[Federal Register: January 30, 2004 (Volume 69, Number 20)]
[Proposed Rules]
[Page 4753-4817]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr30ja04-15]
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Part V
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 412
Medicare Program; Prospective Payment System for Long-Term Care
Hospitals: Proposed Annual Payment Rate Updates and Policy Changes;
Proposed Rule
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 412
[CMS-1263-P]
RIN 0938-AM84
Medicare Program; Prospective Payment System for Long-Term Care
Hospitals: Proposed Annual Payment Rate Updates and Policy Changes
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This rule proposes an update to the annual payment rates for
the Medicare prospective payment system (PPS) for inpatient hospital
services provided by long-term care hospitals (LTCHs). The payment
amounts and factors used to determine the proposed updated Federal
rates that are described in this proposed rule have been determined
based on the LTCH PPS rate year. The annual update of the long-term
care diagnosis-related groups (LTC-DRG) classifications and relative
weights remains linked to the annual adjustments of the acute care
hospital inpatient diagnosis-related group system, and will continue to
be effective each October 1. The proposed outlier threshold for July 1,
2004, through June 30, 2005, would also be derived from the LTCH PPS
rate year calculations. In this proposed rule, we also are proposing to
make clarifications to the existing policy regarding the designation of
a satellite of a LTCH as an independent LTCH. In addition, we are
proposing to expand the existing interrupted stay policy and proposing
a change in the procedure for counting days in the average length of
stay calculation for Medicare patients for hospitals qualifying as
LTCHs.
DATES: We will consider comments if we receive them at the appropriate
address, as provided below, no later than 5 p.m. on March 23, 2004.
ADDRESSES: In commenting, please refer to file code CMS-1263-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
Submit electronic comments to http://www.accessdata.fda.gov/scripts/oc/dockets/comments/commentdocket.cfm?AGENCY=CMS or to http://
linklog&to=http://
">http://&to=http://">http://
">http://
copies) to the following address only: Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Attention: CMS-1263-
P, P.O. Box 8010, Baltimore, MD 21244-1850.
If you prefer, you may deliver, by hand or courier, your written
comments (an original and three copies) to one of the following
addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room C5-14-03, Central Building, 7500 Security Boulevard, Baltimore, MD
21244-1850.
(Because access to the interior of the Humphrey Building is not
readily available to persons without Federal government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available for commenters who wish to retain proof of filing by stamping
in and keeping an extra copy of the comments being filed.)
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and could be considered late.
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. After the close of the comment period, CMS posts all
electronic comments received before the close of the comment period on
its public Web site.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Tzvi Hefter, (410) 786-4487 (General information);
Judy Richter, (410) 786-2590 (General information, transition payments,
payment adjustments, and onsite discharges and readmissions,
interrupted stays, co-located providers, and short-stay outliers);
Michele Hudson, (410) 786-5490 (Calculation of the payment rates,
relative weights and case-mix index, market basket update, and payment
adjustments);
Ann Fagan, (410) 786-5662 (Patient classification system);
Miechal Lefkowitz, (410) 786-5316 (High-cost outliers and budget
neutrality);
Linda McKenna, (410) 786-4537 (Payment adjustments, interrupted stay,
and transition period);
Kathryn McCann, (410) 786-7623 (Medigap);
Robert Nakielny, (410) 786-4466 (Medicaid).
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome comments from the public on all
issues set forth in this rule to assist us in fully considering issues
and developing policies. You can assist us by referencing the file code
CMS-1263-P and the specific ``issue identifier'' that precedes the
section on which you choose to comment.
Inspection of Public Comments: Comments received timely will be
available for public inspection as they are processed, generally
beginning approximately 4 weeks after publication of a document, in
Room C5-12-08 of the Centers for Medicare & Medicaid Services, 7500
Security Blvd., Baltimore, MD, on Monday through Friday of each week
from 8:30 a.m. to 5 p.m. Please call (410) 786-7197 to schedule an
appointment to view public comments.
Availability of Copies and Electronic Access
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or Master Card
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $10. As an alternative, you can view
and photocopy the Federal Register document at most libraries
designated as Federal Depository Libraries and at many other public and
academic libraries throughout the country that receive the Federal
Register.
This Federal Register document is also available from the Federal
Register online database through GPO Access, a service of the U.S.
Government Printing Office. The Web site address is: http://www.access.gpo.gov/nara/index.html
.
To assist readers in referencing sections contained in this
preamble, we are providing the following table of contents.
Table of Contents
I. Background
A. Legislative and Regulatory Authority
B. Criteria for Classification as a LTCH
1. Classification as a LTCH
2. Hospitals Excluded from the LTCH PPS
C. Transition Period for Implementation of the LTCH PPS
D. Limitation on Charges to Beneficiaries
E. Health Insurance Portability and Accountability Act
Compliance
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II. Summary of Major Contents of This Proposed Rule
III. Long-Term Care Diagnosis-Related Group (LTC-DRG)
Classifications and Relative Weights
A. Background
B. Patient Classifications into DRGs
C. Organization of DRGs
D. Update of LTC-DRGs
E. ICD-9-CM Coding System
1. Uniform Hospital Discharge Data Set (UHDDS) Definitions
2. Maintenance of the ICD-9-CM Coding System
3. Coding Rules and Use of ICD-9-CM Codes in LTCHs
F. The Method for Updating the LTC-DRG Relative Weights
IV. Proposed Changes to the LTCH PPS Rates and Proposed Changes in
Policy for the 2005 LTCH PPS Rate Year
A. Overview of the Development of the Payment Rates
B. Proposed Update to the Standard Federal Rate for the 2005
LTCH PPS Rate Year
1. Proposed Standard Federal Rate Update
a. Description of the Market Basket for the Proposed 2005 LTCH
PPS Rate Year
b. Proposed LTCH Market Basket Increase for the 2005 LTCH PPS
Rate Year
2. Proposed Standard Federal Rate for the 2005 LTCH PPS rate
year
C. Calculation of Proposed LTCH Prospective Payments for the
2005 LTCH PPS rate year
1. Proposed Adjustment for Area Wage Levels
a. Background
b. Wage Index Data
c. Proposed Labor-Related Share
2. Proposed Adjustment for Cost-Of-Living in Alaska and Hawaii
3. Proposed Adjustment for High-Cost Outliers
a. Background
b. Establishment of the Proposed Fixed-Loss Amount
c. Reconciliation of Outlier Payments Upon Cost Report
Settlement
d. Application of Outlier Policy to Short-Stay Outlier Cases
4. Proposed Adjustments for Special Cases
a. General
b. Adjustment for Short-Stay Outlier Cases
c. Proposed Extension of the Interrupted Stay Policy
d. Onsite Discharges and Readmittances
5. Other Payment Adjustments
6. Proposed Budget Neutrality Offset to Account for the
Transition Methodology
7. Proposed Changes in the Procedure for Counting Days in the
Average Length of Stay Calculation
8. Clarification of the Requirements for a Satellite Facility or
a Remote Location to Qualify as a LTCH and Proposed Changes to the
Requirements for Certain Satellite Facilities and Remote Locations
V. Computing the Proposed Adjusted Federal Prospective Payments for
the 2005 LTCH PPS Rate Year
VI. Transition Period
VII. Payments to New LTCHs
VIII. Method of Payment
IX. Monitoring
X. Collection of Information Requirements
XI. Regulatory Impact Analysis
A. Introduction
1. Executive Order 12866
2. Regulatory Flexibility Act (RFA)
3. Impact on Rural Hospitals
4. Unfunded Mandates
5. Federalism
B. Anticipated Effects of Proposed Payment Rate Changes
1. Budgetary Impact
2. Impact on Providers
3. Calculation of Prospective Payments
4. Results
5. Effect on the Medicare Program
6. Effect on Medicare Beneficiaries
C. Impact of Proposed Policy Changes
1. Clarification of the Requirements for Satellite Facilities
and Remote Locations of Hospitals to Qualify as Long-Term Care
Hospitals
a. Proposed Policy Change for Certain Satellite Facilities and
Remote Locations of a Hospital
b. Technical Correction
2. Proposed Change in Interruption of a Stay in a LTCH Policy
3. Proposed Change in Procedure for Counting Covered and
Noncovered Days in a Stay that Crosses Two Consecutive Cost
Reporting Periods
D. Executive Order 12866
Regulations Text
Addendum--Tables
Acronyms
Because of the many terms to which we refer by acronym in this
proposed rule, we are listing the acronyms used and their
corresponding terms in alphabetical order below:
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
CMS Centers for Medicare & Medicaid Services
COPS Medicare conditions of participation
DRGs Diagnosis-related groups
FY Federal fiscal year
HCRIS Hospital Cost Report Information System
HHA Home health agency
HIPAA Health Insurance Portability and Accountability Act, Pub. L.
