Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System Payment Update for Rate Year Beginning July 1, 2009 (RY 2010), 20362-20399 [E9-9962]

Agencies

• Centers for Medicare & Medicaid Services
• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 74, Number 83 (Friday, May 1, 2009)]
[Notices]
[Pages 20362-20399]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-9962]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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Medicare Program; Inpatient Psychiatric Facilities Prospective Payment 
System Payment Update for Rate Year Beginning July 1, 2009 (RY 2010); 
Notice

Federal Register / Vol. 74, No. 83 / Friday, May 1, 2009 / Notices

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1495-NC]
RIN 0938-AP50


Medicare Program; Inpatient Psychiatric Facilities Prospective 
Payment System Payment Update for Rate Year Beginning July 1, 2009 (RY 
2010)

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

ACTION: Notice; request for comments.

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SUMMARY: This notice updates the payment rates for the Medicare 
prospective payment system (PPS) for inpatient psychiatric hospital 
services provided by inpatient psychiatric facilities (IPFs). These 
changes are applicable to IPF discharges occurring during the rate year 
beginning July 1, 2009 through June 30, 2010. We are also requesting 
comments on the IPF PPS teaching adjustment and the market basket.

DATES: 
    Effective Date: The updated IPF prospective payment rates are 
effective for discharges occurring on or after July 1, 2009 through 
June 30, 2010.
    Comment Date: To be assured consideration, comments must be 
received at one of the addresses provided below, no later than 5 p.m. 
on June 30, 2009.

ADDRESSES: In commenting, please refer to file code CMS-1495-NC. 
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 specific 
issues in this regulation to https://www.regulations.gov. Follow the 
instructions for ``Comment or Submission'' and enter the file code to 
find the document accepting comments.
    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-1495-NC, P.O. Box 8010, 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-1495-NC, 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) 786-9994 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.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Dorothy Myrick or Jana Lindquist, 
(410) 786-4533 (for general information).
    Bridget Dickensheets, (410) 786-8670 (for information regarding the 
market basket and labor-related share).
    Theresa Bean, (410) 786-2287 (for information regarding the 
regulatory impact analysis).

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 as they are received, 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.

Table of Contents

    To assist readers in referencing sections contained in this 
document, we are providing the following table of contents.

I. Background
    A. Annual Requirements for Updating the IPF PPS
    B. Overview of the Legislative Requirements of the IPF PPS
    C. IPF PPS--General Overview
II. Transition Period for Implementation of the IPF PPS
III. Updates to the IPF PPS for RY Beginning July 1, 2009
    A. Determining the Standardized Budget-Neutral Federal Per Diem 
Base Rate
    1. Standardization of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy Rate
    2. Calculation of the Budget Neutrality Adjustment
    a. Outlier Adjustment
    b. Stop-Loss Provision Adjustment
    c. Behavioral Offset
    B. Update of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy Rate
    1. Market Basket for IPFs Reimbursed Under the IPF PPS
    a. Market Basket Index for the IPF PPS
    b. Overview of the RPL Market Basket
    2. Labor-Related Share
    3. One-Time Prospective Adjustment to the Standard Federal Rate
IV. Update of the IPF PPS Adjustment Factors
    A. Overview of the IPF PPS Adjustment Factors
    B. Patient-Level Adjustments
    1. Adjustment for MS-DRG Assignment
    2. Payment for Comorbid Conditions
    3. Patient Age Adjustments
    4. Variable Per Diem Adjustments
    C. Facility-Level Adjustments
    1. Wage Index Adjustment
    a. Background
    b. Wage Index for RY 2010
    c. OMB Bulletins
    2. Adjustment for Rural Location
    3. Teaching Adjustment
    4. Cost of Living Adjustment for IPFs Located in Alaska and 
Hawaii
    5. Adjustment for IPFs With a Qualifying Emergency Department 
(ED)
    D. Other Payment Adjustments and Policies
    1. Outlier Payments
    a. Update to the Outlier Fixed Dollar Loss Threshold Amount
    b. Statistical Accuracy of Cost-to-Charge Ratios
    2. Expiration of the Stop-Loss Provision
V. Request for Comments
VI. Waiver of Proposed Rulemaking

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VII. Collection of Information Requirements
VIII. Response to Comments
IX. Regulatory Impact Analysis
Addenda

Acronyms

    Because of the many terms to which we refer by acronym in this 
notice, we are listing the acronyms used and their corresponding terms 
in alphabetical order below:

BBRA Medicare, Medicaid and SCHIP [State Children's Health Insurance 
Program] Balanced Budget Refinement Act of 1999, (Pub. L. 106-113)
CBSA Core-Based Statistical Area
CCR Cost-to-charge ratio
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders 
Fourth Edition--Text Revision
DRGs Diagnosis-related groups
FY Federal fiscal year
ICD-9-CM International Classification of Diseases, 9th Revision, 
Clinical Modification
IPFs Inpatient psychiatric facilities
IRFs Inpatient rehabilitation facilities
LTCHs Long-term care hospitals
MedPAR Medicare provider analysis and review file
RY Rate Year
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, (Pub. L. 97-
248)

