.1 19.4 20.9 18.7 18.7 19.6 19.6 19.6 20.5 20.5 20.5 23.9 20.5 19.4 17.3 21.6 20.1 17.4 20.1 17.6 15.9 16.3 16.3 31.6 31.6 31.6 25.2 18.7 16.3 16.3 21.0 18.0 21.0 18.0 18.3 17.6 18.0 18.0 18.0 16.3 27.9 26.3 21.0 34.8 30.2 21.0 18.3 16.7 19.0 18.4 16.2 17.4 15.6 15.6 16.3 16.3 16.3 17.1 17.1 17.1 19.9 17.1 16.2 14.4 18.0 16.8 14.5 16.8 14.7 13.3 E:\FR\FM\30APP2.SGM 30APP2 23894 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 199 200 201 202 203 204 205 206 207 199 199 199 202 202 204 205 205 207 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 208 ........... 208 ........... 215 ........... 216 ........... 215 ........... 216 ........... 217 ........... 216 ........... 218 ........... 216 ........... 219 ........... 219 ........... 220 ........... 219 ........... 221 ........... 219 ........... 222 ........... 222 ........... 223 ........... 222 ........... 224 ........... 224 ........... 225 ........... 224 ........... 226 227 228 229 230 231 232 233 234 235 236 237 238 239 226 226 228 228 228 231 231 233 233 235 235 237 237 239 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 239 ........... 241 ........... 239 ........... 242 243 244 245 246 jlentini on PROD1PC65 with PROPOSALS2 240 ........... 242 242 242 245 246 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 247 ........... 246 ........... 248 ........... 248 ........... 249 ........... 248 ........... 250 ........... 250 ........... VerDate Aug<31>2005 FY 2007 LTCH cases Proposed MS–LTC–DRG title Pneumothorax w MCC ........................................................ Pneumothorax w CC ........................................................... Pneumothorax w/o CC/MCC ............................................... Bronchitis & asthma w CC/MCC ......................................... Bronchitis & asthma w/o CC/MCC ...................................... Respiratory signs & symptoms ............................................ Other respiratory system diagnoses w MCC ...................... Other respiratory system diagnoses w/o MCC ................... Respiratory system diagnosis w ventilator support 96+ hours. Respiratory system diagnosis w ventilator support <96 hours. Other heart assist system implant ....................................... Cardiac valve & oth maj cardiothoracic proc w card cath w MMCC. Cardiac valve & oth maj cardiothoracic proc w card cath w MCC. Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MMCC. Cardiac valve & oth maj cardiothoracic proc w/o card cath w MMCC. Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC. Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC. Cardiac defib implant w cardiac cath w AMI/HF/shock w MMCC. Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MMCC. Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MMCC. Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/ o MMCC. Cardiac defibrillator implant w/o cardiac cath w MMCC ..... Cardiac defibrillator implant w/o cardiac cath w/o MMCC .. Other cardiothoracic procedures w MMCC ......................... Other cardiothoracic procedures w MCC ............................ Other cardiothoracic procedures w/o CC/MMCC ................ Coronary bypass w PTCA w MMCC ................................... Coronary bypass w PTCA w/o MMCC ................................ Coronary bypass w cardiac cath w MMCC ......................... Coronary bypass w cardiac cath w/o MMCC ...................... Coronary bypass w/o cardiac cath w MMCC ...................... Coronary bypass w/o cardiac cath w/o MMCC ................... Major cardiovascular procedures w MMCC ........................ Major cardiovascular procedures w/o MMCC ..................... Amputation for circ sys disorders exc upper limb & toe w MMCC. Amputation for circ sys disorders exc upper limb & toe w MCC. Amputation for circ sys disorders exc upper limb & toe w/o CC/MMCC. Permanent cardiac pacemaker implant w MCC* ................ Permanent cardiac pacemaker implant w MCC .................. Permanent cardiac pacemaker implant w/o CC/MMCC ..... AICD generator procedures ................................................. Percutaneous cardiovascular proc w drug-eluting stent w MMCC. Percutaneous cardiovascular proc w drug-eluting stent w/o MMCC. Percutaneous cardiovasc proc w non-drug-eluting stent w MMCC. Percutaneous cardiovasc proc w non-drug-eluting stent w/ o MCC*. Perc cardiovasc proc w/o coronary artery stent or AMI w MMCC. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00368 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 49 32 5 88 21 233 324 171 13,186 0.7639 0.5906 0.4824 0.6509 0.6327 0.8315 0.8236 0.7182 2.0793 21.8 17.8 19.6 19.6 21.6 22.8 22.3 21.5 34.5 18.2 14.8 16.3 16.3 18.0 19.0 18.6 17.9 28.8 1,452 1.1752 23.6 19.7 0 0 0.8596 1.2617 25.2 31.5 21.0 26.3 0 0.8596 25.2 21.0 0 0.8596 25.2 21.0 0 1.2617 31.5 26.3 0 0.8596 25.2 21.0 0 0.8596 25.2 21.0 0 1.7509 37.9 31.6 0 1.7509 37.9 31.6 0 1.7509 37.9 31.6 0 1.7509 37.9 31.6 11 9 0 0 0 0 0 0 0 0 0 7 2 163 1.7509 1.7509 1.4637 1.2121 0.6327 1.2617 0.8596 1.2617 0.8596 1.2617 0.8596 1.2617 0.8596 1.5067 37.9 37.9 33.3 28.9 21.6 31.5 25.2 31.5 25.2 31.5 25.2 31.5 25.2 36.6 31.6 31.6 27.8 24.1 18.0 26.3 21.0 26.3 21.0 26.3 21.0 26.3 21.0 30.5 83 1.1559 34.1 28.4 10 0.8596 25.2 21.0 12 5 1 0 3 1.7509 1.7509 1.7509 1.7509 1.2617 37.9 37.9 37.9 37.9 31.5 31.6 31.6 31.6 31.6 26.3 1 1.2617 31.5 26.3 2 1.2617 31.5 26.3 1 1.2617 31.5 26.3 3 1.7509 37.9 31.6 E:\FR\FM\30APP2.SGM 30APP2 23895 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 251 ........... 250 ........... 252 253 254 255 252 252 252 255 ........... ........... ........... ........... ........... ........... ........... ........... 255 ........... 257 ........... 255 ........... 258 ........... 259 ........... 260 ........... 258 ........... 258 ........... 260 ........... 261 ........... 260 ........... 262 ........... 260 ........... 263 264 265 280 281 282 jlentini on PROD1PC65 with PROPOSALS2 256 ........... ........... ........... ........... ........... ........... ........... 263 264 265 280 280 280 ........... ........... ........... ........... ........... ........... 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 326 327 328 329 330 331 332 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 283 283 283 286 286 288 288 288 291 291 291 294 294 296 296 296 299 299 299 302 302 304 304 306 306 308 308 308 311 312 313 314 314 314 326 326 326 329 329 329 332 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 FY 2007 LTCH cases Proposed MS–LTC–DRG title Perc cardiovasc proc w/o coronary artery stent or AMI w/o MMCC. Other vascular procedures w MMCC .................................. Other vascular procedures w MCC ..................................... Other vascular procedures w/o CC/MMCC ......................... Upper limb & toe amputation for circ system disorders w MMCC. Upper limb & toe amputation for circ system disorders w MCC. Upper limb & toe amputation for circ system disorders w/o CC/MMCC. Cardiac pacemaker device replacement w MMCC ............. Cardiac pacemaker device replacement w/o MMCC .......... Cardiac pacemaker revision except device replacement w MMCC. Cardiac pacemaker revision except device replacement w CC*. Cardiac pacemaker revision except device replacement w/ o CC/MCC*. Vein ligation & stripping ....................................................... Other circulatory system O.R. procedures .......................... AICD lead procedures ......................................................... Circulatory disorders w AMI, discharged alive w MMCC .... Circulatory disorders w AMI, discharged alive w MCC ....... Circulatory disorders w AMI, discharged alive w/o CC/ MMCC. Circulatory disorders w AMI, expired w MMCC .................. Circulatory disorders w AMI, expired w CC* ....................... Circulatory disorders w AMI, expired w/o CC/MMCC ......... Circulatory disorders except AMI, w card cath w MMCC ... Circulatory disorders except AMI, w card cath w/o MMCC Acute & subacute endocarditis w MMCC ............................ Acute & subacute endocarditis w MCC ............................... Acute & subacute endocarditis w/o CC/MMCC .................. Heart failure & shock w MMCC ........................................... Heart failure & shock w MCC .............................................. Heart failure & shock w/o CC/MMCC .................................. Deep vein thrombophlebitis w CC/MMCC ........................... Deep vein thrombophlebitis w/o CC/MMCC ........................ Cardiac arrest, unexplained w MMCC ................................ Cardiac arrest, unexplained w MCC ................................... Cardiac arrest, unexplained w/o CC/MMCC ....................... Peripheral vascular disorders w MMCC .............................. Peripheral vascular disorders w MCC ................................. Peripheral vascular disorders w/o CC/MMCC ..................... Atherosclerosis w MMCC .................................................... Atherosclerosis w/o MMCC ................................................. Hypertension w MMCC ........................................................ Hypertension w/o MMCC ..................................................... Cardiac congenital & valvular disorders w MMCC .............. Cardiac congenital & valvular disorders w/o MMCC ........... Cardiac arrhythmia & conduction disorders w MMCC ........ Cardiac arrhythmia & conduction disorders w MCC ........... Cardiac arrhythmia & conduction disorders w/o CC/MCC .. Angina pectoris .................................................................... Syncope & collapse ............................................................. Chest pain ............................................................................ Other circulatory system diagnoses w MMCC .................... Other circulatory system diagnoses w MCC ....................... Other circulatory system diagnoses w/o CC/MMCC ........... Stomach, esophageal & duodenal proc w MMCC .............. Stomach, esophageal & duodenal proc w MCC ................. Stomach, esophageal & duodenal proc w/o CC/MCC* ...... Major small & large bowel procedures w MMCC ................ Major small & large bowel procedures w MCC ................... Major small & large bowel procedures w/o CC/MMCC ...... Rectal resection w MMCC ................................................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00369 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 0 1.7509 37.9 31.6 134 51 3 61 1.4637 1.2121 0.6327 1.2589 33.3 28.9 21.6 33.8 27.8 24.1 18.0 28.2 42 0.9416 30.0 25.0 1 0.4824 19.6 16.3 0 1 2 1.2617 1.2617 1.2617 31.5 31.5 31.5 26.3 26.3 26.3 1 0.8596 25.2 21.0 1 0.8596 25.2 21.0 3 608 0 259 110 35 0.4824 1.0954 1.2617 0.7832 0.5772 0.5060 19.6 31.1 31.5 23.0 20.6 19.9 16.3 25.9 26.3 19.2 17.2 16.6 56 17 0 8 9 594 217 48 1,728 901 362 6 0 0 0 0 587 751 78 59 61 6 15 59 38 96 107 36 7 58 6 1,305 285 72 19 3 1 31 12 1 0 0.7924 0.7924 0.7924 1.2617 0.8596 1.0060 0.7920 0.6873 0.7727 0.6294 0.5168 0.6327 0.6327 0.7924 0.7924 0.7924 0.7804 0.5847 0.5385 0.7597 0.5692 0.4824 0.4824 0.8224 0.7367 0.8384 0.5679 0.4590 0.4824 0.5083 0.4824 0.8758 0.6575 0.6026 1.7509 1.2617 1.2617 2.2757 1.7509 1.7509 1.6757 16.1 16.1 16.1 31.5 25.2 26.1 26.1 24.3 21.9 21.2 18.8 21.6 21.6 16.1 16.1 16.1 23.4 22.0 20.3 21.8 20.1 19.6 19.6 22.7 22.9 25.0 20.8 19.4 19.6 19.7 19.6 22.9 21.0 21.0 37.9 31.5 31.5 41.8 37.9 37.9 34.2 13.4 13.4 13.4 26.3 21.0 21.8 21.8 20.3 18.3 17.7 15.7 18.0 18.0 13.4 13.4 13.4 19.5 18.3 16.9 18.2 16.8 16.3 16.3 18.9 19.1 20.8 17.3 16.2 16.3 16.4 16.3 19.1 17.5 17.5 31.6 26.3 26.3 34.8 31.6 31.6 28.5 E:\FR\FM\30APP2.SGM 30APP2 23896 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 333 334 335 336 337 338 339 340 332 332 335 335 335 338 338 338 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 341 ........... 342 ........... 343 ........... 341 ........... 341 ........... 341 ........... 344 345 346 347 348 349 350 351 352 353 354 355 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 344 344 344 347 347 347 350 350 350 353 353 353 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 356 357 358 368 369 370 371 ........... ........... ........... ........... ........... ........... ........... 356 356 356 368 368 368 371 ........... ........... ........... ........... ........... ........... ........... 371 ........... 373 ........... jlentini on PROD1PC65 with PROPOSALS2 372 ........... 371 ........... 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 405 406 407 408 374 374 374 377 377 377 380 380 380 383 383 385 385 385 388 388 388 391 391 393 393 393 405 405 405 408 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 409 ........... VerDate Aug<31>2005 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 408 ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Rectal resection w MCC ...................................................... Rectal resection w/o CC/MMCC .......................................... Peritoneal adhesiolysis w MMCC ........................................ Peritoneal adhesiolysis w MCC ........................................... Peritoneal adhesiolysis w/o CC/MMCC ............................... Appendectomy w complicated principal diag w MMCC ...... Appendectomy w complicated principal diag w MCC ......... Appendectomy w complicated principal diag w/o CC/ MMCC. Appendectomy w/o complicated principal diag w MMCC ... Appendectomy w/o complicated principal diag w MCC ...... Appendectomy w/o complicated principal diag w/o CC/ MMCC. Minor small & large bowel procedures w MMCC ................ Minor small & large bowel procedures w MCC ................... Minor small & large bowel procedures w/o CC/MMCC ...... Anal & stomal procedures w MMCC ................................... Anal & stomal procedures w MCC ...................................... Anal & stomal procedures w/o CC/MMCC .......................... Inguinal & femoral hernia procedures w MMCC ................. Inguinal & femoral hernia procedures w MCC .................... Inguinal & femoral hernia procedures w/o CC/MMCC ........ Hernia procedures except inguinal & femoral w MMCC ..... Hernia procedures except inguinal & femoral w MCC ........ Hernia procedures except inguinal & femoral w/o CC/ MMCC. Other digestive system O.R. procedures w MMCC ............ Other digestive system O.R. procedures w MCC ............... Other digestive system O.R. procedures w/o CC/MCC* .... Major esophageal disorders w MMCC ................................ Major esophageal disorders w MCC ................................... Major esophageal disorders w/o CC/MMCC ....................... Major gastrointestinal disorders & peritoneal infections w MMCC. Major gastrointestinal disorders & peritoneal infections w MCC. Major gastrointestinal disorders & peritoneal infections w/o CC/MCC. Digestive malignancy w MMCC ........................................... Digestive malignancy w MCC .............................................. Digestive malignancy w/o CC/MMCC ................................. G.I. hemorrhage w MMCC .................................................. G.I. hemorrhage w MCC ..................................................... G.I. hemorrhage w/o CC/MMCC ......................................... Complicated peptic ulcer w MMCC ..................................... Complicated peptic ulcer w MCC ........................................ Complicated peptic ulcer w/o CC/MMCC ............................ Uncomplicated peptic ulcer w MMCC ................................. Uncomplicated peptic ulcer w/o MMCC .............................. Inflammatory bowel disease w MMCC ................................ Inflammatory bowel disease w MCC ................................... Inflammatory bowel disease w/o CC/MMCC ....................... G.I. obstruction w MMCC .................................................... G.I. obstruction w MCC ....................................................... G.I. obstruction w/o CC/MMCC ........................................... Esophagitis, gastroent & misc digest disorders w MMCC .. Esophagitis, gastroent & misc digest disorders w/o MMCC Other digestive system diagnoses w MMCC ...................... Other digestive system diagnoses w MCC ......................... Other digestive system diagnoses w/o CC/MMCC ............. Pancreas, liver & shunt procedures w MMCC .................... Pancreas, liver & shunt procedures w CC* ......................... Pancreas, liver & shunt procedures w/o CC/MMCC ........... Biliary tract proc except only cholecyst w or w/o c.d.e. w MMCC. Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00370 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 0 0 6 0 0 0 0 0 1.1606 1.1606 1.7509 1.7509 1.7509 0.9726 0.7768 0.5958 30.0 30.0 37.9 37.9 37.9 25.1 23.2 19.6 25.0 25.0 31.6 31.6 31.6 20.9 19.3 16.3 0 0 0 0.9726 0.7768 0.5958 25.1 23.2 19.6 20.9 19.3 16.3 5 0 0 3 3 0 0 0 0 1 1 0 1.7509 1.7509 1.7509 1.7509 1.2617 1.2617 1.2617 1.2617 1.2617 1.7509 0.6327 0.6327 37.9 37.9 37.9 37.9 31.5 31.5 31.5 31.5 31.5 37.9 21.6 21.6 31.6 31.6 31.6 31.6 26.3 26.3 26.3 26.3 26.3 31.6 18.0 18.0 141 36 4 26 14 4 722 1.6757 1.1606 1.1606 0.9161 0.8596 0.8596 0.9726 34.2 30.0 30.0 21.1 25.2 25.2 25.1 28.5 25.0 25.0 17.6 21.0 21.0 20.9 350 0.7768 23.2 19.3 68 0.5958 19.6 16.3 96 90 3 90 53 18 22 17 5 0 7 36 37 5 213 97 17 255 292 779 449 33 10 2 0 0 0.9011 0.7804 0.6327 0.8200 0.6902 0.6327 0.8596 0.6327 0.4824 0.8596 0.8596 0.8076 0.7126 0.4824 0.9486 0.7302 0.6327 0.7914 0.6568 1.0684 0.7872 0.5783 1.2617 1.2617 1.2617 0.6327 21.5 23.4 21.6 23.8 23.8 21.6 25.2 21.6 19.6 25.2 25.2 23.3 23.1 19.6 22.5 20.9 21.6 21.9 21.0 25.7 22.6 22.1 31.5 31.5 31.5 21.6 17.9 19.5 18.0 19.8 19.8 18.0 21.0 18.0 16.3 21.0 21.0 19.4 19.3 16.3 18.8 17.4 18.0 18.3 17.5 21.4 18.8 18.4 26.3 26.3 26.3 18.0 1 0.6327 21.6 18.0 E:\FR\FM\30APP2.SGM 30APP2 23897 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 410 ........... 408 ........... 411 412 413 414 411 411 411 414 ........... ........... ........... ........... ........... ........... ........... ........... 415 ........... 414 ........... 416 ........... 414 ........... 417 418 419 420 421 422 423 417 417 417 420 420 420 423 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 424 ........... 425 ........... 423 ........... 423 ........... 432 433 434 435 436 437 ........... ........... ........... ........... ........... ........... 432 432 432 435 435 435 ........... ........... ........... ........... ........... ........... 438 439 440 441 442 443 ........... ........... ........... ........... ........... ........... 438 438 438 441 441 441 ........... ........... ........... ........... ........... ........... 444 445 446 453 454 455 456 ........... ........... ........... ........... ........... ........... ........... 444 444 444 453 453 453 456 ........... ........... ........... ........... ........... ........... ........... 456 ........... 458 ........... 456 ........... 459 ........... 460 ........... 461 ........... 459 ........... 459 ........... 461 ........... 462 ........... 461 ........... 463 ........... 463 ........... 464 ........... 463 ........... 465 ........... jlentini on PROD1PC65 with PROPOSALS2 457 ........... 463 ........... 466 467 468 469 466 466 466 469 ........... ........... ........... ........... 470 ........... VerDate Aug<31>2005 ........... ........... ........... ........... 469 ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MMCC. Cholecystectomy w c.d.e. w MMCC .................................... Cholecystectomy w c.d.e. w MCC ....................................... Cholecystectomy w c.d.e. w/o CC/MMCC .......................... Cholecystectomy except by laparoscope w/o c.d.e. w MMCC. Cholecystectomy except by laparoscope w/o c.d.e. w MCC. Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MMCC. Laparoscopic cholecystectomy w/o c.d.e. w MCC* ............ Laparoscopic cholecystectomy w/o c.d.e. w MCC .............. Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MMCC .. Hepatobiliary diagnostic procedures w MMCC ................... Hepatobiliary diagnostic procedures w MCC ...................... Hepatobiliary diagnostic procedures w/o CC/MMCC .......... Other hepatobiliary or pancreas O.R. procedures w MMCC. Other hepatobiliary or pancreas O.R. procedures w MCC Other hepatobiliary or pancreas O.R. procedures w/o CC/ MMCC. Cirrhosis & alcoholic hepatitis w MMCC ............................. Cirrhosis & alcoholic hepatitis w MCC ................................ Cirrhosis & alcoholic hepatitis w/o CC/MMCC .................... Malignancy of hepatobiliary system or pancreas w MMCC Malignancy of hepatobiliary system or pancreas w MCC ... Malignancy of hepatobiliary system or pancreas w/o CC/ MMCC. Disorders of pancreas except malignancy w MMCC .......... Disorders of pancreas except malignancy w MCC ............. Disorders of pancreas except malignancy w/o CC/MMCC Disorders of liver except malig,cirr,alc hepa w MMCC ....... Disorders of liver except malig,cirr,alc hepa w MCC .......... Disorders of liver except malig,cirr,alc hepa w/o CC/ MMCC. Disorders of the biliary tract w MMCC ................................ Disorders of the biliary tract w MCC ................................... Disorders of the biliary tract w/o CC/MCC* ......................... Combined anterior/posterior spinal fusion w MMCC ........... Combined anterior/posterior spinal fusion w MCC .............. Combined anterior/posterior spinal fusion w/o CC/MMCC Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MMCC. Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC. Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w/o CC/MMCC. Spinal fusion except cervical w MMCC ............................... Spinal fusion except cervical w/o MMCC ............................ Bilateral or multiple major joint procs of lower extremity w MMCC. Bilateral or multiple major joint procs of lower extremity w/ o MMCC. Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w MMCC. Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w MCC. Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC. Revision of hip or knee replacement w MMCC .................. Revision of hip or knee replacement w MCC ..................... Revision of hip or knee replacement w/o CC/MMCC ......... Major joint replacement or reattachment of lower extremity w MCC*. Major joint replacement or reattachment of lower extremity w/o MMCC. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00371 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 0 0.6327 21.6 18.0 1 0 0 2 1.7509 1.7509 1.7509 1.7509 37.9 37.9 37.9 37.9 31.6 31.6 31.6 31.6 3 1.7509 37.9 31.6 0 1.7509 37.9 31.6 11 5 0 0 0 0 23 1.7509 1.7509 1.7509 0.8596 0.8596 0.8596 1.7509 37.9 37.9 37.9 25.2 25.2 25.2 37.9 31.6 31.6 31.6 21.0 21.0 21.0 31.6 2 0 0.8596 0.8596 25.2 25.2 21.0 21.0 73 24 0 53 26 4 0.6977 0.6327 0.6327 0.8340 0.4904 0.4824 20.9 21.6 21.6 22.0 17.2 19.6 17.4 18.0 18.0 18.3 14.3 16.3 243 144 24 123 62 14 1.0807 0.7533 0.6327 0.8206 0.7145 0.4824 23.5 22.0 21.6 23.1 21.7 19.6 19.6 18.3 18.0 19.3 18.1 16.3 104 35 8 0 0 0 1 0.8334 0.6140 0.6140 1.7509 1.7509 1.7509 1.7509 22.7 20.7 20.7 37.9 37.9 37.9 37.9 18.9 17.3 17.3 31.6 31.6 31.6 31.6 3 1.7509 37.9 31.6 0 1.7509 37.9 31.6 1 0 0 1.7509 1.7509 1.7509 37.9 37.9 37.9 31.6 31.6 31.6 0 0.8596 25.2 21.0 526 1.4126 38.7 32.3 311 1.0643 34.0 28.3 61 0.9863 34.0 28.3 3 4 1 3 1.2617 1.2617 0.4824 1.7509 31.5 31.5 19.6 37.9 26.3 26.3 16.3 31.6 3 1.7509 37.9 31.6 E:\FR\FM\30APP2.SGM 30APP2 23898 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 471 472 473 474 471 471 471 474 ........... ........... ........... ........... ........... ........... ........... ........... 475 ........... 474 ........... 476 ........... 474 ........... 477 ........... 477 ........... 478 ........... 477 ........... 479 ........... 477 ........... 480 481 482 483 480 480 480 483 ........... ........... ........... ........... ........... ........... ........... ........... 484 ........... 483 ........... 485 486 487 488 489 490 485 485 485 488 488 490 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 490 ........... 492 ........... 492 ........... 493 ........... 492 ........... 494 ........... 492 ........... 495 ........... 495 ........... 496 ........... 495 ........... 497 ........... 495 ........... 498 ........... 498 ........... 499 ........... 498 ........... 500 501 502 503 504 505 506 507 508 509 510 jlentini on PROD1PC65 with PROPOSALS2 491 ........... 500 500 500 503 503 503 506 507 507 509 510 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 511 ........... 510 ........... 512 ........... 510 ........... 513 ........... 513 ........... 514 ........... 513 ........... VerDate Aug<31>2005 FY 2007 LTCH cases Proposed MS–LTC–DRG title Cervical spinal fusion w MMCC .......................................... Cervical spinal fusion w MCC ............................................. Cervical spinal fusion w/o CC/MMCC ................................. Amputation for musculoskeletal sys & conn tissue dis w MMCC. Amputation for musculoskeletal sys & conn tissue dis w MCC. Amputation for musculoskeletal sys & conn tissue dis w/o CC/MMCC. Biopsies of musculoskeletal system & connective tissue w MMCC. Biopsies of musculoskeletal system & connective tissue w MCC. Biopsies of musculoskeletal system & connective tissue w/ o CC/MMCC. Hip & femur procedures except major joint w MMCC ........ Hip & femur procedures except major joint w MCC ........... Hip & femur procedures except major joint w/o CC/MMCC Major joint & limb reattachment proc of upper extremity w CC/MMCC. Major joint & limb reattachment proc of upper extremity w/ o CC/MMCC. Knee procedures w pdx of infection w MMCC .................... Knee procedures w pdx of infection w MCC ....................... Knee procedures w pdx of infection w/o CC/MCC* ............ Knee procedures w/o pdx of infection w CC/MMCC .......... Knee procedures w/o pdx of infection w/o CC/MMCC ....... Back & neck procedures except spinal fusion w CC/MCC or disc devices. Back & neck procedures except spinal fusion w/o CC/ MMCC. Lower extrem & humer proc except hip, foot, femur w MMCC. Lower extrem & humer proc except hip, foot, femur w MCC. Lower extrem & humer proc except hip, foot, femur w/o CC/MMCC. Local excision & removal int fix devices exc hip & femur w MMCC. Local excision & removal int fix devices exc hip & femur w CC*. Local excision & removal int fix devices exc hip & femur w/o CC/MCC*. Local excision & removal int fix devices of hip & femur w CC/MCC. Local excision & removal int fix devices of hip & femur w/o CC/MCC. Soft tissue procedures w MMCC ......................................... Soft tissue procedures w MCC ............................................ Soft tissue procedures w/o CC/MMCC ............................... Foot procedures w MMCC .................................................. Foot procedures w MCC ..................................................... Foot procedures w/o CC/MMCC ......................................... Major thumb or joint procedures ......................................... Major shoulder or elbow joint procedures w CC/MMCC ..... Major shoulder or elbow joint procedures w/o CC/MMCC .. Arthroscopy .......................................................................... Shoulder, elbow or forearm proc, exc major joint proc w MCC*. Shoulder, elbow or forearm proc, exc major joint proc w CC*. Shoulder, elbow or forearm proc, exc major joint proc w/o CC/MCC. Hand or wrist proc, except major thumb or joint proc w CC/MMCC. Hand or wrist proc, except major thumb or joint proc w/o CC/MCC*. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00372 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 2 1 0 91 0.8596 0.8596 0.8596 1.5642 25.2 25.2 25.2 38.4 21.0 21.0 21.0 32.0 67 1.1116 33.9 28.3 4 0.8596 25.2 21.0 22 1.7509 37.9 31.6 12 1.2617 31.5 26.3 0 1.2617 31.5 26.3 21 11 2 0 1.7509 1.2617 0.8596 1.7509 37.9 31.5 25.2 37.9 31.6 26.3 21.0 31.6 0 0.8596 25.2 21.0 10 10 2 1 1 8 1.2617 1.2617 1.2617 1.7509 0.6327 1.2617 31.5 31.5 31.5 37.9 21.6 31.5 26.3 26.3 26.3 31.6 18.0 26.3 0 1.2617 31.5 26.3 10 1.2617 31.5 26.3 10 1.2617 31.5 26.3 1 0.8596 25.2 21.0 42 1.2616 36.9 30.8 20 1.2616 36.9 30.8 5 1.2616 36.9 30.8 9 1.7509 37.9 31.6 0 1.7509 37.9 31.6 68 28 4 15 22 3 0 1 0 0 1 1.3427 1.0746 0.8596 1.2617 0.8596 0.8596 1.2617 1.7509 1.7509 0.8596 0.8596 36.7 33.3 25.2 31.5 25.2 25.2 31.5 37.9 37.9 25.2 25.2 30.6 27.8 21.0 26.3 21.0 21.0 26.3 31.6 31.6 21.0 21.0 2 0.8596 25.2 21.0 0 0.8596 25.2 21.0 6 1.2617 31.5 26.3 1 1.2617 31.5 26.3 E:\FR\FM\30APP2.SGM 30APP2 23899 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 515 ........... 516 ........... 517 ........... 515 ........... 515 ........... 515 ........... 533 534 535 536 537 533 533 535 535 537 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 538 ........... 537 ........... 539 540 541 542 539 539 539 542 ........... ........... ........... ........... ........... ........... ........... ........... 543 ........... 542 ........... 544 ........... 542 ........... 545 546 547 548 549 550 551 552 553 554 555 545 545 545 548 548 548 551 551 553 553 555 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 555 ........... 557 ........... 558 ........... 559 ........... 557 ........... 557 ........... 559 ........... 560 ........... 559 ........... 561 ........... 559 ........... 562 ........... 562 ........... 563 ........... 562 ........... 564 ........... 564 ........... 565 ........... 564 ........... 566 ........... 564 ........... 573 ........... 574 ........... 575 ........... 573 ........... 573 ........... 573 ........... 576 ........... jlentini on PROD1PC65 with PROPOSALS2 556 ........... 576 ........... 577 ........... 578 ........... 576 ........... 576 ........... 579 580 581 582 583 579 579 579 582 582 ........... ........... ........... ........... ........... VerDate Aug<31>2005 ........... ........... ........... ........... ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Other musculoskelet sys & conn tiss O.R. proc w MMCC Other musculoskelet sys & conn tiss O.R. proc w MCC .... Other musculoskelet sys & conn tiss O.R. proc w/o CC/ MMCC. Fractures of femur w MMCC ............................................... Fractures of femur w/o MMCC ............................................ Fractures of hip & pelvis w MMCC ..................................... Fractures of hip & pelvis w/o MMCC .................................. Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MMCC. Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC. Osteomyelitis w MMCC ....................................................... Osteomyelitis w MCC .......................................................... Osteomyelitis w/o CC/MMCC .............................................. Pathological fractures & musculoskelet & conn tiss malig w MMCC. Pathological fractures & musculoskelet & conn tiss malig w MCC. Pathological fractures & musculoskelet & conn tiss malig w/o CC/MMCC. Connective tissue disorders w MMCC ................................ Connective tissue disorders w MCC ................................... Connective tissue disorders w/o CC/MMCC ....................... Septic arthritis w MMCC ...................................................... Septic arthritis w MCC ......................................................... Septic arthritis w/o CC/MMCC ............................................. Medical back problems w MMCC ........................................ Medical back problems w/o MMCC ..................................... Bone diseases & arthropathies w MMCC ........................... Bone diseases & arthropathies w/o MMCC ........................ Signs & symptoms of musculoskeletal system & conn tissue w MMCC. Signs & symptoms of musculoskeletal system & conn tissue w/o MCC. Tendonitis, myositis & bursitis w MMCC ............................. Tendonitis, myositis & bursitis w/o MMCC .......................... Aftercare, musculoskeletal system & connective tissue w MMCC. Aftercare, musculoskeletal system & connective tissue w MCC. Aftercare, musculoskeletal system & connective tissue w/o CC/MMCC. Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MMCC. Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MMCC. Other musculoskeletal sys & connective tissue diagnoses w MMCC. Other musculoskeletal sys & connective tissue diagnoses w MCC. Other musculoskeletal sys & connective tissue diagnoses w/o CC/MMCC. Skin graft &/or debrid for skn ulcer or cellulitis w MMCC ... Skin graft &/or debrid for skn ulcer or cellulitis w MCC ...... Skin graft &/or debrid for skn ulcer or cellulitis w/o CC/ MMCC. Skin graft &/or debrid exc for skin ulcer or cellulitis w MMCC. Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MMCC. Other skin, subcut tiss & breast proc w MMCC .................. Other skin, subcut tiss & breast proc w MCC ..................... Other skin, subcut tiss & breast proc w/o CC/MMCC ......... Mastectomy for malignancy w CC/MMCC .......................... Mastectomy for malignancy w/o CC/MMCC ....................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00373 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 60 27 0 1.3728 0.9133 0.9133 31.5 28.0 28.0 26.3 23.3 23.3 3 6 16 25 1 0.6327 0.6327 0.8596 0.6130 0.4824 21.6 21.6 25.2 26.9 19.6 18.0 18.0 21.0 22.4 16.3 0 0.4824 19.6 16.3 1,317 848 227 23 0.9928 0.7632 0.6901 0.8596 30.2 27.6 27.1 25.2 25.2 23.0 22.6 21.0 42 0.5682 20.5 17.1 17 0.4824 19.6 16.3 50 38 5 172 200 73 83 156 15 59 3 0.9093 0.8478 0.4824 0.8843 0.7080 0.6067 0.8867 0.6146 0.6327 0.5022 0.8596 23.5 25.5 19.6 26.1 26.9 24.2 26.5 24.2 21.6 21.3 25.2 19.6 21.3 16.3 21.8 22.4 20.2 22.1 20.2 18.0 17.8 21.0 8 0.4824 19.6 16.3 84 134 1,368 0.8284 0.6519 0.8146 24.6 23.0 26.1 20.5 19.2 21.8 1,613 0.6469 24.7 20.6 730 0.5579 22.8 19.0 5 0.8596 25.2 21.0 9 0.4824 19.6 16.3 307 0.8803 24.2 20.2 199 0.6473 22.7 18.9 60 0.6236 22.5 18.8 1,814 1,761 200 1.3944 1.0779 0.9033 38.2 36.0 30.1 31.8 30.0 25.1 27 1.7840 37.6 31.3 28 11 0.8093 0.6327 27.3 21.6 22.8 18.0 476 398 34 1 0 1.3648 1.0585 0.8032 1.7509 1.7509 36.5 33.5 30.1 37.9 37.9 30.4 27.9 25.1 31.6 31.6 E:\FR\FM\30APP2.SGM 30APP2 23900 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 584 ........... 584 ........... 585 ........... 584 ........... 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 614 615 616 592 592 592 595 595 597 597 597 600 600 602 602 604 604 606 606 614 614 616 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 617 ........... 616 ........... 618 ........... 616 ........... 619 620 621 622 619 619 619 622 ........... ........... ........... ........... ........... ........... ........... ........... 622 ........... 624 ........... 622 ........... 625 ........... 626 ........... 627 ........... jlentini on PROD1PC65 with PROPOSALS2 623 ........... 625 ........... 625 ........... 625 ........... 628 629 630 637 638 639 640 641 642 643 644 645 652 653 654 655 656 657 658 659 660 661 628 628 628 637 637 637 640 640 642 643 643 643 652 653 653 653 656 656 656 659 659 659 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 662 ........... 663 ........... 664 ........... VerDate Aug<31>2005 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 662 ........... 662 ........... 662 ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Breast biopsy, local excision & other breast procedures w CC/MMCC. Breast biopsy, local excision & other breast procedures w/ o CC/MMCC. Skin ulcers w MMCC ........................................................... Skin ulcers w MCC .............................................................. Skin ulcers w/o CC/MMCC .................................................. Major skin disorders w MMCC ............................................ Major skin disorders w/o MMCC ......................................... Malignant breast disorders w MMCC .................................. Malignant breast disorders w MCC ..................................... Malignant breast disorders w/o CC/MCC* .......................... Non-malignant breast disorders w CC/MMCC .................... Non-malignant breast disorders w/o CC/MMCC ................. Cellulitis w MMCC ............................................................... Cellulitis w/o MMCC ............................................................ Trauma to the skin, subcut tiss & breast w MMCC ............ Trauma to the skin, subcut tiss & breast w/o MMCC ......... Minor skin disorders w MMCC ............................................ Minor skin disorders w/o MMCC ......................................... Adrenal & pituitary procedures w CC/MMCC ...................... Adrenal & pituitary procedures w/o CC/MMCC ................... Amputat of lower limb for endocrine, nutrit,& metabol dis w MMCC. Amputat of lower limb for endocrine, nutrit,& metabol dis w MCC. Amputat of lower limb for endocrine, nutrit,& metabol dis w/o CC/MMCC. O.R. procedures for obesity w MMCC ................................ O.R. procedures for obesity w MCC ................................... O.R. procedures for obesity w/o CC/MMCC ....................... Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC. Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC. Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MMCC. Thyroid, parathyroid & thyroglossal procedures w MMCC Thyroid, parathyroid & thyroglossal procedures w MCC .... Thyroid, parathyroid & thyroglossal procedures w/o CC/ MMCC. Other endocrine, nutrit & metab O.R. proc w MMCC ......... Other endocrine, nutrit & metab O.R. proc w MCC ............ Other endocrine, nutrit & metab O.R. proc w/o CC/MMCC Diabetes w MMCC ............................................................... Diabetes w MCC .................................................................. Diabetes w/o CC/MMCC ..................................................... Nutritional & misc metabolic disorders w MMCC ................ Nutritional & misc metabolic disorders w/o MMCC ............. Inborn errors of metabolism ................................................ Endocrine disorders w MMCC ............................................. Endocrine disorders w MCC ................................................ Endocrine disorders w/o CC/MCC ...................................... Kidney transplant ................................................................. Major bladder procedures w MCC ...................................... Major bladder procedures w MCC ...................................... Major bladder procedures w/o CC/MMCC .......................... Kidney & ureter procedures for neoplasm w MMCC .......... Kidney & ureter procedures forneoplasm w MCC .............. Kidney & ureter procedures for neoplasm w/o CC/MMCC Kidney & ureter procedures for non-neoplasm w MMCC ... Kidney & ureter procedures for non-neoplasm w MCC ...... Kidney & ureter procedures for non-neoplasm w/o CC/ MMCC. Minor bladder procedures w MMCC ................................... Minor bladder procedures w MCC ...................................... Minor bladder procedures w/o CC/MCC ............................. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00374 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 2 0.6327 21.6 18.0 0 0.6327 21.6 18.0 3,044 2,805 435 28 39 7 7 1 17 6 829 1,634 29 53 63 93 0 0 70 0.9490 0.7171 0.6109 0.8138 0.6547 1.2617 0.8596 0.8596 0.8596 0.4824 0.6963 0.5333 0.8236 0.6053 0.8273 0.5599 1.0449 0.8596 1.4804 27.0 26.1 24.8 25.3 22.4 31.5 25.2 25.2 25.2 19.6 21.7 19.9 24.4 23.8 24.5 20.7 32.5 25.2 38.4 22.5 21.8 20.7 21.1 18.7 26.3 21.0 21.0 21.0 16.3 18.1 16.6 20.3 19.8 20.4 17.3 27.1 21.0 32.0 132 1.1478 33.1 27.6 2 0.4824 19.6 16.3 1 0 0 171 1.7509 1.7509 1.7509 1.2978 37.9 37.9 37.9 35.7 31.6 31.6 31.6 29.8 357 1.0065 30.9 25.8 21 0.6327 21.6 18.0 1 1 0 1.2617 0.8596 0.8596 31.5 25.2 25.2 26.3 21.0 21.0 48 110 2 421 1,052 71 638 548 5 30 28 1 0 2 0 0 1 0 0 6 6 1 1.3769 1.0449 0.8596 0.9264 0.6950 0.5777 0.8424 0.6217 0.4824 0.6833 0.5393 0.4824 0.0000 1.7509 1.7509 1.7509 1.7509 1.7509 1.7509 1.2617 1.2617 0.6327 32.3 32.5 25.2 26.6 24.5 20.8 23.1 21.5 19.6 24.0 21.1 19.6 0.0 37.9 37.9 37.9 37.9 37.9 37.9 31.5 31.5 21.6 26.9 27.1 21.0 22.2 20.4 17.3 19.3 17.9 16.3 20.0 17.6 16.3 0.0 31.6 31.6 31.6 31.6 31.6 31.6 26.3 26.3 18.0 2 2 0 1.7509 0.6327 0.6327 37.9 21.6 21.6 31.6 18.0 18.0 E:\FR\FM\30APP2.SGM 30APP2 23901 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 665 666 667 668 669 670 671 672 673 674 675 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 707 708 709 710 711 712 713 714 715 665 665 665 668 668 668 671 671 673 673 673 682 682 682 685 686 686 686 689 689 691 691 693 693 695 695 697 698 698 698 707 707 709 709 711 711 713 713 715 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 716 ........... 715 ........... 717 ........... 717 ........... 718 ........... 717 ........... 722 723 724 725 726 727 728 729 730 734 722 722 722 725 725 727 727 729 729 734 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... jlentini on PROD1PC65 with PROPOSALS2 735 ........... 734 ........... 736 ........... 736 ........... 737 ........... 736 ........... 738 ........... 736 ........... 739 ........... 739 ........... VerDate Aug<31>2005 FY 2007 LTCH cases Proposed MS–LTC–DRG title Prostatectomy w MCC* ....................................................... Prostatectomy w CC* .......................................................... Prostatectomy w/o CC/MMCC ............................................. Transurethral procedures w MMCC .................................... Transurethral procedures w MCC ....................................... Transurethral procedures w/o CC/MMCC ........................... Urethral procedures w CC/MMCC ....................................... Urethral procedures w/o CC/MMCC .................................... Other kidney & urinary tract procedures w MMCC ............. Other kidney & urinary tract procedures w MCC ................ Other kidney & urinary tract procedures w/o CC/MMCC .... Renal failure w MMCC ........................................................ Renal failure w MCC ........................................................... Renal failure w/o CC/MMCC ............................................... Admit for renal dialysis ........................................................ Kidney & urinary tract neoplasms w MMCC ....................... Kidney & urinary tract neoplasms w MCC .......................... Kidney & urinary tract neoplasms w/o CC/MMCC .............. Kidney & urinary tract infections w MMCC ......................... Kidney & urinary tract infections w/o MMCC ...................... Urinary stones w esw lithotripsy w CC/MMCC ................... Urinary stones w esw lithotripsy w/o CC/MMCC ................ Urinary stones w/o esw lithotripsy w MMCC ....................... Urinary stones w/ot esw lithotripsy w/o MMCC ................... Kidney & urinary tract signs & symptoms w MMCC ........... Kidney & urinary tract signs & symptoms w/o MMCC ........ Urethral stricture .................................................................. Other kidney & urinary tract diagnoses w MMCC ............... Other kidney & urinary tract diagnoses w MCC .................. Other kidney & urinary tract diagnoses w/o CC/MMCC ..... Major male pelvic procedures w CC/MMCC ....................... Major male pelvic procedures w/o CC/MMCC .................... Penis procedures w CC/MMCC .......................................... Penis procedures w/o CC/MMCC ....................................... Testes procedures w CC/MMCC ......................................... Testes procedures w/o CC/MMCC ...................................... Transurethral prostatectomy w CC/MMCC ......................... Transurethral prostatectomy w/o CC/MMCC ...................... Other male reproductive system O.R. proc for malignancy w CC/MMCC. Other male reproductive system O.R. proc for malignancy w/o CC/MMCC. Other male reproductive system O.R. proc exc malignancy w CC/MMCC. Other male reproductive system O.R. proc exc malignancy w/o CC/MMCC. Malignancy, male reproductive system w MMCC ............... Malignancy, male reproductive system w MCC .................. Malignancy, male reproductive system w/o CC/MMCC ...... Benign prostatic hypertrophy w MMCC ............................... Benign prostatic hypertrophy w/o MMCC ............................ Inflammation of the male reproductive system w MMCC ... Inflammation of the male reproductive system w/o MMCC Other male reproductive system diagnoses w CC/MMCC Other male reproductive system diagnoses w/o CC/MMCC Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MMCC. Pelvic evisceration, rad hysterectomy & rad vulvectomy w/ o CC/MMCC. Uterine & adnexa proc for ovarian or adnexal malignancy w MMCC. Uterine & adnexa proc for ovarian or adnexal malignancy w MCC. Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MMCC. Uterine,adnexa proc for non-ovarian/adnexal malig w MMCC. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00375 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 2 1 0 4 3 0 1 0 227 67 0 1,458 713 91 32 15 18 3 868 782 0 0 3 5 4 7 0 285 142 33 0 0 15 0 6 0 2 0 0 0.8596 0.8596 0.8596 0.8596 0.6327 0.6327 0.6327 0.6327 1.4418 1.1430 1.1430 0.8945 0.7478 0.6647 0.8341 0.8596 0.8596 0.6327 0.6712 0.5266 0.4824 0.4824 0.8596 0.4824 1.2617 0.6327 0.6327 0.9527 0.6606 0.5695 1.2617 0.6327 1.7509 1.7509 1.2617 1.2617 1.7509 1.7509 1.2617 25.2 25.2 25.2 25.2 21.6 21.6 21.6 21.6 33.8 29.1 29.1 23.8 22.8 20.6 25.1 25.2 25.2 21.6 22.6 20.5 19.6 19.6 25.2 19.6 31.5 21.6 21.6 23.5 22.0 21.1 31.5 21.6 37.9 37.9 31.5 31.5 37.9 37.9 31.5 21.0 21.0 21.0 21.0 18.0 18.0 18.0 18.0 28.2 24.3 24.3 19.8 19.0 17.2 20.9 21.0 21.0 18.0 18.8 17.1 16.3 16.3 21.0 16.3 26.3 18.0 18.0 19.6 18.3 17.6 26.3 18.0 31.6 31.6 26.3 26.3 31.6 31.6 26.3 0 1.2617 31.5 26.3 11 1.2617 31.5 26.3 0 1.2617 31.5 26.3 15 15 0 1 2 27 51 49 8 0 0.6327 0.4824 0.4824 0.8596 0.4824 0.7907 0.5259 0.8878 0.4824 1.2617 21.6 19.6 19.6 25.2 19.6 23.1 20.4 26.2 19.6 31.5 18.0 16.3 16.3 21.0 16.3 19.3 17.0 21.8 16.3 26.3 0 1.2617 31.5 26.3 0 1.2617 31.5 26.3 0 0.8596 25.2 21.0 0 0.4824 19.6 16.3 1 1.2617 31.5 26.3 E:\FR\FM\30APP2.SGM 30APP2 23902 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 740 ........... 739 ........... 741 ........... 739 ........... 742 ........... 743 ........... 744 ........... 742 ........... 742 ........... 744 ........... 745 ........... 744 ........... 746 747 748 749 746 746 748 749 ........... ........... ........... ........... ........... ........... ........... ........... 750 ........... 749 ........... 754 755 756 757 758 759 760 754 754 754 757 757 757 760 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 761 ........... 760 ........... 765 766 767 768 769 770 774 775 776 777 778 779 780 781 782 789 790 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 765 765 767 768 769 770 774 775 776 777 778 779 780 781 782 789 790 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 791 792 793 794 795 799 800 801 802 ........... ........... ........... ........... ........... ........... ........... ........... ........... 791 792 793 794 795 799 799 799 802 ........... ........... ........... ........... ........... ........... ........... ........... ........... 802 ........... 804 ........... jlentini on PROD1PC65 with PROPOSALS2 803 ........... 802 ........... 808 ........... 808 ........... 809 ........... 808 ........... 810 ........... 808 ........... 811 ........... 812 ........... 811 ........... 811 ........... VerDate Aug<31>2005 FY 2007 LTCH cases Proposed MS–LTC–DRG title Uterine,adnexa proc for non-ovarian/adnexal malig w MCC. Uterine,adnexa proc for non-ovarian/adnexal malig w/o CC/MMCC. Uterine & adnexa proc for non-malignancy w CC/MMCC .. Uterine & adnexa proc for non-malignancy w/o CC/MMCC D&C, conization, laparascopy & tubal interruption w CC/ MMCC. D&C, conization, laparascopy & tubal interruption w/o CC/ MMCC. Vagina, cervix & vulva procedures w CC/MMCC ............... Vagina, cervix & vulva procedures w/o CC/MMCC ............ Female reproductive system reconstructive procedures ..... Other female reproductive system O.R. procedures w CC/ MMCC. Other female reproductive system O.R. procedures w/o CC/MMCC. Malignancy, female reproductive system w MMCC ............ Malignancy, female reproductive system w MCC ............... Malignancy, female reproductive system w/o CC/MMCC ... Infections, female reproductive system w MCC* ................ Infections, female reproductive system w CC* ................... Infections, female reproductive system w/o CC/MCC* ....... Menstrual & other female reproductive system disorders w CC/MMCC. Menstrual & other female reproductive system disorders w/o CC/MMCC. Cesarean section w CC/MMCC .......................................... Cesarean section w/o CC/MMCC ....................................... Vaginal delivery w sterilization &/or D&C ............................ Vaginal delivery w O.R. proc except steril &/or D&C .......... Postpartum & post abortion diagnoses w O.R. procedure Abortion w D&C, aspiration curettage or hysterotomy ........ Vaginal delivery w complicating diagnoses ......................... Vaginal delivery w/o complicating diagnoses ...................... Postpartum & post abortion diagnoses w/o O.R. procedure Ectopic pregnancy ............................................................... Threatened abortion ............................................................ Abortion w/o D&C ................................................................ False labor ........................................................................... Other antepartum diagnoses w medical complications ....... Other antepartum diagnoses w/o medical complications .... Neonates, died or transferred to another acute care facility Extreme immaturity or respiratory distress syndrome, neonate. Prematurity w major problems ............................................. Prematurity w/o major problems .......................................... Full term neonate w major problems ................................... Neonate w other significant problems ................................. Normal newborn .................................................................. Splenectomy w MCC ........................................................... Splenectomy w CC .............................................................. Splenectomy w/o CC/MMCC ............................................... Other O.R. proc of the blood & blood forming organs w MMCC. Other O.R. proc of the blood & blood forming organs w MCC. Other O.R. proc of the blood & blood forming organs w/o CC/MMCC. Major hematol/immun diag exc sickle cell crisis & coagul w MMCC. Major hematol/immun diag exc sickle cell crisis & coagul w MCC. Major hematol/immun diag exc sickle cell crisis & coagul w/o CC/MMCC. Red blood cell disorders w MMCC ...................................... Red blood cell disorders w/o MMCC ................................... 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00376 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 0 1.2617 31.5 26.3 0 1.2617 31.5 26.3 0 0 1 0.8596 0.4824 0.8596 25.2 19.6 25.2 21.0 16.3 21.0 0 0.8596 25.2 21.0 1 0 0 4 1.7509 1.7509 1.2617 1.2617 37.9 37.9 31.5 31.5 31.6 31.6 26.3 26.3 0 1.2617 31.5 26.3 22 21 1 52 27 5 0 1.2617 0.8596 0.4824 0.7580 0.7580 0.7580 0.8596 31.5 25.2 19.6 23.7 23.7 23.7 25.2 26.3 21.0 16.3 19.8 19.8 19.8 21.0 0 0.8596 25.2 21.0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0.8596 0.8596 0.8596 0.8596 0.8596 0.8596 0.8596 0.8596 0.8596 0.8596 0.7580 0.7580 0.7580 0.4824 0.4824 0.4824 0.4824 25.2 25.2 25.2 25.2 25.2 25.2 25.2 25.2 25.2 25.2 23.7 23.7 23.7 19.6 19.6 19.6 19.6 21.0 21.0 21.0 21.0 21.0 21.0 21.0 21.0 21.0 21.0 19.8 19.8 19.8 16.3 16.3 16.3 16.3 0 0 0 0 0 0 1 0 4 0.4824 0.4824 0.4824 0.4824 0.4824 0.8596 0.8596 0.8596 1.2617 19.6 19.6 19.6 19.6 19.6 25.2 25.2 25.2 31.5 16.3 16.3 16.3 16.3 16.3 21.0 21.0 21.0 26.3 0 1.2617 31.5 26.3 0 1.2617 31.5 26.3 17 1.2617 31.5 26.3 11 0.8596 25.2 21.0 1 0.4824 19.6 16.3 43 58 0.7905 0.5349 22.8 20.4 19.0 17.0 E:\FR\FM\30APP2.SGM 30APP2 23903 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 813 814 815 816 820 821 822 813 814 814 814 820 820 820 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 823 ........... 823 ........... 824 ........... 823 ........... 825 ........... 823 ........... 826 ........... 826 ........... 827 ........... 826 ........... 828 ........... 826 ........... 829 ........... 829 ........... 830 ........... 829 ........... 834 835 836 837 834 834 834 837 ........... ........... ........... ........... ........... ........... ........... ........... 838 ........... 837 ........... 839 ........... 837 ........... 840 841 842 843 844 845 840 840 840 843 843 843 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 846 ........... 847 ........... 846 ........... 848 ........... 846 ........... 849 ........... 853 ........... 849 ........... 853 ........... 854 ........... 855 ........... 853 ........... 853 ........... 856 ........... 856 ........... 857 ........... 856 ........... 858 ........... jlentini on PROD1PC65 with PROPOSALS2 846 ........... 856 ........... 862 863 864 865 866 867 868 869 862 862 864 865 865 867 867 867 ........... ........... ........... ........... ........... ........... ........... ........... VerDate Aug<31>2005 ........... ........... ........... ........... ........... ........... ........... ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Coagulation disorders .......................................................... Reticuloendothelial & immunity disorders w MMCC ........... Reticuloendothelial & immunity disorders w MCC .............. Reticuloendothelial & immunity disorders w/o CC/MMCC .. Lymphoma & leukemia w major O.R. procedure w MMCC Lymphoma & leukemia w major O.R. procedure w MCC ... Lymphoma & leukemia w major O.R. procedure w/o CC/ MMCC. Lymphoma & non-acute leukemia w other O.R. proc w MMCC. Lymphoma & non-acute leukemia w other O.R. proc w MCC. Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MMCC. Myeloprolif disord or poorly diff neopl w maj O.R. proc w MMCC. Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC. Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MMCC. Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MMCC. Myeloprolif disord or poorly diff neopl w other O.R. proc w/ o CC/MMCC. Acute leukemia w/o major O.R. procedure w MMCC ......... Acute leukemia w/o major O.R. procedure w CC* .............. Acute leukemia w/o major O.R. procedure w/o CC/MCC* Chemo w acute leukemia as sdx or w high dose chemo agent w MMCC. Chemo w acute leukemia as sdx or w high dose chemo agent w MCC. Chemo w acute leukemia as sdx or w high dose chemo agent w/o CC/MMCC. Lymphoma & non-acute leukemia w MMCC ....................... Lymphoma & non-acute leukemia w MCC .......................... Lymphoma & non-acute leukemia w/o CC/MMCC ............. Other myeloprolif dis or poorly diff neopl diag w MMCC .... Other myeloprolif dis or poorly diff neopl diag w MCC ....... Other myeloprolif dis or poorly diff neopl diag w/o CC/ MMCC. Chemotherapy w/o acute leukemia as secondary diagnosis w MMCC. Chemotherapy w/o acute leukemia as secondary diagnosis w MCC. Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MMCC. Radiotherapy ........................................................................ Infectious & parasitic diseases w O.R. procedure w MMCC. Infectious & parasitic diseases w O.R. procedure w MCC Infectious & parasitic diseases w O.R. procedure w/o CC/ MCC*. Postoperative or post-traumatic infections w O.R. proc w MMCC. Postoperative or post-traumatic infections w O.R. proc w MCC. Postoperative or post-traumatic infections w O.R. proc w/o CC/MMCC. Postoperative & post-traumatic infections w MMCC ........... Postoperative & post-traumatic infections w/o MMCC ........ Fever of unknown origin ...................................................... Viral illness w MMCC .......................................................... Viral illness w/o MMCC ....................................................... Other infectious & parasitic diseases diagnoses w MMCC Other infectious & parasitic diseases diagnoses w MCC ... Other infectious & parasitic diseases diagnoses w/o CC/ MMCC. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00377 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 55 16 7 1 0 0 0 0.8402 0.8596 0.6327 0.4824 1.2617 0.8596 0.8596 23.2 25.2 21.6 19.6 31.5 25.2 25.2 19.3 21.0 18.0 16.3 26.3 21.0 21.0 11 1.2617 31.5 26.3 4 0.8596 25.2 21.0 0 0.8596 25.2 21.0 1 1.7509 37.9 31.6 1 1.7509 37.9 31.6 0 1.7509 37.9 31.6 7 1.7509 37.9 31.6 0 1.7509 37.9 31.6 14 14 2 0 0.8596 0.8596 0.8596 1.7509 25.2 25.2 25.2 37.9 21.0 21.0 21.0 31.6 0 1.7509 37.9 31.6 0 1.7509 37.9 31.6 133 63 7 20 11 3 0.9227 0.7247 0.6327 0.8596 0.6327 0.6327 23.1 19.7 21.6 25.2 21.6 21.6 19.3 16.4 18.0 21.0 18.0 18.0 49 1.4778 30.0 25.0 43 1.0877 23.8 19.8 0 1.0877 23.8 19.8 141 837 0.7949 1.7864 21.6 37.3 18.0 31.1 104 5 1.1703 1.1703 33.0 33.0 27.5 27.5 301 1.5591 36.7 30.6 213 1.0707 32.6 27.2 32 0.8943 26.8 22.3 1,163 1,231 11 36 14 357 86 7 0.9629 0.7018 0.4824 0.7998 0.6327 1.1296 0.7458 0.4824 25.3 23.8 19.6 22.2 21.6 23.4 22.6 19.6 21.1 19.8 16.3 18.5 18.0 19.5 18.8 16.3 E:\FR\FM\30APP2.SGM 30APP2 23904 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 870 871 872 876 880 881 882 883 884 885 886 887 894 895 870 871 871 876 880 881 882 883 884 885 886 887 894 895 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 896 ........... 896 ........... 897 ........... 896 ........... 901 902 903 904 905 906 907 908 909 913 914 915 916 917 918 919 920 921 922 923 927 901 901 901 904 904 906 907 907 907 913 913 915 915 917 917 919 919 919 922 922 927 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 928 ........... 928 ........... 933 ........... 934 ........... 935 ........... 939 ........... 934 ........... 935 ........... 939 ........... 940 ........... 939 ........... 941 ........... jlentini on PROD1PC65 with PROPOSALS2 928 ........... 929 ........... 933 ........... 939 ........... 945 946 947 948 949 950 951 955 956 945 945 947 947 949 949 951 955 956 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 957 ........... 957 ........... 958 ........... 957 ........... VerDate Aug<31>2005 FY 2007 LTCH cases Proposed MS–LTC–DRG title Septicemia w MV 96+ hours ............................................... Septicemia w/o MV 96+ hours w MMCC ............................ Septicemia w/o MV 96+ hours w/o MMCC ......................... O.R. procedure w principal diagnoses of mental illness ..... Acute adjustment reaction & psychosocial dysfunction ...... Depressive neuroses ........................................................... Neuroses except depressive ............................................... Disorders of personality & impulse control .......................... Organic disturbances & mental retardation ......................... Psychoses ............................................................................ Behavioral & developmental disorders ................................ Other mental disorder diagnoses ........................................ Alcohol/drug abuse or dependence, left ama ..................... Alcohol/drug abuse or dependence w rehabilitation therapy. Alcohol/drug abuse or dependence w/o rehabilitation therapy w MMCC. Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MMCC. Wound debridements for injuries w MMCC ........................ Wound debridements for injuries w MCC ........................... Wound debridements for injuries w/o CC/MMCC ............... Skin grafts for injuries w CC/MMCC ................................... Skin grafts for injuries w/o CC/MMCC ................................ Hand procedures for injuries ............................................... Other O.R. procedures for injuries w MMCC ...................... Other O.R. procedures for injuries w MCC ......................... Other O.R. procedures for injuries w/o CC/MCC* .............. Traumatic injury w MMCC ................................................... Traumatic injury w/o MMCC ................................................ Allergic reactions w MMCC ................................................. Allergic reactions w/o MMCC .............................................. Poisoning & toxic effects of drugs w MMCC ....................... Poisoning & toxic effects of drugs w/o MMCC .................... Complications of treatment w MMCC .................................. Complications of treatment w MCC ..................................... Complications of treatment w/o CC/MMCC ........................ Other injury, poisoning & toxic effect diag w MMCC .......... Other injury, poisoning & toxic effect diag w/o MMCC ....... Extensive burns or full thickness burns w MV 96+ hrs w skin graft. Full thickness burn w skin graft or inhal inj w CC/MMCC .. Full thickness burn w skin graft or inhal inj w/o CC/MMCC Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft. Full thickness burn w/o skin grft or inhal inj ........................ Non-extensive burns ............................................................ O.R. proc w diagnoses of other contact w health services w MCC. O.R. proc w diagnoses of other contact w health services w MCC. O.R. proc w diagnoses of other contact w health services w/o CC/MMCC. Rehabilitation w CC/MMCC ................................................. Rehabilitation w/o CC/MMCC .............................................. Signs & symptoms w MMCC ............................................... Signs & symptoms w/o MMCC ............................................ Aftercare w CC/MMCC ........................................................ Aftercare w/o CC/MMCC ..................................................... Other factors influencing health status ................................ Craniotomy for multiple significant trauma .......................... Limb reattachment, hip & femur proc for multiple significant trauma. Other O.R. procedures for multiple significant trauma w MMCC. Other O.R. procedures for multiple significant trauma w MCC. 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00378 Fmt 4701 Sfmt 4702 Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 894 4,507 1,608 12 11 14 16 12 146 1,218 18 0 0 2 2.2127 0.8713 0.6584 0.6327 0.4824 0.6327 0.4824 0.8596 0.5159 0.4206 0.4824 0.6327 0.6327 0.4824 33.0 23.4 21.8 21.6 19.6 21.6 19.6 25.2 25.4 23.9 19.6 21.6 21.6 19.6 27.5 19.5 18.2 18.0 16.3 18.0 16.3 21.0 21.2 19.9 16.3 18.0 18.0 16.3 7 1.2617 31.5 26.3 17 0.4824 19.6 16.3 217 129 23 78 6 1 91 63 6 37 66 0 0 8 9 1,235 841 117 7 11 1 1.5251 1.0552 0.8596 1.3404 0.8596 1.7509 1.6273 1.1167 1.1167 0.7480 0.6073 0.4824 0.4824 0.4824 0.4824 1.0924 0.8582 0.6163 0.8596 0.6327 1.7509 35.9 30.1 25.2 35.6 25.2 37.9 37.5 34.0 34.0 24.8 21.8 19.6 19.6 19.6 19.6 26.9 26.0 20.1 25.2 21.6 37.9 29.9 25.1 21.0 29.7 21.0 31.6 31.3 28.3 28.3 20.7 18.2 16.3 16.3 16.3 16.3 22.4 21.7 16.8 21.0 18.0 31.6 9 2 10 1.2617 0.6327 1.2617 31.5 21.6 31.5 26.3 18.0 26.3 40 46 267 0.7755 0.7815 1.3463 24.2 24.5 34.1 20.2 20.4 28.4 135 0.9993 30.6 25.5 15 0.8596 25.2 21.0 2,220 428 57 69 3,802 546 28 0 0 0.6154 0.4311 0.6548 0.5737 0.7034 0.5002 1.2726 1.7509 0.8596 22.1 18.9 22.2 22.2 22.5 19.2 27.0 37.9 25.2 18.4 15.8 18.5 18.5 18.8 16.0 22.5 31.6 21.0 1 1.2617 31.5 26.3 1 0.4824 19.6 16.3 E:\FR\FM\30APP2.SGM 30APP2 23905 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE 11.—PROPOSED FY 2009 MS–LTC–DRGS, PROPOSED RELATIVE WEIGHTS, PROPOSED GEOMETRIC AVERAGE LENGTH OF STAY, AND PROPOSED SHORT-STAY OUTLIER THRESHOLD—Continued Proposed MS–LTC– DRG Proposed base MS– LTC–DRG 959 ........... 957 ........... 963 964 965 969 970 974 975 976 977 981 963 963 963 969 969 974 974 974 977 981 ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... ........... 982 ........... 981 ........... 983 ........... 981 ........... 984 ........... 984 ........... 985 ........... 984 ........... 986 ........... 984 ........... 987 ........... 987 ........... 988 ........... 987 ........... 989 ........... 987 ........... 998 ........... 999 ........... 998 ........... 999 ........... FY 2007 LTCH cases Proposed MS–LTC–DRG title Other O.R. procedures for multiple significant trauma w/o CC/MMCC. Other multiple significant trauma w MMCC ......................... Other multiple significant trauma w MCC ............................ Other multiple significant trauma w/o CC/MMCC ............... HIV w extensive O.R. procedure w MMCC ......................... HIV w extensive O.R. procedure w/o MCC* ....................... HIV w major related condition w MMCC ............................. HIV w major related condition w MCC ................................ HIV w major related condition w/o CC/MMCC .................... HIV w or w/o other related condition ................................... Extensive O.R. procedure unrelated to principal diagnosis w MMCC. Extensive O.R. procedure unrelated to principal diagnosis w MCC. Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MMCC. Prostatic O.R. procedure unrelated to principal diagnosis w MMCC. Prostatic O.R. procedure unrelated to principal diagnosis w MCC. Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MMCC. Non-extensive O.R. proc unrelated to principal diagnosis w MMCC. Non-extensive O.R. proc unrelated to principal diagnosis w MCC. Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MMCC. Ungroupable ........................................................................ Principal diagnosis invalid as discharge diagnosis ............. Proposed relative weight Proposed geometric average length of stay Proposed short-stay outlier (SSO) threshold 1 0 0.4824 19.6 16.3 15 5 3 13 3 196 85 16 45 1,143 0.8596 0.6327 0.4824 1.2617 1.2617 1.0056 0.6433 0.6327 0.6975 2.3516 25.2 21.6 19.6 31.5 31.5 21.9 18.3 21.6 19.0 43.1 21.0 18.0 16.3 26.3 26.3 18.3 15.3 18.0 15.8 35.9 290 1.4645 35.2 29.3 26 1.1662 31.9 26.6 16 1.2617 31.5 26.3 9 1.2617 31.5 26.3 0 1.2617 31.5 26.3 419 1.7561 36.4 30.3 218 1.1596 33.9 28.3 10 0.8596 25.2 21.0 0 0 0.0000 0.0000 0.0 0.0 0.0 0.0 1 The proposed SSO Threshold is calculated as 5⁄6th of the geometric average length of stay of the proposed MS–LTC–DRG (as specified at § 412.529 in conjunction with § 412.503). * In determining the proposed MS–LTC–DRG relative weights, these proposed MS–LTC–DRGs were adjusted for nonmonotonicity as discussed in section II.I.4. (step 6) of the preamble of this proposed rule. jlentini on PROD1PC65 with PROPOSALS2 Appendix A—Regulatory Impact Analysis I. Overall Impact We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96– 354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104–4), Executive Order 13132 on Federalism, and the Congressional Review Act (5 U.S.C. 804(2)). Executive Order 12866 (as amended by Executive Order 13258) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). We have determined that this proposed rule is a major rule as defined in 5 U.S.C. 804(2). We estimate that the proposed changes for FY 2009 operating and capital payments would redistribute in excess of VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 $100 million among different types of inpatient cases. The market basket update to the IPPS rates required by the statute, in conjunction with other payment changes in this proposed rule, would result in an approximate $4 billion increase in FY 2009 operating and capital payments. Our impact estimate includes the ¥0.9 percent adjustment for documentation and coding changes to the IPPS standardized amounts and capital Federal rates for FY 2009 in accordance with section 7 of Pub. L. 110–90. For purposes of the impact analysis, we also assume an additional 1.8 percent increase in case-mix between FY 2008 and FY 2009 because we believe the adoption of the MS– DRGs will result in case-mix growth due to documentation and coding changes that do not reflect real changes in patient severity of illness. The estimates of IPPS operating payments do not reflect any changes in hospital admissions or real case-mix intensity, which would also affect overall payment changes. The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small government jurisdictions. Most hospitals and most other PO 00000 Frm 00379 Fmt 4701 Sfmt 4702 providers and suppliers are considered to be small entities, either by being nonprofit organizations or by meeting the Small Business Administration definition of a small business (having revenues of $31.5 million or less in any 1 year). (For details on the latest standards for heath care providers, we refer readers to page 33 of the Table of Small Business Size Standards at the Small Business Administration Web site at: https:// www.sba.gov/services/ contractingopportunities/ sizestandardstopics/tableofsize/.) For purposes of the RFA, all hospitals and other providers and suppliers are considered to be small entities. Individuals and States are not included in the definition of a small entity. We believe that this proposed rule would have a significant impact on small entities as explained in this Appendix. Because we acknowledge that many of the affected entities are small entities, the analysis discussed throughout the preamble of this proposed rule constitutes our initial regulatory flexibility analysis. Therefore, we are soliciting comments on our estimates and analysis of the impact of the proposed rule on those small entities. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact E:\FR\FM\30APP2.SGM 30APP2 23906 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 analysis for any proposed or final rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we now define a small rural hospital as a hospital that is located outside of an urban area and has fewer than 100 beds. Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98–21) designated hospitals in certain New England counties as belonging to the adjacent urban area. Thus, for purposes of the IPPS, we continue to classify these hospitals as urban hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104–4) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. That threshold level is currently approximately $130 million. This proposed rule will not mandate any requirements for State, local, or tribal governments, nor will it affect private sector costs. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. As stated above, this proposed rule would not have a substantial effect on State and local governments. The following analysis, in conjunction with the remainder of this document, demonstrates that this proposed rule is consistent with the regulatory philosophy and principles identified in Executive Order 12866, the RFA, and section 1102(b) of the Act. The proposed rule would affect payments to a substantial number of small rural hospitals, as well as other classes of hospitals, and the effects on some hospitals may be significant. II. Objectives The primary objective of the IPPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs. In addition, we share national goals of preserving the Medicare Hospital Insurance Trust Fund. We believe the proposed changes in this proposed rule would further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that these proposed changes would ensure that the outcomes of this payment system are reasonable and equitable while avoiding or minimizing unintended adverse consequences. III. Limitations of Our Analysis The following quantitative analysis presents the projected effects of our proposed VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 policy changes, as well as statutory changes effective for FY 2009, on various hospital groups. We estimate the effects of individual proposed policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but, generally, we do not attempt to make adjustments for future changes in such variables as admissions, lengths of stay, or case-mix. However, in the FY 2008 IPPS final rule, we indicated that we believe that implementation of the MS–DRGs would lead to increases in case-mix that do not reflect actual increases in patients’ severity of illness as a result of more comprehensive documentation and coding. As explained in section II.D. of the preamble of this proposed rule, the FY 2008 IPPS final rule with comment period established a documentation and coding adjustment of ¥1.2 percent for FY 2008, ¥1.8 percent for FY 2009, and ¥1.8 percent for FY 2010 to maintain budget neutrality for the transition to the MS DRGs. Subsequently, Congress enacted Pub. L. 110–90. Section 7 of Public L. 110–90 reduced the IPPS documentation and coding adjustment from ¥1.2 percent to ¥0.6 percent for FY 2008 and from ¥1.8 percent to ¥0.9 percent for FY 2009. Following enactment of Pub. L. 110–90, we revised the FY 2008 standardized amounts (as well as other affected payment factors and thresholds) to reflect the ¥0.6 percent FY 2008 documentation and coding adjustment. The proposed FY 2009 IPPS national standardized amount included in this proposed rule reflects the documentation and coding adjustment of ¥0.9 percent for FY 2009. While we have adopted the statutorily mandated documentation and coding adjustments for payment purposes, we continue to believe that an increase in casemix of 1.8 percent between FY 2008 and FY 2009 is likely as a result of the adoption of the MS DRGs. The impacts shown below illustrate the impact of the FY 2009 IPPS changes on hospital operating payments, including the ¥0.9 percent FY 2009 documentation and coding adjustment to the IPPS national standardized amounts, both prior to and following the expected 1.8 percent growth in case-mix between FY 2008 and FY 2009. As we have done in the previous rules, we are soliciting comments and information about the anticipated effects of the proposed changes on hospitals and our methodology for estimating them. IV. Hospitals Included in and Excluded From the IPPS The prospective payment systems for hospital inpatient operating and capitalrelated costs encompass most general shortterm, acute care hospitals that participate in the Medicare program. There were 35 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment methodology for these hospitals. Among other short-term, acute care hospitals, only the 46 such hospitals in Maryland remain excluded from the IPPS under the waiver at section 1814(b)(3) of the Act. As of March 2008, there are 3,528 IPPS hospitals to be included in our analysis. This represents about 58 percent of all Medicare- PO 00000 Frm 00380 Fmt 4701 Sfmt 4702 participating hospitals. The majority of this impact analysis focuses on this set of hospitals. There are also approximately 1,311 CAHs. These small, limited service hospitals are paid on the basis of reasonable costs rather than under the IPPS. There are also 1,219 specialty hospitals and 2,291 specialty units that are excluded from the IPPS. These specialty hospitals include IPFs, IRFs, LTCHs, RNHCIs, children’s hospitals, and cancer hospitals. Changes in payments for IPFs and IRFs are made through other separate rulemaking. Payment impacts for these specialty hospitals and units are not included in this proposed rule. There is also a separate rule to update and make changes to the LTCH PPS for its current July 1 through June 30 rate year (RY). However, we have traditionally used the IPPS rule to update the LTCH patient classifications and relative weights because the LTCH PPS uses the same DRGs as the IPPS, resulting in the LTCH relative weights being reclassified and recalibrated according to the same schedule as the IPPS (that is, for each Federal fiscal year). The impacts of our policy changes on LTCHs, where applicable, are discussed below. (We note that, as discussed in section II.I. of the preamble of this proposed rule, in the RY 2009 LTCH PPS proposed rule 73 FR 5351 through 5352), we proposed to move the annual LTCH PPS RY update (currently effective July 1) to be effective October 1 through September 30 (the Federal fiscal year) each year beginning October 1, 2009. Under this proposal, RY 2009 would be extended 3 months, such that RY 2009 would be the 15-month period of July 1, 2008 through September 30, 2009.) V. Effects on Excluded Hospitals and Hospital Units As of March 2008, there were 1,219 hospitals excluded from the IPPS. Of these 1,219 hospitals, 314 IPFs, 78 children’s hospitals, 11 cancer hospitals, and 19 RNHCIs are either being paid on a reasonable cost basis or have a portion of the PPS payment based on reasonable cost principles subject to the rate-of-increase ceiling under § 413.40. The remaining providers, 221 IRFs, 394 LTCHs, and 182 IPFs, are paid 100 percent of the Federal prospective rate under the IRF PPS and the LTCH PPS, respectively, or 100 percent of the Federal per diem amount under the IPF PPS. As stated above, IRFs and IPFs are not affected by this proposed rule. The impacts of the changes to LTCHs are discussed separately below. In addition, there are 1,319 IPFs co-located in hospitals otherwise subject to the IPPS, 788 of which are paid on a blend of the IPF PPS per diem payment and the reasonable costbased payment. The remaining 531 IPF units are paid 100 percent of the Federal amount under the IPF PPS. There are 972 IRFs (paid under the IRF PPS) co-located in hospitals otherwise subject to the IPPS. In the past, hospitals and units excluded from the IPPS have been paid based on their reasonable costs subject to limits as established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that continue to be paid fully on a reasonable cost basis are subject to TEFRA limits for FY 2009. For these hospitals E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules jlentini on PROD1PC65 with PROPOSALS2 (cancer and children’s hospitals), consistent with section 1886(b)(3)(B)(ii) of the Act, we are proposing an update that is the percentage increase in the FY 2009 IPPS operating market basket, which is estimated to be 3.0 percent, based on Global Insights, Inc.’s 2008 first quarter forecast of the IPPS operating market basket increase. In addition, in accordance with § 403.752(a) of the regulations, RNHCIs are paid under § 413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to update target amounts by the rateof-increase percentage. For RNHCIs, the proposed update is the percentage increase in the FY 2009 IPPS operating market basket increase, which is estimated to be 3.0 percent, based on Global Insight, Inc.’s 2008 first quarter forecast of the IPPS operating market basket increase. The final rule implementing the IPF PPS (69 FR 66922) established a 3-year transition to the IPF PPS during which some providers received a blend of the IPF PPS per diem payment and the TEFRA reasonable costbased payment. This transitional period for a blended payment amount for IPFs ended for cost reporting periods that began on or after January 1, 2008. Because the reasonable costbased amount is zero percent for cost reporting periods beginning during CY 2008, no IPF will have a portion of its PPS payment that is based in part on reasonable cost subject to the rate-of-increase ceiling during FY 2009. Thus, there is no longer a need for an update factor for IPFs’ TEFRA target amount for FY 2009 and thereafter. The impact on excluded hospitals and hospital units of the proposed update in the rate-of-increase limit depends on the cumulative cost increases experienced by each excluded hospital or unit since its applicable base period. For excluded hospitals and units that have maintained their cost increases at a level below the rateof-increase limits since their base period, the major effect is on the level of incentive payments these hospitals and hospital units receive. Conversely, for excluded hospitals and hospital units with per-case cost increases above the cumulative update in their rate-of-increase limits, the major effect is the amount of excess costs that will not be reimbursed. We note that, under § 413.40(d)(3), an excluded hospital or unit whose costs exceed 110 percent of its rate-of-increase limit receives its rate-of-increase limit plus 50 percent of the difference between its reasonable costs and 110 percent of the limit, not to exceed 110 percent of its limit. In addition, under the various provisions set forth in § 413.40, certain excluded hospitals and hospital units can obtain payment adjustments for justifiable increases in operating costs that exceed the limit. VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS for Operating Costs A. Basis and Methodology of Estimates In this proposed rule, we are announcing proposed policy changes and payment rate updates for the IPPS for operating costs. Changes to the capital payments are discussed in section VIII. of this Appendix. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Based on the overall percentage change in payments per case estimated using our payment simulation model, we estimate that total FY 2009 operating payments will increase 4.1 percent compared to FY 2008, largely due to the statutorily mandated update to the IPPS rates. This amount also reflects the ¥0.9 percent FY 2009 documentation and coding adjustment to the IPPS national standardized amounts and our assumption of an additional 1.8 percent increase in case-mix between FY 2008 and FY 2009 as a result of improvements in documentation and coding that do not represent real increases in underlying resource demands and patient acuity due to the adoption of the MS–DRGs. The impacts do not illustrate changes in hospital admissions or real case-mix intensity, which will also affect overall payment changes. We have prepared separate impact analyses of the changes to each system. This section deals with changes to the operating prospective payment system. Our payment simulation model relies on the most recent available data to enable us to estimate the impacts on payments per case of certain changes in this proposed rule. However, there are other changes for which we do not have data available that would allow us to estimate the payment impacts using this model. For those changes, we have attempted to predict the payment impacts based upon our experience and other more limited data. The data used in developing the quantitative analyses of changes in payments per case presented below are taken from the FY 2007 MedPAR file and the most current Provider-Specific File that is used for payment purposes. Although the analyses of the changes to the operating PPS do not incorporate cost data, data from the most recently available hospital cost report were used to categorize hospitals. Our analysis has several qualifications. First, in this analysis, we do not make adjustments for future changes in such variables as admissions, lengths of stay, or underlying growth in real case-mix. Second, due to the interdependent nature of the IPPS payment components, it is very difficult to precisely quantify the impact associated with each change. Third, we use various sources for the data used to categorize hospitals in the tables. In some cases, particularly the number of beds, there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available source overall. However, for individual hospitals, some miscategorizations are possible. Using cases from the FY 2007 MedPAR file, we simulated payments under the operating IPPS given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the IPPS (Indian Health Service hospitals and hospitals in Maryland) were excluded from the simulations. The impact of payments under the capital IPPS, or the impact of payments for costs other than inpatient operating costs, are not analyzed in this section. Estimated payment impacts of FY 2009 changes to the capital IPPS are discussed in section VIII. of this Appendix. The changes discussed separately below are the following: PO 00000 Frm 00381 Fmt 4701 Sfmt 4702 23907 • The effects of the annual reclassification of diagnoses and procedures, full implementation of the MS–DRG system and 100 percent cost-based DRG relative weights, • The effects of the changes in hospitals’ wage index values reflecting wage data from hospitals’ cost reporting periods beginning during FY 2005, compared to the FY 2004 wage data. • The effects of the recalibration of the DRG relative weights as required by section 1886(d)(4)(C) of the Act, including the wage and recalibration budget neutrality factors. • The effects of geographic reclassifications by the MGCRB that will be effective in FY 2009. • The effects of the proposal to apply the rural floor budget neutrality adjustment at the State level, redistributing payments within the State, rather than adjusting payments to hospitals in other States. • The effects of the proposal to apply the imputed rural floor budget neutrality adjustment to the wage index at the Statelevel, rather than applying it to the standardized amount at the national level. • The effects of section 505 of Pub. L. 108– 173, which provides for an increase in a hospital’s wage index if the hospital qualifies by meeting a threshold percentage of residents of the county where the hospital is located who commute to work at hospitals in counties with higher wage indexes. • The effect of the budget neutrality adjustment being made for the adoption of the MS–DRGs under section 1886(d)(3)(A)(iv) of the Act for the change in aggregate payments that is a result of changes in the coding or classification of discharges that do not reflect real changes in case-mix. • The total estimated change in payments based on the proposed FY 2009 policies relative to payments based on FY 2008 policies. To illustrate the impacts of the proposed FY 2009 changes, our analysis begins with a FY 2008 baseline simulation model using: the proposed FY 2009 update of 3.0 percent; the FY 2008 DRG GROUPER (Version 25.0); the most current CBSA designations for hospitals based on OMB’s MSA definitions; the FY 2008 wage index; and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total operating DRG and outlier payments. Section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a) of Pub. L. 109–171, provides that for FY 2007 and subsequent years, the update factor will be reduced by 2.0 percentage points for any hospital that does not submit quality data in a form and manner and at a time specified by the Secretary. At the time this impact was prepared, 186 providers did not receive the full market basket rate-of-increase for FY 2008 because they failed the quality data submission process. For purposes of the simulations shown below, we modeled the proposed payment changes for FY 2009 using a reduced update for these 186 hospitals. However, we do not have enough information to determine which hospitals will not receive the full market basket rateof-increase for FY 2009 at this time. Each policy change, statutorily or otherwise, is then added incrementally to E:\FR\FM\30APP2.SGM 30APP2 23908 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules this baseline, finally arriving at an FY 2009 model incorporating all of the proposed changes. This simulation allows us to isolate the effects of each proposed change. Our final comparison illustrates the proposed percent change in payments per case from FY 2008 to FY 2009. Three factors not discussed separately have significant impacts here. The first is the update to the standardized amount. In accordance with section 1886(b)(3)(B)(i) of the Act, we are updating the standardized amounts for FY 2009 using the most recently forecasted hospital market basket increase for FY 2009 of 3.0 percent. (Hospitals that fail to comply with the quality data submission requirements to receive the full update will receive an update reduced by 2.0 percentage points to 1.0 percent.) Under section 1886(b)(3)(B)(iv) of the Act, the updates to the hospital-specific amounts for SCHs and for MDHs are also equal to the market basket increase, or 3.0 percent. A second significant factor that affects the proposed changes in hospitals’ payments per case from FY 2008 to FY 2009 is the change in a hospital’s geographic reclassification status from one year to the next. That is, payments may be reduced for hospitals reclassified in FY 2008 that are no longer reclassified in FY 2009. Conversely, payments may increase for hospitals not reclassified in FY 2008 that are reclassified in FY 2009. Particularly with the expiration of section 508 of Pub. L. 108–173, the reclassification provision, these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage change in payments for the category may be below the national mean. A third significant factor is that we currently estimate that actual outlier payments during FY 2008 will be 4.8 percent of total DRG payments. When the FY 2008 final rule was published, we projected FY 2008 outlier payments would be 5.1 percent of total DRG plus outlier payments; the average standardized amounts were offset correspondingly. The effects of the lower than expected outlier payments during FY 2009 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2008 payments per case to estimated FY 2009 payments per case (with outlier payments projected to equal 5.1 percent of total DRG payments). geographic reclassifications (including reclassifications under section 1886(d)(8)(B) and section 1886(d)(8)(E) of the Act that have implications for capital payments) are 2,584, 1,424, 1,160 and 944, respectively. The next three groupings examine the impacts of the proposed changes on hospitals grouped by whether or not they have GME residency programs (teaching hospitals that receive an IME adjustment) or receive DSH payments, or some combination of these two adjustments. There are 2,485 nonteaching hospitals in our analysis, 805 teaching hospitals with fewer than 100 residents, and 238 teaching hospitals with 100 or more residents. In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural for DSH purposes. The next category groups together hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither. The next five rows examine the impacts of the proposed changes on rural hospitals by special payment groups (SCHs, RRCs, and MDHs). There were 197 RRCs, 355 SCHs, 156 MDHs, 102 hospitals that are both SCHs and RRCs, and 12 hospitals that are both an MDH and an RRC. The next series of groupings are based on the type of ownership and the hospital’s Medicare utilization expressed as a percent of total patient days. These data were taken from the FY 2005 Medicare cost reports. The next two groupings concern the geographic reclassification status of hospitals. The first grouping displays all urban hospitals that were reclassified by the MGCRB for FY 2009. The second grouping shows the MGCRB rural reclassifications. The final category shows the impact of the proposed policy changes on the 20 cardiac specialty hospitals in our analysis. B. Analysis of Table I Table I displays the results of our analysis of the proposed changes for FY 2009. The table categorizes hospitals by various geographic and special payment consideration groups to illustrate the varying impacts on different types of hospitals. The top row of the table shows the overall impact on the 3,528 hospitals included in the analysis. The next four rows of Table I contain hospitals categorized according to their geographic location: all urban, which is further divided into large urban and other urban; and rural. There are 2,542 hospitals located in urban areas included in our analysis. Among these, there are 1,402 hospitals located in large urban areas (populations over 1 million), and 1,140 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 986 hospitals in rural areas. The next two groupings are by bed-size categories, shown separately for urban and rural hospitals. The final groupings by geographic location are by census divisions, also shown separately for urban and rural hospitals. The second part of Table I shows hospital groups based on hospitals’ FY 2009 payment classifications, including any reclassifications under section 1886(d)(10) of the Act. For example, the rows labeled urban, large urban, other urban, and rural show that the number of hospitals paid based on these categorizations after consideration of TABLE I.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009 jlentini on PROD1PC65 with PROPOSALS2 (1) (2) All Hospitals ................................................ By Geographic Location: Urban hospitals .................................... Large urban areas ............................... Other urban areas ................................ Rural hospitals ..................................... Bed Size (Urban): 0–99 beds ............................................ 100–199 beds ...................................... 200–299 beds ...................................... 300–499 beds ...................................... 500 or more beds ................................ Bed Size (Rural): 0–49 beds ............................................ 50–99 beds .......................................... 100–149 beds ...................................... 150–199 beds ...................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Proposed FY 2009 wage data 3 Proposed FY 2009 DRG, rel. wts. and wage index changes 4 FY 2009 MGCRB Reclassifications 5 (3) Number of hospitals 1 Proposed FY 2009 cost based DRG Weights & MS–DRG changes 2 Application of proposed rural floor and imputed rural floor, including proposed within state budget neutrality 6 (4) (5) (6) Proposed FY 2009 out-migration adjustment 7 All proposed FY 2009 changes w/CMI adjustment prior to estimated CMI growth 8 All proposed FY 2009 changes w/CMI adjustment and estimated CMI growth 9 (7) (8) (9) 3,528 0.1 ¥0.1 0 0 0 0 2.3 4.1 2,542 1,402 1,140 986 0.2 0.5 0 ¥1 ¥0.1 ¥0.1 0 0 0.1 0.3 ¥0.1 ¥1.1 ¥0.2 ¥0.4 ¥0.1 2.1 0 ¥0.1 0.1 ¥0.1 0 0 0 0.1 2.4 2.6 2.2 1.5 4.2 4.4 3.9 3.3 643 829 483 411 176 ¥0.7 0.1 0.2 0.3 0.5 ¥0.1 0 0 0 ¥0.3 ¥0.8 0 0.2 0.3 0.1 ¥0.4 ¥0.1 ¥0.2 ¥0.2 ¥0.3 0.1 0.1 ¥0.1 0 0 0 0 0 0 0 1.6 2.2 2.4 2.6 2.5 3.4 4 4.2 4.3 4.3 338 373 166 67 ¥2.3 ¥1.2 ¥0.9 ¥0.6 0.1 0 0.1 ¥0.1 ¥2.3 ¥1.3 ¥0.8 ¥0.8 0.6 1.1 2.5 3 0 ¥0.1 0 ¥0.1 0.2 0.2 0.1 0 0.7 1.2 1.5 2 2.5 3 3.3 3.8 PO 00000 Frm 00382 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23909 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE I.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009—Continued jlentini on PROD1PC65 with PROPOSALS2 (1) (2) 200 or more beds ................................ Urban by Region: New England ........................................ Middle Atlantic ...................................... South Atlantic ....................................... East North Central ............................... East South Central ............................... West North Central .............................. West South Central .............................. Mountain .............................................. Pacific ................................................... Puerto Rico .......................................... Rural by Region: New England ........................................ Middle Atlantic ...................................... South Atlantic ....................................... East North Central ............................... East South Central ............................... West North Central .............................. West South Central .............................. Mountain .............................................. Pacific ................................................... By Payment Classification: Urban hospitals .................................... Large urban areas ............................... Other urban areas ................................ Rural areas .......................................... Teaching Status: Nonteaching ......................................... Fewer than 100 residents .................... 100 or more residents .......................... Urban DSH: Non-DSH .............................................. 100 or more beds ................................ Less than 100 beds ............................. Rural DSH: SCH ...................................................... RRC ..................................................... 100 or more beds ................................ Less than 100 beds ............................. Urban teaching and DSH: Both teaching and DSH ....................... Teaching and no DSH ......................... No teaching and DSH .......................... No teaching and no DSH ..................... Special Hospital Types: RRC ..................................................... SCH ...................................................... MDH ..................................................... SCH and RRC ..................................... MDH and RRC ..................................... Type of Ownership: Voluntary .............................................. Proprietary ............................................ Government ......................................... Medicare Utilization as a Percent of Inpatient Days: 0–25 ..................................................... 25–50 ................................................... 50–65 ................................................... Over 65 ................................................ FY 2009 Reclassifications by the Medicare Geographic Classification Review Board: All Reclassified Hospitals ..................... Non-Reclassified Hospitals .................. Urban Hospitals Reclassified ............... Urban Nonreclassified, FY 2009 .......... All Rural Hospitals Reclassified Full Year FY 2009 ................................... Rural Nonreclassified Hospitals Full Year FY 2009 ................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 (4) FY 2009 MGCRB Reclassifications 5 Application of proposed rural floor and imputed rural floor, including proposed within state budget neutrality 6 (5) Proposed FY 2009 wage data 3 Proposed FY 2009 DRG, rel. wts. and wage index changes 4 (3) Number of hospitals 1 Proposed FY 2009 cost based DRG Weights & MS–DRG changes 2 (6) Proposed FY 2009 out-migration adjustment 7 All proposed FY 2009 changes w/CMI adjustment prior to estimated CMI growth 8 All proposed FY 2009 changes w/CMI adjustment and estimated CMI growth 9 (7) (8) (9) 42 ¥0.3 ¥0.1 ¥0.4 3.2 ¥0.1 0 2.1 3.9 121 348 385 394 163 157 371 157 393 53 0 0 0.4 0.5 ¥0.1 ¥0.1 0.4 0.3 0.4 ¥0.2 0 ¥0.5 ¥0.3 ¥0.5 ¥0.2 0.2 0 0.1 0.9 ¥0.7 ¥0.1 ¥0.5 0.1 ¥0.1 ¥0.2 0.1 0.3 0.5 1.2 ¥0.9 0.5 0.1 ¥0.4 ¥0.4 ¥0.2 ¥0.7 ¥0.6 ¥0.2 ¥0.2 ¥0.7 0.1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1.2 1.2 2.7 2.4 2.4 2.8 2.9 3.2 3.4 1.4 3 3 4.4 4.1 4.2 4.5 4.7 5 5.2 3.2 23 70 172 121 176 113 200 75 36 ¥0.8 ¥0.9 ¥0.6 ¥0.9 ¥1.3 ¥0.9 ¥1.7 ¥0.9 ¥0.7 ¥0.4 ¥0.1 ¥0.1 ¥0.3 ¥0.1 0.1 0.5 0 0.6 ¥1.3 ¥1.1 ¥0.7 ¥1.3 ¥1.4 ¥0.8 ¥1.3 ¥1 ¥0.2 2.4 2 2.2 1.6 2.7 1.7 2.5 0.5 1.8 ¥0.9 0 0 0 0 0 0 0 ¥0.3 0 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0 0.6 1.3 1.9 1.4 1.6 1.6 1.3 1.2 1.8 2.3 3.1 3.7 3.2 3.4 3.4 3.1 3.1 3.6 2,584 1,424 1,160 944 0.2 0.4 0 ¥1 ¥0.1 ¥0.1 0 0 0.1 0.3 ¥0.1 ¥1.1 ¥0.2 ¥0.4 0 2 0 ¥0.1 0.1 ¥0.1 0 0 0 0.1 2.4 2.6 2.2 1.5 4.2 4.4 3.9 3.3 2,485 805 238 ¥0.2 0.2 0.5 0 0 ¥0.3 ¥0.2 0.1 0.2 0.3 ¥0.2 ¥0.3 0 0 0 0 0 0 2.2 2.4 2.5 4 4.2 4.2 838 1,534 354 ¥0.3 0.4 ¥0.7 ¥0.2 ¥0.1 0 ¥0.4 0.3 ¥0.8 ¥0.1 ¥0.3 0 0 0 0 0 0 0 1.8 2.6 1.6 3.6 4.3 3.4 389 206 39 168 ¥1.5 ¥0.6 ¥0.8 ¥1.7 0 0 0 0 ¥1.5 ¥0.6 ¥0.9 ¥1.8 0.4 3.4 1.3 1.3 0 ¥0.1 0 0 0.1 0 0.4 0.3 1.5 1.9 1.3 0.6 3.3 3.7 3.1 2.4 811 172 1,077 524 0.4 ¥0.1 0.2 ¥0.2 ¥0.1 ¥0.2 0 ¥0.2 0.3 ¥0.3 0.2 ¥0.4 ¥0.4 0 0 ¥0.3 0 0 0.1 0 0 0 0 0 2.5 1.8 2.5 1.9 4.3 3.6 4.3 3.7 197 355 156 102 12 ¥0.4 ¥1.3 ¥1.8 ¥0.5 ¥1.3 ¥0.1 0.1 0.1 0.1 0.1 ¥0.4 ¥1.3 ¥1.8 ¥0.5 ¥1.3 3.2 0.4 0.5 1.7 0.9 0 0 0 0 ¥0.3 0 0.1 0.2 0 0 2.3 1.2 2 2.2 1 4.1 3 3.8 4.1 2.8 2,027 827 587 0.1 0 0.1 ¥0.1 0 ¥0.1 0 ¥0.1 0 0 0 0.1 0 ¥0.1 0.1 0 0 0 2.3 2.4 2.6 4 4.1 4.4 255 1,350 1,431 392 0.8 0.3 ¥0.1 ¥0.8 ¥0.1 0 ¥0.2 ¥0.2 0.7 0.3 ¥0.3 ¥1 ¥0.4 ¥0.3 0.4 0.5 ¥0.2 0 0.1 0 0 0 0 0.1 3.2 2.7 1.9 1.2 4.9 4.4 3.7 3 805 2,723 445 2,075 0 0.2 0.2 0.3 0 ¥0.1 0 ¥0.1 0 0 0.2 0.1 2 ¥0.7 1.5 ¥0.7 ¥0.1 0 ¥0.2 0.1 0 0 0 0 2.1 2.4 2.1 2.5 3.8 4.2 3.9 4.3 360 ¥0.7 0 ¥0.7 3.3 ¥0 0 1.8 3.7 565 ¥1.5 ¥0 ¥1.6 ¥0.4 ¥0.1 0.3 1 2.8 PO 00000 Frm 00383 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 23910 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE I.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009—Continued (1) (2) (4) FY 2009 MGCRB Reclassifications 5 Application of proposed rural floor and imputed rural floor, including proposed within state budget neutrality 6 (5) Proposed FY 2009 wage data 3 Proposed FY 2009 DRG, rel. wts. and wage index changes 4 (3) Number of hospitals 1 Proposed FY 2009 cost based DRG Weights & MS–DRG changes 2 (6) Proposed FY 2009 out-migration adjustment 7 All proposed FY 2009 changes w/CMI adjustment prior to estimated CMI growth 8 All proposed FY 2009 changes w/CMI adjustment and estimated CMI growth 9 (7) (8) (9) 29 ¥1.3 ¥0.2 ¥1.6 0.6 0 0 1.6 3.5 61 ¥1 ¥0.2 ¥1.3 3.2 ¥0.2 0.1 1 2.8 20 All Section 401 Reclassified Hospitals Other Reclassified Hospitals (Section 1886(d)(8)(B)) ................................... Specialty Hospitals Cardiac specialty Hospitals .................. ¥2.2 ¥0.1 ¥2.4 ¥0.7 0.1 0 0 1.8 1 Because jlentini on PROD1PC65 with PROPOSALS2 data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the national total. Discharge data are from FY 2007, and hospital cost report data are from reporting periods beginning in FY 2006 and FY 2005. 2 This column displays the payment impact of the changes to the V26 GROUPER and the recalibration of the DRG weights based on FY 2007 MedPAR data in accordance with section 1886(d)(4)(C)(iii) of the Act. 3 This column displays the payment impact of updating the wage index data to the FY 2005 cost report data. 4 This column displays the combined payment impact of the changes in column 2 and column 3 and the budget neutrality factors for DRG and wage index changes in accordance with section 1886(d)(4)(C)(iii) of the Act and section 1886(d)(3)(E) of the Act. 5 Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate the FY 2009 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2008. Reclassification for prior years has no bearing on the payment impacts shown here. This column reflects the geographic budget neutrality factor of 0.992333. 6 This column displays the effects of the rural floor and the imputed rural floor, including the proposal to apply the budget neutrality adjustment within State. 7 This column displays the impact of section 505 of Pub. L. 108–173, which provides for an increase in a hospital’s wage index if the hospital qualifies by meeting a threshold percentage of residents of the county where the hospital is located who commute to work at hospitals in counties with higher wage indexes. 8 This column shows changes in payments from FY 2008 to FY 2009, including the proposed FY 2009 ¥0.9 percent documentation and coding adjustment, but not the projected 1.8 percent increase in case-mix expected to occur in FY 2009 due to improvements in documentation and coding. It incorporates all of the changes displayed in Columns 4, 5, 6, 7 (the changes displayed in Columns 2 and 3 are included in Column 4). It also reflects the impact of the FY 2009 update, and changes in hospitals’ reclassification status in FY 2009 compared to FY 2008. 9 This column shows changes in payments from FY 2008 to FY 2009 including the proposed FY 2009 ¥0.9 percent documentation and coding adjustment and the projected 1.8 percent increase in case-mix expected to occur in FY 2009 due to improvements in documentation and coding. It incorporates all of the changes displayed in Columns 4, 5, 6, 7, 8 (the changes displayed in Columns 2 and 3 are included in Column 4). It also reflects the impact of the FY 2008 update, and changes in hospitals’ reclassification status in FY 2009 compared to FY 2008. The sum of these impacts may be different from the percentage changes shown here due to rounding and interactive effects. C. Effects of the Proposed Changes to the MS–DRG Reclassifications and Relative CostBased Weights (Column 2) In Column 2 of Table I, we present the effects of the DRG reclassifications, as discussed in section II. of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of the Act requires us annually to make appropriate classification changes in order to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. As discussed in the preamble of this proposed rule, the FY2009 DRG relative weights will be 100 percent cost-based and 100 percent MS–DRGs, thus completing our three year transition to cost-based relative weights and our two year transition to MS– DRGs. For FY 2009, the MS–DRGs are calculated using the FY2007 MedPAR data grouped to the Version 26.0 (FY2009) DRGs. The proposed methods of calculating the relative weights and the reclassification changes to the GROUPER are described in more detail in section II.H. of the preamble to this proposed rule. In previous years, this column would also reflect the effects of the recalibration budget neutrality factor that is applied to the hospital-specific rates and the Puerto Rico-specific standardized amount. However, for this proposed rule, we show the effects of the recalibration budget neutrality factor of 0.998700 in column 4. We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we are applying a budget neutrality factor to the national standardized amounts to ensure that the overall payment impact of the DRG changes (combined with the wage VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 index changes) is budget neutral. This proposed wage and recalibration budget neutrality factor of 0.99525 is applied to payments in Column 4 and not Column 2. The proposed changes to the relative weights and DRGs shown in column 2 are prior to any offset for budget neutrality. The ‘‘All Hospitals’’ line indicates that proposed changes in this column will increase payments by 0.1 percent. However, as stated earlier, the proposed changes shown in this column are combined with revisions to the wage index, and the budget neutrality adjustments made for these changes are shown in column 4. Thus, the impact after accounting only for budget neutrality for proposed changes to the DRG relative weights and classification is somewhat lower than the figures shown in this column (approximately 0.1 percent). D. Effects of Proposed Wage Index Changes (Column 3) Section 1886(d)(3)(E) of the Act requires that, beginning October 1, 1993, we annually update the wage data used to calculate the wage index. In accordance with this requirement, the wage index for FY 2009 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 2004 and before October 1, 2005. The estimated impact of the proposed wage data on hospital payments is isolated in Column 3 by holding the other payment parameters constant in this simulation. That is, Column 3 shows the percentage changes in payments when going from a model using the FY 2008 wage index, based on FY 2004 wage data and having a 100-percent PO 00000 Frm 00384 Fmt 4701 Sfmt 4702 occupational mix adjustment applied, to a model using the FY 2009 pre-reclassification wage index, also having a 100-percent occupational mix adjustment applied, based on FY 2005 wage data (while holding other payment parameters such as use of the version 26.0 DRG grouper constant). The wage data collected on the FY 2005 cost report include overhead costs for contract labor that were not collected on FY 2004 and earlier cost reports. The impacts below incorporate the effects of the FY 2005 wage data collected on hospital cost reports, including additional overhead costs for contract labor compared to the wage data from FY 2004 cost reports that were used to calculate the FY 2008 wage index. Column 3 shows the impacts of updating the wage data using FY 2004 cost reports. Overall, the new wage data will lead to a ¥0.1 percent change for all hospitals before application of the wage and DRG recalibration budget neutrality adjustment shown in column 4. Thus, the figures in this column are approximately 0.1 below what they otherwise would be if they also illustrated a budget neutrality adjustment solely for changes to the wage index. Among the regions, the largest increase is in the urban Pacific region, which experiences a 0.9 percent increase before applying an adjustment for budget neutrality. The largest decline from updating the wage data is seen in Puerto Rico (0.7 percent decrease). In looking at the wage data itself, the national average hourly wage increased 4.2 percent compared to FY 2008. Therefore, the only manner in which to maintain or exceed E:\FR\FM\30APP2.SGM 30APP2 23911 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules the previous year’s wage index was to match or exceed the national 4.2 percent increase in average hourly wage. Of the 3,457 hospitals with wage data for both FYs 2008 and 2009, 1,707, or 49.4 percent, experienced an average hourly wage increase of 4.2 percent or more. The following chart compares the shifts in wage index values for hospitals for FY 2009 relative to FY 2008. Among urban hospitals, 32 will experience an increase of more than 5 percent and less than 10 percent and 5 will experience an increase of more than 10 percent. Among rural hospitals, none will experience an increase of more than 5 percent and less than 10 percent, and none will experience an increase of more than 10 percent. However, 972 rural hospitals will experience increases or decreases of less than 5 percent, while 2,420 urban hospitals will experience increases or decreases of less than 5 percent. Eighteen urban hospitals will experience decreases in their wage index values of more than 5 percent and less than 10 percent. Ten urban hospitals will experience decreases in their wage index values of greater than 10 percent. No rural hospitals will experience decreases of more than 5 percent. These figures reflect changes in the wage index which is an adjustment to either 69.7 percent or 62 percent of a hospital’s standardized amount depending upon whether its wage index is greater than 1.0 or less than or equal to 1.0. Therefore, these figures are illustrating a somewhat larger change in the wage index than would occur to the hospital’s total payment. The following chart shows the projected impact for urban and rural hospitals. Number of hospitals Percentage change in area wage index values Urban Increase more than 10 percent ....................................................................................................................................... Increase more than 5 percent and less than 10 percent ................................................................................................ Increase or decrease less than 5 percent ....................................................................................................................... Decrease more than 5 percent and less than 10 percent .............................................................................................. Decrease more than 10 percent ...................................................................................................................................... jlentini on PROD1PC65 with PROPOSALS2 E. Combined Effects of Proposed MS–DRG and Wage Index Changes (Column 4) primarily due to the changes to MS–DRGs and the relative cost weights. Section 1886(d)(4)(C)(iii) of the Act requires that changes to MS–DRG reclassifications and the relative weights cannot increase or decrease aggregate payments. In addition, section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. As noted in the Addendum to this proposed rule, in determining the budget neutrality factor, we equated simulated aggregate payments for FY 2008 and FY 2009 using the FY 2007 Medicare utilization data after applying the changes to the DRG relative weights and the wage index. We computed a wage and MS–DRG recalibration budget neutrality factor of 0.999525 (which is applied to the national standardized amounts) and a recalibration budget neutrality factor 0.998700 (which is applied to the hospital-specific rates and the Puerto Rico-specific standardized amount). The 0.0 percent impact for all hospitals demonstrates that the proposed MS–DRG and wage changes, in combination with the budget neutrality factor, are budget neutral. In Table I, the combined overall impacts of the effects of both the MS–DRG reclassifications and the updated wage index are shown in Column 4. The estimated changes shown in this column reflect the combined effects of the changes in Columns 2 and 3 and the budget neutrality factors discussed previously. We estimate that the combined impact of the proposed changes to the relative weights and DRGs and the updated wage data with budget neutrality applied will increase payments to hospitals located in large urban areas (populations over 1 million) by approximately 0.3. These proposed changes would generally increase payments to hospitals in all urban areas (0.1 percent) and large teaching hospitals (0.2 percent). Rural hospitals will generally experience a decrease in payments (¥1.1 percent). Among the rural hospital categories, rural hospitals with less than 50 beds will experience the greatest decline in payment (¥2.3 percent) F. Effects of MGCRB Reclassifications (Column 5) VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 Our impact analysis to this point has assumed hospitals are paid on the basis of their actual geographic location (with the exception of ongoing policies that provide that certain hospitals receive payments on other bases than where they are geographically located). The proposed changes in Column 5 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2009 which affect hospitals’ wage index area assignments. By February 28 of each year, the MGCRB makes reclassification determinations that will be effective for the next fiscal year, which begins on October 1. The MGCRB may approve a hospital’s reclassification request for the purpose of using another area’s wage index value. Hospitals may appeal denials of MGCRB decisions to the CMS Administrator. Further, hospitals have 45 days from publication of the IPPS rule in the Federal Register to decide whether to withdraw or terminate an approved geographic reclassification for the following year. This column reflects all MGCRB decisions, Administrator appeals and decisions of hospitals for FY 2009 geographic reclassifications. The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we are proposing to apply an adjustment of 0.992333 to ensure that the effects of the section 1886(d)(10) reclassifications are budget neutral. (See section II.A. of the Addendum to this proposed rule.) Geographic reclassification generally benefits hospitals in rural areas. We estimate that geographic reclassification will increase payments to rural hospitals by an average of 2.1 percent. PO 00000 Frm 00385 Fmt 4701 Sfmt 4702 5 32 2,420 18 10 Rural 0 0 972 0 0 G. Effects of the Proposed Rural Floor and Imputed Rural Floor, Including the Proposed Application of Budget Neutrality at the State Level (Column 6) As discussed in section III.B. of the preamble of this FY 2009 proposed rule, section 4410 of Pub. L. 105–33 established the rural floor by requiring that the wage index for a hospital in any urban area cannot be less than the area wage index determined for the state’s rural area. In FY 2008, we changed how we applied budget neutrality to the rural floor. Rather than applying a budget neutrality adjustment to the standardized amount, a uniform budget neutrality adjustment is applied to the wage index. For FY 2009, we are proposing to apply the rural floor budget neutrality adjustment at the State level, which would redistribute payments within