104-191
IPPS Acute Care Hospital Inpatient Prospective Payment System
IRF Inpatient rehabilitation facility
LTC-DRG Long-term care diagnosis-related group
LTCH Long-term care hospital
MedPAC Medicare Payment Advisory Commission
MedPAR Medicare provider analysis and review file
OSCAR Online Survey Certification and Reporting (System)
PPS Prospective Payment System
QIO Quality Improvement Organization (formerly Peer Review
organization (PRO))
SNF Skilled nursing facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-
248
I. Background
(If you choose to comment on issues in this section, please include the
caption ``BACKGROUND'' at the beginning of your comments.)
A. Legislative and Regulatory Authority
The Medicare, Medicaid, and SCHIP (State Children's Health
Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA) (Pub.
L. 106-113) and the Medicare, Medicaid, and SCHIP Benefits Improvement
and Protection Act of 2000 (BIPA) (Pub. L. 106-554) provide for payment
for both the operating and capital-related costs of hospital inpatient
stays in long-term care hospitals (LTCHs) under Medicare Part A based
on prospectively set rates. The Medicare prospective payment system
(PPS) for LTCHs applies to hospitals described in section
1886(d)(1)(B)(iv) of the Social Security Act (the Act), effective for
cost reporting periods beginning on or after October 1, 2002.
Section 1886(d)(1)(B)(iv)(I) of the Act defines a LTCH as ``a
hospital which has an average inpatient length of stay (as determined
by the Secretary) of greater than 25 days.'' Section
1886(d)(1)(B)(iv)(II) of the Act also provides an alternative
definition of LTCHs: specifically, a hospital that first received
payment under section 1886(d) of the Act in 1986 and has an average
inpatient length of stay (as determined by the Secretary) of greater
than 20 days and has 80 percent or more of its annual Medicare
inpatient discharges with a principal diagnosis that reflects a finding
of neoplastic disease in the 12-month cost reporting period ending in
FY 1997.
Section 123 of Pub. L. 106-113 requires the PPS for LTCHs to be a
per discharge system with a diagnosis-related group (DRG) based patient
classification system that reflects the differences in patient
resources and costs in LTCHs while maintaining budget neutrality.
Section 307(b)(1) of Pub. L. 106-554, among other things, mandates
that the Secretary shall examine and may provide for adjustments to
payments under the LTCH PPS, including adjustments to DRG weights, area
wage adjustments, geographic reclassification, outliers, updates, and a
disproportionate share adjustment.
In a Federal Register document issued on August 30, 2002 (67 FR
55954), we implemented the LTCH PPS authorized under Pub. L. 106-113
and
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Pub. L. 106-554. This system uses information from LTCH patient records
to classify patients into distinct long-term care diagnosis-related
groups (LTC-DRGs) based on clinical characteristics and expected
resource needs. Payments are calculated for each LTC-DRG and provisions
are made for appropriate payment adjustments. Payment rates under the
LTCH PPS are updated annually and published in the Federal Register.
The LTCH PPS replaced the reasonable cost-based payment system
under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA),
Pub. L. 97-248, for payments for inpatient services provided by a LTCH
with a cost reporting period beginning on or after October 1, 2002.
(The regulations implementing the TEFRA (reasonable cost-based) payment
provisions are located at 42 CFR part 413.) With the implementation of
the prospective payment system for acute care hospitals authorized by
the Social Security Amendments of 1983 (Pub. L. 98-21), which added
section 1886(d) to the Act, certain hospitals, including LTCHs, were
excluded from the PPS for acute care hospitals and were paid their
reasonable costs for inpatient services subject to a per discharge
limitation or target amount under the TEFRA system. For each cost
reporting period, a hospital-specific ceiling on payments was
determined by multiplying the hospital's updated target amount by the
number of total current year Medicare discharges. The August 30, 2002,
final rule further details payment policy under the TEFRA system (67 FR
55954).
In the August 30, 2002, final rule, we presented an in-depth
discussion of the LTCH PPS, including the patient classification
system, relative weights, payment rates, additional payments, and the
budget neutrality requirements mandated by section 123 of Pub. L. 106-
113. The same final rule, that established regulations for the LTCH PPS
under 42 CFR part 412, subpart O, also contained provisions related to
covered inpatient services, limitation on charges to beneficiaries,
medical review requirements, furnishing of inpatient hospital services
directly or under arrangement, and reporting and recordkeeping
requirements.
We refer readers to the August 30, 2002, final (67 FR 55954) rule
for a comprehensive discussion of the research and data that supported
the establishment of the LTCH PPS.
On June 6, 2003, we published a final rule in the Federal Register
(68 FR 34122) that set forth the annual update of the payment rates for
the Medicare PPS for inpatient hospital services furnished by LTCHs. It
also changed the annual period for which the payment rates are
effective. The annual updated rates are now effective from July 1 to
June 30 instead of from October 1 through September 30. We refer to
this time period as a ``long-term care hospital rate year'' (LTCH PPS
rate year). In addition, we changed the publication schedule for these
updates to allow for an effective date of July 1. The payment amounts
and factors used to determine the annual update of the Federal rates
are based on a LTCH PPS rate year. The annual update of the LTC-DRG
classifications and relative weights are linked to the annual
adjustments of the acute care hospital inpatient diagnosis-related
groups and are effective each October 1.
B. Criteria for Classification as a LTCH
1. Classification as a LTCH
Under the existing regulations at Sec.Sec. 412.23(e)(1) and (2)(i),
which implement section 1886(d)(1)(B)(iv)(I) of the Act, to qualify to
be paid under the LTCH PPS, a hospital must have a provider agreement
with Medicare and must have an average Medicare inpatient length of
stay of greater than 25 days. Alternatively, for cost reporting periods
beginning on or after August 5, 1997, a hospital that was first
excluded from the PPS in 1986, and can demonstrate that at least 80
percent of its annual Medicare inpatient discharges in the 12-month
cost reporting period ending in FY 1997 have a principal diagnosis that
reflects a finding of neoplastic disease must have an average inpatient
length of stay for all patients, including both Medicare and non-
Medicare inpatients, of greater than 20 days (Sec. 412.23(e)(2)(ii)).
Existing Sec. 412.23(e)(3) provides that the average Medicare
inpatient length of stay is determined based on all covered and
noncovered days of stay of Medicare patients as calculated by dividing
the total number of covered and noncovered days of stay of Medicare
inpatients (less leave or pass days) by the number of total Medicare
discharges for the hospital's most recent complete cost reporting
period. Fiscal intermediaries verify that LTCHs meet the average length
of stay requirements. We note that the inpatient days of a patient who
is admitted to a LTCH without any remaining Medicare days of coverage,
regardless of the fact that the patient is a Medicare beneficiary, will
not be included in the above calculation. Because Medicare would not be
paying for any of the patient's treatment, the patient is not a
``Medicare inpatient'' and data on the patient's stay would not be
included in the Medicare claims processing systems. In order for both
covered and noncovered days of a LTCH hospitalization to be included,
for purposes of the average length of stay calculation, a patient
admitted to the LTCH must have at least one remaining benefit day as
described in Sec. 409.61.
The fiscal intermediary's determination of whether or not a
hospital qualifies as an LTCH is based on the hospital's discharge data
from its most recent cost reporting period and is effective at the
start of the hospital's next cost reporting period (Sec. 412.22(d)). If
a hospital does not meet the length of stay requirement, the hospital
may provide the intermediary with data indicating a change in the
hospital's average length of stay by the same method for the period of
at least 5 months of the immediately preceding 6-month period (Sec.
412.23(e)(3)(ii)). (See 68 FR 45464, August 1, 2003.) Requirements for
hospitals seeking classification as LTCHs that have undergone a change
in ownership, as described in Sec. 489.18, are set forth in Sec.
412.23(e)(3)(iii).
LTCHs that exist as hospitals-within-hospitals or satellite
facilities of LTCHs must also meet the criteria set forth in Sec.
412.22(e) or Sec. 412.22(h), respectively, for the LTCH to be excluded
from the acute care hospital inpatient prospective payment system
(IPPS) and paid under the LTCH PPS.
2. Hospitals Excluded From the LTCH PPS
The following hospitals are paid under special payment provisions,
as described in Sec. 412.22(c) and, therefore, are not subject to the
LTCH PPS rules:
Veterans Administration hospitals.
Hospitals that are reimbursed under State cost
control systems approved under 42 CFR part 403.
Hospitals that are reimbursed in accordance with
demonstration projects authorized under section 402(a) of Public Law
90-248 (42 U.S.C. 1395b-1) or section 222(a) of Public Law 92-603 (42
U.S.C. 1395b-1 (note)) (statewide all-payer systems, subject to the
rate-of-increase test at section 1814(b) of the Act).
Nonparticipating hospitals furnishing emergency
services to Medicare beneficiaries.