I. Background

A. Annual Requirements for Updating the IPF PPS

    In November 2004, we implemented the inpatient psychiatric 
facilities (IPF) prospective payment system (PPS) in a final rule that 
appeared in the November 15, 2004 Federal Register (69 FR 66922). In 
developing the IPF PPS, in order to ensure that the IPF PPS is able to 
account adequately for each IPF's case-mix, we performed an extensive 
regression analysis of the relationship between the per diem costs and 
certain patient and facility characteristics to determine those 
characteristics associated with statistically significant cost 
differences on a per diem basis. For characteristics with statistically 
significant cost differences, we used the regression coefficients of 
those variables to determine the size of the corresponding payment 
adjustments.
    In that final rule, we explained that we believe it is important to 
delay updating the adjustment factors derived from the regression 
analysis until we have IPF PPS data that includes as much information 
as possible regarding the patient-level characteristics of the 
population that each IPF serves. Therefore, we indicated that we did 
not intend to update the regression analysis and recalculate the 
Federal per diem base rate and the patient- and facility-level 
adjustments until we complete that analysis. Until that analysis is 
complete, we stated our intention to publish a notice in the Federal 
Register each spring to update the IPF PPS (71 FR 27041).
    Updates to the IPF PPS as specified in 42 CFR 412.428 include the 
following:
     A description of the methodology and data used to 
calculate the updated Federal per diem base payment amount.
     The rate of increase factor as described in Sec.  
412.424(a)(2)(iii), which is based on the excluded hospital with 
capital market basket under the update methodology of section 
1886(b)(3)(B)(ii) of the Social Security Act (the Act) for each year 
(effective from the implementation period until June 30, 2006).
     For discharges occurring on or after July 1, 2006, the 
rate of increase factor for the Federal portion of the IPF's payment, 
which is based on the rehabilitation, psychiatric, and long-term care 
(RPL) market basket.
     The best available hospital wage index and information 
regarding whether an adjustment to the Federal per diem base rate is 
needed to maintain budget neutrality.
     Updates to the fixed dollar loss threshold amount in order 
to maintain the appropriate outlier percentage.
     Description of the International Classification of 
Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding and 
diagnosis-related groups (DRGs) classification changes discussed in the 
annual update to the hospital inpatient prospective payment system 
(IPPS) regulations.
     Update to the electroconvulsive therapy (ECT) payment by a 
factor specified by CMS.
     Update to the national urban and rural cost-to-charge 
ratio medians and ceilings.
     Update to the cost of living adjustment factors for IPFs 
located in Alaska and Hawaii, if appropriate.
    Our most recent annual update occurred in the May 2008 IPF PPS 
notice (73 FR 25709) that set forth updates to the IPF PPS payment 
rates for RY 2009. This notice updates the IPF per diem payment rates 
that were published in the May 2008 IPF PPS notice in accordance with 
our established policies.

B. Overview of the Legislative Requirements for the IPF PPS

    Section 124 of the Medicare, Medicaid, and SCHIP (State Children's 
Health Insurance Program) Balanced Budget Refinement Act of 1999, (Pub. 
L. 106-113) (BBRA) required implementation of the IPF PPS. 
Specifically, section 124 of the BBRA mandated that the Secretary 
develop a per diem PPS for inpatient hospital services furnished in 
psychiatric hospitals and psychiatric units that includes an adequate 
patient classification system that reflects the differences in patient 
resource use and costs among psychiatric hospitals and psychiatric 
units.
    Section 405(g)(2) of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF 
PPS to distinct part psychiatric units of critical access hospitals 
(CAHs).
    To implement these provisions, we published various proposed and 
final rules in the Federal Register. For more information regarding 
these rules, see the CMS Web sites https://www.cms.hhs.gov/InpatientPsychFacilPPS/ and https://www.cms.hhs.gov/InpatientpsychfacilPPS/02_regulations.asp.

C. IPF PPS--General Overview

    The November 2004 IPF PPS final rule (69 FR 66922) established the 
IPF PPS, as authorized under section 124 of the BBRA and codified at 
subpart N of part 412 of the Medicare regulations. The November 2004 
IPF PPS final rule set forth the per diem Federal rates for the 
implementation year (the 18-month period from January 1, 2005 through 
June 30, 2006), and it provided payment for the inpatient operating and 
capital costs to IPFs for covered psychiatric services they furnish 
(that is, routine, ancillary, and capital costs, but not costs of 
approved educational activities, bad debts, and other services or items 
that are outside the scope of the IPF PPS). Covered psychiatric 
services include services for which benefits are provided under the 
fee-for-service Part A (Hospital Insurance Program) Medicare program.
    The IPF PPS established the Federal per diem base rate for each 
patient day in an IPF derived from the national average daily routine 
operating, ancillary, and capital costs in IPFs in FY 2002. The average 
per diem cost was updated to the midpoint of the first year under the 
IPF PPS, standardized to account for the overall positive effects of 
the IPF PPS payment adjustments, and adjusted for budget neutrality.
    The Federal per diem payment under the IPF PPS is comprised of the 
Federal per diem base rate described above and certain patient- and 
facility-level payment adjustments that were found in the regression 
analysis to be associated with statistically significant per diem cost 
differences.

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    The patient-level adjustments include age, DRG assignment, 
comorbidities, and variable per diem adjustments to reflect higher per 
diem costs in the early days of an IPF stay. Facility-level adjustments 
include adjustments for the IPF's wage index, rural location, teaching 
status, a cost of living adjustment for IPFs located in Alaska and 
Hawaii, and presence of a qualifying emergency department (ED).
    The IPF PPS provides additional payment policies for: Outlier 
cases; stop-loss protection (which was applicable only during the IPF 
PPS transition period); interrupted stays; and a per treatment 
adjustment for patients who undergo ECT.
    A complete discussion of the regression analysis appears in the 
November 2004 IPF PPS final rule (69 FR 66933 through 66936).
    Section 124 of BBRA does not specify an annual update rate strategy 
for the IPF PPS and is broadly written to give the Secretary discretion 
in establishing an update methodology. Therefore, in the November 2004 
IPF PPS final rule, we implemented the IPF PPS using the following 
update strategy:
     Calculate the final Federal per diem base rate to be 
budget neutral for the 18-month period of January 1, 2005 through June 
30, 2006.
     Use a July 1 through June 30 annual update cycle.
     Allow the IPF PPS first update to be effective for 
discharges on or after July 1, 2006 through June 30, 2007.

II. Transition Period for Implementation of the IPF PPS

    In the November 2004 IPF PPS final rule, we provided for a 3-year 
transition period. During this 3-year transition period, an IPF's total 
payment under the PPS was based on an increasing percentage of the 
Federal rate with a corresponding decreasing percentage of the IPF PPS 
payment that is based on reasonable cost concepts. However, effective 
for cost reporting periods beginning on or after January 1, 2008, IPF 
PPS payments are based on 100 percent of the Federal rate.

III. Updates to the IPF PPS for RY Beginning July 1, 2009

    The IPF PPS is based on a standardized Federal per diem base rate 
calculated from IPF average per diem costs and adjusted for budget-
neutrality in the implementation year. The Federal per diem base rate 
is used as the standard payment per day under the IPF PPS and is 
adjusted by the applicable wage index factor and the patient-and 
facility-level adjustments that are applicable to the IPF stay. A 
detailed explanation of how we calculated the average per diem cost 
appears in the November 2004 IPF PPS final rule (69 FR 66926).