the State rather than across all other providers within the Nation. Furthermore, the FY 2005 IPPS final rule (69 FR 49109) established a temporary imputed rural floor for all urban States from FY 2005 to FY 2007. The rural floor requires that an urban wage index cannot be lower than the wage index for any rural hospital in that State. Therefore, an imputed rural floor was established for States that do not have rural areas or rural IPPS hospitals. In the FY 2008 IPPS final rule with comment period (72 FR 47321), we finalized our rule to extend the imputed rural floor for 1 additional year. In this proposed rule, we are proposing to extend the imputed rural floor for an additional 3 years through FY 2011. Furthermore, consistent with our proposal to apply the rural floor budget neutrality adjustment at the State level, we are proposing to apply the imputed rural floor budget neutrality adjustment to the wage index at the State level. Column 6 shows the projected impact of the rural floor and the imputed rural floor, including the proposed application of the budget neutrality adjustment at the State level. The column compares the postreclassification FY 2009 wage index of providers before the rural floor adjustment and the post-reclassification FY 2009 wage index of providers with the rural floor and E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23912 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules imputed rural floor adjustment. Only urban hospitals can benefit from the rural floor provision. Because the provision is budget neutral, in prior years, all other hospitals (that is, all rural hospitals and those urban hospitals to which the adjustment is not made) had experienced a decrease in payments due to the budget neutrality adjustment applied nationally. However, under this proposal, States that have no hospitals receiving a rural floor wage index would no longer have a negative budget neutrality adjustment applied to their wage indices. Conversely, all hospitals in States with hospitals receiving a rural floor would have their wage indices downwardly adjusted to achieve budget neutrality within the State. We project that, in aggregate, rural hospitals will experience a 0.1 percent decrease in payments. We project hospitals located in other urban areas (populations of 1 million or fewer) will experience a 0.1 percent increase in payments because the rural floor adjustment applies to urban hospitals. Rural New England hospitals can expect the greatest decrease in payment by 0.9 percent because hospitals in Vermont will receive a rural floor budget neutrality adjustment of 0.901 or a reduction of approximately 10 percent, and hospitals in Connecticut will receive a rural floor budget neutrality adjustment of 0.9639 or a reduction of approximately 4 percent. New Jersey, which is the only State that benefits from the imputed rural floor, is expected to receive a rural floor budget neutrality adjustment of 0.987838 or a reduction of approximately 1.2 percent. The table that appears in section III B.2.b. of the preamble of this proposed rule shows how payments would change, at the State level, if we moved from our current policy of applying rural floor budget neutrality at the national level to our proposed policy to apply the rural floor budget neutrality within the State. The table shows that, under our current policy of applying budget neutrality at the national level, States that do not have any hospitals receiving the rural floor wage index would expect a decrease in payments because, in order to maintain budget neutrality nationally, these hospitals have to pay for the hospitals in other States that do receive a rural floor. For example, States such as Arizona, New York, and Rhode Island, which do not have hospitals receiving a rural floor, would expect to lose 0.2 percent in payments under a national rural floor budget neutrality adjustment. However, under our proposed policy to apply rural floor budget neutrality within each State, States that do not have hospitals receiving a floor would see an increase in payments (compared with our current policy of applying budget neutrality at the national level) because they would no longer have their wage indexes adjusted to maintain budget neutrality. However, all hospitals in States with hospitals receiving a rural floor would expect a decrease in their payments in order to achieve budget neutrality within their States (that is, the wage indices for hospitals in that State would be decreased in order to make the additional payments to hospitals in that State receiving the rural floor). Therefore, VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 compared with our current policy of applying budget neutrality at the national level, States such as Arizona, New York, and Rhode Island could expect payment increases of 0.3 percent under a rural floor budget neutrality applied at the State level, while States such as California and Connecticut, which have several hospitals that benefit from the rural floor, could expect decreases in payments by 0.8 percent and 2.2 percent, respectively. H. Effects of the Proposed Wage Index Adjustment for Out-Migration (Column 7) Section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108–173, provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county, but work in a different area with a higher wage index. Hospitals located in counties that qualify for the payment adjustment are to receive an increase in the wage index that is equal to a weighted average of the difference between the wage index of the resident county, post-reclassification and the higher wage index work area(s), weighted by the overall percentage of workers who are employed in an area with a higher wage index. With the out-migration adjustment, rural providers will experience a 0.1 percent increase in payments in FY 2009 relative to no adjustment at all. We included these additional payments to providers in the impact table shown above, and we estimate the impact of these providers receiving the out-migration increase to be approximately $20 million. I. Effects of All Proposed Changes With CMI Adjustment Prior to Estimated Growth (Column 8) Column 8 compares our estimate of payments per case between FY 2008 and FY 2009 with all changes reflected in this proposed rule for FY 2009, including a ¥0.9 percent documentation and coding adjustment to the FY 2009 national standardized amounts to account for anticipated improvements in documentation and coding that are expected to increase casemix. We generally apply an adjustment to the DRGs to ensure budget neutrality assuming constant utilization. However, in the FY 2008 IPPS final rule with comment period, we indicated that we believe that the adoption of MS–DRGs would lead to increases in casemix as a result of improved documentation and coding. In the FY 2008 IPPS final rule with comment period, we had finalized a policy to apply a documentation and coding adjustment to the standardized amount of ¥1.2 percent for FY 2008, ¥1.8 percent for FY 2009, and ¥1.8 percent for FY 2010 to offset the expected increase in case-mix and achieve budget neutrality. However, in compliance with section 7 of Pub. L. 110–90, we reduced the documentation and coding adjustment to ¥0.6 percent for FY 2008. In accordance with section 7 of Pub. L. 110–90, for FY 2009, we are applying a documentation and coding adjustment of ¥0.9 percent to the FY 2009 national standardized amounts (in addition to the ¥0.6 percent adjustment made for FY 2008). PO 00000 Frm 00386 Fmt 4701 Sfmt 4702 We are not proposing to apply the documentation and coding adjustment to the FY 2009 hospital-specific rates and the FY 2009 Puerto Rico-specific standardized amount. However, we continue to believe that case-mix growth of an additional 1.8 percent compared to FY 2008 is likely to occur across all hospitals as a result of improvements in documentation and coding. Column 8 illustrates the total payment change for FY 2009 compared to FY 2008, taking into account the ¥0.9 percent FY 2009 documentation and coding adjustment but not the projected 1.8 percent case-mix increase itself. Therefore, this column illustrates a total payment change that is less than what is anticipated to occur. J. Effects of All Proposed Changes With CMI Adjustment and Estimated Growth (Column 9) Column 9 compares our estimate of payments per case between FY 2008 and FY 2009, incorporating all changes reflected in this proposed rule for FY 2009 (including statutory changes). This column includes the FY 2009 documentation and coding adjustment of ¥0.9 percent and the projected 1.8 percent increase in case-mix from improved documentation and coding (with the 1.8 percent case-mix increase assumed to occur equally across all hospitals). Column 9 reflects the impact of all FY 2009 changes relative to FY 2008, including those shown in Columns 2 through 7. The average increase for all hospitals is approximately 4.1 percent. This increase includes the effects of the 3.0 percent market basket update. It also reflects the 0.3 percentage point difference between the projected outlier payments in FY 2008 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2008 (4.8 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. As a result, payments are projected to be 0.3 percentage points lower in FY 2008 than originally estimated, resulting in a 0.3 percentage point greater increase for FY 2009 than would otherwise occur. In addition, the impact of expiration of section 508 of Pub. L. 108–173 reclassification accounts for a 0.1 percent decrease in estimated payments. There might also be interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in Column 9 may not equal the product of the percentage changes described above. The overall change in payments per case for hospitals in FY 2009 is proposed to increase by 4.1 percent. Hospitals in urban areas will experience an estimated 4.2 percent increase in payments per case compared to FY 2008. Hospitals in large urban areas will experience an estimated 4.4 percent increase and hospitals in other urban areas will experience an estimated 3.9 percent increase in payments per case in FY 2008. Hospital payments per case in rural areas are estimated to increase 3.3 percent. The increases that are larger than the national average for larger urban areas and smaller than the national average for other urban and rural areas are largely attributed to the differential impact of adopting MS–DRGs. E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Among urban census divisions, the largest estimated payment increases will be 5.2 percent in the Pacific region (generally attributed to MS–DRGs and wage data) and 5.0 percent in the Mountain region (mostly due to MS–DRGs). The smallest urban increase is estimated at 3.0 percent in the Middle Atlantic and New England regions. Among the rural regions in Column 9, the providers in the New England region experience the smallest increase in payments (2.3 percent) primarily due to the Statespecific rural floor budget neutrality adjustment. The South Atlantic and Pacific regions will have the highest increases among rural regions, with 3.7 percent and 3.6 percent estimated increases, respectively. Again, increases in rural areas are generally less than the national average due to the adoption of MS–DRGs. Among special categories of rural hospitals in Column 9, the SCH and RRC providers will receive an estimated increase in payments of 4.1 percent, and the MDH and RRCs will experience an estimated increase in payments by 2.8 percent. Urban hospitals reclassified for FY 2009 are anticipated to receive an increase of 3.9 percent, while urban hospitals that are not reclassified for FY 2009 are expected to receive an increase of 4.3 percent. Rural hospitals reclassifying for FY 2009 are anticipated to receive a 3.7 percent payment increase and rural hospitals that are not reclassifying are estimated to receive a payment increase of 2.8 percent. K. Effects of Policy on Payment Adjustments for Low-Volume Hospitals For FY 2009, we are continuing to apply the volume adjustment criteria we specified in the FY 2005 IPPS final rule (69 FR 49099). We expect that three providers will receive the low-volume adjustment for FY 2009. We 23913 estimate the impact of these providers receiving the additional 25-percent payment increase to be approximately $2,300. L. Impact Analysis of Table II Table II presents the projected impact of the proposed changes for FY 2009 for urban and rural hospitals and for the different categories of hospitals shown in Table I. It compares the estimated payments per case for FY 2008 with the proposed average estimated payments per case for FY 2009, as calculated under our models. Thus, this table presents, in terms of the average dollar amounts paid per discharge, the combined effects of the proposed changes presented in Table I. The proposed percentage changes shown in the last column of Table II equal the proposed percentage changes in average payments from Column 9 of Table I. TABLE II.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009 OPERATING PROSPECTIVE PAYMENT SYSTEM [Payments per case] All hospitals .................................................................................................................... By Geographic Location: Urban hospitals ....................................................................................................... Large urban areas (populations over 1 million) ..................................................... Other urban areas (populations of 1 million or fewer) ........................................... Rural hospitals ........................................................................................................ Bed Size (Urban): 0–99 beds ............................................................................................................... 100–199 beds ......................................................................................................... 200–299 beds ......................................................................................................... 300–499 beds ......................................................................................................... 500 or more beds ................................................................................................... Bed Size (Rural): 0–49 beds ............................................................................................................... 50–99 beds ............................................................................................................. 100–149 beds ......................................................................................................... 150–199 beds ......................................................................................................... 200 or more beds ................................................................................................... Urban by Region: New England .......................................................................................................... Middle Atlantic ........................................................................................................ South Atlantic ......................................................................................................... East North Central .................................................................................................. East South Central ................................................................................................. West North Central ................................................................................................. West South Central ................................................................................................ Mountain ................................................................................................................. Pacific ..................................................................................................................... Puerto Rico ............................................................................................................. Rural by Region: New England .......................................................................................................... Middle Atlantic ........................................................................................................ South Atlantic ......................................................................................................... East North Central .................................................................................................. East South Central ................................................................................................. West North Central ................................................................................................. West South Central ................................................................................................ Mountain ................................................................................................................. Pacific ..................................................................................................................... By Payment Classification: Urban hospitals ....................................................................................................... Large urban areas (populations over 1 million) ..................................................... Other urban areas (populations of 1 million or fewer) ........................................... VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00387 Fmt 4701 Sfmt 4702 Average FY 2008 payment per case 1 Average proposed FY 2009 payment per case 1 All proposed FY 2009 changes (1) jlentini on PROD1PC65 with PROPOSALS2 Number of hospitals (2) (3) (4) 3,528 $9,144 $9,519 4.1 2,542 1,402 1,140 986 9,571 10,045 9,000 6,683 9,972 10,484 9,355 6,905 4.2 4.4 3.9 3.3 643 829 483 411 176 7,283 8,103 8,985 10,046 11,875 7,533 8,428 9,363 10,482 12,382 3.4 4 4.2 4.3 4.3 338 373 166 67 42 5,509 6,097 6,660 7,467 8,361 5,644 6,279 6,884 7,752 8,686 2.5 3 3.4 3.8 3.9 121 348 385 394 163 157 371 157 393 53 9,935 10,440 9,025 9,065 8,681 9,140 9,043 9,571 11,614 4,706 10,230 10,752 9,427 9,440 9,044 9,555 9,466 10,051 12,219 4,857 3 3 4.5 4.1 4.2 4.5 4.7 5 5.2 3.2 23 70 172 121 176 113 200 75 36 9,051 6,912 6,529 6,872 6,263 6,886 6,088 6,802 8,162 9,263 7,124 6,773 7,093 6,474 7,119 6,276 7,010 8,455 2.3 3.1 3.7 3.2 3.4 3.4 3.1 3.1 3.6 2,584 1,424 1,160 9,549 10,026 8,975 9,948 10,464 9,328 4.2 4.4 3.9 E:\FR\FM\30APP2.SGM 30APP2 23914 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE II.—IMPACT ANALYSIS OF PROPOSED CHANGES FOR FY 2009 OPERATING PROSPECTIVE PAYMENT SYSTEM— Continued [Payments per case] Number of hospitals Average FY 2008 payment per case 1 Average proposed FY 2009 payment per case 1 All proposed FY 2009 changes (1) (2) (3) (4) Rural areas ............................................................................................................. Teaching Status: Non-teaching .......................................................................................................... Fewer than 100 Residents ..................................................................................... 100 or more Residents ........................................................................................... Urban DSH: Non-DSH ................................................................................................................ 100 or more beds ................................................................................................... Less than 100 beds ................................................................................................ Rural DSH: SCH ........................................................................................................................ RRC ........................................................................................................................ 100 or more beds ................................................................................................... Less than 100 beds ................................................................................................ Urban teaching and DSH: Both teaching and DSH .......................................................................................... Teaching and no DSH ............................................................................................ No teaching and DSH ............................................................................................ No teaching and no DSH ....................................................................................... Rural Hospital Types: RRC ........................................................................................................................ SCH ........................................................................................................................ MDH ........................................................................................................................ SCH and RRC ........................................................................................................ MDH and RRC ....................................................................................................... Type of Ownership: Voluntary ................................................................................................................. Proprietary .............................................................................................................. Government ............................................................................................................ Medicare Utilization as a Percent of Inpatient Days: 0–25 ........................................................................................................................ 25–50 ...................................................................................................................... 50–65 ...................................................................................................................... Over 65 ................................................................................................................... Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2009 Reclassifications: All Reclassified Hospitals FY 2009 ........................................................................ All Non-Reclassified Hospitals FY 2009 ................................................................ Urban Reclassified Hospitals FY 2009: ................................................................. Urban Non-reclassified Hospitals FY 2009: ........................................................... Rural Reclassified Hospitals FY 2009: ................................................................... Rural Nonreclassified Hospitals FY 2009: ............................................................. All Section 401 Reclassified Hospitals: .................................................................. Other Reclassified Hospitals (Section 1886(d)(8)(B)) ............................................ Specialty Hospitals: Cardiac Specialty Hospitals .................................................................................... 1 These 944 6,716 6,941 3.3 2,485 805 238 7,716 9,193 13,392 8,023 9,577 13,951 4 4.2 4.2 838 1,534 354 8,118 10,062 6,792 8,409 10,498 7,022 3.6 4.3 3.4 389 206 39 168 6,093 7,465 6,110 5,451 6,293 7,740 6,299 5,580 3.3 3.7 3.1 2.4 811 172 1,077 524 10,986 8,885 8,283 7,796 11,457 9,201 8,644 8,083 4.3 3.6 4.4 3.7 197 355 156 102 12 7,783 6,564 5,757 7,901 7,303 8,100 6,764 5,975 8,223 7,510 4.1 3 3.8 4.1 2.8 2,027 827 587 9,252 8,424 9,440 9,625 8,772 9,853 4 4.1 4.4 255 1,350 1,431 392 13,112 10,344 7,950 7,033 13,751 10,801 8,245 7,245 4.9 4.4 3.7 3 805 2,723 445 2,075 360 565 29 61 8,803 9,264 9,547 9,586 7,240 5,870 7,555 6,534 9,141 9,651 9,921 9,994 7,505 6,033 7,816 6,716 3.8 4.2 3.9 4.3 3.7 2.8 3.5 2.8 20 10,894 11,085 1.8 payment amounts per case do not reflect any estimates of annual case-mix increase. jlentini on PROD1PC65 with PROPOSALS2 VII. Effects of Other Proposed Policy Changes A. Effects of Proposed Policy on HACs, Including Infections In addition to those policy changes discussed above that we are able to model using our IPPS payment simulation model, we are proposing to make various other changes in this proposed rule. Generally, we have limited or no specific data available with which to estimate the impacts of these proposed changes. Our estimates of the likely impacts associated with these other proposed changes are discussed below. In section II.F. of the preamble of this proposed rule, we discuss our implementation of section 5001(c) of Pub. L. 109–171, which requires the Secretary to identify conditions that (1) are high cost, high volume, or both, (2) result in the assignment of a case to a MS–DRG that has a higher payment when present as a secondary diagnosis, and (3) could reasonably have been prevented through application of evidence-based guidelines. For VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00388 Fmt 4701 Sfmt 4702 discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. However, the statute also requires the Secretary to continue counting the condition as a secondary diagnosis that results in a higher IPPS payment when doing the budget neutrality calculations for MS– DRG reclassifications and recalibration. Therefore, we do our budget neutrality calculations as though the payment provision E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules did not apply but Medicare will make a lower payment to the hospital for the specific case that includes the secondary diagnosis. Thus, the provision will result in cost savings to the Medicare program. We note that the provision will only apply when one or more of the selected conditions are the only secondary diagnosis or diagnoses present on the claim that will lead to higher payment. Therefore, if at least one nonselected secondary diagnosis that leads to the same higher payment is on the claim, the case will continue to be assigned to the higher paying DRG and there will be no savings to Medicare from the case. Medicare beneficiaries will generally have multiple secondary diagnoses during a hospital stay, such that beneficiaries having one MCC or CC will frequently have additional conditions that also will generate higher payment. Therefore, in only a small percentage of the cases will the beneficiary have only one secondary diagnosis that would lead to higher payment. The section 5001(c) payment provision will go into effect on October 1, 2008. Our savings estimate for the next 5 fiscal years from this provision has changed from our savings estimate published in the FY 2008 IPPS final rule with comment period because of the potential addition to the list of selected HACs for FY 2009 of the nine conditions considered in section II.F. of this proposed rule. We had estimated a savings of $20 million per year from this provision for the eight conditions we originally selected in the FY 2008 IPPS final rule with comment period (72 FR 48168). We now estimate that this provision will save $50 million per year for the first 3 years beginning October 1, 2008. Beginning in FY 2012, we estimate a savings of $60 million per year as a result of this provision. Our savings estimates for the next 5 fiscal years are shown below: Savings (in millions) Year jlentini on PROD1PC65 with PROPOSALS2 FY FY FY FY FY 2009 2010 2011 2012 2013 ...................................... ...................................... ...................................... ...................................... ...................................... $50 50 50 60 60 B. Effects of Proposed MS–LTC–DRG Reclassifications and Relative Weights for LTCHs In section II.I. of the preamble to this proposed rule, we discuss the proposed MS– LTC–DRGs (proposed Version 26.0 of the GROUPER) and development of the proposed relative weights for use under the LTCH PPS for FY 2009. We also discuss that when we adopted the new severity adjusted MS–LTC– DRG patient classification system under the LTCH PPS in the FY 2008 IPPS final rule with comment, we implemented a 2-year transition, in which the MS–LTC–DRG relative weights for FY 2009 would be based completely on the MS–LTC–DRG patient classification system (and no longer based in part on the former LTC–DRG patient classification system). Consistent with the requirement at § 412.517 established in the RY 2008 LTCH PPS final rule (72 FR 26880 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 through 26884), the proposed annual update to the classification and relative weights under the LTCH PPS for RY 2009 was done in a budget neutral manner, such that estimated aggregate LTCH PPS payments would be unaffected; that is, they would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the MS– LTC–DRG classification and relative weight changes. To achieve budget neutrality under § 412.517, in determining the proposed FY 2009 MS–LTC–DRG relative weights, we applied a factor of 1.038266 in the first step of the budget neutrality process (normalization), and we applied a budget neutrality factor of 0.9965 after normalization (see section II.I.4. (step 7) of the preamble of this proposed rule). These proposed factors that were applied to maintain budget neutrality were based on the most recent available LTCH claims data (FY 2007 MedPAR files) for the 387 LTCHs in our database. Consistent with the budget neutrality requirement under § 412.517, we estimate that with the proposed changes to the MS–LTC–DRG classifications and relative weights for FY 2009, there would be no change in aggregate LTCH PPS payments. In applying the budget neutrality adjustment described above, we assumed constant utilization. C. Effects of Proposed Policy Change Relating to New Medical Service and Technology Add-On Payments In section II.J. of the preamble to this proposed rule, we discuss proposed add-on payments for new medical services and technologies. As explained in that section, add-on payments for new technology under section 1886(d)(5)(K) of the Act are not required to be budget neutral. As discussed in section II.J.4. of this proposed rule, we have yet to determine whether any of the four applications we received will meet the criteria for new technology add-on payments for FY 2009. Consequently, it is premature to estimate the potential payment impact in FY 2009 of any potential new technology add-on payments for FY 2009. There are no technologies receiving new technology addon payment in FY 2008. Therefore, at this time, we estimate that Medicare’s new technology add-on payments would remain unchanged in FY 2009 compared to FY 2008. If any of the four applicants are found to be eligible for new technology add-on payments for FY 2009 in the final rule, we would discuss the estimated payment impact for FY 2009 in that final rule. D. Effects of Proposed Policy Regarding Postacute Care Transfers to Home Health Services In section IV.A. of the preamble to this proposed rule, we noted that, under current regulations, the postacute care transfer policy applies to acute care discharges for which home health care (for a related condition) begins within 3 days of the discharge from an acute care hospital where the patient was discharged from the hospital prior to the geometric mean length of stay for a ‘‘qualified’’ MS–DRG. In that section, we discussed the reasons why we believe that PO 00000 Frm 00389 Fmt 4701 Sfmt 4702 23915 the 3-day timeframe is no longer an appropriate threshold under the postacute care transfer policy. We discussed our rationale for extending the timeframe from within 3 days to within 7 days. Accordingly, we proposed to revise the timeframe in our regulations to within 7 days of discharge to home under a written plan for the provision of home health services, effective with discharges occurring on or after October 1, 2008. To estimate the impact of this proposal, we used acute care hospital claims from the FY 2005 MedPAR file and searched for claims with a discharge destination code of ‘‘01’’ (Discharged to Home or Self-Care (Routine Discharge)) or ‘‘06’’ (Discharged/Transferred to Home under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care). We then matched the acute care hospital MedPAR claims with HHA final action claims for 2005, using beneficiary identification numbers. We then compared the hospital discharge date with the home health admission date and determined a distribution by the difference in these two dates. We found that, for those patients for whom home health services began within 60 days of hospital discharge, in 6.7 percent of the cases, the services began on days 4 through day 7 after the acute care hospital discharge. We estimate that applying the proposed change to the hospital postacute care transfer policy would reduce Medicare payments to acute care inpatient hospitals by approximately $330 million over 5 years. For FY 2009, we estimate that Medicare payments would be reduced by approximately $50 million. E. Effects of Proposed Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update In section IV.B. of the preamble of this proposed rule, we discuss the requirements for hospitals to report quality data in order for hospitals to receive the full annual hospital payment update for FY 2009 and FY 2010. There are an estimated 186 hospitals in this analysis that may not receive the full market basket update for FY 2009. Most of these hospitals are either small rural or small urban hospitals. However, at this time, information is not available to determine the hospitals that do not meet the requirements for the full hospital market increase for FY 2009. We also note that, for the FY 2009 payment update, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the four quarters of data from FY 2007. These data were due to the QIO Clinical Warehouse by May 15, 2007 (fourth quarter CY 2006 discharges), August 15, 2007 (first quarter CY 2007 discharges), November 15, 2007 (second quarter CY 2007 discharges), and February 15, 2008 (third quarter CY 2007 discharges). We have continued our efforts to ensure that QIOs provide assistance to all hospitals that wish to submit data. In the preamble of this proposed rule, we are proposing to provide additional validation criteria to ensure that the quality data being sent to CMS are accurate. The requirement of 5 charts per E:\FR\FM\30APP2.SGM 30APP2 23916 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules hospital will result in approximately 21,500 charts per quarter total submitted to the agency. We reimburse hospitals for the cost of sending charts to the Clinical Data Abstraction Center (CDAC) at the rate of 12 cents per page for copying and approximately $4.00 per chart for postage. Our experience shows that the average chart received at the CDAC is approximately 150 pages. Thus, the agency will have expenditures of approximately $597,600 per quarter to collect the charts. Given that we reimburse for the data collection effort, we believe that a requirement for five charts per hospital per quarter represents a minimal burden to the participating hospital. F. Effects of Proposed Policy Change to Methodology for Computing Core Staffing Factors for Volume Decrease Adjustment for SCHs and MDHs In section IV.D. of the preamble of this proposed rule, we discuss a change to the methodology we would use to compute the average nursing staff factors (nursing hours per patient days) for the volume decrease adjustment for SCHs and MDHs. If certain requirements are met, this adjustment may be made if the hospital’s total discharges decrease by more than 5 percent from one cost reporting period to the next. We do not believe this proposed change would have any significant impact on Medicare payments to these hospitals. jlentini on PROD1PC65 with PROPOSALS2 G. Effects of Proposed Clarification of Policy for Collection of Risk Adjustment Data From MA Organizations In section IV.H. of the preamble of this proposed rule, we discuss our proposed revision of our regulations to clarify that CMS has the authority to require MA organizations to submit encounter data for each item and service provided to an MA plan enrollee. The proposed revision also would clarify that CMS will determine the formats for submitting encounter data, which may be more abbreviated than those used for the Medicare fee-for-service claims data submission process. At this time, we have not yet determined an approach for submission of the encounter data. Therefore, we are not in a position to determine the extent to which the cost impact of submitting encounter data would differ from the current costs to MA organizations of submitting risk adjustment data. H. Effects of Proposed Policy Changes Relating to Hospital Emergency Services Under EMTALA In section IV.I. of the preamble of this proposed rule, we are proposing to clarify our policy regarding the applicability of EMTALA to hospital inpatients. We are proposing to amend the regulations to state that when an individual covered by EMTALA was admitted as an inpatient and remains unstabilized with an emergency medical condition, a receiving hospital with specialized capabilities has an EMTALA obligation to accept that individual, assuming that the transfer of the individual is an appropriate transfer and the participating hospital with specialized capabilities has the capacity to treat the individual. In addition, we are proposing two VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 changes relating to the requirements for oncall physicians in hospital emergency departments. We are proposing to delete the provision relating to maintaining a list of oncall physicians from the regulations referring to EMTALA at § 489.24(j)(1) because a provision addressing the on-call physician list is already included in the regulations relating to provider agreements at § 489.20(r)(2). We are proposing to incorporate the language of § 489.24(j)(1) as replacement language for the existing § 489.20(r)(2) and amend the regulatory language to make it more consistent with the statutory language found at section 1866(a)(1)(I)(iii) of the Act, which refers to hospital CoPs and the requirement to maintain an on-call list. These proposed changes would make the regulations consistent with the statutory basis for maintaining an on-call list. In addition, we are proposing to amend our regulations to provide that hospitals may comply with the on-call list requirement by participating in a formal community call plan so long as the plan includes a number of elements that are specified in the preamble to the proposed rule. Lastly, we are proposing to make a technical change to the regulations to conform them to the statutory language found in the Pandemic and All-Hazards Preparedness Act. These proposals do not include any substantive new requirements. Although hospitals choosing to participate in a community call arrangement will be required to devise a formal community call plan, such a plan would increase a hospital’s flexibility in meeting its on-call requirements. We are estimating no impact on Medicare expenditures and no significant impact on hospitals with emergency departments. I. Effects of Implementation of Rural Community Hospital Demonstration Program In section IV.K. of the preamble to this proposed rule, we discuss our implementation of section 410A of Pub. L. 108–173 that required the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) requires that ‘‘in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.’’ There are currently nine hospitals participating in the demonstration. We are currently conducting a solicitation for up to six additional hospitals to participate in the demonstration program. As discussed in section IV.K. of the preamble to this proposed rule, we are satisfying this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. We estimate that the average additional annual payment for FY 2009 that would be made to each participating hospital under the demonstration would be approximately $2,134,123. We based this estimate on the recent historical experience of the difference PO 00000 Frm 00390 Fmt 4701 Sfmt 4702 between inpatient cost and payment for hospitals that are participating in the demonstration. As an estimate for the 15 hospitals that may participate, the total annual impact of the demonstration program for FY 2009 is projected to be $32,011,849. (In the final rule, we should know the exact number of hospitals participating in the demonstration program and would revise our estimates accordingly.) The adjustment factor to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999903. J. Effects of Proposed Policy Changes Relating to Payments to Hospitals-Within-Hospitals In section VI.F. of the preamble of this proposed rule, we discuss our proposed policy change to allow a HwH that cannot meet the criteria in regulations for a separate governing body solely because it is a State hospital occupying space with another State hospital or located on the same campus as another State hospital and both hospitals are under the same governing authority, or the governing authority of a third entity that controls both State hospitals, to nevertheless qualify for an exclusion from the IPPS if the hospital meets other applicable criteria for HwHs in the regulations and the specified proposed criteria in this proposed rule. We are only aware of one hospital that would be allowed qualify for exclusion from the IPPS under the proposed criteria and to expand its bed size under the proposed provisions. Because any expansion would occur at some point in the future, we are unable to quantify the impact of this proposed change. K. Effects of Proposed Policy Changes Relating to Requirements for Disclosure of Physician Ownership in Hospitals In section VII. of the preamble of this proposed rule, we discuss our proposals concerning (1) the definition of a physicianowned hospital; (2) the requirement that physician-owned hospitals disclose the ownership to patients; and (3) the requirement that all hospitals and CAHs must furnish written notice to their patients at the beginning of their hospital stay or outpatient visit if a physician is not present in the hospital 24 hours per day, 7 days per week, and that the notice must indicate how the hospital will meet the medical needs of any patient who develops an emergency medical condition at a time when there is no physician present in the hospital. The definition and the above requirements were implemented in the FY 2008 IPPS final rule with comment period (72 FR 47387 and 47391). In this proposed rule, we are proposing to revise the definition of a physician-owned hospital at § 489.3 to include hospitals that have an ownership or investment interests by a physician and/or by an immediate family member of a physician. (The existing definition refers to an ownership or investment interest by a physician only, and not to an ownership or investment interest by an immediate family member.) We are also proposing to except from the definition of physician-owned hospital those hospitals that do not have at least one physician owner/investor or immediate family member E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules owner/investor who refers patients to the hospital. We believe that the proposed changes to the definition of physician-owned hospital would result in no more than a de minimis increase in the number of hospitals that are subject to the disclosure requirements applicable to physician-owned hospitals. We believe that there would be very few hospitals that would now meet the definition of physician-owned hospital, if we adopt our proposal to include immediate family members within the group of owners or investors that cause a hospital to be considered physician-owned, that did not already meet the definition. That is, we believe there are very few hospitals for which an immediate family member of a physician, but not the physician himself or herself, or any other physician, has an ownership or investment interest. Moreover, to the extent that such hospitals exist, that is, hospitals that have no physician owner/investors but which have owners/investors who are immediate family members of one or more physicians, such hospitals would not be subject to the disclosure requirement if we adopt our proposed exception to the definition of a physician-owned hospital for those hospitals that do not have at least one referring physician whose immediate family member is an owner/investor. Also, if we adopt this proposed exception to the definition of physician-owned hospital, the number of hospitals that now are subject to the disclosure requirement may be reduced slightly as we understand that there are some hospitals that have no referring physician owner/investors but rather have physician owner/investors who have retired from the practice of medicine. Thus, if both our proposed changes to the definition of physician-owned hospital are adopted, the net result may be no change, or a minimal increase or decrease in the number of hospitals that are subject to the disclosure requirement. Finally, if our proposal to change the definition of physician-owned hospital is adopted to encompass immediate family members, some hospitals that already meet the definition based on the presence of physician owner/investors may have to amend their list of physician owner/investors to add immediate family members, which we believe would be a minimal burden. We are proposing to clarify that the list of the hospital’s owners or investors who are physicians or immediate family members of physicians must be provided to the patient at the time the request for the list is made by or on behalf of the patient. We note that hospitals are already currently required to furnish the list of physician owners or investors and, thus, we believe that the impact of stipulating a timeframe for furnishing the list is negligible. We are proposing to require all hospitals to require that all physician owners who also are members of the hospital’s medical staff to agree, as a condition of continued medical staff membership or admitting privileges, to disclose, in writing, to all patients they refer to the hospital any ownership or investment interest that is held by themselves or by an immediate family member (as defined in § 411.351). Disclosure would be required at the time the referral is made. Both hospitals VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 and physicians would participate in the disclosure process. We believe this proposal would have a small effect on physicianowned hospitals to the extent that it may require them to change their bylaws or make similar changes. We do not anticipate that our proposals in section VII. of the preamble of this proposed rule would have a significant economic impact on a substantial number of physicians, other health care providers and suppliers, or the Medicare or Medicaid programs and their beneficiaries. Specifically, we believe that this proposed rule would affect mostly hospitals, physicians, and beneficiaries. The proposed changes concerning both the definition of a physician-owned hospital and the disclosure of physician ownership in hospitals are consistent with the physician self-referral statute and regulations as well as the current practices of most hospitals. Thus, our proposed requirement that the list of physician owners be provided to the patient at the time the request for the list is made by or on behalf of the patient would present a negligible economic impact on the hospital. Similarly, the cost borne by individual physicians to implement these provisions would be limited to a one-time cost associated with developing a disclosure notice that would be shared with patients at the time the referral is made in addition to the negligible time associated with providing the list to the patient and maintaining a copy of the notice in the patient’s medical record. We are also proposing to provide authority for CMS to terminate the Medicare provider agreement of any hospital that fails to furnish the required written notice that a physician is not available 24 hours per day, 7 days per week and to describe how the hospital will meet the medical needs of any patient who develops an emergency medical condition at a time when there is no physician present in the hospital. We believe that the cost borne by hospitals to implement this proposal would be limited to a one-time cost associated with completing minor revisions to the hospital’s policies and procedures to comply with the requirements of its Medicare provider agreement. Most hospitals have standard procedures to satisfy CMS by correcting deficiencies (such as the failure to furnish notice of physician ownership in the hospital to patients) before action is taken by CMS to terminate the Medicare provider agreement. Overall, we believe that beneficiaries would be positively impacted by these provisions. Specifically, disclosure of physician ownership or investment interests equips patients to make informed decisions about where they elect to receive care. Our proposals make no significant changes that have the potential to impede patient access to health care facilities and services. In fact, we believe that our proposals would help minimize anti-competitive behavior that can affect the decision as to where a beneficiary receives health care services and possibly the quality of the services furnished. L. Effects of Proposed Changes Relating to Physician Self-Referral Provisions In section VIII. of the preamble of this proposed rule, we discuss our proposals PO 00000 Frm 00391 Fmt 4701 Sfmt 4702 23917 pertaining to physician self-referral provisions, including: stand in the shoes, period of disallowance, and reporting of financial relationships between hospitals and physicians. We do not anticipate that our proposals would have a significant impact on physicians, other health care providers and suppliers, or the Medicare or Medicaid programs and their beneficiaries. With respect to the proposals to modify the physician ‘‘stand in the shoes’’ provisions, we do not anticipate that entities that include one or more physician organizations would find it necessary to restructure their organizational relationships. We believe that if either of our alternative approaches is adopted, compliance with the ‘‘stand in the shoes’’ provisions would be made easier by simplifying the required analysis of arrangements in which a physician organization is interposed between the referring physician and the entity furnishing DHS. In addition to our proposals concerning the physician ‘‘stand in the shoes’’ provisions, we are making an entity ‘‘stand in the shoes’’ proposal, whereby an entity that furnishes DHS would be deemed to stand in the shoes of an organization in which it has a 100-percent ownership interest and would be deemed to have the same compensation arrangements with the same parties and on the same terms as does the organization that it owns. We believe that the entity stand in the shoes proposal may result in more financial relationships between entities and physicians being subject to the physician self-referral provisions, but we are unable to quantify at this time the possible increase or determine the effect of the proposal on the referral patterns or organization structures of DHS entities and their wholly-owned organizations. Rather, we welcome public comments on these issues. Our proposal pertaining to the period of disallowance is a codification of what we believe is existing law and reflects what we believe most entities furnishing DHS are already following. Therefore, we do not anticipate a significant economic impact on the industry. M. Effects of Proposed Changes Relating to Reporting of Financial Relationships Between Hospitals and Physicians As discussed in section IX. of the preamble to this proposed rule, we are proposing to require that 500 hospitals furnish information concerning their financial relationships with their physicians. The financial relationships include ownership and investment interests and compensation arrangements. We are proposing that this information be submitted in a collection of information instrument that CMS has developed—the ‘‘DFRR,’’ which is included in Appendix C to this proposed rule. We are unable to quantify the number of physicians who have ownership and investment interests and compensation arrangements with hospitals. Even if we assume that the 500 hospitals have a substantial number of financial relationships with physicians, we believe that, in general, the economic impact on these hospitals would not be substantial. Because we are proposing that the DFRR be completed by hospitals and that the E:\FR\FM\30APP2.SGM 30APP2 23918 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules physician information requested in the DFRR will be on file at the hospital, we believe there should be negligible, if any, impact upon physicians or other health care providers or suppliers. Specifically, we believe that the cost to complete the DFRR for each hospital would be approximately $1,550, and the total cost burden for the industry would be approximately $775,000. We expect that this proposed rule may result in savings to the Medicare program by minimizing anti-competitive business arrangements as well as financial incentives that encourage overutilization. In addition, to the extent that we determine that any arrangements are noncompliant with the physician self-referral statute and regulations, there may be monies returned to the Medicare Trust Fund. We cannot gauge with any certainty the extent of these savings to the Medicare program at this time. Finally, we do not anticipate any financial burden on beneficiaries or impact on beneficiary access to medically necessary services because the completion of the DFRR would be conducted by hospitals. VIII. Effects of Proposed Changes in the Capital IPPS jlentini on PROD1PC65 with PROPOSALS2 A. General Considerations Fiscal year (FY) 2001 was the last year of the 10-year transition period established to phase in the PPS for hospital capital-related costs. During the transition period, hospitals were paid under one of two payment methodologies: fully prospective or hold harmless. Under the fully prospective methodology, hospitals were paid a blend of the capital Federal rate and their hospitalspecific rate (see § 412.340). Under the holdharmless methodology, unless a hospital elected payment based on 100 percent of the capital Federal rate, hospitals were paid 85 percent of reasonable costs for old capital costs (100 percent for SCHs) plus an amount for new capital costs based on a proportion of the capital Federal rate (see § 412.344). As we state in section V. of the preamble of this proposed rule, with the 10-year transition period ending with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002), beginning in FY 2002 capital prospective payment system payments for most hospitals are based solely on the capital Federal rate. Therefore, we no longer include information on obligated capital costs or projections of old capital costs and new capital costs, which were factors needed to calculate payments during the transition period, for our impact analysis. The basic methodology for determining a capital PPS payment is set forth at § 412.312. The basic methodology for calculating capital IPPS payments in FY 2009 would be as follows: (Standard Federal Rate) × (DRG weight) × (GAF) × (COLA for hospitals located in Alaska and Hawaii) × (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). We note that, in accordance with § 412.322(c), the IME adjustment factor for FY 2009 is equal to half of the current adjustment, as discussed in section V.B.2. of the preamble of this proposed rule. In addition, hospitals may also receive outlier VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 payments for those cases that qualify under the threshold established for each fiscal year. The data used in developing the impact analysis presented below are taken from the December 2007 update of the FY 2007 MedPAR file and the December 2007 update of the Provider-Specific File that is used for payment purposes. Although the analyses of the proposed changes to the capital prospective payment system do not incorporate cost data, we used the December 2007 update of the most recently available hospital cost report data (FYs 2005 and 2006) to categorize hospitals. Our analysis has several qualifications. We use the best data available and make assumptions about casemix and beneficiary enrollment as described below. In addition, as discussed in section III. of the Addendum to this proposed rule, as we established for FY 2008, we are proposing to adjust the national capital rate to account for improvements in documentation and coding under the MS– DRGs in FY 2009. (As discussed in section III.A.6. of the Addendum to this proposed rule, we are not proposing to adjust the Puerto Rico specific capital rate to account for improvements in documentation and coding under the MS–DRGs in FY 2009.) Furthermore, due to the interdependent nature of the IPPS, it is very difficult to precisely quantify the impact associated with each proposed change. In addition, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases (for instance, the number of beds), there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available sources overall. However, for individual hospitals, some miscategorizations are possible. Using cases from the December 2007 update of the FY 2007 MedPAR file, we simulated payments under the capital PPS for FY 2008 and FY 2009 for a comparison of total payments per case. Any short-term, acute care hospitals not paid under the general IPPS (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations. As we explain in section III.A. of the Addendum to this proposed rule, payments are no longer made under the regular exceptions provision under §§ 412.348(b) through (e). Therefore, we no longer use the actuarial capital cost model (described in Appendix B of the August 1, 2001 proposed rule (66 FR 40099)). We modeled payments for each hospital by multiplying the capital Federal rate by the GAF and the hospital’s case-mix. We then added estimated payments for indirect medical education (which are reduced by 50 percent in FY 2009 in accordance with § 412.322(c), as discussed in section V.B.2. of the preamble of this proposed rule), disproportionate share, and outliers, if applicable. For purposes of this impact analysis, the model includes the following assumptions: • We estimate that the Medicare case-mix index will increase by 1.0 percent in both FYs 2008 and 2009. (We note that this does not reflect the expected growth in case-mix due to improvement in documentation and coding under the MS–DRGs, as discussed below.) PO 00000 Frm 00392 Fmt 4701 Sfmt 4702 • We estimate that the Medicare discharges will be 13.2 million in FY 2008 and 13.3 million in FY 2009 for an approximately 0.4 percent increase from FY 2008 to FY 2009. • The capital Federal rate was updated beginning in FY 1996 by an analytical framework that considers changes in the prices associated with capital-related costs and adjustments to account for forecast error, changes in the case-mix index, allowable changes in intensity, and other factors. As discussed in section VIII. of the preamble and section III.A.2.1. of the Addendum to this proposed rule, the proposed FY–2009 update is 0.7 percent. • In addition to the proposed FY 2009 update factor, the proposed FY 2009 capital Federal rate was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0007, a proposed outlier adjustment factor of 0.9427, and a proposed exceptions adjustment factor of 0.9998. • For FY 2009, as discussed in section III.A. of the Addendum to this proposed rule, the proposed FY 2009 national capital rate was further adjusted by a factor to account for anticipated improvements in documentation and coding that are expected to increase case-mix under the MS–DRGs. In the FY 2008 IPPS final rule with comment period (72 FR 47186), we established adjustments to the IPPS rates based on the Office of the Actuary projected case-mix growth resulting from improved documentation and coding of 1.2 percent for FY 2008, 1.8 percent for FY 2009, and 1.8 percent for FY 2010. However, we reduced the documentation and coding adjustment to –0.6 percent for FY 2008, and for FY 2009, we are proposing to apply an adjustment of 0.9 percent, consistent with section 7 of Pub. L. 110–90. As noted above and as discussed in section III.A.6. of the Addendum to this proposed rule, we are not proposing to adjust the Puerto Rico-specific capital rate to account for improvements in documentation and coding under the MS–DRGs in FY 2009. B. Results We used the actuarial model described above to estimate the potential impact of our proposed changes for FY 2009 on total capital payments per case, using a universe of 3,528 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2007 update of the FY 2007 MedPAR file, the December 2007 update to the PSF, and the most recent cost report data from the December 2007 update of HCRIS. In Table III, we present a comparison of total payments per case for FY 2008 compared to proposed FY 2009 based on the proposed FY 2009 payment policies. Column 2 shows estimates of payments per case under our model for FY 2008. Column 3 shows estimates of payments per case under our model for FY 2009. Column 4 shows the total percentage change in payments from FY 2008 to FY 2009. The change represented in Column 4 includes the proposed 0.7 percent update to the capital Federal rate, other changes in the adjustments to the capital Federal rate (for example, the 50 percent reduction to the teaching adjustment for FY E:\FR\FM\30APP2.SGM 30APP2 23919 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 2009), and the additional 0.9 percent reduction to the national capital rate to account for improvements in documentation and coding (or other changes in coding that do not reflect real changes in case-mix) for implementation of the MS–DRGs. Consistent with the impact analysis for the proposed policy changes under the IPPS for operating costs in section VI. of this Appendix, for purposes of this impact analysis, we also assume a 1.8 percent increase in case-mix growth for FY 2009, as determined by the Office of the Actuary, because we believe the adoption of the MS–DRG will result in casemix growth due to documentation and coding changes that do not reflect real changes in patient severity of illness. The comparisons are provided by: (1) Geographic location; (2) region; and (3) payment classification. The simulation results show that, on average, capital payments per case in FY 2009 can be expected to remain about the same as capital payments per case in FY 2008. The proposed capital rate for FY 2009 would decrease 1.14 percent as compared to the FY 2008 capital rate, and the proposed changes to the GAFs are expected to result in a slight decrease (0.3 percent) in capital payments. In addition, the 50 percent reduction to the teaching adjustment in FY 2009 will also result in a decrease in capital payments from FY 2008 as compared to FY 2009. Countering these factors is the projected case-mix growth as a result of improved documentation and coding (discussed above) as well as an estimated increase in outlier payments in FY 2008 as compared to FY 2009. The net result of these changes is an estimated 0.0 percent change in capital payments per discharge from FY 2008 to FY 2009 for all hospitals (as shown below in Table III). The results of our comparisons by geographic location and by region are consistent with the results we expected with the decrease to the teaching adjustment in FY 2009 (§ 412.522(c)). The geographic comparison shows that all urban hospitals are expected to experience no change in capital IPPS payments per case in FY 2009 as compared to FY 2008, while hospitals in large urban areas are expected to experience a slight decrease (0.3 percent) in capital IPPS payments per case in FY 2009 as compared to FY 2008. Capital IPPS payments per case for rural hospitals are expected to increase 0.5 percent. These differences in payments per case by geographic location are mostly due to the decrease in the teaching adjustment. Because teaching hospitals generally tend to be located in urban or large urban areas, we would expect that the 50 percent decrease in the teaching adjustment for FY 2009 would have a more significant impact on hospitals in those areas than those hospitals located in rural areas. Most regions are estimated to experience an increase in total capital payments per case from FY 2008 to FY 2009. These increases vary by region and range from a 1.9 percent increase in the Pacific urban and West South Central urban regions to a 0.1 percent increase in the East North Central urban region. Two urban regions are projected to experience a relatively larger decrease in capital payments, with the difference mostly due to proposed changes in the GAFs and the 50 percent reduction in the teaching adjustment for FY 2009: ¥2.7 percent in the Middle Atlantic urban region and ¥3.6 percent in the New England urban region. The East North Central urban region is also expected to experience a decrease of 0.1 percent in capital payments in FY 2009 as compared to FY 2008, mostly due to proposed changes in the GAFs. There are two rural regions that expected to experience a decrease in total capital payments per case: A ¥4.5 percent decrease in the New England rural region and a ¥1.0 percent decrease in the Middle Atlantic rural region. Again, for these two rural regions, the projected decrease in capital payments is mostly due to proposed changes in the GAF, as well as a smaller than average increase in changes payments due to the adoption of the MS– DRGs. By type of ownership, voluntary and government hospitals are estimated to experience a decrease of 0.2 percent and 0.8 percent, respectively. The projected decrease in capital payments per case is primarily due to the 50 percent teaching adjustment reduction for FY 2009. Proprietary hospitals are estimated to experience an increase in capital payments per case of 1.6 percent. This estimated increase in capital payments is mostly due to a smaller than average decrease in payments resulting from the 50 percent teaching adjustment reduction for FY 2009. Section 1886(d)(10) of the Act established the MGCRB. Before FY 2005, hospitals could apply to the MGCRB for reclassification for purposes of the standardized amount, wage index, or both. Section 401(c) of Pub. L. 108– 173 equalized the standardized amounts under the operating IPPS. Therefore, beginning in FY 2005, there is no longer reclassification for the purposes of the standardized amounts; however, hospitals still may apply for reclassification for purposes of the wage index for FY 2009. Reclassification for wage index purposes also affects the GAFs because that factor is constructed from the hospital wage index. To present the effects of the hospitals being reclassified for FY 2009, we show the average capital payments per case for reclassified hospitals for FY 2008. Urban reclassified hospitals are expected to have the largest decrease in capital payments of 0.4 percent, while rural reclassified hospitals are expected to have the largest increase in capital payments of 1.0 percent. Urban nonreclassified hospitals are not expected to experience any change in capital payment from FY 2008 to FY 2009, while rural nonreclassified hospitals are expected to experience a slight decrease in capital payments of 0.3 percent. The projected changes in capital payments for rural hospitals are mainly due to the proposed changes to the GAF (including the proposal to apply the rural floor budget neutrality at a State level). The projected changes in capital payments for urban hospitals are mainly due to the 50 percent reduction in the teaching adjustment in FY 2009. TABLE III.—COMPARISON OF TOTAL CAPITAL PAYMENTS PER CASE [FY 2008 payments compared to FY 2009 payments] jlentini on PROD1PC65 with PROPOSALS2 Number of hospitals By Geographic Location: All hospitals .............................................................................................................. Large urban areas (populations over 1 million) ....................................................... Other urban areas (populations of 1 million or fewer) ............................................. Rural areas ............................................................................................................... Urban hospitals ......................................................................................................... 0–99 beds .......................................................................................................... 100–199 beds .................................................................................................... 200–299 beds .................................................................................................... 300–499 beds .................................................................................................... 500 or more beds .............................................................................................. Rural hospitals .......................................................................................................... 0–49 beds .......................................................................................................... 50–99 beds ........................................................................................................ 100–149 beds .................................................................................................... 150–199 beds .................................................................................................... 200 or more beds .............................................................................................. By Region: VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00393 Fmt 4701 Sfmt 4702 Average FY 2008 payments/case Average FY 2009 payments/case 757 834 752 528 796 632 684 752 829 973 528 429 485 532 586 652 757 831 754 531 796 642 692 758 827 957 531 427 487 537 595 652 3,528 1,402 1,140 986 2,542 643 829 483 411 176 986 338 373 166 67 42 E:\FR\FM\30APP2.SGM 30APP2 Change 0.0 ¥0.3 0.3 0.5 0.0 1.6 1.1 0.8 ¥0.3 ¥1.7 0.5 ¥0.5 0.4 1.0 1.4 0.0 23920 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules TABLE III.—COMPARISON OF TOTAL CAPITAL PAYMENTS PER CASE—Continued [FY 2008 payments compared to FY 2009 payments] Average FY 2008 payments/case Average FY 2009 payments/case 2,542 121 348 385 394 163 157 371 157 393 53 986 23 70 172 121 176 113 200 75 36 796 835 858 755 777 719 777 747 807 925 367 528 706 543 516 555 480 560 479 533 650 796 805 835 763 770 727 779 761 822 943 368 531 675 537 524 555 484 567 483 539 660 0.0 ¥3.6 ¥2.7 1.1 ¥0.9 1.2 0.2 1.9 1.8 1.9 0.3 0.5 ¥4.5 ¥1.0 1.5 0.1 0.9 1.1 0.8 1.2 1.6 3,528 1,424 1,160 944 757 832 750 528 757 830 752 531 0.0 ¥0.3 0.3 0.6 2,484 805 238 643 765 1,085 657 769 1,037 2.1 0.5 ¥4.4 1,534 354 823 567 820 573 ¥0.3 1.2 389 206 467 584 469 589 0.4 0.8 39 168 489 438 493 438 0.8 0.1 811 172 1,077 524 896 784 683 702 881 777 700 716 ¥1.6 ¥0.8 2.5 2.0 2,459 63 36 11 15 800 700 654 457 751 799 714 659 456 776 ¥0.1 2.0 0.8 ¥0.2 3.4 445 2,075 360 565 54 802 796 573 459 535 799 796 579 458 538 ¥0.4 0.0 1.0 ¥0.3 0.5 2,027 827 587 770 699 752 769 710 746 ¥0.2 1.6 ¥0.8 255 1,350 1,431 392 998 847 671 598 971 843 677 601 ¥2.8 ¥0.5 0.9 0.5 jlentini on PROD1PC65 with PROPOSALS2 Number of hospitals Urban by Region ...................................................................................................... New England ..................................................................................................... Middle Atlantic ................................................................................................... South Atlantic .................................................................................................... East North Central ............................................................................................. East South Central ............................................................................................ West North Central ............................................................................................ West South Central ........................................................................................... Mountain ............................................................................................................ Pacific ................................................................................................................ Puerto Rico ........................................................................................................ Rural by Region ........................................................................................................ New England ..................................................................................................... Middle Atlantic ................................................................................................... South Atlantic .................................................................................................... East North Central ............................................................................................. East South Central ............................................................................................ West North Central ............................................................................................ West South Central ........................................................................................... Mountain ............................................................................................................ Pacific ................................................................................................................ By Payment Classification: All hospitals .............................................................................................................. Large urban areas (populations over 1 million) ....................................................... Other urban areas (populations of 1 million or fewer) ............................................. Rural areas ............................................................................................................... Teaching Status: Non-teaching ..................................................................................................... Fewer than 100 Residents ................................................................................ 100 or more Residents ...................................................................................... Urban DSH: 100 or more beds ....................................................................................... Less than 100 beds ................................................................................... Rural DSH: Sole Community (SCH/EACH) ................................................................... Referral Center (RRC/EACH) .................................................................... Other Rural: 100 or more beds ............................................................................... Less than 100 beds ............................................................................ Urban teaching and DSH: Both teaching and DSH .................................................................................... Teaching and no DSH ....................................................................................... No teaching and DSH ....................................................................................... No teaching and no DSH .................................................................................. Rural Hospital Types: Non special status hospitals RRC/EACH ........................................................................................................ SCH/EACH ........................................................................................................ Medicare-dependent hospitals (MDH) .............................................................. SCH, RRC and EACH ....................................................................................... Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2009 Reclassifications: All Urban Reclassified ....................................................................................... All Urban Non-Reclassified ............................................................................... All Rural Reclassified ........................................................................................ All Rural Non-Reclassified ................................................................................ Other Reclassified Hospitals (Section 1886(d)(8)(B)) ....................................... Type of Ownership: Voluntary ........................................................................................................... Proprietary ......................................................................................................... Government ....................................................................................................... Medicare Utilization as a Percent of Inpatient Days: 0–25 ................................................................................................................... 25–50 ................................................................................................................. 50–65 ................................................................................................................. Over 65 .............................................................................................................. VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00394 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 Change Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules IX. Alternatives Considered This proposed rule contains a range of proposed policies. The preamble of this proposed rule provides descriptions of the statutory provisions that are addressed, identifies those proposed policies when discretion has been exercised, and presents rationale for our decisions and, where relevant, alternatives that were considered. X. Overall Conclusion The changes we are proposing in this proposed rule will affect all classes of hospitals. Some hospitals are expected to experience significant gains and others less significant gains, but overall hospitals are projected to experience positive updates in IPPS payments in FY 2009. Table I of section VI. of this Appendix demonstrates the estimated distributional impact of the IPPS budget neutrality requirements for proposed MS–DRG and wage index changes, and for the wage index reclassifications under the MGCRB. Table I also shows an overall increase of 4.1 percent in operating payments. We estimate operating payments to increase by $3.96 billion. This accounts for the projected savings associated with the postacute care transfer policy proposal and the HACs policy, which each have an estimated savings of $50 million. In addition, this estimate includes the hospital reporting of quality data program costs ($2.39 million) and all proposed operating payment policies as described in section VII. of this Appendix. Capital payments are estimated to increase by 0.0 percent per case, as shown in Table III of section VIII. of this Appendix. Therefore, we project that the increase in capital payments in FY 2009 compared to FY 2008 is negligible ($6 million). The proposed 23921 operating and capital payments should result in a net increase of $3.967 billion to IPPS providers. The discussions presented in the previous pages, in combination with the rest of this proposed rule, constitute a regulatory impact analysis. XI. Accounting Statement As required by OMB Circular A–4 (available at https://www.whitehousegov/omb/ circulars/a004/a-4.pdf), in Table IV below, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the increase in Medicare payments to providers as a result of the proposed changes to the IPPS presented in this proposed rule. All expenditures are classified as transfers to Medicare providers. TABLE IV.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES FROM FY 2008 TO FY 2009 Category Transfers Annualized Monetized Transfers .............................................................. From Whom to Whom .............................................................................. Total ................................................................................................... XII. Executive Order 12866 In accordance with the provisions of Executive Order 12866, the Office of Management and Budget reviewed this proposed rule. Appendix B: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services jlentini on PROD1PC65 with PROPOSALS2 I. Background Section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of the MedPAC, recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care and high quality care. Under section 1886(e)(5)(B) of the Act, we are required to publish update factors recommended by the Secretary in the proposed and final IPPS rules, respectively. Accordingly, this Appendix provides the recommendations for the update factors for the IPPS national standardized amount, the Puerto Rico-specific standardized amount, the hospital-specific rates for SCHs and MDHs, and the rate-of-increase limits for hospitals and hospital units excluded from the IPPS, as well as LTCHS, IPFs, and IRFs. We also discuss our response to MedPAC’s recommended update factors for inpatient hospital services. II. Inpatient Hospital Update for FY 2009 Section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a) of Pub. L. 109– 171, sets the FY 2009 percentage increase in the operating cost standardized amount equal to the rate-of-increase in the hospital market basket for IPPS hospitals in all areas, subject to the hospital submitting quality information under rules established by the VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 $3.967 Billion. Federal Government to IPPS Medicare Providers. $3.967 Billion. Secretary in accordance with 1886(b)(3)(B)(viii) of the Act. For hospitals that do not provide these data, the update is equal to the market basket percentage increase less 2.0 percentage points. Consistent with current law, based on Global Insight, Inc.’s first quarter 2008 forecast of the FY 2009 market basket increase, we are estimating that the FY 2009 update to the standardized amount will be 3.0 percent (that is, the current estimate of the market basket rate-of-increase) for hospitals in all areas, provided the hospital submits quality data in accordance with our rules. For hospitals that do not submit quality data, we are estimating that the update to the standardized amount will be 1.0 percent (that is, the current estimate of the market basket rate-of-increase minus 2.0 percentage points). Section 1886(d)(9)(C)(1) of the Act is the basis for determining the percentage increase to the Puerto Rico-specific standardized amount. For FY 2009, we are applying the full rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Ricospecific standardized amount. Therefore, the update to the Puerto Rico-specific standardized amount is estimated to be 3.0 percent. Section 1886(b)(3)(B)(iv) of the Act sets the FY 2009 percentage increase in the hospitalspecific rates applicable to SCHs and MDHs equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act (that is, the same update factor as for all other hospitals subject to the IPPS, or the rate-of-increase in the market basket). Therefore, the update to the hospital-specific rates applicable to SCHs and MDHs is estimated to be 3.0 or 1.0 percent, depending upon whether the hospital submits quality data. Section 1886(b)(3)(B)(ii) of the Act is used for purposes of determining the percentage increase in the rate-of-increase limits for PO 00000 Frm 00395 Fmt 4701 Sfmt 4702 children’s and cancer hospitals. Section 1886(b)(3)(B)(ii) of the Act sets the percentage increase in the rate-of-increase limits equal to the market basket percentage increase. In accordance with § 403.752(a) of the regulations, RNHCIs are paid under § 413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate-of-increase limits. Section 1886(j)(3)(C) of the Act addresses the increase factor for the Federal prospective payment rate of IRFs. Section 123 of Pub. L. 106–113, as amended by section 307(b) of Pub. L. 106–554, provides the statutory authority for updating payment rates under the LTCH PPS. As discussed below, for cost reporting periods beginning on or after October 1, 2006, LTCHs that are not defined as new under § 412.23(e)(4), and that had not elected to be paid under 100 percent of the Federal rate are paid 100 percent of the adjusted Federal PPS rate. Therefore, because no portion of LTCHs’ prospective payments will be based on reasonable cost concepts for cost reporting periods beginning on or after October 1, 2006, we are not proposing a rate-of-increase percentage to the reasonable cost portion for FY 2009 for LTCHs to be used under § 413.40. In addition, section 124 of Pub. L. 106–113 provides the statutory authority for updating all aspects of the payment rates for IPFs. Under this broad authority, IPFs that are not defined as new under § 412.426(c) are paid under a blended methodology for cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008. For cost reporting periods beginning on or after January 1, 2008, existing IPFs are paid based on 100 percent of the Federal per diem rate. Therefore, because no portion of the existing IPFs prospective payments will be based on reasonable cost concepts for cost reporting periods beginning on or after E:\FR\FM\30APP2.SGM 30APP2 jlentini on PROD1PC65 with PROPOSALS2 23922 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules January 1, 2008, we are not proposing a rateof-increase percentage to the reasonable cost portion for FY 2009 for IPFs to be used under § 412.426(c). New IPFs are paid based on 100 percent of the Federal per diem payment amount. Currently, children’s hospitals, cancer hospitals, and RNHCIs are the remaining three types of hospitals still reimbursed under the reasonable cost methodology. We are providing our current estimate of the FY 2009 IPPS operating market basket percentage increase (3.0 percent) to update the target limits for children’s hospitals, cancer hospitals, and RNHCIs. Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs have been paid under the LTCH PPS. Additionally, for cost reporting periods beginning on or after October 1, 2006, no portion of a LTCH’s PPS payments can be based on reasonable cost concepts. Consequently, there is no need to propose to update the target limit under § 413.40 effective October 1, 2008, for LTCHs. In the RY 2009 LTCH PPS proposed rule (73 FR 5361 through 5362), we proposed an update of 2.6 percent to the LTCH PPS Federal rate for RY 2009, which is based on a proposed market basket increase of 3.5 percent and a proposed adjustment of 0.9 percent to account for the increase in casemix in a prior year that resulted from changes in coding practices rather than an increase in patient severity. The proposed market basket of 3.5 percent used in determining this proposed update factor is based on our proposal in the LTCH proposed rule to extend the LTCH RY 2009 by 3 months (a total of 15 months instead of 12 months) through September 30, 2009. (A full discussion of the reasons for this proposed extension of RY 2009 can be found in the RY 2009 LTCH PPS proposed rule (73 FR 5351 through 5353).) However, if we were not proposing to extend the 2009 LTCH PPS rate year by 3 months, we would have proposed a market basket update of 3.1 percent for a 12-month RY 2009 offset by the proposed adjustment of 0.9 percent to account for the increase in case-mix in a prior year that resulted from changes in coding practices rather than an increase in patient severity. Effective for cost reporting periods beginning on or after January 1, 2005, IPFs are paid under the IPF PPS. IPF PPS payments are based on a Federal per diem rate that is derived from the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. For cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008, existing IPFs (those not defined as ‘‘new’’ under § 412.426(c)) are paid based on a blend of the reasonable costbased PPS payments and the Federal per diem base rate. For cost reporting periods beginning on or after January 1, 2008, existing IPFs are paid based on 100 percent of the Federal per diem rate. Consequently, there is no need to propose to update the target limit under § 412.426(c) effective October 1, 2008, for IPFs. IRFs are paid under the IRF PPS for cost reporting periods beginning on or after VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 January 1, 2002. For cost reporting periods beginning on or after October 1, 2002 (FY 2003), and thereafter, the Federal prospective payments to IRFs are based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually (69 FR 45721). Section 1886(j)(3)(C) of the Act, as amended by section 115 of Pub. L. 110–173 sets the FY 2009 IRF PPS update factor equal to 0 percent. Thus, we are not applying an update (market basket) to the IRF PPS rates for FY 2009. III. Secretary’s Recommendation MedPAC is recommending an inpatient hospital update equal to the market basket rate of increase for FY 2009. MedPAC’s rationale for this update recommendation is described in more detail below. Based on the FY 2009 President’s Budget, we are recommending an update to the standardized amount of 0 percent. We are recommending that this same update factor apply to SCHs and MDHs. Section 1886(d)(9)(C)(1) of the Act is the basis for determining the percentage increase to the Puerto Rico-specific standardized amount. For FY 2009, we are applying the full rate-of-increase in the hospital market basket for IPPS hospitals to the Puerto Ricospecific standardized amount. Therefore, the update to the Puerto Rico-specific standardized amount is estimated to be 3.0 percent. In addition to making a recommendation for IPPS hospitals, in accordance with section 1886(e)(4)(A) of the Act, we are also recommending update factors for all other types of hospitals. Consistent with the President’s Budget, we are recommending an update based on the IPPS market basket increase for children’s hospitals, cancer hospitals, and RNHCIs of 0 percent. As mentioned above, for cost reporting periods beginning on or after January 1, 2008, existing IPFs are paid based on 100 percent of the Federal per diem rate (and are no longer paid a blend of the reasonable costbased PPS payments and the Federal per diem base rate). Consequently, we are no longer recommending an update factor for the portion of the payment that is based on reasonable costs. Consistent with the President’s Budget, based on Global Insight, Inc.’s first quarter 2008 forecast of the RPL market basket increase, we are recommending an update to the IPF PPS Federal rate for RY 2009 of 3.2 percent for the Federal per diem payment amount. In the RY 2009 LTCH PPS proposed rule (73 FR 5361 through 5362), we proposed an update of 2.6 percent to the LTCH PPS Federal rate for RY 2009, which is based on a proposed market basket increase of 3.5 percent and a proposed adjustment of 0.9 percent to account for the increase in casemix in a prior year that resulted from changes in coding practices rather than an increase in patient severity. The proposed market basket of 3.5 percent used in determining this proposed update factor is based on our proposal in the LTCH proposed rule to extend the LTCH RY 2009 by 3 months (a total of 15 months instead of 12 months) through September 30, 2009. (A full discussion on the reasons for this proposed PO 00000 Frm 00396 Fmt 4701 Sfmt 4702 extension of RY 2009 can be found in the RY 2009 LTCH PPS proposed rule (73 FR 5351 through 5353).) However, if we were not proposing to extend the 2009 LTCH PPS rate year by 3 months, we would have proposed a market basket update for a 12 month RY 2009 of 3.1 percent in determining the proposed update factor for RY 2009 offset by the proposed adjustment of 0.9 percent to account for the increase in case-mix in a prior year that resulted from changes in coding practices rather than an increase in patient severity. Finally, consistent with the President’s FY 2009 Budget, we are recommending a zero percent update to the IRF PPS Federal rate for FY 2009. This recommendation is consistent with the zero percent increase factor specified in section 1886(j)(3)(C) of the Act, as amended by section 115 of Pub. L. 110–173. IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare In its March 2008 Report to Congress, MedPAC assessed the adequacy of current payments and costs, and the relationship between payments and an appropriate cost base, utilizing an established methodology used by MedPAC in the past several years. MedPAC recommended an update to the hospital inpatient rates equal to the increase in the hospital market basket in FY 2009, concurrent with implementation of a quality incentive program. Similar to last year, MedPAC also recommended that CMS put pressure on hospitals to control their costs rather than accommodate the current rate of cost growth, which is, in part, caused by a lack of pressure from private payers. MedPAC noted that indicators of payment adequacy are almost uniformly positive. MedPAC expects Medicare margins to remain low in 2008. At the same time though, MedPAC’s analysis finds that hospitals with low non-Medicare profit margins have below average standardized costs and most of these facilities have positive overall Medicare margins. Response: Similar to our response last year, we agree with MedPAC that hospitals should control costs rather than accommodate the current rate of growth. An update equal to less than the market basket will motivate hospitals to control their costs, consistent with MedPAC’s recommendation. As MedPAC noted, the lack of financial pressure at certain hospitals can lead to higher costs and in turn bring down the overall Medicare margin for the industry. As discussed in section II of the preamble of this proposed rule, CMS implemented the MS–DRGs in FY 2008 to better account for severity of illness under the IPPS, and is basing the DRG weights on costs rather than charges. We continue to believe that these refinements will better match Medicare payment of the cost of care and provide incentives for hospitals to be more efficient in controlling costs. We note that, because the operating and capital prospective payment systems remain separate, we are proposing to continue to use separate updates for operating and capital payments. The proposed update to the E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules capital rate is discussed in section III of the Addendum to this proposed rule. Appendix C—Disclosure of Financial Relationship Report (DFRR) Form Disclosure of Financial Relationship Report (DFRR) jlentini on PROD1PC65 with PROPOSALS2 Requirement Completion of the Disclosure of Financial Relationship Report (DFRR or Report) is required under section 1877(f) of the Social Security Act. The Report must be completed, certified by the appropriate officer of the hospital, and received by CMS within 60 days of the date that appears on the cover letter or e-mail transmission. Pursuant to 42 CFR 411.361(f), failure to timely submit the requested information concerning an entity’s ownership, investment, and compensation arrangements may result in civil monetary penalties of up to $10,000 for each day beyond the deadline established for disclosure. Please be advised that the results from the DFRR may be shared with other Federal agencies and with Congressional committees, as permitted or mandated by law. We intend to protect from public disclosure, to the fullest extent permitted by Exemptions 4 and 6 of the Freedom of Information Act, 5 U.S.C. 552(b)(4) and (6), any confidential business information and any individual-specific information collected. We note that CMS is prevented by the Trade Secrets Act, 18 U.S.C. 1905, from releasing confidential business information, except as authorized by law. Information collected from each hospital will be analyzed separately to determine whether the financial relationships are in compliance with the physician self-referral laws and implementing regulations. At this time, we do not plan to aggregate data. Exception to Mandatory Reporting An entity that furnishes 20 or fewer Part A and/or Part B services during a calendar year is excepted from this reporting requirement pursuant to 42 CFR 411.361(b). If you believe that the hospital qualifies for this exception: • The Chief Executive Officer, Chief Financial Officer, or a comparable officer of the Hospital must certify in writing that the hospital furnishes 20 or fewer Part A and/or Part B services during a calendar year. • The certification statement must read as follows: ‘‘I, (insert name), hereby certify that, to the best of my knowledge and belief, (insert name of Hospital) furnishes 20 or fewer Part A and/or Part B services during a calendar year. Therefore the hospital is relying on the exception in 42 CFR 411.361(b) and will not be reporting financial relationship data concerning the facility.’’ The certification statement must be signed and dated, and include the title of the signatory. • If the hospital or entity qualifies for the exception at 42 CFR 411.361(b), please mail the original and one copy of the signed certification statement to: Physician SelfReferral, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mailstop C4–25–02, Baltimore, Maryland 21244–1850. In addition, we request, but do not require, VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 that you e-mail a PDF or other electronically scanned version of the document to HOSPITALDISCLOSURE@cms.hhs.gov. In the subject line, please include the title ‘‘Exception to Disclosure Report.’’ General Instructions for DFRR • The requested disclosures on Worksheets 1 through 6 pertain only to hospitals with physician ownership or investment. For purposes of this Report, ownership is synonymous with investment. • For any question pertaining to the financial relationship between a physician and the Hospital or entity or individual, ‘‘physician’’ shall include each immediate family member of the physician, as defined in 42 CFR 411.351. • The terms, ‘‘physician-owner’’ and ‘‘physician-investor’’ are used interchangeably throughout this report. • Please provide the physician’s last name, first name, and Medicare National Provider Identifier (NPI). Only for those physicians who have not yet received an NPI, may the physician’s Unique Physician Identification Number (UPIN) be submitted instead. We will not accept a hospital created identifier (for example, Physician 1, Physician 2, etc.). • Where supporting documentation or an explanation is requested, please include the name of the physician-owner or physicianinvestor, and his/her NPI. • Supplemental documents should be provided only when specifically requested on a worksheet. Supporting documentation should be organized and clearly labeled to reference the relevant worksheet. Please include only information that responds to the question asked; extraneous information should not be included. For example, if only a few pages of a large document are responsive to a question, please only submit those relevant pages. • If a particular question does not apply to the hospital, please type ‘‘N/A.’’ • If sufficient rows are not provided, please save the Excel spreadsheet, insert the necessary number of additional rows, and print a copy of the revised Excel spreadsheet. • Upon completion of the entire DFRR, please verify all information presented (including the totals for the respective fields or columns) and return an original and one copy to: Physician Self-Referral, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mailstop C4–25–02, Baltimore, Maryland 21244–1850. CMS also requests, but does not require, that a PDF or other electronically scanned version of the DFRR and accompanying documentation be sent to HOSPITALDISCLOSURE@cms.hhs.gov. • Please enter all date fields in the following format: MM/DD/YY. For example, ‘‘March 31, 2006’’ must be entered as follows: 03/31/06. Report Contents The attached report consists of the following spreadsheets: • Cover Sheet—(Certification Page) • Worksheet 1—Hospital Characteristics • Worksheet 2—Direct Ownership in Hospital • Worksheet 3—Indirect Ownership in Hospital PO 00000 Frm 00397 Fmt 4701 Sfmt 4702 23923 • Worksheet 4—Payments Made to Hospital by Direct Owners • Worksheet 5—Payments Made to Hospital by Indirect Owners • Worksheet 6—Investment Reconciliation • Worksheet 7—Compensation Arrangements—Rentals, Personal Service Arrangements, and Recruitment (See 42 CFR 411.357) • Worksheet 8—Other Types of Compensation Arrangements (See 42 CFR 411.357) Key Terms 1. Additional Purchases: Stocks purchased after initial or starting investment. Report the total cost and number of additional shares of stock purchased. 2. Assessments: Any cost or fee required and paid by any investor of the hospital. These fees usually do not involve any basis or change in the owner’s investment in the facility. 3. Back-up Guarantee: Physician-owner’s risk of loss or liability related to the ownership of his or her stock is guaranteed by another entity. If the borrower has problems in repayment, the payment is guaranteed by a third party. 4. Basis of Stock/Shares: The cost of the stock at the end of the cost reporting period(s) ending in 2006. 5. Capital Calls: Each investor is asked/ required to put additional capital in the company. Depending on the structure of the call, if no additional shares are issued, the basis (cost) of the investor’s stock will increase, or if additional shares are issued, the number of the investor’s shares will increase. 6. Compilation of Financial Statements: A compilation presents information in the form of financial statements that are the representation of management without expressing assurances. 7. Direct Ownership or Investment Interest: Direct ownership or investment interest is defined at 42 CFR 411.354(a)(2). 8. Disproportionate Guarantee by Physician Investor: Physician investor’s risk of loss or liability related to the ownership of his/her stock is guaranteed by the corporate investor in a disproportionate percentage to the percentage of stock owned by that physician investor (i.e.: Physician investor owns 40% of the stock of a hospital, but assumes risk of loss or liability equal to 20%.) 9. Fair Market Value: Fair market value is defined at 42 CFR 411.351. 10. Hospital: Hospital is synonymous with operating entity (that is, the corporation or legal entity through which the hospital operates). 11. Immediate family member: An immediate family member means: Husband or wife; birth or adoptive parent, child, or sibling; stepparent, stepchild, stepbrother, or stepsister; father-in-law, mother-in-law, sonin-law, daughter-in-law, brother-in-law, sister-in-law; grandparent or grandchild; and spouse of a grandparent or grandchild. 42 CFR 411.351. 12. Indirect Ownership or Investment Interest: An indirect ownership or investment interest is defined at 42 CFR 411.354(b)(5). E:\FR\FM\30APP2.SGM 30APP2 23924 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 13. Internally prepared: Internally prepared financial statements are prepared by employees of the hospital, and are used mostly to monitor the hospital’s performance. 14. Loan Guarantees: A situation when the borrower’s liability is collateralized by a third party. 15. NPI: Medicare National Provider Identifier. 16. Other Capital Assessments: Report only if shares of stock are involved. Fees assessed should not be reported. 17. Relinquishments or Sales: For each share of stock that is sold during the cost reporting period(s) in 2006, report the dollar amount of the sale and the number of shares sold. 18. Reporting Period: The reporting period refers to any cost reporting period(s) ending in 2006. 19. Return of Capital Dividends: A distribution that is not paid out of the earnings and profits of the company. This distribution reduces the basis of the stock. 20. Review of Financial Statements: A review of financial statements is an engagement that results in an accountant’s opinion that expresses less assurance than that of a certified audit, but more than a compilation. Typically this involves limited auditing, testing, analytical procedures, and/ or inquiries. 21. Stock/share: These terms are used interchangeably throughout the worksheets. 22. Stock Dividends: Stock dividends are distributions made by a corporation of its own stock. Worksheet 1—Hospital Characteristics • Please include month, date, and year for the beginning and end of your cost reporting period(s). jlentini on PROD1PC65 with PROPOSALS2 Worksheet 2—Direct Ownership in Hospital • Identify the class of stock (if applicable) and list all owners of that class within the same grouping on the Worksheet. • If the direct owner is the physician, enter ‘‘Self’’ in Column B. • If the direct owner is not the physician, please write the individual’s name in Column A and in Column B indicate his/her relationship to the physician and give the physician’s name. • The basis of the stock/shares is the cost of the stock at the end of the cost reporting period(s) ending in 2006. This amount should equal Worksheet 6, Column B, Line 18. • One hundred percent of ownership should be identified for each individual class of stock. Worksheet 3—Indirect Ownership in Hospital • Report only indirect ownership interests of physicians and immediate family members on this Worksheet. • In Column A, identify each entity with ownership in the hospital and identify the type of entity in Column B. The entity’s percentage of direct ownership should be listed in Column C. • List each investor-owner of the group entity in Column D. Indicate if the investorowner is a physician. If the investor-owner is an immediate family member, please indicate VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 the relationship to, and name of the physician to whom the investor-owner is related. • Column E should indicate each investorowner’s percentage ownership in the entity at the end of the cost reporting period(s) in 2006, with the number of shares owned (if applicable) listed in Column F. Each type of share owned (if applicable) should be listed individually with the type of stock labeled in Column G. • To calculate the percent of indirect ownership in Column H for each investorowner of the entity, multiply the percentage in Column C by the percentage in Column E. Worksheet 4—Payments Made to Hospital by Direct Owners • Report only payments to the hospital by direct physician-owners and immediate family member owners on this Worksheet. • Complete one line for each payment made by a physician-owner related to his or her investment interest, including, but not limited to: Initial investments, assessments, capital calls, and loan guarantees. If necessary, please insert additional lines. • In Column B, indicate ‘‘Self’’ if the physician is the direct owner. If the direct owner is not the physician, please list the direct owner’s name in Column A and in Column B, indicate the immediate family member’s relationship to the physician and give the physician’s name. • Do not group payments under one physician name, but rather use a separate line for each type of payment made by a physician. Worksheet 5—Payments Made to Hospital by Indirect Owners • Report only payments made by indirect physician-owners and immediate family member owners on this Worksheet. • Complete one line for each payment made by an entity related to an investment interest, including, but not limited to: Initial investments, assessments, capital calls, and loan guarantees. If necessary, please insert additional lines. • List the name of the indirect ownership entity in Column A. In Column B, list the names of individuals that compose that entity, placing only one person per line and indicating his or her status, i.e. ‘‘Self’’ for physician, or ‘‘IFM’’ for immediate family member. • For immediate family members, enter the relationship to and name of, the physician family member in Column C. • Do not group payments under one entity name, but rather use a separate line for each type of payment made by an entity. Worksheet 6—Investment Reconciliation • Please complete a separate Worksheet for each physician-owner or immediate family member owner. • Please provide the owner’s Social Security Number (SSN) or NPI as appropriate. • If a physician owns more than one class of stock/equity, a separate worksheet must be completed for each class of stock/equity. • Line 10, Column A—The begin date must be the start of the cost reporting period(s) that end(s) in 2006. That is, for a PO 00000 Frm 00398 Fmt 4701 Sfmt 4702 cost reporting period of July 1, 2005 to June 30, 2006, the begin date is 07/01/05. • Line 10, Columns B, C, and D must reflect the physician-owner’s total investment for the class of stock/equity described, as of the beginning of the period being evaluated (all cost period(s) ending in 2006). • Lines 11 through 17, Columns B, C, and D must reflect any and all changes to the physician-owner’s stock/equity during the period being evaluated, so that line 18 reflects the owner’s total investment at the end of the period. • Line 17 must reflect all other capital assessments that occurred during the cost reporting period(s) ending in 2006. • Line 18, Column A—The end date must be the end date of the cost reporting period(s) that end(s) in 2006. That is, for a cost reporting period of July 1, 2005 to June 30, 2006, the end date is 06/30/06. • Line 18, Column B—The amount entered here should be equal to the amount listed on Worksheet 2, Column C for each class of stock for each physician owner. Worksheet 7—Compensation Arrangements—Rentals, Personal Service Arrangements, and Recruitment (See 42 CFR 411.357) • For all physicians who had one or more of the compensation arrangements listed in columns A through D list the physician’s complete name in the first column, the physician’s NPI, and insert either a Y or N as to whether the physician is an owner/ investor of the hospital. In addition, please insert the applicable number of compensation arrangements in each respective column. • For those compensation arrangements listed in columns A through D, include not just those that you believe fit within an exception in 42 CFR 411.357, but those that are implicated by the referenced exception. • The information requested in columns A and B must include compensation arrangements that occur in either direction (i.e., rentals to/from physicians). • Please indicate in the appropriate column the number of compensation arrangements that pertain to the physician for the reporting period(s) ending in 2006. • Note that each Column A–D that is filled in with a number requires the submission of supporting documentation for each compensation arrangement. With the exception of uniform personal service arrangements, please submit a copy of the written agreement(s) that were in effect during the reporting period(s) ending in 2006. • Personal Service Arrangements (PSA— Column C) Æ For each physician listed, please indicate the number of PSAs in effect for the cost reporting period(s) ending in 2006. Æ In the next column indicate if the physician used a uniform PSA prepared by the hospital. We consider a PSA to be uniform if all of the elements present in the arrangements are materially the same. Only one copy of the uniform PSA should be included in the supplemental materials. The E:\FR\FM\30APP2.SGM 30APP2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 with the supplemental materials for this Worksheet. Worksheet 8—Other Types of Compensation Arrangements (See 42 CFR 411.357) • This Worksheet addresses other compensation arrangements exceptions that are found at 42 CFR 411.357. • Please note that you may be required to furnish an explanation or additional documentation depending on the answer to each question. PO 00000 Frm 00399 Fmt 4701 Sfmt 4725 • Submit only the information that is necessary to answer the question by removing extraneous documentation where possible. Questions Questions regarding these instructions may be directed to: DFRRQuestions@cms.hhs.gov. BILLING CODE 4120–01–P E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.022</GPH> jlentini on PROD1PC65 with PROPOSALS2 one copy will satisfy the supporting documentation requirement for all physicians who entered into a uniform PSA with the hospital. Æ Indicate whether or not the hospital has a signed copy of this agreement on file for this physician in the next sub-column with a Y or N. Æ If the physician had a non-uniform PSA in effect for the cost reporting period(s) ending in 2006, please indicate this on the Worksheet and provide a copy of the PSA 23925 VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00400 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.023</GPH> jlentini on PROD1PC65 with PROPOSALS2 23926 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00401 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23927 EP30AP08.024</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00402 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.025</GPH> jlentini on PROD1PC65 with PROPOSALS2 23928 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00403 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23929 EP30AP08.026</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00404 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.027</GPH> jlentini on PROD1PC65 with PROPOSALS2 23930 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00405 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23931 EP30AP08.028</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00406 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.029</GPH> jlentini on PROD1PC65 with PROPOSALS2 23932 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00407 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23933 EP30AP08.030</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00408 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.031</GPH> jlentini on PROD1PC65 with PROPOSALS2 23934 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00409 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23935 EP30AP08.032</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules VerDate Aug<31>2005 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00410 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.033</GPH> jlentini on PROD1PC65 with PROPOSALS2 23936 VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00411 Fmt 4701 Sfmt 4725 E:\FR\FM\30APP2.SGM 30APP2 23937 EP30AP08.035</GPH> jlentini on PROD1PC65 with PROPOSALS2 Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules Federal Register / Vol. 73, No. 84 / Wednesday, April 30, 2008 / Proposed Rules [FR Doc. 08–1135 Filed 4–14–08; 9:19 am] BILLING CODE 4120–01–C VerDate Aug<31>2005 19:42 Apr 29, 2008 Jkt 214001 PO 00000 Frm 00412 Fmt 4701 Sfmt 4702 E:\FR\FM\30APP2.SGM 30APP2 EP30AP08.036</GPH> jlentini on PROD1PC65 with PROPOSALS2 23938