C. Transition Period for Implementation of the LTCH PPS
In the August 30, 2002, final rule, we provided for a 5-year
transition period from reasonable cost-based reimbursement to fully
Federal prospective payment for LTCHs (67 FR 56038). During the 5-year
period, two
[[Page 4757]]
payment percentages are to be used to determine a LTCH's total payment
under the PPS. The blend percentages are as follows:
------------------------------------------------------------------------
Reasonable cost-
Cost reporting periods beginning Prospective based
on or after payment federal reimbursement
rate percentage rate percentage
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October 1, 2002................... 20 80
October 1, 2003................... 40 60
October 1, 2004................... 60 40
October 1, 2005................... 80 20
October 1, 2006................... 100 0
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D. Limitation on Charges to Beneficiaries
In the August 30, 2002, final rule, we presented an in-depth
discussion of beneficiary liability under the LTCH prospective payment
system (67 FR 55974-55975). Under Sec. 412.507, as consistent with
other established hospital prospective payment systems, a LTCH may not
bill a Medicare beneficiary for more than the deductible and
coinsurance amounts as specified under Sec.Sec. 409.82, 409.83, and
409.87 and for items and services as specified under Sec. 489.30(a), if
the Medicare payment to the LTCH is the full LTC-DRG payment amount.
However, under the LTCH PPS, Medicare will only pay for days for which
the beneficiary has coverage until the short-stay outlier threshold is
exceeded. (See section IV.C.4.b.) Therefore, if the Medicare payment
was for a short-stay outlier case (Sec. 412.529) that was less than the
full LTC-DRG payment amount because the beneficiary had insufficient
remaining Medicare days, the LTCH could also charge the beneficiary for
services delivered on those uncovered days. (Sec. 412.507).
Since the origin of the Medicare system, the intent of our
regulations has been to set limits on beneficiary liability and to
clearly establish the circumstances under which the beneficiary would
be required to assume responsibility for payment, that is, upon
exhausting benefits described in 42 CFR part 409, subpart F. The
discussion in the August 30, 2002, final rule was not meant to
establish rates or payments for, or define, Medicare-eligible expenses.
While we regulate beneficiary liability for coinsurance and deductibles
for hospital stays that are covered by Medicare, payments from Medigap
insurers to providers for inpatient hospital coverage after Medicare
benefits are exhausted are not regulated by us. Furthermore,
regulations beginning at Sec. 403.200 and the 1991 National Association
of Insurance Commissioners (NAIC) Model Regulation for Medicare
Supplemental Insurance, which was incorporated by reference into
section 1882 of the Act, govern the relationship between Medigap
insurers and beneficiaries.
E. Health Insurance Portability and Accountability Act Compliance
We note that as of October 16, 2002, a LTCH that was required to
comply with the Administrative Simplification Standards under the
Health Insurance Portability and Accountability Act (HIPAA) (Pub. L.
104-191) and that had not obtained an extension in compliance with the
Administrative Compliance Act (Pub. L. 107-105) is obligated to comply
with the standards for submitting claim forms to the LTCH's Medicare
fiscal intermediary (45 CFR 162.1002 and 45 CFR 162.1102). Beginning
October 16, 2003, LTCHs that obtained an extension and that are
required to comply with the HIPAA Administrative Simplification
Standards must start submitting electronic claims in compliance with
the HIPAA regulations cited above, among others.
II. Summary of Major Contents of This Proposed Rule
We are proposing an annual update of the payment rates for the
Medicare PPS for inpatient hospital services provided by LTCHs for the
2005 LTCH PPS rate year. (The annual update of the LTC-DRG
classifications and relative weights for FY 2005 remains linked to the
annual adjustments of the acute care hospital inpatient DRG system and
will be effective October 1, 2004.)
We are proposing an outlier threshold for July 1, 2004, through
June 30, 2005, derived from the LTCH PPS rate year calculations.
As discussed in section I.B.2. of this preamble, we are proposing a
change in the procedure for counting the days in the inpatient average
length of stay for hospitals to qualify as LTCHs.
In section I.B.3. of this preamble, we discuss and clarify existing
policies regarding the classification of a satellite facility, or a
remote location, of a LTCH as an independent LTCH and propose new
policies for certain satellite facilities and remote locations.
In section IV.C.4.c. of this preamble, we are proposing to revise
existing interrupted stay policy applicable under the LTCH PPS.
III. Long-Term Care Diagnosis-Related Group (LTC-DRG) Classifications
and Relative Weights
(If you choose to comment on issues in this section, please include the
caption ``LTC-DRG CLASSIFICATIONS AND RELATIVE WEIGHTS'' at the
beginning of your comments.)
A. Background
Section 123 of Pub. L. 106-113 specifically requires that the PPS
for LTCHs be a per discharge system with a DRG-based patient
classification system reflecting the differences in patient resources
and costs in LTCHs while maintaining budget neutrality. Section
307(b)(1) of Pub. 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 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.''
In accordance with section 307(b)(1) of Pub. L. 106-554 and Sec.
412.515 of our existing regulations, the LTCH PPS uses information from
LTCH patient records to classify patient cases into distinct LTC-DRGs
based on clinical characteristics and expected resource needs. The LTC-
DRGs used as the patient classification component of the LTCH PPS
correspond to the hospital inpatient DRGs in the IPPS. We apply weights
to the existing hospital inpatient DRGs to account for the difference
in resource use by patients exhibiting the case complexity and multiple
medical problems characteristic of LTCHs.
In a departure from the IPPS, we use low volume LTC-DRGs (less than
25
[[Page 4758]]
LTCH cases) in determining the LTC-DRG weights, since LTCHs do not
typically treat the full range of diagnoses as do acute care hospitals.
In order to deal with the large number of low volume DRGs (all DRGs
with fewer than 25 cases), we group low volume DRGs into 5 quintiles
based on average charge per discharge. (A listing of the composition of
low volume quintiles appears in the August 30, 2002, LTCH PPS final
rule at 67 FR 55986.) We also take into account adjustments to payments
for cases in which the stay at the LTCH is five-sixths of the geometric
average length of stay and classify these cases as short-stay outlier
cases. (A detailed discussion of the application of the Lewin Group
model that was used to develop the LTC-DRGs appears in the August 30,
2002 LTCH PPS final rule at 67 FR 55978.)
B. Patient Classifications Into DRGs
Generally, under the LTCH PPS, Medicare payment is made at a
predetermined specific rate for each discharge; that payment varies by
the LTC-DRG to which a beneficiary's stay is assigned. Cases are
classified into LTC-DRGs for payment based on the following six data
elements:
(1) Principal diagnosis.
(2) Up to eight additional diagnoses.
(3) Up to six procedures performed.
(4) Age.
(5) Sex.
(6) 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 International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-
9-CM). As of October 16, 2002, a LTCH that was required to comply with
the HIPAA Administrative Simplification Standards and that had not
obtained an extension in compliance with the Administrative Compliance
Act (Pub. L. 107-105) is obligated to comply with the standards at 45
CFR 162.1002 and 45 CFR 162.1102. Completed claim forms are to be
submitted to the LTCH's Medicare fiscal intermediary.
Medicare fiscal intermediaries enter the clinical and demographic
information into their claims processing systems and subject this
information to a series of automated screening processes called the
Medicare Code Editor (MCE). These screens are designed to identify
cases that require further review before assignment into a DRG can be
made. 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 68.6, 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 3-digit, 4-digit, and 5-digit codes. That
is, code 136.3, Pneumocystosis, contains all appropriate digits, but if
it is reported with either fewer or more than 4 digits, the claim will
be rejected by the MCE as invalid.)
Cases with principal diagnoses that do not
usually justify admission to the hospital. (For example, code 437.9,
Unspecified cerebrovascular disease. While this code is valid according
to the ICD-9-CM coding scheme, a more precise code should be used for
the principal diagnosis.)
After screening through the MCE, each claim will be classified into
the appropriate LTC-DRG by the Medicare LTCH GROUPER. The LTCH GROUPER
is specialized computer software based on the same GROUPER used by the
IPPS. The GROUPER software was developed as a means of classifying each
case into a DRG on the basis of diagnosis and procedure codes and other
demographic information (age, sex, and discharge status). Following the
LTC-DRG assignment, the Medicare fiscal intermediary will determine the
prospective payment by using the Medicare PRICER program, which
accounts for hospital-specific adjustments. As provided for under the
IPPS, we provide an opportunity for the LTCH to review the LTC-DRG
assignments made by the fiscal intermediary and to submit additional
information within a specified timeframe (Sec. 412.513(c)).
The GROUPER is used both to classify past cases in order to measure
relative hospital resource consumption to establish the DRG weights and
to classify current cases for purposes of determining payment. The
records for all Medicare hospital inpatient discharges are maintained
in the MedPAR file. The data in this file are used to evaluate possible
DRG classification changes and to recalibrate the DRG weights during
our annual update. DRG weights are based on data for the population of
LTCH discharges, reflecting the fact that LTCH patients represent a
different patient-mix than patients in short-term acute care hospitals.