A. Determining the Standardized Budget-Neutral Federal Per Diem Base 
Rate

    Section 124(a)(1) of the BBRA requires that we implement the IPF 
PPS in a budget neutral manner. In other words, the amount of total 
payments under the IPF PPS, including any payment adjustments, must be 
projected to be equal to the amount of total payments that would have 
been made if the IPF PPS were not implemented. Therefore, we calculated 
the budget-neutrality factor by setting the total estimated IPF PPS 
payments to be equal to the total estimated payments that would have 
been made under the Tax Equity and Fiscal Responsibility Act of 1982 
(TEFRA) (Pub. L. 97-248) methodology had the IPF PPS not been 
implemented.
    Under the IPF PPS methodology, we calculated the final Federal per 
diem base rate to be budget neutral during the IPF PPS implementation 
period (that is, the 18-month period from January 1, 2005 through June 
30, 2006) using a July 1 update cycle. We updated the average cost per 
day to the midpoint of the IPF PPS implementation period (that is, 
October 1, 2005), and this amount was used in the payment model to 
establish the budget-neutrality adjustment.
    A step-by-step description of the methodology used to estimate 
payments under the TEFRA payment system appears in the November 2004 
IPF PPS final rule (69 FR 66926).
1. Standardization of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy (ECT) Rate
    In the November 2004 IPF PPS final rule, we describe how we 
standardized the IPF PPS Federal per diem base rate in order to account 
for the overall positive effects of the IPF PPS payment adjustment 
factors. To standardize the IPF PPS payments, we compared the IPF PPS 
payment amounts calculated from the FY 2002 Medicare Provider Analysis 
and Review (MedPAR) file to the projected TEFRA payments from the FY 
2002 cost report file updated to the midpoint of the IPF PPS 
implementation period (that is, October 2005). The standardization 
factor was calculated by dividing total estimated payments under the 
TEFRA payment system by estimated payments under the IPF PPS. The 
standardization factor was calculated to be 0.8367.
    As described in detail in the May 2006 IPF PPS final rule (71 FR 
27045), in reviewing the methodology used to simulate the IPF PPS 
payments used for the November 2004 IPF PPS final rule, we discovered 
that due to a computer code error, total IPF PPS payments were 
underestimated by about 1.36 percent. Since the IPF PPS payment total 
should have been larger than the estimated figure, the standardization 
factor should have been smaller (0.8254 vs. 0.8367). In turn, the 
Federal per diem base rate and the ECT rate should have been reduced by 
0.8254 instead of 0.8367.
    To resolve this issue, in RY 2007, we amended the Federal per diem 
base rate and the ECT payment rate prospectively. Using the 
standardization factor of 0.8254, the average cost per day was 
effectively reduced by 17.46 percent (100 percent minus 82.54 percent = 
17.46 percent).
2. Calculation of the Budget Neutrality Adjustment
    To compute the budget neutrality adjustment for the IPF PPS, we 
separately identified each component of the adjustment, that is, the 
outlier adjustment, stop-loss adjustment, and behavioral offset.
    A complete discussion of how we calculate each component of the 
budget neutrality adjustment appears in the November 2004 IPF PPS final 
rule (69 FR 66932 through 66933) and in the May 2006 IPF PPS final rule 
(71 FR 27044 through 27046).
a. Outlier Adjustment
    Since the IPF PPS payment amount for each IPF includes applicable 
outlier amounts, we reduced the standardized Federal per diem base rate 
to account for aggregate IPF PPS payments estimated to be made as 
outlier payments. The outlier adjustment was calculated to be 2 
percent. As a result, the standardized Federal per diem base rate was 
reduced by 2 percent to account for projected outlier payments.
b. Stop-Loss Provision Adjustment
    As explained in the November 2004 IPF PPS final rule, we provided a 
stop-loss payment during the transition from cost-based reimbursement 
to the per diem payment system to ensure that an IPF's total PPS 
payments were no less than a minimum percentage of their TEFRA payment, 
had the IPF PPS not been implemented. We reduced the standardized 
Federal per diem base rate by the percentage of aggregate IPF PPS 
payments estimated to be made for stop-loss payments. As a result, the 
standardized Federal per diem base rate was reduced by 0.39 percent to 
account for stop-loss payments. Since the transition was completed in 
RY 2009,

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the stop-loss provision is no longer applicable, and for cost reporting 
periods beginning on or after January 1, 2008, IPFs were paid 100 
percent PPS.
c. Behavioral Offset
    As explained in the November 2004 IPF PPS final rule, 
implementation of the IPF PPS may result in certain changes in IPF 
practices, especially with respect to coding for comorbid medical 
conditions. As a result, Medicare may make higher payments than assumed 
in our calculations. Accounting for these effects through an adjustment 
is commonly known as a behavioral offset.
    Based on accepted actuarial practices and consistent with the 
assumptions made in other PPSs, we assumed in determining the 
behavioral offset that IPFs would regain 15 percent of potential 
``losses'' and augment payment increases by 5 percent. We applied this 
actuarial assumption, which is based on our historical experience with 
new payment systems, to the estimated ``losses'' and ``gains'' among 
the IPFs. The behavioral offset for the IPF PPS was calculated to be 
2.66 percent. As a result, we reduced the standardized Federal per diem 
base rate by 2.66 percent to account for behavioral changes. As 
indicated in the November 2004 IPF PPS final rule, we do not plan to 
change adjustment factors or projections until we analyze IPF PPS data.
    If we find that an adjustment is warranted, the percent difference 
may be applied prospectively to the established PPS rates to ensure the 
rates accurately reflect the payment level intended by the statute. In 
conducting this analysis, we will be interested in the extent to which 
improved coding of patients' principal and other diagnoses, which may 
not reflect real increases in underlying resource demands, has occurred 
under the PPS.