Agencies

[Federal Register Volume 73, Number 84 (Wednesday, April 30, 2008)]
[Proposed Rules]
[Pages 23528-23938]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 08-1135]



[[Page 23527]]

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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid



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42 CFR Parts 411, 412, 413 et al.



Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed 
Changes to Disclosure of Physician Ownership in Hospitals and Physician 
Self-Referral Rules; Proposed Collection of Information Regarding 
Financial Relationships Between Hospitals and Physicians; Proposed Rule

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

[[Page 23528]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 411, 412, 413, 422, and 489

[CMS-1390-P]
RIN 0938-AP15


Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed 
Changes to Disclosure of Physician Ownership in Hospitals and Physician 
Self-Referral Rules; Proposed Collection of Information Regarding 
Financial Relationships Between Hospitals and Physicians

AGENCY: Centers for Medicare and Medicaid Services (CMS), HHS.

ACTION: Proposed rule.

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SUMMARY: We are proposing to revise the Medicare hospital inpatient 
prospective payment systems (IPPS) for operating and capital-related 
costs to implement changes arising from our continuing experience with 
these systems, and to implement certain provisions made by the Deficit 
Reduction Act of 2005, the Medicare Improvements and Extension Act, 
Division B, Title I of the Tax Relief and Health Care Act of 2006, and 
the TMA, Abstinence Education, and QI Programs Extension Act of 2007. 
In addition, in the Addendum to this proposed rule, we describe the 
proposed changes to the amounts and factors used to determine the rates 
for Medicare hospital inpatient services for operating costs and 
capital-related costs. These proposed changes would be applicable to 
discharges occurring on or after October 1, 2008. We also are setting 
forth the proposed update to the rate-of-increase limits for certain 
hospitals and hospital units excluded from the IPPS that are paid on a 
reasonable cost basis subject to these limits. The proposed updated 
rate-of-increase limits would be effective for cost reporting periods 
beginning on or after October 1, 2008.
    Among the other policy decisions and changes that we are proposing 
to make are changes related to: Limited proposed revisions of the 
classification of cases to Medicare severity diagnosis-related groups 
(MS-DRGs), proposals to address charge compression issues in the 
calculation of MS-DRG relative weights, the proposed revisions to the 
classifications and relative weights for the Medicare severity long-
term care diagnosis-related groups (MS-LTC-DRGs); applications for new 
medical services and technologies add-on payments; wage index reform 
changes and the wage data, including the occupational mix data, used to 
compute the proposed FY 2009 wage indices; submission of hospital 
quality data; proposed changes to the postacute care transfer policy 
relating to transfers to home for the furnishing of home health 
services; and proposed policy changes relating to the requirements for 
furnishing hospital emergency services under the Emergency Medical 
Treatment and Labor Act of 1986 (EMTALA).
    In addition, we are proposing policy changes relating to disclosure 
to patients of physician ownership or investment interests in hospitals 
and soliciting public comments on a proposed collection of information 
regarding financial relationships between hospitals and physicians. We 
are also proposing changes or soliciting comments on issues relating to 
policies on physician self-referrals.

DATES: To be assured consideration, comments must be received at one of 
the addresses provide below, no later than 5 p.m. E.S.T. on June 13, 
2008.

ADDRESSES: When commenting on issues presented in this proposed rule, 
please refer to filecode CMS-1390-P. Because of staff and resource 
limitations, we cannot accept comments by facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to https://www.regulations.gov. Follow the instructions for 
``Comment or Submission'' and enter the file code CMS-1390-P to submit 
comments on this proposed rule.
    2. By regular mail. You may mail written comments (one original and 
two copies) to the following address ONLY: Centers for Medicare & 
Medicaid Services, Department of Health and Human Services, Attention: 
CMS-1390-P, P.O. Box 8011, Baltimore, MD 21244-1850.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments (one 
original and two copies) to the following address ONLY: Centers for 
Medicare & Medicaid Services, Department of Health and Human Services, 
Attention: CMS-1390-P, Mail Stop C4-26-05, 7500 Security Boulevard, 
Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to either of the following addresses:
    a. Room 445-G, Hubert H. Humphrey Building, 200 Independence 
Avenue, SW., Washington, DC 20201.
    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for persons wishing to retain a proof of filing by stamping 
in and retaining an extra copy of the comments being filed.)
    b. 7500 Security Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members.
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    Submission of comments on paperwork requirements. You may submit 
comments on this document's paperwork requirements by following the 
instructions at the end of the ``Collection of Information 
Requirements'' section in this document.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION, CONTACT: 
    Michele Hudson, (410) 786-4487, Operating Prospective Payment, MS-
DRGs, Wage Index, New Medical Service and Technology Add-On Payments, 
Hospital Geographic Reclassifications, and Postacute Care Transfer 
Issues.
    Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded 
Hospitals, Direct and Indirect Graduate Medical Education, MS-LTC-DRGs, 
EMTALA, Hospital Emergency Services, and Hospital-within-Hospital 
Issues.
    Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital 
Demonstration Program Issues.
    Sheila Blackstock, (410) 786-3502, Quality Data for Annual Payment 
Update Issues.
    Thomas Valuck, (410) 786-7479, Hospital Value-Based Purchasing and 
Readmissions to Hospital Issues.
    Anne Hornsby, (410) 786-1181, Collection of Managed Care Encounter 
Data Issues.
    Jacqueline Proctor, (410) 786-8852, Disclosure of Physician 
Ownership in

[[Page 23529]]

Hospitals and Financial Relationships between Hospitals and Physicians 
Issues.
    Lisa Ohrin, (410) 786-4565, and Don Romano, (410) 786-1404, 
Physician Self-Referral Issues.

SUPPLEMENTARY INFORMATION:
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: https://
www.regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received timely will also be available for public 
inspection, generally beginning approximately 3 weeks after publication 
of a document, at the headquarters of the Centers for Medicare & 
Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, 
Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule 
an appointment to view public comments, phone 1-800-743-3951.

Electronic Access

    This Federal Register document is also available from the Federal 
Register online database through GPO Access, a service of the U.S. 
Government Printing Office. Free public access is available on a Wide 
Area Information Server (WAIS) through the Internet and via 
asynchronous dial-in. Internet users can access the database by using 
the World Wide Web (the Superintendent of Documents' home page address 
is https://www.gpoaccess.gov/), by using local WAIS client software, or 
by telnet to swais.access.gpo.gov, then login as guest (no password 
required). Dial-in users should use communications software and modem 
to call (202) 512-1661; type swais, then login as guest (no password 
required).

Acronyms

AARP American Association of Retired Persons
AAHKS American Association of Hip and Knee Surgeons
AAMC Association of American Medical Colleges
ACGME Accreditation Council for Graduate Medical Education
AF Artrial fibrillation
AHA American Hospital Association
AICD Automatic implantable cardioverter defibrillator
AHIMA American Health Information Management Association
AHIC American Health Information Community
AHRQ Agency for Healthcare Research and Quality
AMA American Medical Association
AMGA American Medical Group Association
AMI Acute myocardial infarction
AOA American Osteopathic Association
APR DRG All Patient Refined Diagnosis Related Group System
ASC Ambulatory surgical center
ASITN American Society of Interventional and Therapeutic 
Neuroradiology
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BBRA Medicare, Medicaid, and SCHIP [State Children's Health 
Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 
106-113
BIPA Medicare, Medicaid, and SCHIP [State Children's Health 
Insurance Program] Benefits Improvement and Protection Act of 2000, 
Pub. L. 106-554
BLS Bureau of Labor Statistics
CAH Critical access hospital
CARE [Medicare] Continuity Assessment Record & Evaluation 
[Instrument]
CART CMS Abstraction & Reporting Tool
CBSAs Core-based statistical areas
CC Complication or comorbidity
CCR Cost-to-charge ratio
CDAC [Medicare] Clinical Data Abstraction Center
CDAD Clostridium difficile-associated disease
CIPI Capital input price index
CMI Case-mix index
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-
272
CoP [Hospital] condition of participation
CPI Consumer price index
CY Calendar year
DFRR Disclosure of financial relationship report
DRA Deficit Reduction Act of 2005, Pub. L. 109-171
DRG Diagnosis-related group
DSH Disproportionate share hospital
DVT Deep vein thrombosis
ECI Employment cost index
EMR Electronic medical record
EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 
99-272
FAH Federation of Hospitals
FDA Food and Drug Administration
FHA Federal Health Architecture
FIPS Federal information processing standards
FQHC Federally qualified health center
FTE Full-time equivalent
FY Fiscal year
GAAP Generally Accepted Accounting Principles
GAF Geographic Adjustment Factor
GME Graduate medical education
HACs Hospital-acquired conditions
HCAHPS Hospital Consumer Assessment of Healthcare Providers and 
Systems
HCFA Health Care Financing Administration
HCRIS Hospital Cost Report Information System
HHA Home health agency
HHS Department of Health and Human Services
HIC Health insurance card
HIPAA Health Insurance Portability and Accountability Act of 1996, 
Pub. L. 104-191
HIPC Health Information Policy Council
HIS Health information system
HIT Health information technology
HMO Health maintenance organization
HPMP Hospital Payment Monitoring Program
HSA Health savings account
HSCRC [Maryland] Health Services Cost Review Commission
HSRV Hospital-specific relative value
HSRVcc Hospital-specific relative value cost center
HQA Hospital Quality Alliance
HQI Hospital Quality Initiative
HWH Hospital-within-a hospital
ICD-9-CM International Classification of Diseases, Ninth Revision, 
Clinical Modification
ICD-10-PCS International Classification of Diseases, Tenth Edition, 
Procedure Coding System
ICR Information collection requirement
IHS Indian Health Service
IME Indirect medical education
IOM Institute of Medicine
IPF Inpatient psychiatric facility
IPPS [Acute care hospital] inpatient prospective payment system
IRF Inpatient rehabilitation facility
LAMCs Large area metropolitan counties
LTC-DRG Long-term care diagnosis-related group
LTCH Long-term care hospital
MA Medicare Advantage
MAC Medicare Administrative Contractor
MCC Major complication or comorbidity
MCE Medicare Code Editor
MCO Managed care organization
MCV Major cardiovascular condition
MDC Major diagnostic category
MDH Medicare-dependent, small rural hospital
MedPAC Medicare Payment Advisory Commission
MedPAR Medicare Provider Analysis and Review File
MEI Medicare Economic Index
MGCRB Medicare Geographic Classification Review Board
MIEA-TRHCA Medicare Improvements and Extension Act, Division B of 
the Tax Relief and Health Care Act of 2006, Pub. L. 109-432
MMA Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, Pub. L. 108-173
MPN Medicare provider number
MRHFP Medicare Rural Hospital Flexibility Program
MRSA Methicillin-resistant Staphylococcus aureus
MSA Metropolitan Statistical Area
MS-DRG Medicare severity diagnosis-related group
MS-LTC-DRG Medicare severity long-term care diagnosis-related group
NAICS North American Industrial Classification System
NCD National coverage determination

[[Page 23530]]

NCHS National Center for Health Statistics
NCQA National Committee for Quality Assurance
NCVHS National Committee on Vital and Health Statistics
NECMA New England County Metropolitan Areas
NQF National Quality Forum
NTIS National Technical Information Service
NVHRI National Voluntary Hospital Reporting Initiative
OES Occupational employment statistics
OIG Office of the Inspector General
OMB Executive Office of Management and Budget
O.R. Operating room
OSCAR Online Survey Certification and Reporting [System]
PE Pulmonary embolism
PMSAs Primary metropolitan statistical areas
POA Present on admission
PPI Producer price index
PPS Prospective payment system
PRM Provider Reimbursement Manual
ProPAC Prospective Payment Assessment Commission
PRRB Provider Reimbursement Review Board
PSF Provider-Specific File
PS&R Provider Statistical and Reimbursement (System)
QIG Quality Improvement Group, CMS
QIO Quality Improvement Organization
RCE Reasonable compensation equivalent
RHC Rural health clinic
RHQDAPU Reporting hospital quality data for annual payment update
RNHCI Religious nonmedical health care institution
RRC Rural referral center
RUCAs Rural-urban commuting area codes
RY Rate year
SAF Standard Analytic File
SCH Sole community hospital
SFY State fiscal year
SIC Standard Industrial Classification
SNF Skilled nursing facility
SOCs Standard occupational classifications
SOM State Operations Manual
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-
248
TMA TMA [Transitional Medical Assistance], Abstinence Education, and 
QI [Qualifying Individuals] Programs Extension Act of 2007, Pub. L. 
110-09
TJA Total joint arthroplasty
UHDDS Uniform hospital discharge data set
VAP Ventilator-associated pneumonia
VBP Value-based purchasing

Table of Contents

I. Background
    A. Summary
    1. Acute Care Hospital Inpatient Prospective Payment System 
(IPPS)
    2. Hospitals and Hospital Units Excluded From the IPPS
    a. Inpatient Rehabilitation Facilities (IRFs)
    b. Long-Term Care Hospitals (LTCHs)
    c. Inpatient Psychiatric Facilities (IPFs)
    3. Critical Access Hospitals (CAHs)
    4. Payments for Graduate Medical Education (GME)
    B. Provisions of the Deficit Reduction Act of 2005 (DRA)
    C. Provisions of the Medicare Improvements and Extension Act 
under Division B, Title I of the Tax Relief and Health Care Act of 
2006 (MIEA-TRHCA)
    D. Provision of the TMA, Abstinence Education, and QI Programs 
Extension Act of 2007
    E. Major Contents of this Proposed Rule
    1. Proposed Changes to MS-DRG Classifications and Recalibrations 
of Relative Weights
    2. Proposed Changes to the Hospital Wage Index
    3. Other Decisions and Proposed Changes to the IPPS for 
Operating Costs and GME Costs
    4. Proposed Changes to the IPPS for Capital-Related Costs
    5. Proposed Changes to the Payment Rates for Excluded Hospitals 
and Hospital Units: Rate-of-Increase Percentages
    6. Proposed Changes Relating to Disclosure of Physician 
Ownership in Hospitals
    7. Proposed Changes and Solicitation of Comments on Physician 
Self-Referral Provisions
    8. Proposed Collection of Information Regarding Financial 
Relationships between Hospitals and Physicians
    9. Determining Proposed Prospective Payment Operating and 
Capital Rates and Rate-of-Increase Limits
    10. Impact Analysis
    11. Recommendation of Update Factors for Operating Cost Rates of 
Payment for Inpatient Hospital Services
    12. Disclosure of Financial Relationships Report (DFRR) Form
    13. Discussion of Medicare Payment Advisory Commission 
Recommendations
    F. Public Comments Received on Issues in Related Rules
    1. Comments on Phase-Out of the Capital Teaching Adjustment 
under the IPPS Included in the FY 2008 IPPS Final Rule with Comment 
Period
    2. Policy Revisions Related to Medicare GME Group Affiliations 
for Hospitals in Certain Declared Emergency Areas
II. Proposed Changes to Medicare Severity DRG (MS-DRG) 
Classifications and Relative Weights
    A. Background
    B. MS-DRG Reclassifications
    1. General
    2. Yearly Review for Making MS-DRG Changes
    C. Adoption of the MS-DRGs in FY 2008
    D. MS-DRG Documentation and Coding Adjustment, Including the 
Applicability to the Hospital-Specific Rates and the Puerto Rico-
Specific Standardized Amount
    1. MS-DRG Documentation and Coding Adjustment
    2. Application of the Documentation and Coding Adjustment to the 
Hospital-Specific Rates
    3. Application of the Documentation and Coding Adjustment to 
Puerto Rico-Specific Standardized Amount
    4. Potential Additional Payment Adjustments in FYs 2010 through 
2012
    E. Refinement of the MS-DRG Relative Weight Calculation
    1. Background
    2. Refining the Medicare Cost Report
    3. Timeline for Revising the Medicare Cost Report
    4. Revenue Codes used in the MedPAR File
    F. Preventable Hospital-Acquired Conditions (HACs), Including 
Infections
    1. General
    2. Statutory Authority
    3. Public Input
    4. Collaborative Process
    5. Selection Criteria for HACs
    6. HACs Selected in FY 2008 and Proposed Changes to Certain 
Codes
    a. Foreign Object Retained After Surgery: Proposed Inclusion of 
ICD-9-CM Code 998.7 (CC)
    b. Pressure Ulcers: Proposed Changes in Code Assignments
    7. HACs Under Consideration as Additional Candidates
    a. Surgical Site Infections Following Elective Surgeries
    b. Legionnaires' Disease
    c. Glycemic Control
    d. Iatrogenic Pneumothorax
    e. Delirium
    f. Ventilator-Associated Pneumonia (VAP)
    g. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
    h. Staphylococcus aureus Septicemia
    i. Clostridium Difficile-Associated Disease (CDAD)
    j. Methicillin-Resistant Staphylococcus aureus (MRSA)
    8. Present on Admission (POA) Indicator Reporting
    9. Enhancement and Future Issues
    a. Risk Adjustment
    b. Rates of HACs
    c. Use of POA Information
    d. Transition to ICD-10-PCS
    e. Application of Nonpayment for HACs to Other Settings
    f. Relationship to NQF's Serious Reportable Adverse Events
    G. Proposed Changes to Specific MS-DRG Classifications
    1. Pre-MDCs: Artificial Heart Devices
    2. MDC 1 (Diseases and Disorders of the Nervous System)
    a. Transferred Stroke Patients Receiving Tissue Plasminogen 
Activator (tPA)
    b. Intractable Epilepsy with Video Electroencephalogram (EEG)
    3. MDC 5 (Diseases and Disorders of the Circulatory System)
    a. Automatic Implantable Cardioverter-Defibrillators (AICD) Lead 
and Generator Procedures
    b. Left Atrial Appendage Device
    4. MDC 8 (Diseases and Disorders of the Musculoskeletal System 
and Connective Tissue): Hip and Knee Replacements and Revisions
    a. Brief History of Development of Hip and Knee Replacement 
Codes
    b. Prior Recommendations of the AAHKS
    c. Adoption of MS-DRGs for Hip and Knee Replacements for FY 2008 
and AAHKS' Recommendations
    d. AAHKS' Recommendations for FY 2009
    e. CMS' Response to AAHKS' Recommendations
    f. Conclusion
    5. MDC 18 (Infections and Parasitic Diseases Systemic or 
Unspecified Sites): Severe Sepsis

[[Page 23531]]

    6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs): 
Traumatic Compartment Syndrome
    7. Medicare Code Editor (MCE) Changes
    a. List of Unacceptable Principal Diagnoses in MCE
    b. Diagnoses Allowed for Male Only Edit c. Limited Coverage Edit
    8. Surgical Hierarchies
    9. CC Exclusions List
     a. Background
    b. CC Exclusions List for FY 2009
    10. Review of Procedure Codes in MS-DRGs 981, 982, and 983; 984, 
985, and 986; and 987, 988, and 989
    a. Moving Procedure Codes from MS-DRG 981 through 983 or MS-DRG 
987 through 989 to MDCs
    b. Reassignment of Procedures among MS-DRGs 981 through 983, 984 
through 986, and 987 through 989
    c. Adding Diagnosis or Procedure Codes to MDCs
    11. Changes to the ICD-9-CM Coding System
    H. Recalibration of MS-DRG Weights
    I. Proposed Medicare Severity Long-Term Care Diagnosis-Related 
Group (MS-LTC-DRG) Reclassifications and Relative Weights for LTCHs 
for FY 2009
    1. Background
    2. Proposed Changes in the MS-LTC-DRG Classifications
    a. Background
    b. Patient Classifications into MS-LTC-DRGs
    3. Development of the Proposed FY 2009 MS-LTC-DRG Relative 
Weights
    a. General Overview of Development of the MS-LTC-DRG Relative 
Weights
    b. Data
    c. Hospital-Specific Relative Value (HSRV) Methodology
    d. Treatment of Severity Levels in Developing Proposed Relative 
Weights
    e. Proposed Low-Volume MS-LTC-DRGs
    4. Steps for Determining the Proposed FY 2009 MS-LTC-DRG 
Relative Weights
    J. Proposed Add-On Payments for New Services and Technologies
    1. Background
    2. Public Input Before Publication of a Notice of Proposed 
Rulemaking on Add-On Payments
    3. FY 2009 Status of Technologies Approved for FY 2008 Add-On 
Payments
    4. FY 2009 Applications for New Technology Add-On Payments
    a. CardioWest^TM Temporary Total Artificial Heart 
System (CardioWest^TM TAH-t)
    b. Emphasys Medical Zephyr[supreg] Endobronchial Valve 
(Zephyr[supreg] EBV)
    c. Oxiplex[supreg]
    d. TherOx Downstream[supreg] System
    5. Proposed Regulatory Change
III. Proposed Changes to the Hospital Wage Index
    A. Background
    B. Requirements of Section 106 of the MIEA-TRHCA
    1. Wage Index Study Required Under the MIEA-TRHCA
    2. CMS Proposals in Response to Requirements Under Section 
106(b) of the MIEA-TRHCA
    a. Proposed Revision of the Reclassification Average Hourly Wage 
Comparison Criteria
    b. Within-State Budget Neutrality Adjustment for the Rural and 
Imputed Floors
    c. Within-State Budget Neutrality Adjustment for Geographic 
Reclassification
    C. Core-Based Statistical Areas for the Hospital Wage Index
    D. Proposed Occupational Mix Adjustment to the Proposed FY 2009 
Wage Index
    1. Development of Data for the Proposed FY 2009 Occupational Mix 
Adjustment
    2. Calculation of the Proposed Occupational Mix Adjustment for 
FY 2009
    3. 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index
    E. Worksheet S-3 Wage Data for the Proposed FY 2009 Wage Index
    1. Included Categories of Costs
    2. Excluded Categories of Costs
    3. Use of Wage Index Data by Providers Other Than Acute Care 
Hospitals Under the IPPS
    F. Verification of Worksheet S-3 Wage Data
    1. Wage Data for Multicampus Hospitals
    2. New Orleans' Post-Katrina Wage Index
    G. Method for Computing the Proposed FY 2009 Unadjusted Wage 
Index
    H. Analysis and Implementation of the Proposed Occupational Mix 
Adjustment and the Proposed FY 2009 Occupational Mix Adjustment Wage 
Index
    I. Proposed Revisions to the Wage Index Based on Hospital 
Redesignations
    1. General
    2. Effects of Reclassification/Redesignation
    3. FY 2009 MGCRB Reclassifications
    4. FY 2008 Policy Clarifications and Revisions
    5. Redesignations of Hospitals under Section 1886(d)(8)(B) of 
the Act
    6. Reclassifications under Section 1886(d)(8)(B) of the Act
    J. Proposed FY 2009 Wage Index Adjustment Based on Commuting 
Patterns of Hospital Employees
    K. Process for Requests for Wage Index Data Corrections
    L. Labor-Related Share for the Proposed Wage Index for FY 2009
IV. Other Decisions and Proposed Changes to the IPPS for Operating 
Costs and GME Costs
    A. Proposed Changes to the Postacute Care Transfer Policy
    1. Background
    2. Proposed Policy Change Relating to Transfers to Home with a 
Written Plan for the Provision of Home Health Services
    3. Evaluation of MS-DRGs under Postacute Care Transfer Policy 
for FY 2009
    B. Reporting of Hospital Quality Data for Annual Hospital 
Payment Update
    1. Background
    a. Overview
    b. Voluntary Hospital Quality Data Reporting
    c. Hospital Quality Data Reporting under Section 501(b) of Pub. 
L. 108-173
    d. Hospital Quality Data Reporting under Section 5001(a) of Pub. 
L. 109-171
    2. Proposed Quality Measures for FY 2010 and Subsequent Years
    a. Proposed Quality Measures for FY 2010
    b. Possible New Quality Measures, Measure Sets, and Program 
Requirements for FY 2011 and Subsequent Years
    c. Considerations in Expanding and Updating Quality Measures 
Under the RHQDAPU Program
    3. Form and Manner and Timing of Quality Data Submission
    4. Current and Proposed RHQDAPU Program Procedures
    a. RHQDAPU Program Procedures for FY 2009
    b. Proposed RHQDAPU Program Procedures for FY 2010
    5. Current and Proposed HCAHPS Requirements
    a. FY 2009 HCAHPS Requirements
    b. Proposed FY 2010 HCAHPS Requirements
    6. Current and Proposed Chart Validation Requirements
    a. Chart Validation Requirements for FY 2009
    b. Proposed Chart Validation Requirements for FY 2010
    c. Chart Validation Methods and Requirements Under Consideration 
for FY 2011 and Subsequent Years
    7. Data Attestation Requirements
    a. Proposed Change to Requirements for FY 2009
    b. Proposed Requirements for FY 2010
    8. Public Display Requirements
    9. Proposed Reconsideration and Appeal Procedures
    10. Proposed RHQDAPU Program Withdrawal Deadline for FYs 2009 
and 2010
    11. Requirements for New Hospitals
    12. Electronic Medical Records
    C. Medicare Hospital Value-Based Purchasing (VBP)
    1. Medicare Hospital VBP Plan Report to Congress
    2. Testing and Further Development of the Medicare Hospital VBP 
Plan
    D. Sole Community Hospitals (SCHs) and Medicare-Dependent, Small 
Rural Hospitals (MDHs): Volume Decrease Adjustment
    1. Background
    2. Volume Decrease Adjustment for SCHs and MDHs: Data Sources 
for Determining Core Staff Values
    a. Occupational Mix Survey
    b. AHA Annual Survey
    E. Rural Referral Centers (RRCs)
    1. Case-Mix Index
    2. Discharges
    F. Indirect Medical Education (IME) Adjustment
    1. Background
    2. IME Adjustment Factor for FY 2009
    G. Medicare GME Affiliation Provisions for Teaching Hospitals in 
Certain Emergency Situations; Technical Correction
    1. Background
    2. Technical Correction
    H. Payments to Medicare Advantage Organizations: Collection of 
Risk Adjustment Data
    I. Hospital Emergency Services under EMTALA

[[Page 23532]]