C. Organization of DRGs
The DRGs are organized into 25 Major Diagnostic Categories (MDCs),
most of which are based on a particular organ system of the body; the
remainder involve multiple organ systems (such as MDC 22, Burns).
Accordingly, the principal diagnosis determines MDC assignment. Within
most MDCs, cases are then divided into surgical DRGs and medical DRGs.
Surgical DRGs are assigned based on a surgical hierarchy that orders
operating room (O.R.) procedures or groups of O.R. procedures by
resource intensity. The GROUPER does not recognize all ICD-9-CM
procedure codes as procedures that affect DRG assignment, that is,
procedures which are not surgical (for example, EKG), or minor surgical
procedures (for example, 86.11, Biopsy of skin and subcutaneous
tissue).
The medical DRGs are generally differentiated on the basis of
diagnosis. Both medical and surgical DRGs may be further differentiated
based on age, sex, discharge status, and presence or absence of
complications or comorbidities (CC). We note that CCs are defined by
certain secondary diagnoses not related to, or not inherently a part
of, the disease process identified by the principal diagnosis. (For
example, the GROUPER would not recognize a code from the 800.0x series,
Skull fracture, as a CC when combined with principal diagnosis 850.4,
Concussion with prolonged loss of consciousness, without return to
preexisting conscious level.) In addition, we note that the presence of
additional diagnoses does not automatically generate a CC, as not all
DRGs recognize a comorbid or complicating condition in their
definition. (For example, DRG 466, Aftercare without History of
Malignancy as Secondary Diagnosis, is based solely on the principal
diagnosis, without consideration of additional diagnoses for DRG
determination.)
In its June 2000 Report to Congress, MedPAC recommended that the
Secretary ``* * * improve the hospital inpatient prospective payment
system by adopting, as soon as practicable, diagnosis-related group
refinements that more fully capture differences in severity of illness
among patients.'' (Recommendation 3A, p. 63) We have determined it is
not practical at this time to develop a refinement to inpatient
hospital DRGs based on severity due to time and resource requirements.
However, this does not preclude us from development of a severity-
adjusted DRG refinement in the future. That is, a refinement to the
list
[[Page 4759]]
of comorbidities and complications could be incorporated into the
existing DRG structure. It is also possible a more comprehensive
severity adjusted structure may be created if a new code set is
adopted. That is, if ICD-9-CM is replaced by ICD-10-CM (for diagnostic
coding) and ICD-10-PCS (for procedure coding) or by other code sets, a
severity concept may be built into the resulting DRG assignments. Of
course any change to the code set would be adopted through the process
established in the HIPAA Administrative Simplification Standards
provisions.
D. Update of LTC-DRGs
For FY 2004, the LTC-DRG patient classification system was based on
LTCH data from the FY 2002 MedPAR file, which contained hospital bills
data from the December 2002 update. The patient classification system
consisted of 518 DRGs that formed the basis of the FY 2004 LTCH PPS
GROUPER. The 518 LTC-DRGs included two ``error DRGs''. As in the IPPS,
we included two error DRGs in which cases that cannot be assigned to
valid DRGs will be grouped. These two error DRGs are DRG 469 (Principal
Diagnosis Invalid as a Discharge Diagnosis) and DRG 470 (Ungroupable).
(See the August 1, 2001, Medicare Program final rule, Changes to the
Hospital Inpatient Prospective Payment Systems and Rates and Costs of
Graduate Medical Education; Fiscal Year 2002 Rates (66 FR 40062).) The
other 516 LTC-DRGs are the same DRGs used in the IPPS GROUPER for FY
2004 (Version 21.0).
In the health care industry, annual changes to the ICD-9-CM codes
are effective for discharges occurring on or after October 1 each year.
Thus, the manual and electronic versions of the GROUPER software, which
are based on the ICD-9-CM codes, are also revised annually and
effective for discharges occurring on or after October 1 each year. As
discussed earlier, the patient classification system for the LTCH PPS
(LTC-DRGs) is based on the IPPS patient classification system (CMS-
DRGs), which is updated annually and effective for discharges occurring
on or after October 1 through September 30 each year. The updated DRGs
and GROUPER software are based on the latest revision to the ICD-9-CM
codes, which are published annually in the IPPS proposed rule and final
rule. The new or revised ICD-9-CM codes are not used by the industry
for either the IPPS or the LTCH PPS until the beginning of the next
Federal fiscal year (effective for discharges occurring on or after
October 1 through September 30). (The use of the ICD-9-CM codes in this
manner is consistent with current usage and the HIPAA regulations.)
October 1 is also when the changes to the CMS-DRGs and the next version
of the GROUPER software becomes effective.
As indicated in the June 3, 2002, LTCH PPS and the August 1, 2003,
IPPS final rules (68 FR 34122 and 68 FR 45374), we make the annual
update to the LTCH PPS effective from July 1 through June 30 each year.
As a result, the LTCH PPS uses two GROUPERS during the course of a 12-
month period: one GROUPER for 3 months (from July 1 through September
30); and an updated GROUPER for 9 months (from October 1 through June
30). The need to use two GROUPERs is based upon the October 1 effective
date of the updated ICD-9-CM coding system. As previously discussed,
new ICD-9-CM codes may result in changes to the structure of the DRGs.
In order for the industry to be on the same schedule (for both the IPPS
and the LTCH PPS) for the use of the most current ICD-9-CM codes, it is
necessary for us to apply two GROUPER programs to the LTCH PPS. LTCHs
will continue to code diagnosis and procedures using the most current
version of the ICD-9-CM coding system.
Currently, for Federal FY 2004, we are using Version 21.0 of the
GROUPER software for both the IPPS and the LTCH PPS. Discharges
beginning on October 1, 2003, and before October 1, 2004 (Federal FY
2004), will use Version 21.0 of the GROUPER software for both the IPPS
and the LTCH PPS. Thus, changes to the CMS-DRGs (the DRGs on which the
LTC-DRGs are based) and their relative weights, as well as the LTC-DRGs
and their relative weights, that will be effective for October 1, 2004,
through September 30, 2005, will be presented in the IPPS FY 2005
proposed rule that will be published in the Federal Register in the
spring of 2004 and finalized in a final rule to be published by August
1, 2004. Accordingly, we will notify LTCHs of any revised LTC-DRG
relative weights based on the final DRGs and the applicable GROUPER
version for the IPPS that will be effective October 1, 2004.
E. ICD-9-CM Coding System
1. Uniform Hospital Discharge Data Set (UHDDS) Definitions
Because the assignment of a case to a particular LTC-DRG will help
determine the amount that will be paid for the case, it is important
that the coding is accurate. Classifications and terminology used in
the LTCH PPS are consistent with the ICD-9-CM and the UHDDS, as
recommended to the Secretary by the National Committee on Vital and
Health Statistics (``Uniform Hospital Discharge Data: Minimum Data Set,
National Center for Health Statistics, April 1980'') and as revised in
1984 by the Health Information Policy Council (HIPC) of the U.S.
Department of Health and Human Services.
We point out that the ICD-9-CM coding terminology and the
definitions of principal and other diagnoses of the UHDDS are
consistent with the requirements of the HIPAA Administrative
Simplification Act of 1996 (45 CFR Part 162). Furthermore, the UHDDS
has been used as a standard for the development of policies and
programs related to hospital discharge statistics by both governmental
and nongovernmental sectors for over 30 years. In addition, the
following definitions (as described in the 1984 Revision of the UHDDS,
approved by the Secretary of Health and Human Services for use starting
January 1986) are requirements of the ICD-9-CM coding system, and have
been used as a standard for the development of the CMS-DRGs:
Diagnoses include all diagnoses that affect the
current hospital stay.
Principal diagnosis is defined as the condition
established after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care.
Other diagnoses (also called secondary diagnoses
or additional diagnoses) are defined as all conditions that coexist at
the time of admission, that develop subsequently, or that affect the
treatment received or the length of stay or both. Diagnoses that relate
to an earlier episode of care that have no bearing on the current
hospital stay are excluded.
All procedures performed will be reported. This
includes those that are surgical in nature, carry a procedural risk,
carry an anesthetic risk, or require specialized training.
We provide LTCHs with a 60-day window after the date of the notice
of the initial LTC-DRG assignment to request review of that assignment.
Additional information may be provided by the LTCH to the fiscal
intermediary as part of that review.
2. Maintenance of the ICD-9-CM Coding System
The ICD-9-CM Coordination and Maintenance (C&M) Committee is a
Federal interdepartmental committee, co-chaired by the National Center
for Health Statistics (NCHS) and CMS, that is charged with maintaining
and updating the ICD-9-CM system. The C&M Committee is jointly
responsible
[[Page 4760]]
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 C&M 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 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 C&M Committee encourages participation by health-related
organizations in the above process and holds public meetings for
discussion of educational issues and proposed coding changes twice a
year at the CMS Central Office located in Baltimore, Maryland. The
agenda and dates of the meetings can be accessed on the CMS Web site
at: http://www.cms.gov/paymentsystems/icd9.