B. Update of the Federal Per Diem Base Rate and Electroconvulsive 
Therapy Rate

1. Market Basket for IPFs Reimbursed Under the IPF PPS
    As described in the November 2004 IPF PPS final rule (69 FR 66931), 
the average per diem cost was updated to the midpoint of the 
implementation year. This updated average per diem cost of $724.43 was 
reduced by 17.46 percent to account for standardization to projected 
TEFRA payments for the implementation period, by 2 percent to account 
for outlier payments, by 0.39 percent to account for stop-loss 
payments, and by 2.66 percent to account for the behavioral offset. The 
Federal per diem base rate in the implementation year was $575.95. The 
increase in the per diem base rate for RY 2009 included the 0.39 
percent increase due to the removal of the stop-loss provision. We 
indicated in the November 2004 IPF PPS final rule (69 FR 66932) that we 
would remove this 0.39 percent reduction to the Federal per diem base 
rate after the transition. For RY 2009 and beyond, the stop-loss 
provision has ended and is therefore no longer a part of budget 
neutrality.
    Applying the market basket increase of 2.1 percent and the wage 
index budget neutrality factor of 1.0009 to the RY 2009 Federal per 
diem base rate of $637.78 yields a Federal per diem base rate of 
$651.76 for RY 2010. Similarly, applying the market basket increase and 
wage index budget neutrality factor to the RY 2009 ECT rate yields an 
ECT rate of $280.60 for RY 2010.
a. Market Basket Index for the IPF PPS
    The market basket index that was used to develop the IPF PPS was 
the excluded hospital with capital market basket. This market basket 
was based on 1997 Medicare cost report data and included data for 
Medicare-participating IPFs, inpatient rehabilitation facilities 
(IRFs), long-term care hospitals (LTCHs), cancer, and children's 
hospitals.
    Beginning with the May 2006 IPF PPS final rule (71 FR 27046 through 
27054), IPF PPS payments were updated using a 2002-based market basket 
reflecting the operating and capital cost structures for IRFs, IPFs, 
and LTCHs (hereafter referred to as the rehabilitation, psychiatric, 
long-term care (RPL) market basket).
    We excluded cancer and children's hospitals from the RPL market 
basket because their payments are based entirely on reasonable costs 
subject to rate-of-increase limits established under the authority of 
section 1886(b) of the Act, which are implemented in regulations at 
Sec.  413.40. They are not reimbursed through a PPS. Also, the FY 2002 
cost structures for cancer and children's hospitals are noticeably 
different than the cost structures of the IRFs, IPFs, and LTCHs. A 
complete discussion of the RPL market basket appears in the May 2006 
IPF PPS final rule (71 FR 27046 through 27054).
    We seek comments below on the possibility of creating a stand-alone 
IPF market basket.
b. Overview of the RPL Market Basket
    The RPL market basket is a fixed weight, Laspeyres-type price 
index. A market basket is described as a fixed-weight index because it 
answers the question of how much it would cost, at another time, to 
purchase the same mix (quantity and intensity) of goods and services 
needed to provide hospital services in a base period. The effects on 
total expenditures resulting from changes in the mix of goods and 
services purchased subsequent to the base period are not measured. In 
this manner, the market basket measures pure price change only. Only 
when the index is rebased would changes in the quantity and intensity 
be captured in the cost weights. Therefore, we rebase the market basket 
periodically so that cost weights reflect recent changes in the mix of 
goods and services that hospitals purchase to furnish patient care 
between base periods.
    The terms ``rebasing'' and ``revising,'' while often used 
interchangeably, actually denote different activities. Rebasing means 
moving the base year for the structure of costs of an input price index 
(for example, shifting the base year cost structure from FY 1997 to FY 
2002). Revising means changing data sources, methodology, or price 
proxies used in the input price index. In 2006, we rebased and revised 
the market basket used to update the IPF PPS.
    Table 1 below sets forth the completed FY 2002-based RPL market 
basket including the cost categories, weights, and price proxies.

                                  Table 1--FY 2002-Based RPL Market Basket Cost Categories, Weights, and Price Proxies
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                             FY 2002-based RPL
             Cost categories                market basket cost                        FY 2002-based RPL market basket price proxies
                                                  weight
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total....................................               100.000  .......................................................................................
Compensation.............................                65.877  .......................................................................................
    Wages and Salaries\*\................                52.895  ECI-Wages and Salaries, Civilian Hospital Workers.
    Employee Benefits\*\.................                12.982  ECI-Benefits, Civilian Hospital Workers.
Professional Fees, Non-Medical\*\........                 2.892  ECI-Compensation for Professional & Related occupations.

[[Page 20366]]

 
Utilities................................                 0.656  .......................................................................................
    Electricity..........................                 0.351  PPI-Commercial Electric Power.
    Fuel Oil, Coal, etc..................                 0.108  PPI-Commercial Natural Gas.
    Water and Sewage.....................                 0.197  CPI-U--Water & Sewage Maintenance.
Professional Liability Insurance.........                 1.161  CMS Professional Liability Premium Index.
All Other Products and Services..........                19.265  .......................................................................................
    All Other Products...................                13.323  .......................................................................................
    Pharmaceuticals......................                 5.103  PPI Prescription Drugs.
    Food: Direct Purchase................                 0.873  PPI Processed Foods & Feeds.
    Food: Contract Service...............                 0.620  CPI-U Food Away From Home.
    Chemicals............................                 1.100  PPI Industrial Chemicals.
    Medical Instruments..................                 1.014  PPI Medical Instruments & Equipment.
    Photographic Supplies................                 0.096  PPI Photographic Supplies.
    Rubber and Plastics..................                 1.052  PPI Rubber & Plastic Products.
    Paper Products.......................                 1.000  PPI Converted Paper & Paperboard Products.
    Apparel..............................                 0.207  PPI Apparel.
    Machinery and Equipment..............                 0.297  PPI Machinery & Equipment
    Miscellaneous Products\**\...........                 1.963  PPI Finished Goods less Food & Energy.
All Other Services.......................                 5.942  .......................................................................................
    Telephone............................                 0.240  CPI-U Telephone Services.
    Postage..............................                 0.682  CPI-U Postage.
    All Other: Labor Intensive\*\........                 2.219  ECI-Compensation for Private Service Occupations.
    All Other: Non-labor Intensive.......                 2.800  CPI-U All Items.
Capital-Related Costs\***\...............                10.149  .......................................................................................
Depreciation.............................                 6.186  .......................................................................................
    Fixed Assets.........................                 4.250  Boeckh Institutional Construction 23-year useful life.
    Movable Equipment....................                 1.937  WPI Machinery & Equipment 11-year useful life.
Interest Costs...........................                 2.775  .......................................................................................
    Nonprofit............................                 2.081  Average yield on domestic municipal bonds (Bond Buyer 20 bonds) vintage-weighted (23
                                                                  years).
    For Profit...........................                 0.694  Average yield on Moody's Aaa bond vintage-weighted (23 years).
Other Capital-Related Costs..............                 1.187  CPI-U Residential Rent.
--------------------------------------------------------------------------------------------------------------------------------------------------------
\*\ Labor-related.
\**\ Blood and blood-related products is included in miscellaneous products.
\***\ A portion of capital costs (0.46) are labor-related.
 