    1. Background
    2. EMTALA Technical Advisory Group (TAG): Recommendations
    3. Proposed Changes Relating to Applicability of EMTALA 
Requirements to Hospital Inpatients
    4. Proposed Changes to the EMTALA Physician On-Call Requirements
    a. Relocation of Regulatory Provisions
    b. Shared/Community Call
    5. Proposed Technical Change to Regulations
    J. Application of Incentives To Reduce Avoidable Readmissions to 
Hospitals
    1. Introduction
    2. Measurement
    3. Accountability
    4. Interventions
    5. Financial Incentive: Direct Payment Adjustment
    6. Financial Incentive: Performance-Based Payment Adjustment
    7. Nonfinancial Incentive: Public Reporting
    8. Conclusion
    K. Rural Community Hospital Demonstration Program
V. Proposed Changes to the IPPS for Capital-Related Costs
    A. Background
    1. Exception Payments
    2. New Hospitals
    3. Hospitals Located in Puerto Rico
    B. Revisions to the Capital IPPS Based on Data on Hospitals 
Medicare Capital Margins
    1. Elimination of the Large Add-On Payment Adjustment
    2. Changes to the Capital IME Adjustment
    a. Background and Changes Made for FY 2008
    b. Public Comments Received on Phase Out of Capital IPPS 
Teaching Adjustment Provisions Included in the FY 2008 Final Rule 
With Comment Period and Further Solicitation of Public Comments
VI. Proposed Changes for Hospitals and Hospital Units Excluded From 
the IPPS
    A. Proposed Payments to Excluded Hospitals and Hospital Units
    B. IRF PPS
    C. LTCH PPS
    D. IPF PPS
    E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) under 
the LTCH PPS
    F. Proposed Change to the Regulations Governing Hospitals-
Within-Hospitals
VII. Disclosure Required of Certain Hospitals and Critical Access 
Hospitals Regarding Physician Ownership
VIII. Physician Self-Referrals Provisions
    A. Stand in the Shoes Provisions
    1. Physician ``Stand in the Shoes'' Provisions
    a. Background
    b. Proposals
    2. DHS Entity ``Stand in the Shoes'' Provisions
    3. Application of the Physician ``Stand in the Shoes'' and the 
Entity ``Stand in the Shoes'' Provisions
    4. Definitions: ``Physician'' and ``Physician Organization''
    B. Period of Disallowance
    C. Gainsharing Arrangements
    1. Background
    2. Statutory Impediments to Gainsharing Arrangements
    3. Office of Inspector General (OIG) Approach Towards 
Gainsharing Arrangements
    4. MedPAC Recommendation
    5. Demonstration Programs
    6. Solicitation of Comments
    D. Physician-Owned Implant and Other Medical Device Companies
    1. Background
    2. Solicitation of Comments
IX. Financial Relationships between Hospitals and Physicians
    A. Background
    B. Section 5006 of the Deficit Reduction Act (DRA) of 2005
    C. Disclosure of Financial Relationships Report (DFRR)
    D. Civil Monetary Penalties
    E. Uses of Information Captured by the DFRR
    F. Solicitation of Comments
X. MedPAC Recommendations
XI. Other Required Information
    A. Requests for Data from the Public
    B. Collection of Information Requirements
    1. Legislative Requirement for Solicitation of Comments
    2. Solicitation of Comments on Proposed Requirements in 
Regulatory Text
    a. ICRs Regarding Physician Reporting Requirements
    b. ICRs Regarding Risk Adjustment Data
    c. ICRs Regarding Basic Commitments of Providers
    3. Associated Information Collections Not Specified in 
Regulatory Text
    a. Present on Admission (POA) Indicator Reporting
    b. Proposed Add-On Payments for New Services and Technologies
    c. Reporting of Hospital Quality Data for Annual Hospital 
Payment Update
    d. Occupational Mix Adjustment to the FY 2009 Index (Hospital 
Wage Index Occupational Mix Survey)
    4. Addresses for Submittal of Comments on Information Collection 
Requirements
    C. Response to Public Comments

Regulation Text

Addendum--Proposed Schedule of Standardized Amounts, Update Factors, 
and Rate-of-Increase Percentages Effective With Cost Reporting Periods 
Beginning On or After October 1, 2008

I. Summary and Background
II. Proposed Changes to the Prospective Payment Rates for Hospital 
Inpatient Operating Costs for FY 2009
    A. Calculation of the Adjusted Standardized Amount
    B. Proposed Adjustments for Area Wage Levels and Cost-of-Living
    C. Proposed MS-DRG Relative Weights
    D. Calculation of the Proposed Prospective Payment Rates
III. Proposed Changes of Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2009
    A. Determination of Proposed Federal Hospital Inpatient Capital-
Related Prospective Payment Rate Update
    B. Calculation of the Proposed Inpatient Capital-Related 
Prospective Payments for FY 2009
    C. Capital Input Price Index
IV. Proposed Changes to Payment Rates for Excluded Hospitals and 
Hospital Units: Rate-of-Increase Percentages
V. Tables
    Table 1A.--National Adjusted Operating Standardized Amounts, 
Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share 
If Wage Index Is Greater Than 1)
    Table 1B.--National Adjusted Operating Standardized Amounts, 
Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If 
Wage Index Is Less Than or Equal to 1)
    Table 1C.--Adjusted Operating Standardized Amounts for Puerto 
Rico, Labor/Nonlabor
    Table 1D.--Capital Standard Federal Payment Rate
    Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in 
Federal Fiscal Year 2007; Hospital Wage Indexes for Federal Fiscal 
Year 2009; Hospital Average Hourly Wages for Federal Fiscal Years 
2007 (2003 Wage Data), 2008 (2004 Wage Data), and 2009 (2005 Wage 
Data); and 3-Year Average of Hospital Average Hourly Wages
    Table 3A.--FY 2009 and 3-Year Average Hourly Wage for Urban 
Areas by CBSA
    Table 3B.--FY 2009 and 3-Year Average Hourly Wage for Rural 
Areas by CBSA
    Table 4A.--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Urban Areas by CBSA and by State--FY 2009
    Table 4B.--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Rural Areas by CBSA and by State--FY 2009
    Table 4C.--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Hospitals That Are Reclassified by CBSA and by State--FY 
2009
    Table 4D-1.--Rural Floor Budget Neutrality Factors--FY 2009
    Table 4D-2.--Urban Areas with Hospitals Receiving the Statewide 
Rural Floor or Imputed Floor Wage Index--FY 2009
    Table 4E.--Urban CBSAs and Constituent Counties--FY 2009
    Table 4F.--Puerto Rico Wage Index and Capital Geographic 
Adjustment Factor (GAF) by CBSA--FY 2009
    Table 4J.--Out-Migration Wage Adjustment--FY 2009
    Table 5.--List of Medicare Severity Diagnosis-Related Groups 
(MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic 
Mean Length of Stay
    Table 6A.--New Diagnosis Codes
    Table 6B.--New Procedure Codes
    Table 6C.--Invalid Diagnosis Codes
    Table 6D.--Invalid Procedure Codes
    Table 6E.--Revised Diagnosis Code Titles
    Table 6F.--Revised Procedure Code Titles
    Table 6G.--Additions to the CC Exclusions List (Available 
through the Internet on the CMS Web site at: https://www.cms.hhs.gov/
AcuteInpatientPPS/)
    Table 6H.--Deletions From the CC Exclusions List (Available 
Through the

[[Page 23533]]

Internet on the CMS Web site at: https://www.cms.hhs.gov/
AcuteInpatientPPS/)
    Table 6I.--Complete List of Complication and Comorbidity (CC) 
Exclusions (Available Only Through the Internet on the CMS Web site 
at: http:/www.cms.hhs.gov/AcuteInpatientPPS/)
    Table 6J.--Major Complication and Comorbidity (MCC) List 
(Available Through the Internet on the CMS Web Site at: https://
www.cms.hhs.gov/AcuteInpatientPPS/)
    Table 6K.--Complication and Comorbidity (CC) List (Available 
Through the Internet on the CMS Web site at: https://www.cms.hhs.gov/
AcuteInpatientPPS/)
    Table 7A.--Medicare Prospective Payment System Selected 
Percentile Lengths of Stay: FY 2007 MedPAR Update--December 2007 
GROUPER V25.0 MS-DRGs
    Table 7B.--Medicare Prospective Payment System Selected 
Percentile Lengths of Stay: FY 2007 MedPAR Update--December 2007 
GROUPER V26.0 MS-DRGs
    Table 8A.--Proposed Statewide Average Operating Cost-to-Charge 
Ratios--March 2008
    Table 8B.--Proposed Statewide Average Capital Cost-to-Charge 
Ratios--March 2008
    Table 8C.--Proposed Statewide Average Total Cost-to-Charge 
Ratios for LTCHs--March 2008
    Table 9A.--Hospital Reclassifications and Redesignations--FY 
2009
    Table 9B.--Hospitals Redesignated as Rural under Section 
1886(d)(8)(E) of the Act--FY 2009
    Table 10.--Geometric Mean Plus the Lesser of .75 of the National 
Adjusted Operating Standardized Payment Amount (Increased to Reflect 
the Difference Between Costs and Charges) or .75 of One Standard 
Deviation of Mean Charges by Medicare Severity Diagnosis-Related 
Groups (MS-DRGs)--March 2008
    Table 11.--Proposed FY 2009 MS-LTC-DRGs, Proposed Relative 
Weights, Proposed Geometric Average Length of Stay, and Proposed 
Short-Stay Outlier Threshold

Appendix A--Regulatory Impact Analysis

I. Overall Impact
II. Objectives
III. Limitations on Our Analysis
IV. Hospitals Included in and Excluded From the IPPS
V. Effects on Excluded Hospitals and Hospital Units
VI. Quantitative Effects of the Proposed Policy Changes Under the 
IPPS for Operating Costs
    A. Basis and Methodology of Estimates
    B. Analysis of Table I
    C. Effects of the Proposed Changes to the MS-DRG 
Reclassifications and Relative Cost-Based Weights (Column 2)
    D. Effects of Proposed Wage Index Changes (Column 3)
    E. Combined Effects of Proposed MS-DRG and Wage Index Changes 
(Column 4)
    F. Effects of MGCRB Reclassifications (Column 5)
    G. Effects of the Proposed Rural Floor and Imputed Rural Floor, 
Including the Proposed Application of Budget Neutrality at the State 
Level (Column 6)
    H. Effects of the Proposed Wage Index Adjustment for Out-
Migration (Column 7)
    I. Effects of All Proposed Changes with CMI Adjustment Prior to 
Estimated Growth (Column 8)
    J. Effects of All Proposed Changes with CMI Adjustment and 
Estimated Growth (Column 9)
    K. Effects of Policy on Payment Adjustment for Low-Volume 
Hospitals
    L. Impact Analysis of Table II
VII. Effects of Other Proposed Policy Changes
    A. Effects of Proposed Policy on HACs, Including Infections
    B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative 
Weights for LTCHs
    C. Effects of Proposed Policy Change Relating to New Medical 
Service and Technology Add-On Payments
    D. Effects of Proposed Policy Change Regarding Postacute Care 
Transfers to Home Health Services
    E. Effects of Proposed Requirements for Hospital Reporting of 
Quality Data for Annual Hospital Payment Update
    F. Effects of Proposed Policy Change to Methodology for 
Computing Core Staffing Factors for Volume Decrease Adjustment for 
SCHs and MDHs
    G. Effects of Proposed Clarification of Policy for Collection of 
Risk Adjustment Data From MA Organizations
    H. Effects of Proposed Policy Changes Relating to Hospital 
Emergency Services under EMTALA
    I. Effects of Implementation of Rural Community Hospital 
Demonstration Program
    J. Effects of Proposed Policy Changes Relating to Payments to 
Hospitals-Within-Hospitals
    K. Effects of Proposed Policy Changes Relating to Requirements 
for Disclosure of Physician Ownership in Hospitals
    L. Effects of Proposed Changes Relating to Physician Self-
Referral Provisions
    M. Effects of Proposed Changes Relating to Reporting of 
Financial Relationships Between Hospitals and Physicians
VIII. Effects of Proposed Changes in the Capital IPPS
    A. General Considerations
    B. Results
IX. Alternatives Considered
X. Overall Conclusion
XI. Accounting Statement
XII. Executive Order 12866

Appendix B--Recommendation of Update Factors for Operating Cost Rates 
of Payment for Inpatient Hospital Services

I. Background
II. Inpatient Hospital Update for FY 2009
III. Secretary's Recommendation
IV. MedPAC Recommendation for Assessing Payment Adequacy and 
Updating Payments in Traditional Medicare

Appendix C--Disclosure of Financial Relationships Report (DFRR) Form

I. Background

A. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)
    Section 1886(d) of the Social Security Act (the Act) sets forth a 
system of payment for the operating costs of acute care hospital 
inpatient stays under Medicare Part A (Hospital Insurance) based on 
prospectively set rates. Section 1886(g) of the Act requires the 
Secretary to pay for the capital-related costs of hospital inpatient 
stays under a prospective payment system (PPS). Under these PPSs, 
Medicare payment for hospital inpatient operating and capital-related 
costs is made at predetermined, specific rates for each hospital 
discharge. Discharges are classified according to a list of diagnosis-
related groups (DRGs).
    The base payment rate is comprised of a standardized amount that is 
divided into a labor-related share and a nonlabor-related share. The 
labor-related share is adjusted by the wage index applicable to the 
area where the hospital is located. If the hospital is located in 
Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-
living adjustment factor. This base payment rate is multiplied by the 
DRG relative weight.
    If the hospital treats a high percentage of low-income patients, it 
receives a percentage add-on payment applied to the DRG-adjusted base 
payment rate. This add-on payment, known as the disproportionate share 
hospital (DSH) adjustment, provides for a percentage increase in 
Medicare payments to hospitals that qualify under either of two 
statutory formulas designed to identify hospitals that serve a 
disproportionate share of low-income patients. For qualifying 
hospitals, the amount of this adjustment may vary based on the outcome 
of the statutory calculations.
    If the hospital is an approved teaching hospital, it receives a 
percentage add-on payment for each case paid under the IPPS, known as 
the indirect medical education (IME) adjustment. This percentage 
varies, depending on the ratio of residents to beds.
    Additional payments may be made for cases that involve new 
technologies or medical services that have been approved for special 
add-on payments. To qualify, a new technology or medical service must 
demonstrate that it is a substantial clinical improvement over 
technologies or services otherwise available, and that, absent an add-
on

[[Page 23534]]

payment, it would be inadequately paid under the regular DRG payment.
    The costs incurred by the hospital for a case are evaluated to 
determine whether the hospital is eligible for an additional payment as 
an outlier case. This additional payment is designed to protect the 
hospital from large financial losses due to unusually expensive cases. 
Any outlier payment due is added to the DRG-adjusted base payment rate, 
plus any DSH, IME, and new technology or medical service add-on 
adjustments.
    Although payments to most hospitals under the IPPS are made on the 
basis of the standardized amounts, some categories of hospitals are 
paid in whole or in part based on their hospital-specific rate based on 
their costs in a base year. For example, sole community hospitals 
(SCHs) receive the higher of a hospital-specific rate based on their 
costs in a base year (the higher of FY 1982, FY 1987, or FY 1996) or 
the IPPS rate based on the standardized amount. Until FY 2007, a 
Medicare-dependent, small rural hospital (MDH) has received the IPPS 
rate plus 50 percent of the difference between the IPPS rate and its 
hospital-specific rate if the hospital-specific rate based on their 
costs in a base year (the higher of FY 1982, FY 1987, or FY 2002) is 
higher than the IPPS rate. As discussed below, for discharges occurring 
on or after October 1, 2007, but before October 1, 2011, an MDH will 
receive the IPPS rate plus 75 percent of the difference between the 
IPPS rate and its hospital-specific rate, if the hospital-specific rate 
is higher than the IPPS rate. SCHs are the sole source of care in their 
areas, and MDHs are a major source of care for Medicare beneficiaries 
in their areas. Both of these categories of hospitals are afforded this 
special payment protection in order to maintain access to services for 
beneficiaries.
    Section 1886(g) of the Act requires the Secretary to pay for the 
capital-related costs of inpatient hospital services ``in accordance 
with a prospective payment system established by the Secretary.'' The 
basic methodology for determining capital prospective payments is set 
forth in our regulations at 42 CFR 412.308 and 412.312. Under the 
capital IPPS, payments are adjusted by the same DRG for the case as 
they are under the operating IPPS. Capital IPPS payments are also 
adjusted for IME and DSH, similar to the adjustments made under the 
operating IPPS. However, as discussed in section V.B.2. of this 
preamble, we are phasing out the IME adjustment beginning with FY 2008. 
In addition, hospitals may receive outlier payments for those cases 
that have unusually high costs.
    The existing regulations governing payments to hospitals under the 
IPPS are located in 42 CFR Part 412, Subparts A through M.
2. Hospitals and Hospital Units Excluded From the IPPS
    Under section 1886(d)(1)(B) of the Act, as amended, certain 
specialty hospitals and hospital units are excluded from the IPPS. 
These hospitals and units are: Rehabilitation hospitals and units; 
long-term care hospitals (LTCHs); psychiatric hospitals and units; 
children's hospitals; and cancer hospitals. Religious nonmedical health 
care institutions (RNHCIs) are also excluded from the IPPS. Various 
sections of the Balanced Budget Act of 1997 (Pub. L. 105-33), the 
Medicare, Medicaid and SCHIP [State Children's Health Insurance 
Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113), and 
the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 
Act of 2000 (Pub. L. 106-554) provide for the implementation of PPSs 
for rehabilitation hospitals and units (referred to as inpatient 
rehabilitation facilities (IRFs)), LTCHs, and psychiatric hospitals and 
units (referred to as inpatient psychiatric facilities (IPFs)), as 
discussed below. Children's hospitals, cancer hospitals, and RNHCIs 
continue to be paid solely under a reasonable cost-based system.
    The existing regulations governing payments to excluded hospitals 
and hospital units are located in 42 CFR Parts 412 and 413.
a. Inpatient Rehabilitation Facilities (IRFs)
    Under section 1886(j) of the Act, as amended, rehabilitation 
hospitals and units (IRFs) have been transitioned from payment based on 
a blend of reasonable cost reimbursement subject to a hospital-specific 
annual limit under section 1886(b) of the Act and the adjusted facility 
Federal prospective payment rate for cost reporting periods beginning 
on or after January 1, 2002 through September 30, 2002, to payment at 
100 percent of the Federal rate effective for cost reporting periods 
beginning on or after October 1, 2002. IRFs subject to the blend were 
also permitted to elect payment based on 100 percent of the Federal 
rate. The existing regulations governing payments under the IRF PPS are 
located in 42 CFR Part 412, Subpart P.
b. Long-Term Care Hospitals (LTCHs)
    Under the authority of sections 123(a) and (c) of Pub. L. 106-113 
and section 307(b)(1) of Pub. L. 106-554, the LTCH PPS was effective 
for a LTCH's first cost reporting period beginning on or after October 
1, 2002. LTCHs that do not meet the definition of ``new'' under Sec.  
412.23(e)(4) are paid, during a 5-year transition period, a LTCH 
prospective payment that is comprised of an increasing proportion of 
the LTCH Federal rate and a decreasing proportion based on reasonable 
cost principles. Those LTCHs that did not meet the definition of 
``new'' under Sec.  412.23(e)(4) could elect to be paid based on 100 
percent of the Federal prospective payment rate instead of a blended 
payment in any year during the 5-year transition. For cost reporting 
periods beginning on or after October 1, 2006, all LTCHs are paid 100 
percent of the Federal rate. The existing regulations governing payment 
under the LTCH PPS are located in 42 CFR Part 412, Subpart O.
c. Inpatient Psychiatric Facilities (IPFs)
    Under the authority of sections 124(a) and (c) of Pub. L. 106-113, 
inpatient psychiatric facilities (IPFs) (formerly psychiatric hospitals 
and psychiatric units of acute care hospitals) are paid under the IPF 
PPS. For cost reporting periods beginning on or after January 1, 2008, 
all IPFs are paid 100 percent of the Federal per diem payment amount 
established under the IPF PPS. (For cost reporting periods beginning on 
or after January 1, 2005, and ending on or before December 31, 2007, 
some IPFs received transitioned payments for inpatient hospital 
services based on a blend of reasonable cost-based payment and a 
Federal per diem payment rate.) The existing regulations governing 
payment under the IPF PPS are located in 42 CFR part 412, Subpart N.
3. Critical Access Hospitals (CAHs)
    Under sections 1814, 1820, and 1834(g) of the Act, payments are 
made to critical access hospitals (CAHs) (that is, rural hospitals or 
facilities that meet certain statutory requirements) for inpatient and 
outpatient services are based on 101 percent of reasonable cost. 
Reasonable cost is determined under the provisions of section 
1861(v)(1)(A) of the Act and existing regulations under 42 CFR Parts 
413 and 415.
4. Payments for Graduate Medical Education (GME)
    Under section 1886(a)(4) of the Act, costs of approved educational 
activities are excluded from the operating costs of inpatient hospital 
services. Hospitals with approved graduate medical education (GME) 
programs are paid for the direct costs of GME in accordance with 
section 1886(h) of the Act. The amount of payment for direct GME costs

[[Page 23535]]

for a cost reporting period is based on the hospital's number of 
residents in that period and the hospital's costs per resident in a 
base year. The existing regulations governing payments to the various 
types of hospitals are located in 42 CFR Part 413.

B. Provisions of the Deficit Reduction Act of 2005 (DRA)

    Section 5001(b) of the Deficit Reduction Act of 2005 (DRA), Pub. L. 
109-171, requires the Secretary to develop a plan to implement, 
beginning with FY 2009, a value-based purchasing plan for section 
1886(d) hospitals defined in the Act. In section IV.C. of the preamble 
of this proposed rule, we discuss the report to Congress on the 
Medicare value-based purchasing plan and the current testing of the 
plan.

C. Provisions of the Medicare Improvements and Extension Act Under 
Division B, Title I of the Tax Relief and Health Care Act of 2006 
(MIEA-TRHCA)

    Section 106(b)(2) of the MIEA-TRHCA instructs the Secretary of 
Health and Human Services to include in the FY 2009 IPPS proposed rule 
one or more proposals to revise the wage index adjustment applied under 
section 1886(d)(3)(E) of the Act for purposes of the IPPS. The 
Secretary was also instructed to consider MedPAC's recommendations on 
the Medicare wage index classification system in developing these 
proposals. In section III. of the preamble of this proposed rule, we 
discuss MedPAC's recommendations in a report to Congress and present 
our proposed changes to the FY 2009 wage index in response to those 
recommendations.

D. Provision of the TMA, Abstinence Education, and QI Programs 
Extension Act of 2007

    Section 7 of the TMA [Transitional Medical Assistance], Abstinence 
Education, and QI [Qualifying Individuals] Programs Extension Act of 
2007 (Pub. L. 110-90) provides for a 0.9 percent prospective 
documentation and coding adjustment in the determination of 
standardized amounts under the IPPS (except for MDHs and SCHs) for 
discharges occurring during FY 2009. The prospective documentation and 
coding adjustment was established in FY 2008 in response to the 
implementation of an MS-DRG system under the IPPS that resulted in 
changes in coding and classification that did not reflect real changes 
in case-mix under section 1886(d) of the Act. We discuss our proposed 
implementation of this provision in section II.D. of the preamble of 
this proposed rule and in the Addendum and in Appendix A to this 
proposed rule.

E. Major Contents of This Proposed Rule

    In this proposed rule, we are setting forth proposed changes to the 
Medicare IPPS for operating costs and for capital-related costs in FY 
2009. We also are setting forth proposed changes relating to payments 
for IME costs and payments to certain hospitals and units that continue 
to be excluded from the IPPS and paid on a reasonable cost basis. In 
addition, we are presenting proposed changes relating to disclosure to 
patients of physician ownership and investment interests in hospitals, 
proposed changes to our physician self-referral regulations, and a 
solicitation of public comments on a proposed collection of information 
regarding financial relationships between hospitals and physicians.
    The following is a summary of the major changes that we are 
proposing to make:
1. Proposed Changes to MS-DRG Classifications and Recalibrations of 
Relative Weights
    In section II. of the preamble to this proposed rule, we are 
including--
     Proposed changes to MS-DRG reclassifications based on our 
yearly review.
     Proposed application of the documentation and coding 
adjustment to hospital-specific rates resulting from implementation of 
the MS-DRG system.
     Proposed changes to address the RTI reporting 
recommendations on charge compression.
     Proposed recalibrations of the MS-DRG relative weights.
    We also are proposing to refine the hospital cost reports so that 
charges for relatively inexpensive medical supplies are reported 
separately from the costs and charges for more expensive medical 
devices. This proposal would be applied to the determination of both 
the IPPS and the OPPS relative weights as well as the calculation of 
the ambulatory surgical center payment rates.
    We are presenting a listing and discussion of additional hospital-
acquired conditions (HACs), including infections, that are being 
proposed to be subject to the statutorily required quality adjustment 
in MS-DRG payments for FY 2009.
    We are presenting our evaluation and analysis of the FY 2009 
applicants for add-on payments for high-cost new medical services and 
technologies (including public input, as directed by Pub. L. 108-173, 
obtained in a town hall meeting).
    We are proposing the annual update of the MS-LTC-DRG 
classifications and relative weights for use under the LTCH PPS for FY 
2009.
2. Proposed Changes to the Hospital Wage Index
    In section III. of the preamble to this proposed rule, we are 
proposing revisions to the wage index and the annual update of the wage 
data. Specific issues addressed include the following:
     Proposed wage index reform changes in response to 
recommendations made to Congress as a result of the wage index study 
required under Pub. L. 109-432. We discuss changes related to 
reclassifications criteria, application of budget neutrality in 
reclassifications, and the rural floor and imputed floor budget 
neutrality at the State level.
     Changes to the CBSA designations.
     The methodology for computing the proposed FY 2009 wage 
index.
     The proposed FY 2009 wage index update, using wage data 
from cost reporting periods that began during FY 2006.
     Analysis and implementation of the proposed FY 2009 
occupational mix adjustment to the wage index.
     Proposed revisions to the wage index based on hospital 
redesignations and reclassifications.
     The proposed adjustment to the wage index for FY 2009 
based on commuting patterns of hospital employees who reside in a 
county and work in a different area with a higher wage index.
     The timetable for reviewing and verifying the wage data 
used to compute the proposed FY 2009 wage index.
     The proposed labor-related share for the FY 2009 wage 
index, including the labor-related share for Puerto Rico.
3. Other Decisions and Proposed Changes to the IPPS for Operating Costs 
and GME Costs
    In section IV. of the preamble to this proposed rule, we discuss a 
number of the provisions of the regulations in 42 CFR Parts 412, 413, 
and 489, including the following:
     Proposed changes to the postacute care transfer policy as 
it relates to transfers to home with the provision of home health 
services.
     The reporting of hospital quality data as a condition for 
receiving the full annual payment update increase.
     Proposed changes in the collection of Medicare Advantage 
(MA) encounter data that are used for computing the risk payment 
adjustment made to MA organizations.
     Discussion of the report to Congress on the Medicare 
value-based purchasing

[[Page 23536]]

plan and current testing and further development of the plan.
     Proposed changes to the methodology for determining core 
staff values for the volume decrease payment adjustment for SCHs and 
MDHs.
     The proposed updated national and regional case-mix values 
and discharges for purposes of determining RRC status.
     The statutorily-required IME adjustment factor for FY 2009 
and technical changes to the GME payment policies.
     Proposed changes to policies on hospital emergency 
services under EMTALA to address EMTALA Technical Advisory Group (TAG) 
recommendations.
     Solicitation of public comments on Medicare policies 
relating to incentives for avoidable readmissions to hospitals.
     Discussion of the fifth year of implementation of the 
Rural Community Hospital Demonstration Program.
4. Proposed Changes to the IPPS for Capital-Related Costs
    In section V. of the preamble to this proposed rule, we discuss the 
payment policy requirements for capital-related costs and capital 
payments to hospitals. We acknowledge the public comments that we 
received on the phase-out of the capital teaching adjustment included 
in the FY 2008 IPPS final rule with comment period, and again are 
soliciting public comments on this phase-out in this proposed rule.
5. Proposed Changes to the Payment Rates for Excluded Hospitals and 
Hospital Units: Rate-of-Increase Percentages
    In section VI. of the preamble to this proposed rule, we discuss 
proposed changes to payments to excluded hospitals and hospital units, 
proposed changes for determining LTCH CCRs under the LTCH PPS, 
including a discussion regarding changing the annual payment rate 
update schedule for the LTCH PPS, and proposed changes to the 
regulations on hospitals-within-hospitals.
6. Proposed Changes Relating to Disclosure of Physician Ownership in 
Hospitals
    In section VII. of the preamble of this proposed rule, we present 
proposed changes to the regulations relating to the disclosure to 
patients of physician ownership or investment interests in hospitals.
7. Proposed Changes and Solicitation of Comments on Physician Self-
Referrals Provisions
    In section VIII. of the preamble of this proposed rule, we present 
proposed changes to the policies on physician self-referrals relating 
to the ``Stand in Shoes'' provision, In addition, we solicit public 
comments regarding physician-owned implant companies and gainsharing 
arrangements.
8. Proposed Collection of Information Regarding Financial Relationships 
Between Hospitals and Physicians
    In section IX. of the preamble of this proposed rule, we solicit 
public comments on our proposed collection of information regarding 
financial relationships between hospitals and physicians.
9. Determining Proposed Prospective Payment Operating and Capital Rates 
and Rate-of-Increase Limits
    In the Addendum to this proposed rule, we set forth proposed 
changes to the amounts and factors for determining the FY 2009 
prospective payment rates for operating costs and capital-related 
costs. We also establish the proposed threshold amounts for outlier 
cases. In addition, we address the proposed update factors for 
determining the rate-of-increase limits for cost reporting periods 
beginning in FY 2009 for hospitals and hospital units excluded from the 
PPS.
10. Impact Analysis
    In Appendix A of this proposed rule, we set forth an analysis of 
the impact that the proposed changes would have on affected hospitals.
11. Recommendation of Update Factors for Operating Cost Rates of 
Payment for Inpatient Hospital Services
    In Appendix B of this proposed rule, as required by sections 
1886(e)(4) and (e)(5) of the Act, we provided our recommendations of 
the appropriate percentage changes for FY 2009 for the following:
     A single average standardized amount for all areas for 
hospital inpatient services paid under the IPPS for operating costs 
(and hospital-specific rates applicable to SCHs and MDHs).
     Target rate-of-increase limits to the allowable operating 
costs of hospital inpatient services furnished by hospitals and 
hospital units excluded from the IPPS.
12. Disclosure of Financial Relationships Report (DFRR) Form
    In Appendix C of this proposed rule, we present the reporting form 
that we are proposing to use for the proposed collection of information 
on financial relationships between hospitals and physicians discussed 
in section IX, of the preamble of this proposed rule.
13. Discussion of Medicare Payment Advisory Commission Recommendations
    Under section 1805(b) of the Act, MedPAC is required to submit a 
report to Congress, no later than March 1 of each year, in which MedPAC 
reviews and makes recommendations on Medicare payment policies. 
MedPAC's March 2008 recommendations concerning hospital inpatient 
payment policies address the update factor for inpatient hospital 
operating costs and capital-related costs under the IPPS and for 
hospitals and distinct part hospital units excluded from the IPPS. We 
address these recommendations in Appendix B of this proposed rule. For 
further information relating specifically to the MedPAC March 2008 
reports or to obtain a copy of the reports, contact MedPAC at (202) 
220-3700 or visit MedPAC's Web site at: www.medpac.gov.

F. Public Comments Received on Issues in Related Rules

1. Comments on Phase-Out of the Capital Teaching Adjustment Under the 
IPPS Included in the FY 2008 IPPS Final Rule With Comment Period
    In the FY 2008 IPPS final rule with comment period, we solicited 
public comments on our policy changes related to phase-out of the 
capital teaching adjustment to the capital payment update under the 
IPPS (72 FR 47401). We received approximately 90 timely pieces of 
correspondence in response to our solicitation. (These public comments 
may be viewed on the following Web site: https://www.cms.hhs.gov/
eRulemaking/ECCMSR/list.asp under file code CMS-1533-FC.) In section V. 
of the preamble of this proposed rule, we acknowledge receipt of these 
public comments and again solicit public comments on the phase-out in 
this proposed rule. We will respond to the public comments received in 
response to both the FY 2008 IPPS final rule with comment period and 
this proposed rule in the FY 2009 IPPS final rule, which is scheduled 
to be published in August 2008.
2. Policy Revisions Related to Medi

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