All changes to the ICD-9-CM coding system affecting DRG assignment
are addressed annually in the IPPS proposed and final rules. Because
the DRG-based patient classification system for the LTCH PPS is based
on the IPPS DRGs, these changes will also affect the LTCH PPS LTC-DRG
patient classification system.
As discussed above, the ICD-9-CM coding changes that have been
adopted by the C&M Committee become effective at the beginning of each
Federal fiscal year, October 1. Regardless of the annual update of the
LTCH PPS on July 1 of each year, coders will use the most current
updated ICD-9-CM coding book, which is effective from October 1 through
September 30 of each year. This means that coders and LTCHs that use
the updated ICD-9-CM coding system will be on the same schedule
(effective October 1) as the rest of the health care industry. The
newest version of ICD-9-CM is not available for use until October 1 of
each year, which is 5 months after the date that we publish the LTCH
annual payment rate update final rule. The new codes on which the LTC-
DRGs are based will go into effect and be available for use for
discharges occurring on or after October 1 through September 30 of each
year. This annual schedule of the revision to the ICD-9-CM coding
system and the change of the ICD-9-CM coding books or electronic coding
programs has been in effect since the adoption of Revision 9 of the ICD
in 1979.
Of particular note to LTCHs will be the invalid diagnosis codes
(Table 6C) and the invalid procedure codes (Table 6D) located in the
annual proposed and final rules for the IPPS. Claims with invalid codes
will not be processed by the Medicare claims processing system.
3. Coding Rules and Use of ICD-9-CM Codes in LTCHs
We emphasize the need for proper coding by LTCHs. Inappropriate
coding of cases can adversely affect the uniformity of cases in each
LTC-DRG and produce inappropriate weighting factors at recalibration.
We continue to urge LTCHs to focus on improved coding practices.
Because of concerns raised by LTCHs concerning correct coding, we have
asked the American Hospital Association (AHA) to provide additional
clarification or instruction on proper coding in the LTCH setting. The
AHA will provide this instruction via their established process of
addressing questions through their publication ``Coding Clinic for ICD-
9-CM''. Written questions or requests for clarification may be
addressed to the Central Office on ICD-9-CM, American Hospital
Association, One North Franklin, Chicago, IL 60606. A form for the
question(s) is available to be downloaded and mailed on AHA's Web site
at: http://www.ahacentraloffice.org. In addition, current coding
guidelines are available at the National Center for Health Statistics
(NCHS) Web site: http://www.cdc.gov/nchs.icd9.htm.
In conjunction with the cooperating parties (AHA, the American
Health Information Management Association (AHIMA), and NCHS), we have
reviewed actual medical records and are concerned about the quality of
the documentation under the LTCH PPS, as was the case at the beginning
of the IPPS. We fully believe that, with experience, the quality of the
documentation and coding will improve, just as it did for the IPPS. As
noted above, the cooperating parties have plans to assist their members
with improvement in documentation and coding issues for the LTCHs
through specific questions and coding guidelines. The importance of
good documentation is emphasized in the revised ICD-9-CM Official
Guidelines for Coding and Reporting (October 1, 2002): ``A joint effort
between the attending physician and coder is essential to achieve
complete and accurate documentation, code assignment, and reporting of
diagnoses and procedures. The importance of consistent, complete
documentation in the medical record cannot be overemphasized. Without
such documentation, the application of all coding guidelines is a
difficult, if not impossible, task. (Coding Clinic for ICD-9-CM, Fourth
Quarter 2002, page 115)
To improve medical record documentation, LTCHs should be aware that
if the patient is being admitted for continuation of treatment of an
acute or chronic condition, guidelines at Section I.B.10 of the Coding
Clinic for ICD-9-CM, Fourth Quarter 2002 (page 129) are applicable
concerning selection of principal diagnosis. To clarify coding advice
issued in the August 30, 2002, final rule (67 FR 55979-55981), we would
like to point out that at Guideline I.B.12, Late Effects, a late effect
is considered to be the residual effect (condition produced) after the
acute phase of an illness or injury has terminated (Coding Clinic for
ICD-9-CM, Fourth Quarter 2002, page 129). Regarding whether a LTCH
should report the ICD-9-CM code(s) for an unresolved acute condition
instead of the code(s) for late effect of rehabilitation, we emphasize
that each case must be evaluated on its unique circumstances and coded
appropriately. Depending on the documentation in the medical record,
either a code reflecting the acute condition or rehabilitation could be
appropriate in a LTCH.
Since implementation of the LTCH PPS, our Medicare fiscal
intermediaries have been conducting training and providing assistance
to LTCHs in correct coding. We have also issued manuals containing
procedures as well as coding instructions to LTCHs and fiscal
intermediaries. We will continue to conduct such training and provide
guidance on an as-needed basis. We also refer readers to the detailed
discussion on correct coding practices in the August 30, 2002, LTCH PPS
final rule (67 FR 55979-55981). Additional coding instructions and
examples will be published in Coding Clinic for ICD-9-CM.
F. The Method for Updating the LTC-DRG Relative Weights
As discussed in the June 6, 2003, LTCH PPS final rule (68 FR
34131), under the LTCH PPS each LTCH will receive a payment that
represents an appropriate amount for the efficient delivery of care to
Medicare patients. The system must be able to account adequately for
each LTCH's case-mix in order to ensure both fair distribution of
Medicare payments and access to adequate care for those Medicare
patients whose care is more costly. Therefore, in accordance with
section
[[Page 4761]]
412.523(c), we adjust the standard Federal PPS rate by the LTC-DRG
relative weights in determining payment to LTCHs for each case.
Under this payment system, relative weights for each LTC-DRG are a
primary element used to account for the variations in cost per
discharge and resource utilization among the payment groups (section
412.515). To ensure that Medicare patients who are classified to each
LTC-DRG have access to an appropriate level of services and to
encourage efficiency, we calculate a relative weight for each LTC-DRG
that represents the resources needed by an average inpatient LTCH case
in that LTC-DRG. For example, cases in a LTC-DRG with a relative weight
of 2 will, on average, cost twice as much as cases in a LTC-DRG with a
weight of 1.
As we discussed in the August 1, 2003, IPPS final rule (68 FR
45374-45384), the LTC-DRG relative weights effective under the LTCH PPS
for Federal FY 2004 were calculated using the December 2002 update of
FY 2002 MedPAR data and Version 21.0 of the CMS GROUPER software. We
use total days and total charges in the calculation of the LTC-DRG
relative weights.
By nature, LTCHs often specialize in certain areas, such as
ventilator-dependent patients and rehabilitation and wound care. Some
case types (DRGs) may be treated, to a large extent, in hospitals that
have, from a perspective of charges, relatively high (or low) charges.
Such distribution of cases with relatively high (or low) charges in
specific LTC-DRGs has the potential to inappropriately distort the
measure of average charges. To account for the fact that cases may not
be randomly distributed across LTCHs, we use a hospital-specific
relative value method to calculate relative weights. We believe this
method removes this hospital-specific source of bias in measuring
average charges. Specifically, we reduce the impact of the variation in
charges across providers on any particular LTC-DRG relative weight by
converting each LTCH's charge for a case to a relative value based on
that LTCH's average charge. (See the August 1, 2003, IPPS final rule
(68 FR 45376) for further information on the hospital-specific relative
value methodology.)
In order to account for LTC-DRGs with low volume (that is, with
fewer than 25 LTCH cases), we grouped those low volume LTC-DRGs into
one of five categories (quintiles) based on average charges, for the
purposes of determining relative weights. For FY 2004 based on the FY
2002 MedPAR data, we identified 173 LTC-DRGs that contained between 1
and 24 cases. This list of low volume LTC-DRGs was then divided into
one of the five low volume quintiles, each containing a minimum of 34
LTC-DRGs (173/5 = 34 with 1 LTC-DRG as a remainder). Each of the low
volume LTC-DRGs grouped to a specific quintile received the same
relative weight and average length of stay using the formula applied to
the regular LTC-DRGs (25 or more cases), as described below. (See the
August 1, 2003, final rule (68 FR 45376-45380) for further explanation
of the development and composition of each of the five low volume
quintiles for FY 2004.)
After grouping the cases in the appropriate LTC-DRG, we calculate
the relative weights by first removing statistical outliers and cases
with a length of stay of 7 days or less. Next, we adjust the number of
cases in each LTC-DRG for the effect of short-stay outlier cases under
Sec. 412.529. The short-stay adjusted discharges and corresponding
charges were used to calculate ``relative adjusted weights'' in each
LTC-DRG using the hospital-specific relative value method described
above. (See August 1, 2003, final rule (68 FR 45376-45385) for further
details on the steps for calculating the LTC-DRG relative weights.)