Note: Due to rounding, weights may not sum to total.

    We evaluated the price proxies using the criteria of reliability, 
timeliness, availability, and relevance. Reliability indicates that the 
index is based on valid statistical methods and has low sampling 
variability. Timeliness implies that the proxy is published regularly 
(preferably at least once a quarter). Availability means that the proxy 
is publicly available. Finally, relevance means that the proxy is 
applicable and representative of the cost category weight to which it 
is applied. The Consumer Price Indexes (CPIs), Producer Price Indexes 
(PPIs), and Employment Cost Indexes (ECIs) used as proxies in this 
market basket meet these criteria.
    We note that the proxies are the same as those used for the FY 
1997-based excluded hospital with capital market basket. Because these 
proxies meet our criteria of reliability, timeliness, availability, and 
relevance, we believe they continue to be the best measure of price 
changes for the cost categories. For further discussion on the FY 1997-
based excluded hospital with capital market basket, see the August 1, 
2002 hospital inpatient prospective payment system (IPPS) final rule 
(67 FR at 50042).
    The RY 2010 (that is, beginning July 1, 2009) update for the IPF 
PPS using the FY 2002-based RPL market basket and Information Handling 
Services (IHS) Global Insight's 1st quarter 2009 forecast for the 
market basket components is 2.1 percent. This includes increases in 
both the operating section and the capital section for the 12-month RY 
period (that is, July 1, 2009 through June 30, 2010). IHS Global 
Insight, Inc. is a nationally recognized economic and financial 
forecasting firm that contracts with CMS to forecast the components of 
the market baskets.
2. Labor-Related Share
    Due to the variations in costs and geographic wage levels, we 
believe that payment rates under the IPF PPS should continue to be 
adjusted by a geographic wage index. This wage index applies to the 
labor-related portion of the Federal per diem base rate, hereafter 
referred to as the labor-related share.
    The labor-related share is determined by identifying the national 
average proportion of operating costs that are related to, influenced 
by, or vary with the local labor market. Using our current definition 
of labor-related, the labor-related share is the sum of the relative 
importance of wages and salaries, fringe benefits, professional fees, 
labor-intensive services, and a portion of the capital share from an 
appropriate market basket. We used the FY 2002-based RPL market basket 
cost weights relative importance to determine the labor-related share 
for the IPF PPS.
    The labor-related share for RY 2010 is the sum of the RY 2010 
relative importance of each labor-related cost category, and reflects 
the different rates of price change for these cost categories between 
the base year (FY 2002) and RY 2010. The sum of the relative importance 
for the RY 2010 operating costs (wages and salaries, employee benefits, 
professional fees, and labor-

[[Page 20367]]

intensive services) is 71.935, as shown in below. The portion of 
capital that is influenced by the local labor market is estimated to be 
46 percent, which is the same percentage used in the FY 1997-based IRF 
and IPF payment systems.
    Since the relative importance for capital is 8.596 percent of the 
FY 2002-based RPL market basket in RY 2010, we are taking 46 percent of 
8.596 percent to determine the labor-related share of capital for RY 
2010. The result is 3.954 percent, which we added to 71.935 percent for 
the operating cost amount to determine the total labor-related share 
for RY 2010. Thus, the labor-related share that we are using for IPF 
PPS in RY 2010 is 75.889 percent. Table 2 below shows the RY 2010 
labor-related share using the FY 2002-based RPL market basket. We note 
that this labor-related share is determined by using the same 
methodology as employed in calculating all previous IPF labor-related 
shares.
    A complete discussion of the IPF labor-related share methodology 
appears in the November 2004 IPF PPS final rule (69 FR 66952 through 
66954).

   Table 2--Total Labor-Related Share--Relative Importance for RY 2010
------------------------------------------------------------------------
                                 FY 2002-based RPL    FY 2002[dash]based
                                market basket labor-  RPL market basket
         Cost category             related share     labor-related share
                                relative importance  relative importance
                                 (percent) RY 2009*  (percent) RY 2010**
------------------------------------------------------------------------
Wages and salaries............               52.645               53.062
Employee benefits.............               14.004               13.852
Professional fees.............                2.895                2.895
All other labor-intensive                     2.137                2.126
 services.....................
                               -----------------------------------------
    Subtotal..................               71.681               71.935
Labor-related share of capital                3.950                3.954
 costs (0.46).................
                               -----------------------------------------
    Total.....................               75.631              75.889
------------------------------------------------------------------------
* Based on 2008 1st Quarter forecast.
** Based on 2009 1st Quarter forecast.

3. One-time Prospective Adjustment to the Standard Federal Rate
    As we discussed in the November 2004 IPF PPS final rule, consistent 
with the statutory requirement for budget neutrality in section 124 of 
the BBRA, we estimated aggregate payments under the IPF PPS for the IPF 
PPS implementation year (that is, the 18-month period from January 1, 
2005 through June 30, 2006) to be equal to the estimated aggregate 
payments that would be made if the IPF PPS had not been implemented. 
Our methodology for estimating payments for purposes of the budget 
neutrality calculations used the best available data at the time and 
necessarily reflected several assumptions (for example, costs, 
inflation factors and intensity of services provided).
    We indicated from the inception of the IPF PPS that it was possible 
for the aggregate amount of actual payments in the implementation year 
to be significantly higher or lower than the estimates on which the 
budget neutrality calculations were based to the extent that later, 
more complete data differ significantly from the data that were 
available at the time of the original calculations.
    Section 124 of the BBRA provides broad authority to the Secretary 
in developing the IPF PPS, including the authority for establishing 
appropriate adjustments. Under this broad authority to make appropriate 
adjustments, we provided in Sec.  412.424(c)(3)(ii) for the possibility 
of making a one-time prospective adjustment to the IPF PPS rates, so 
that the effect of any significant difference between actual payments 
and estimated payments for the first year of the IPF PPS would not be 
perpetuated in the IPF PPS rates for future years.
    The November 2004 IPF PPS final rule implementing the IPF PPS (69 
FR 66922), was based upon the broad authority granted to the Secretary 
under section 124 of the BBRA. In that same final rule, we discussed 
our authority to make a one-time prospective adjustment to the IPF PPS 
rates, which was reflected in Sec.  412.424(c)(3)(ii).
    Evaluating the appropriateness of the possible one-time prospective 
adjustment under Sec.  412.424(c)(3)(ii) requires a thorough review of 
the relevant IPF data. When we established the IPF PPS Federal per diem 
base rate in a budget neutral manner, we used the most recent IPF cost 
report data available at that time (that is, FY 2002 data), and trended 
that data forward to estimate what CMS would have paid to IPFs in the 
implementation year under the TEFRA payment system if the PPS were not 
implemented (69 FR 66927). We have since conducted a review of the 
relevant data. From the cost reports, we have TEFRA and PPS payment 
data for January 1, 2005 through June 30, 2006, the 18-month period for 
the implementation of the IPF PPS. These data are drawn from reports 
with cost reporting periods beginning in FY 2005 and FY 2006. More than 
70 percent of the cost reports from FY 2005 were settled. However, only 
approximately 33 percent of the cost reports from FY 2006 have been 
settled. The remaining 67 percent from FY 2006 are either as-submitted 
or have been reopened. Therefore, because we lack a complete set of 
final cost report data from the IPF PPS 18-month implementation period, 
we are not making a one-time adjustment to the IPF PPS rates for RY 
2010.
    We plan to revisit the possibility of making a one-time prospective 
adjustment to the IPF PPS rates as more cost report data becomes 
available.