We also adjust the LTC-DRG relative weights to account for
nonmonotonically increasing relative weights. That is, we make an
adjustment if cases classified to the LTC-DRG ``with comorbidities
(CCs)'' of a ``with CC''/``without CC'' pair had a lower average charge
than the corresponding LTC-DRG ``without CCs'' by assigning the same
weight to both LTC-DRGs in the ``with CC''/``without CC'' pair. (See
August 1, 2003, final rule, 68 FR 45381-45382.) In addition, of the 518
LTC-DRGs in the LTCH PPS for FY 2004, based on the FY 2002 MedPAR data,
we identified 167 LTC-DRGs for which there were no LTCH cases in the
database. That is, no patients who would have been classified to those
DRGs were treated in LTCHs during FY 2002 and, therefore, no charge
data were reported for those DRGs. Thus, in the process of determining
the relative weights of LTC-DRGs, we were unable to determine weights
for these 167 LTC-DRGs using the method described above. However, since
patients with a number of the diagnoses under these LTC-DRGs may be
treated at LTCHs beginning in FY 2004, we assigned relative weights to
each of the 167 ``no volume'' LTC-DRGs based on clinical similarity and
relative costliness to one of the remaining 351 (518 - 167 = 351) LTC-
DRGs for which we were able to determine relative weights, based on the
FY 2002 claims data. (A list of the no volume LTC-DRGs and further
explanation of their relative weight assignment can be found in the
August 1, 2003, IPPS final rule (68 FR 45374-45385).)
Furthermore, for FY 2004 we established LTC-DRG relative weights of
0.0000 for heart, kidney, liver, lung, pancreas, and simultaneous
pancreas/kidney transplants (LTC-DRGs 103, 302, 480, 495, 512 and 513,
respectively) 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. If
in the future, however, a LTCH applies for certification as a Medicare-
approved transplant center, we believe that the application and
approval procedure would allow sufficient time for us to propose
appropriate weights for the LTC-DRGs effected. At the present time,
though, we include these six transplant LTC-DRGs in the GROUPER program
for administrative purposes. As the LTCH PPS uses the same GROUPER
program for LTCHs as is used under the IPPS, removing these DRGs would
be administratively burdensome.
As we stated in the August 1, 2003, IPPS final rule, we will
continue to use the same LTC-DRGs and relative weights for FY 2004
until October 1, 2004. Accordingly, Table 3 in the Addendum to this
proposed rule lists the LTC-DRGs and their respective relative weights
and arithmetic mean length of stay that we will continue to use for the
period of July 1, 2004, through September 30, 2004. (This table is the
same as Table 3 of the Addendum to the August 1, 2003, IPPS final rule
(68 FR 45650-45658), except that it includes the proposed five-sixth of
the average length of stay for short-stay outliers under Sec. 412.529.)
As we noted earlier, the final DRGs and GROUPER for FY 2005 that will
be used for the IPPS and the LTCH PPS, effective October 1, 2004, will
be presented in the IPPS FY 2005 proposed and final rule in the Federal
Register.
Accordingly, we will notify LTCHs of the revised LTC-DRG relative
weights for use in determining payments for discharges occurring
between October 1, 2004, and September 30, 2005, based on the final
DRGs and the applicable GROUPER version that will be published in the
IPPS rule by August 1, 2004.
IV. Proposed Changes to the LTCH PPS Rates and Proposed Changes in
Policy for the 2005 LTCH PPS Rate Year
(If you choose to comment on issues in this section, please include the
caption
[[Page 4762]]
``PROPOSED CHANGES TO LTCH PPS RATES AND POLICY FOR THE 2005 LTCH PPS
RATE YEAR'' at the beginning of your comments.)
A. Overview of the Development of the Payment Rates
The LTCH PPS was effective for a LTCH's first cost reporting period
beginning on or after October 1, 2002. Effective with that cost
reporting period, LTCHs are paid, during a 5-year transition period, on
the basis of an increasing proportion of the LTCH PPS Federal rate and
a decreasing proportion of a hospital's payment under reasonable cost-
based payment system, unless the hospital makes a one-time election to
receive payment based on 100 percent of the Federal rate (see Sec.
412.533). New LTCHs (as defined at Sec. 412.23(e)(4)) are paid based on
100 percent of the Federal rate, with no phase-in transition payments.
The basic methodology for determining LTCH PPS Federal prospective
payment rates is set forth in the regulations at Sec.Sec. 412.515
through 412.532. Below we discuss the proposed factors used to update
the LTCH PPS standard Federal rate for the 2005 LTCH PPS rate year that
will be effective for LTCHs discharges occurring on or after July 1,
2004, through June 30, 2005.
When we implemented the LTCH PPS in the August 30, 2002, final rule
(67 FR 56029-56031), we computed the LTCH PPS standard Federal payment
rate for FY 2003 by updating the best available (FY 1998 or FY 1999)
Medicare inpatient operating and capital costs per case data, using the
excluded hospital market basket.
Section 123(a)(1) of Pub. L. 106-113 requires that the PPS
developed for LTCHs be budget neutral. Therefore, in calculating the
standard Federal rate under Sec. 412.523(d)(2), we set total estimated
PPS payments equal to estimated payments that would have been made
under the reasonable cost-based payment methodology had the PPS for
LTCHs not been implemented. Section 307(a) of Pub. L. 106-554 specified
that the increases to the hospital-specific target amounts and cap on
the target amounts for LTCHs for FY 2002 provided for by section
307(a)(1) of Pub. L. 106-554 shall not be taken into account in the
development and implementation of the LTCH PPS. In addition, the
statute as amended by section 122 of Pub. L. 106-113 provides for
enhanced bonus payments for LTCHs for 2 years, FY 2001 and FY 2002.
Furthermore, as specified at Sec. 412.523(d)(1), the standard Federal
rate is reduced by an adjustment factor to account for the estimated
proportion of outlier payments under the LTCH PPS to total LTCH PPS
payments (8 percent). For further details on the development of the FY
2003 standard Federal rate, see the August 30, 2002, final rule (67 FR
56027-56037) and for the 2004 LTCH PPS rate year rate, see the June 6,
2003, final rule (68 FR 34122-34190).
Under the existing regulations at Sec. 412.523(c)(3)(ii), we update
the standard Federal rate annually to adjust for the most recent
estimate of the projected increases in prices for LTCH inpatient
hospital services.
B. Proposed Update to the Standard Federal Rate for the 2005 LTCH PPS
Rate Year
As established in the June 6, 2003, final rule (68 FR 34122), based
on the most recent estimate of the excluded hospital with capital
market basket, adjusted to account for the change in the LTCH PPS rate
year update cycle, the LTCH PPS standard Federal rate effective from
July 1, 2003, through June 30, 2004, (the 2004 LTCH PPS rate year), is
$35,726.18.
In the discussion that follows, we explain how we developed the
proposed standard Federal rate for the 2005 LTCH PPS rate year. The
proposed standard Federal rate for the 2005 LTCH PPS rate year would be
calculated based on the proposed update factor of 1.029. Thus, we
estimate that the proposed standard Federal rate for the 2005 LTCH PPS
rate year would increase 2.9 percent compared to the 2004 LTCH PPS rate
year standard Federal rate.
1. Proposed Standard Federal Rate Update
Under Sec. 412.523, the annual update to the LTCH PPS standard
Federal rate must be equal to the percentage change in the excluded
hospital with capital market basket (described in further detail
below). As we discussed in the August 30, 2002, final rule (67 FR
56087), in the future we may propose to develop a framework to update
payments to LTCHs that would account for other appropriate factors that
affect the efficient delivery of services and care provided to Medicare
patients. As we discussed in the June 6, 2003, final rule (68 FR
34122), because the LTCH PPS has only been implemented for less than 2
years (for cost reporting periods beginning on or after October 1,
2002), we have not yet collected sufficient data to allow for the
analysis and development of an update framework under the LTCH PPS.
Therefore, we are not proposing an update framework for the 2005 LTCH
PPS rate year in this proposed rule. However, we noted that a
conceptual basis for the proposal of developing an update framework in
the future can be found in Appendix B of the August 30, 2002, final
rule (67 FR 56086-56090).
a. Description of the Proposed Market Basket for LTCHs for the 2005
LTCH PPS Rate Year
A market basket has historically been used in the Medicare program
to account for price increases of the services furnished by providers.
The market basket used for the LTCH PPS includes both operating and
capital-related costs of LTCHs because the LTCH PPS uses a single
payment rate for both operating and capital-related costs. The
development of the LTCH PPS standard Federal rate is discussed in
further detail in the August 30, 2002, final rule (67 FR 56027-56037).
Under the reasonable cost-based payment system, the excluded
hospital market basket was used to update the hospital-specific limits
on payment for operating costs of LTCHs. The excluded hospital market
basket is based on operating costs from FY 1992 cost report data and
includes data from Medicare-participating long-term care,
rehabilitation, psychiatric, cancer, and children's hospitals. Since
LTCHs' costs are included in the excluded hospital market basket, this
market basket index, in part, also reflects the costs of LTCHs.
However, in order to capture the total costs (operating and capital-
related) of LTCHs, we added a capital component to the excluded
hospital market basket for use under the LTCH PPS. We refer to this
index as the excluded hospital with capital market basket.
As we discussed in the August 30, 2002, final rule (67 FR 56016 and
56086), beginning with the implementation of the LTCH PPS in FY 2003,
the excluded hospital with capital market basket based on FY 1992
Medicare cost report data has been used for updating payments to LTCHs.
In the June 6, 2003, final rule (68 FR 34137), we revised and rebased
the excluded hospital with capital market basket, using more recent
data, that is, using FY 1997 base year data beginning with the 2004
LTCH PPS rate year. (For further details on the development of the FY
1997-based LTCH PPS market basket, see the June 6, 2003, final rule (68
FR 34134-34137).
In the August 30, 2002, LTCH PPS final rule (67 FR 56016 and 56085-
56086), we discussed why we believe the excluded hospital with capital
market basket provides a reasonable measure of the price changes facing
LTCHs. However, as we discussed in the June 6, 2003, final rule (68 FR
34137),
[[Page 4763]]
we have been researching the feasibility of developing a market basket
specific to LTCH services. This research has included analyzing data
sources for cost category weights, specifically the Medicare cost
reports, and investigating other data sources on cost, expenditure, and
price information specific to LTCHs. Based on this research, we did not
develop a market basket specific to LTCH services.
As we also discussed in the June 6, 2003, final rule (68 FR 34137),
our analysis of the Medicare cost reports indicates that the
distribution of costs among major cost report categories (wages,
pharmaceuticals, capital) for LTCHs is not substantially different from
the 1997-based excluded hospital with capital market basket. Data on
other major cost categories (benefits, blood, contract labor) that we
would like to analyze were excluded by many LTCHs in their Medicare
cost reports. An analysis based on only the data available to us for
these cost categories presented a potential problem since no other
major cost category weight would be based on LTCH data.
Furthermore, as we also discussed in that same final rule (68 FR
34137), we conducted a sensitivity analysis of annual percent changes
in the market basket when the weights for wages, pharmaceuticals, and
capital in LTCHs were substituted into the excluded hospital with
capital market basket. Other cost categories were recalibrated using
ratios available from the IPPS market basket. On average between FY
1995 and FY 2002, the excluded hospital with capital market basket
shows increases at nearly the same average annual rate (2.9 percent) as
the market basket with LTCH weights for wages, pharmaceuticals, and
capital (2.8 percent). This difference is less than the 0.25 percentage
point criterion that determines whether a forecast error adjustment is
warranted under the IPPS update framework.
We continue to believe that an excluded hospital with capital
market basket adequately reflects the price changes facing LTCHs. We
continue to solicit comments about issues particular to LTCHs that
should be considered in relation to the FY 1997-based excluded hospital
with capital market basket and to encourage suggestions for additional
data sources that may be available. Accordingly, in this proposed rule,
we are proposing to use the FY 1997-based excluded hospital with
capital market basket as the LTCH PPS market basket for determining the
proposed update to the LTCH PPS standard Federal rate for the 2005 LTCH
PPS rate year.
b. Proposed LTCH Market Basket Increase for the 2005 LTCH Rate Year
As we discussed in the June 6, 2003, final rule (68 FR 34137), for
LTCHs paid under the LTCH PPS, we stated that the 2004 rate year update
would apply to discharges occurring from July 1, 2003, through June 30,
2004. Because we changed the timeframe of the LTCH PPS standard Federal
rate annual update from October 1 to July 1, as we explained in that
same final rule, we calculated an update factor that reflected that
change in the update cycle. For the update to the 2004 LTCH PPS rate
year, we calculated the estimated increase between FY 2003 and the 2004
LTCH PPS rate year (July 1, 2003, through June 30, 2004). Accordingly,
based on Global Insight's forecast of the revised and rebased FY 1997-
based excluded hospital with capital market basket using data from the
fourth quarter of 2002, we used a market basket update of 2.5 percent
for the 2004 LTCH PPS rate year (68 FR 34138).
Consistent with our historical practice of estimating market basket
increases based on Global Insight's forecast of the FY 1997-based
excluded hospital with capital market basket using more recent data
from the third quarter of 2003, we are proposing a 2.9 percent update
to the Federal rate for the 2005 LTCH PPS rate year.
In accordance with Sec. 412.523, this update represents the most
recent estimate of the increase in the excluded hospital with capital
market basket for the 2005 LTCH PPS rate year.
2. Proposed Standard Federal Rate for the 2005 LTCH PPS Rate Year
In the June 6, 2003, final rule (68 FR 34140), we established a
standard Federal rate of $35,726.18 for the 2004 LTCH PPS rate year.
For the 2005 LTCH PPS rate year, we are proposing a standard Federal
rate of $36,762.24. Since the proposed 2005 LTCH PPS rate year standard
Federal rate has already been adjusted for differences in case-mix,
wages, cost-of-living, and high-cost outlier payments, we are not
proposing to make any additional adjustments in the proposed standard
Federal rate for these factors.
C. Calculation of Proposed LTCH Prospective Payments for the 2005 LTCH
PPS Rate Year
The basic methodology for determining prospective payment rates for
LTCH inpatient operating and capital-related costs is set forth in Sec.
412.515 through Sec. 412.532. In accordance with Sec. 412.515, we
assign appropriate weighting factors to each LTC-DRG to reflect the
estimated relative cost of hospital resources used for discharges
within that group as compared to discharges classified within other
groups. The amount of the prospective payment is based on the standard
Federal rate, established under Sec. 412.523, and adjusted for the LTC-
DRG relative weights, differences in area wage levels, cost-of-living
in Alaska and Hawaii, high-cost outliers, and other special payment
provisions (short-stay outliers under Sec. 412.529 and interrupted
stays under Sec. 412.531).
In accordance with Sec. 412.533, during the 5-year transition
period, payment is based on the applicable transition blend percentage
of the adjusted Federal rate and the reasonable cost-based payment rate
unless the LTCH makes a one-time election to receive payment based on
100 percent of the Federal rate. A LTCH defined as ``new'' under Sec.
412.23(e)(4) is paid based on 100 percent of the Federal rate with no
blended transition payments (Sec. 412.533(d)). As discussed in the
August 30, 2002 final rule (67 FR 56038) and in accordance with Sec.
412.533(a), the applicable transition blends are as follows:
------------------------------------------------------------------------
Reasonable
Federal cost-based
Cost reporting periods beginning on or after rate payment
percentage rate
percentage
------------------------------------------------------------------------
October 1, 2002................................. 20 80
October 1, 2003................................. 40 60
October 1, 2004................................. 60 40
October 1, 2005................................. 80 20
October 1, 2006................................. 100 0
------------------------------------------------------------------------
Accordingly, for cost reporting periods beginning during FY 2004
(that is, on or after October 1, 2003, and before September 30, 2004),
blended payments under the transition methodology are based on 60
percent of the LTCH's reasonable cost-based payment rate and 40 percent
of the adjusted LTCH PPS Federal rate. For cost reporting periods that
begin during FY 2005 (that is, on or after October 1, 2004, and before
September 30, 2005), blended payments under the transition methodology
will be based on 40 percent of the LTCH's reasonable cost-based payment
rate and 60 percent of the adjusted LTCH PPS Federal rate.
1. Adjustment for Area Wage Levels
a. Background
Under the authority of section 307(b) of Pub. L. 106-554, we
established an adjustment to account for differences in LTCH area wage
levels under Sec. 412.525(c) using the labor-related
[[Page 4764]]
share estimated by the excluded hospital market basket with capital and
wage indices that were computed using wage data from inpatient acute
care hospitals without regard to reclassification under section
1886(d)(8) or section 1886(d)(10) of the Act. Furthermore, as we
discussed in the August 30, 2002, final rule (67 FR 56015-56019), we
established a 5-year transition to the full wage adjustment. The
applicable wage index phase-in percentages are based on the start of a
LTCH's cost reporting period as shown in the following table:
------------------------------------------------------------------------
Cost reporting periods beginning on or Phase-in percentage of the
after full wage index
------------------------------------------------------------------------
October 1, 2002........................... \1/5\ths (20 percent).
October 1, 2003........................... \2/5\ths (40 percent).
October 1, 2004........................... \3/5\ths (60 percent).
October 1, 2005........................... \4/5\ths (80 percent).
October 1, 2006........................... \5/5\ths (100 percent).