IV. Update of the IPF PPS Adjustment Factors

A. Overview of the IPF PPS Adjustment Factors

    The IPF PPS payment adjustments were derived from a regression 
analysis of 100 percent of the FY 2002 MedPAR data file, which 
contained 483,038 cases. For this notice, we used the same results of 
the regression analysis used to implement the November 2004 IPF PPS 
final rule. For a more detailed description of the data file used for 
the regression analysis, see the November 2004 IPF PPS final rule (69 
FR 66935 through 66936). While we have since used more recent claims 
data to set the fixed dollar loss threshold amount, we use the same 
results of this regression

[[Page 20368]]

analysis to update the IPF PPS for RY 2009 as well as RY 2010.
    As previously stated, we do not plan to update the regression 
analysis until we are able to analyze IPF PPS claims and cost report 
data. However, we continue to monitor claims and payment data 
independently from cost report data to assess issues, to determine 
whether changes in case-mix or payment shifts have occurred among 
freestanding governmental, non-profit and private psychiatric 
hospitals, and psychiatric units of general hospitals, and CAHs and 
other issues of importance to IPFs.

B. Patient-Level Adjustments

    In the May 2008 IPF PPS notice (73 FR 25709), we provided payment 
adjustments for the following patient-level characteristics: Medicare 
Severity diagnosis related groups (MS-DRGs) assignment of the patient's 
principal diagnosis, selected comorbidities, patient age, and the 
variable per diem adjustments.
1. Adjustment for MS-DRG Assignment
    The IPF PPS includes payment adjustments for the psychiatric DRG 
assigned to the claim based on each patient's principal diagnosis. The 
IPF PPS recognizes the MS-DRGs. The DRG adjustment factors were 
expressed relative to the most frequently reported psychiatric DRG in 
FY 2002, that is, DRG 430 (psychoses). The coefficient values and 
adjustment factors were derived from the regression analysis.
    In accordance with Sec.  412.27(a), payment under the IPF PPS is 
conditioned on IPFs admitting ``only patients whose admission to the 
unit is required for active treatment, of an intensity that can be 
provided appropriately only in an inpatient hospital setting, of a 
psychiatric principal diagnosis that is listed in Chapter Five 
(``Mental Disorders'') of the International Classification of Diseases, 
Ninth Revision, Clinical Modification (ICD-9-CM)]'' or in the Fourth 
Edition, Text Revision of the American Psychiatric Association's 
Diagnostic and Statistical Manual, (DSM-IV-TR). IPF claims with a 
principal diagnosis included in Chapter Five of the ICD-9-CM or the 
DSM-IV-TR are paid the Federal per diem base rate under the IPF PPS and 
all other applicable adjustments, including any applicable DRG 
adjustment. Psychiatric principal diagnoses that do not group to one of 
the designated DRGs still receive the Federal per diem base rate and 
all other applicable adjustments, but the payment would not include a 
DRG adjustment.
    The Standards for Electronic Transaction final rule published in 
the Federal Register on August 17, 2000 (65 FR 50312), adopted the ICD-
9-CM as the designated code set for reporting diseases, injuries, 
impairments, other health related problems, their manifestations, and 
causes of injury, disease, impairment, or other health related 
problems. Therefore, we use the ICD-9-CM as the designated code set for 
the IPF PPS.
    We believe that it is important to maintain the same diagnostic 
coding and DRG classification for IPFs that are used under the IPPS for 
providing the psychiatric care. Therefore, when the IPF PPS was 
implemented for cost reporting periods beginning on or after January 1, 
2005, we adopted the same diagnostic code set and DRG patient 
classification system (that is, the CMS DRGs) that were utilized at the 
time under the hospital inpatient prospective payment system (IPPS). 
Since the inception of the IPF PPS, the DRGs used as the patient 
classification system under the IPF PPS have corresponded exactly with 
the CMS DRGs applicable under the IPPS for acute care hospitals.
    Every year, changes to the ICD-9-CM coding system are addressed in 
the IPPS proposed and final rules. The changes to the codes are 
effective October 1 of each year and must be used by acute care 
hospitals as well as other providers to report diagnostic and procedure 
information. The IPF PPS has always incorporated ICD-9-CM coding 
changes made in the annual IPPS update. We publish coding changes in a 
Transmittal/Change Request, similar to how coding changes are announced 
by the IPPS and LTCH PPS. Those ICD-9-CM coding changes are also 
published in the following IPF PPS RY update, in either the IPF PPS 
proposed and final rules, or in an IPF PPS update notice.
    In the May 2008 IPF PPS notice (73 FR 25714), we discussed CMS' 
effort to better recognize resource use and the severity of illness 
among patients. CMS adopted the new MS-DRGs for the IPPS in the FY 2008 
IPPS final rule with comment period (72 FR 47130). We believe by better 
accounting for patients' severity of illness in Medicare payment rates, 
the MS-DRGs encourage hospitals to improve their coding and 
documentation of patient diagnoses. The MS-DRGs, which are based on the 
CMS DRGs, represent a significant increase in the number of DRGs (from 
538 to 745, an increase of 207). For a full description of the 
development and implementation of the MS-DRGs, see the FY 2008 IPPS 
final rule with comment period (72 FR 47141 through 47175).
    All of the ICD-9-CM coding changes are reflected in the FY 2009 
GROUPER, Version 26.0, effective for IPPS discharges occurring on or 
after October 1, 2008 through September 30, 2009. The GROUPER Version 
26.0 software package assigns each case to an MS-DRG on the basis of 
the diagnosis and procedure codes and demographic information (that is, 
age, sex, and discharge status). The Medicare Code Editor (MCE) 25.0 
uses the new ICD-9-CM codes to validate coding for IPPS discharges on 
or after October 1, 2008. For additional information on the GROUPER 
Version 26.0 and MCE 25.0, see Transmittal 1610 (Change Request 6189), 
dated October 3, 2008. The IPF PPS has always used the same GROUPER and 
Code Editor as the IPPS. Therefore, the ICD-9-CM changes, which were 
reflected in the GROUPER Version 26.0 and MCE 25.0 on October 1, 2008, 
also became effective for the IPF PPS for discharges occurring on or 
after October 1, 2008.
    The impact of the new MS-DRGs on the IPF PPS was negligible. 
Mapping to the MS-DRGs resulted in the current 17 MS-DRGs, instead of 
the original 15, for which the IPF PPS provides an adjustment. Although 
the code set is updated, the same associated adjustment factors apply 
now that have been in place since implementation of the IPF PPS, with 
one exception that is unrelated to the update to the codes. When DRGs 
521 and 522 were consolidated into MS-DRG 895, we carried over the 
adjustment factor of 1.02 from DRG 521 to the newly consolidated MS-
DRG. This was done to reflect the higher claims volume under DRG 521, 
with more than eight times the number of claims than billed under DRG 
522. The updates are reflected in Table 5. For a detailed description 
of the mapping changes from the original DRG adjustment categories to 
the current MS-DRG adjustment categories we refer readers to the May 
2008 IPF PPS notice (73 FR 25714).
    The official version of the ICD-9-CM is available on CD-ROM from 
the U.S. Government Printing Office. The FY 2009 version can be ordered 
by contacting the Superintendent of Documents, U.S. Government Printing 
Office, Department 50, Washington, DC 20402-9329, telephone number 
(202) 512-1800. Questions concerning the ICD-9-CM should be directed to 
Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination and 
Maintenance Committee, CMS, Center for Medicare Management, Hospital 
and Ambulatory Policy Group, Division of Acute Care, Mailstop C4-08-06, 
7500 Security

[[Page 20369]]

Boulevard, Baltimore, Maryland 21244-1850.
    Further information concerning the official version of the ICD-9-CM 
can be found in the IPPS final rule with comment period, ``Changes to 
Hospital Inpatient Prospective Payment System and Fiscal Year 2009 
Rates'' in the August 19, 2008 Federal Register (73 FR 48434) and at 
https://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/list.asp#TopOfPage.
    Tables 3 and 4 below list the FY 2009 new and invalid ICD-9-CM 
diagnosis codes that group to one of the 17 MS-DRGs for which the IPF 
PPS provides an adjustment. These tables are only a listing of FY 2009 
changes and do not reflect all of the currently valid and applicable 
ICD-9-CM codes classified in the MS-DRGs. When coded as a principal 
code or diagnosis, these codes receive the correlating MS-DRG 
adjustment.

                  Table 3--FY 2009 New Diagnosis Codes
------------------------------------------------------------------------
          Diagnosis code                  Description           MS-DRG
------------------------------------------------------------------------
046.11...........................  Variant Creutzfeldt-         056, 057
                                    Jakob disease.
046.19...........................  Other and unspecified        056, 057
                                    Creutzfeldt-Jakob
                                    disease.
046.71...........................  Gerstmann-                   056, 057
                                    Str[auml]ussler-
                                    Scheinker syndrome.
046.72...........................  Fatal familial insomnia.     056, 057
046.79...........................  Other and unspecified        056, 057
                                    prion disease of
                                    central nervous system.
------------------------------------------------------------------------


                Table 4--FY 2009 Invalid Diagnosis Codes
------------------------------------------------------------------------
          Diagnosis code                  Description           MS-DRG
------------------------------------------------------------------------
046.1............................  Jakob-Creutzfeldt.......     056, 057
------------------------------------------------------------------------

    We do not plan to update the regression analysis until we are able 
to analyze IPF PPS data. The MS-DRG adjustment factors (as shown in 
Table 5) will continue to be paid for discharges occurring in RY 2010.

 Table 5--RY 2010 Current MS-DRGs Applicable for the Principal Diagnosis
                               Adjustment
------------------------------------------------------------------------
                                                              Adjustment
              MS-DRG                  MS-DRG descriptions       factor
------------------------------------------------------------------------
056..............................  Degenerative nervous             1.05
                                    system disorders w MCC.
057..............................  Degenerative nervous             1.05
                                    system disorders w/o
                                    MCC.
080..............................  Nontraumatic stupor &            1.07
                                    coma w MCC.
081..............................  Nontraumatic stupor &            1.07
                                    coma w/o MCC.
876..............................  O.R. procedure w                 1.22
                                    principal diagnoses of
                                    mental illness.
880..............................  Acute adjustment                 1.05
                                    reaction & psychosocial
                                    dysfunction.
881..............................  Depressive neuroses.....         0.99
882..............................  Neuroses except                  1.02
                                    depressive.
883..............................  Disorders of personality         1.02
                                    & impulse control.
884..............................  Organic disturbances &           1.03
                                    mental retardation.
885..............................  Psychoses...............         1.00
886..............................  Behavioral &                     0.99
                                    developmental disorders.
887..............................  Other mental disorder            0.92
                                    diagnoses.
894..............................  Alcohol/drug abuse or            0.97
                                    dependence, left AMA.
895..............................  Alcohol/drug abuse or            1.02
                                    dependence w
                                    rehabilitation therapy.
896..............................  Alcohol/drug abuse or            0.88
                                    dependence w/o
                                    rehabilitation therapy
                                    w MCC.
897..............................  Alcohol/drug abuse or            0.88
                                    dependence w/o
                                    rehabilitation therapy
                                    w/o MCC.
------------------------------------------------------------------------

2. Payment for Comorbid Conditions
    The intent of the comorbidity adjustments is to recognize the 
increased costs associated with comorbid conditions by providing 
additional payments for certain concurrent medical or psychiatric 
conditions that are expensive to treat. In the May 2008 IPF PPS notice 
(73 FR 25716), we explained that the IPF PPS includes 17 comorbidity 
categories and identified the new, revised, and deleted ICD-9-CM 
diagnosis codes that generate a comorbid condition payment adjustment 
under the IPF PPS for RY 2009 (73 FR 25718).
    Comorbidities are specific patient conditions that are secondary to 
the patient's principal diagnosis and that require treatment during the 
stay. Diagnoses that relate to an earlier episode of care and have no 
bearing on the current hospital stay are excluded and must not be 
reported on IPF claims. Comorbid conditions must exist at the time of 
admission or develop subsequently, and affect the treatment received, 
length of stay (LOS), or both treatment and LOS.
    For each claim, an IPF may receive only one comorbidity adjustment 
per comorbidity category, but it may receive an adjustment for more 
than one comorbidity category. Billing instructions require that IPFs 
must enter the full ICD-9-CM codes for up to 8 additional diagnoses if 
they co-exist at the time of admission or develop subsequently and 
impact the treatment provided.
    The comorbidity adjustments were determined based on the regression 
analysis using the diagnoses reported by IPFs in FY 2002. The principal 
diagnoses were used to establish the DRG adjustments and were not 
accounted for in establishing the comorbidity category adjustments, 
except where ICD-9-CM ``code first'' instructions apply. As we 
explained in

[[Page 20370]]

the May 2008 IPF PPS notice (73 FR 25716), the code first rule applies 
when a condition has both an underlying etiology and a manifestation 
due to the underlying etiology. For these conditions, the ICD-9-CM has 
a coding convention that requires the underlying conditions to be 
sequenced first followed by the manifestation. Whenever a combination 
exists, there is a ``use additional code'' note at the etiology code 
and a code first note at the manifestation code.
    As discussed in the MS-DRG section, it is our policy to maintain 
the same diagnostic coding set for IPFs that is used under the IPPS for 
providing the same psychiatric care. Although the ICD-9-CM code set has 
been updated, the same adjustment factors have been in place since the 
implementation of the IPF PPS. Table 6 below lists the FY 2009 new ICD 
diagnosis codes that impact the comorbidity adjustments under the IPF 
PPS. Table 6 is not a list of all currently valid ICD codes applicable 
for the IPF PPS comorbidity adjustments.

                    Table 6--FY 2009 New ICD Codes Applicable for the Comorbidity Adjustment
----------------------------------------------------------------------------------------------------------------
             Diagnosis code                          Description                    Comorbidity category
----------------------------------------------------------------------------------------------------------------
038.12..................................  Methicillin resistant             Infectious Disease.
                                           Staphylococcus aureus
                                           septicemia.
046.11..................................  Variant Creutzfeldt-Jakob         Infectious Disease.
                                           disease.
046.19..................................  Other and unspecified             Infectious Disease.
                                           Creutzfeldt-Jakob disease.
046.71..................................  Gerstmann-Str[auml]ussler-        Infectious Disease.
                                           Scheinker syndrome.
046.72..................................  Fatal familial insomnia.........  Infectious Disease.
046.79..................................  Other and unspecified prion       Infectious Disease.
                                           disease of central nervous
                                           system.
051.01..................................  Cowpox..........................  Infectious Disease.
051.02..................................  Vaccinia not from vaccination...  Infectious Disease.
059.00..................................  Orthopoxvirus infection,          Infectious Disease.
                                           unspecified.
059.01..................................  Monkeypox.......................  Infectious Disease.
059.09..................................  Other orthopoxvirus infections..  Infectious Disease.
059.10..................................  Parapoxvirus infection,           Infectious Disease.
                                           unspecified.
059.11..................................  Bovine stomatitis...............  Infectious Disease.
059.12..................................  Sealpox.........................  Infectious Disease.
059.19..................................  Other parapoxvirus infections...  Infectious Disease.
059.20..................................  Yatapoxvirus infection,           Infectious Disease.
                                           unspecified.
059.21..................................  Tanapox.........................  Infectious Disease.
059.22..................................  Yaba monkey tumor virus.........  Infectious Disease.
059.8...................................  Other poxvirus infections.......  Infectious Disease.
059.9...................................  Poxvirus infections, unspecified  Infectious Disease.
199.2...................................  Malignant neoplasm associated     Oncology Treatment.
                                           with transplant organ.
203.02..................................  Multiple myeloma, in relapse....  Oncology Treatment.
203.12..................................  Plasma cell leukemia, in relapse  Oncology Treatment.
203.82..................................  Other immunoproliferative         Oncology Treatment.
                                           neoplasms, in relapse.
204.02..................................  Acute lymphoid leukemia, in       Oncology Treatment.
                                           relapse.
204.12..................................  Chronic lymphoid leukemia, in     Oncology Treatment.
                                           relapse.
204.22..................................  Subacute lymphoid leukemia, in    Oncology Treatment.
                                           relapse.
204.82..................................  Other lymphoid leukemia, in       Oncology Treatment.
                                           relapse.
204.92..................................  Unspecified lymphoid leukemia,    Oncology Treatment.
                                           in relapse.
205.02..................................  Acute myeloid leukemia, in        Oncology Treatment.
                                           relapse.
205.12..................................  Chronic myeloid leukemia, in      Oncology Treatment.
                                           relapse.
205.22..................................  Subacute myeloid leukemia, in     Oncology Treatment.
                                           relapse.
205.32..................................  Myeloid sarcoma, in relapse.....  Oncology Treatment.
205.82..................................  Other myeloid leukemia, in        Oncology Treatment.
                                           relapse.
205.92..................................  Unspecified myeloid leukemia, in  Oncology Treatment.
                                           relapse.
206.02..................................  Acute monocytic leukemia, in      Oncology Treatment.
                                           relapse.
206.12..................................  Chronic monocytic leukemia, in    Oncology Treatment.
                                           relapse.
206.22..................................  Subacute monocytic leukemia, in   Oncology Treatment.
                                           relapse.
206.82..................................  Other monocytic leukemia, in      Oncology Treatment.
                                           relapse.
206.92..................................  Unspecified monocytic leukemia,   Oncology Treatment.
                                           in relapse.
207.02..................................  Acute erythremia and              Oncology Treatment.
                                           erythroleukemia, in relapse.
207.12..................................  Chronic erythremia, in relapse..  Oncology Treatment.
207.22.......