------------------------------------------------------------------------
For example, for cost reporting periods beginning on or after
October 1, 2004, and before September 30, 2005 (FY 2005), the
applicable LTCH wage index value would be three-fifths of the
applicable full wage index value without taking into account geographic
reclassification under sections 1886(d)(8) and (d)(10) of the Act.
In that same final rule (67 FR 56018), we stated that we would
continue to reevaluate LTCH data as they become available and would
propose to adjust the phase-in if subsequent data support a change. As
we discussed in the June 6, 2003, final rule (68 FR 34140), because the
LTCH PPS has only been implemented for less than 2 years, sufficient
new data have not been generated that would enable us to conduct a
comprehensive reevaluation of the appropriateness of adjusting the
phase-in. However, in that same final rule, we explained that we had
reviewed the most recent data available at that time and did not find
any evidence to support a change in the 5-year phase-in of the wage
index.
Because of the recent implementation of the LTCH PPS and the lag
time in availability of cost report data, we still do not yet have
sufficient new data to allow us to conduct a comprehensive reevaluation
of the appropriateness of the phase-in of the wage index adjustment.
Again, we have reviewed the most recent data available and did not find
any evidence to support a change in the 5-year phase-in of the wage
index. Therefore, at this time, we are not proposing to adjust the
phase-in of the wage index adjustment in this proposed rule.
b. Wage Index Data
In the June 6, 2003, final rule (68 FR 34142), for the 2004 LTCH
PPS rate year, we established that we would use the same data that was
used to compute the FY 2003 acute care hospital inpatient wage index
without taking into account geographic reclassifications under sections
1886(d)(8) and (d)(10) of the Act because that was the best available
data at that time. The acute care hospital inpatient wage index data is
also used in the inpatient rehabilitation PPS (IRF PPS), the home
health agency PPS (HHA PPS), and the skilled nursing facility PPS (SNF
PPS). As we discussed in the August 30, 2002, final rule (67 FR 56019),
since hospitals that are excluded from the IPPS are not required to
provide wage-related information on the Medicare cost report and we
would need to establish instructions for the collection of such LTCH
data in order to establish a geographic reclassification adjustment
under the LTCH PPS, the wage adjustment established under the LTCH PPS
is based on a LTCH's actual location without regard to the urban or
rural designation of any related or affiliated provider.
In this proposed rule, we are proposing that for the 2005 LTCH PPS
rate year, the same data used to compute the FY 2004 acute care
hospital inpatient wage index without taking into account geographic
reclassifications under sections 1886(d)(8) and (d)(10) of the Act
would be used to determine the applicable wage index values under the
LTCH PPS, because these are the most recent available complete data.
These data are the same wage data that were used to compute the FY 2003
wage indices currently used under the IPPS and SNF PPS. The proposed
LTCH wage index values that would be used for discharges occurring on
or after July 1, 2004, through June 30, 2005, are shown in Table 1 (for
urban areas) and Table 2 (for rural areas) in the Addendum to this
proposed rule.
As noted above, the applicable wage index phase-in percentages are
based on the start of a LTCH's cost reporting period beginning on or
after October 1st of each year during the 5-year transition period. For
cost reporting periods beginning on or after October 1, 2003, and
before September 30, 2004 (FY 2004), the labor portion of the proposed
standard Federal rate would be adjusted by two-fifths of the applicable
LTCH wage index value. Specifically, for a LTCH's cost reporting period
beginning during FY 2004, for discharges occurring on or after July 1,
2004, through June 30, 2005, the applicable wage index value would be
two-fifths of the full FY 2004 acute care hospital inpatient wage index
data, without taking into account geographic reclassifications under
sections 1886(d)(8) and (d)(10) of the Act) as shown in Tables 1 and 2
in the Addendum to this proposed rule. Similarly, for cost reporting
periods beginning on or after October 1, 2004, and before October 1,
2005 (FY 2005), the labor portion of the proposed standard Federal rate
would be adjusted by three-fifths of the applicable LTCH wage index
value. Specifically, for a LTCH's cost reporting period beginning
during FY 2005, for discharges occurring on or after July 1, 2004,
through June 30, 2005, the applicable wage index value would be three-
fifths of the full FY 2005 acute care hospital inpatient wage index
data, without taking into account geographic reclassification under
sections 1886(d)(8) and (d)(10) of the Act as shown in Tables 1 and 2
in the addendum to this proposed rule.
Because the phase-in of the wage index does not coincide with the
LTCH PPS rate year (July 1st through June 30th), most LTCHs will
experience a change in the wage index phase-in percentages during the
LTCH PPS rate year. For example, during the 2005 LTCH PPS rate year,
for a LTCH with a January 1st fiscal year, the two-fifths wage index
would be applicable for the first 6 months of the 2005 LTCH PPS rate
year (July 1, 2004, through December 31, 2004) and the three-fifths
wage index would be applicable for the second 6 months of the 2005 LTCH
PPS rate year (January 1, 2005, through June 30, 2005). We also note
that some providers will still be in the first year of the 5-year
phase-in of the LTCH wage index (that is, those LTCHs with cost
reporting periods that began during FY 2003 and are ending during the
first 3 months of the 2005 LTCH PPS rate year (July 1, 2004, through
September 30, 2004). For the remainder of those LTCHs' FY 2003 cost
reporting periods, for discharges occurring on or after July 1, 2004,
through June 30, 2005, the applicable wage index value would be one-
fifth of the full FY 2005 acute care hospital inpatient wage index
data, without taking into account geographic reclassification under
sections 1886(d)(8) and (d)(10) of the Act as shown in Tables 1 and 2
in the Addendum to this proposed rule.
c. Labor-Related Share
In the August 30, 2002, final rule (67 FR 56016), we established a
labor-related share of 72.885 percent based on the relative importance
of the labor-
[[Page 4765]]
related share of operating and capital costs of the excluded hospital
with capital market basket based on FY 1992 data. In the June 6, 2003,
final rule (68 FR 34142), in conjunction with our revision and rebasing
of the excluded hospital with capital market basket from an FY 1992 to
an FY 1997 base year, we used a labor-related share that is determined
based on the relative importance of the labor-related share of
operating costs (wages and salaries, employee benefits, professional
fees, postal services, and all other labor-intensive services) and
capital costs of the excluded hospital with capital market basket based
on FY 1997 data. While we adopted the revised and rebased FY 1997-based
LTCH PPS market basket as the LTCH PPS update factor for the 2004 LTCH
PPS rate year, we decided not to update the labor-related share under
the LTCH PPS pending further analysis. Accordingly, the labor-share for
the 2004 LTCH PPS rate year was 72.885 percent.
In the August 1, 2003, IPPS final rule (68 FR 50041-50042), we did
not use a revised labor-related share for FY 2004 because we had not
yet completed our research into the appropriateness of this updated
measure. In that rule, we discussed two methods that we were reviewing
for establishing the labor-related share--(1) updating the regression
analysis that was done when the IPPS was originally developed and (2)
reevaluating the methodology we currently use for determining the
labor-related share using the hospital market basket. We also explained
that we would continue to explore all options for alternative data and
a methodology for determining the labor-related share, and would
propose to update the IPPS and excluded hospital labor-related shares,
if necessary, once our research is complete.
As we explained in the August 30, 2002, final rule, which
implemented the LTCH PPS, the June 6, 2003, LTCH PPS final rule, and
the June 9, 2003, high-cost outlier final rule, the LTCH PPS was
modeled after the IPPS for short-term, acute care hospitals.
Specifically, the LTCH PPS uses the same patient classification system
(CMS-DRGs) as the IPPS, and many of the case-level and facility-level
adjustments explored or adopted for the LTCH PPS are payment
adjustments under the IPPS (that is, wage index, high-cost outliers,
and the evaluation of adjustments for indirect teaching costs and the
treatment of a disproportionate share of low-income patients).
Furthermore, as discussed in greater detail in the August 30, 2002,
LTCH PPS final rule (67 FR 55960), LTCHs are certified as acute care
hospitals that meet the criteria set forth in section 1861(e) of the
Act to participate as a hospital in the Medicare program, and in
general, hospitals qualify for payment under the LTCH PPS instead of
the IPPS solely because their inpatient average length of stay is
greater than 25 days in accordance with section 1886(d)(1)(B)(iv)(I) of
the Act, implemented in Sec. 412.23(e). In the June 6, 2003, LTCH PPS
final rule (68 FR 34144), we explained that prior to qualifying as a
LTCH under Sec. 412.23(e)(2)(i), hospitals generally are paid as acute
care hospitals under the IPPS during the period in which they
demonstrate that they have an average Medicare inpatient length of stay
of greater than 25 days.
The primary reason that we did not update the LTCH PPS labor-
related share for the 2004 LTCH PPS rate year was due to the same
reason that we explained for not updating the labor-related share under
the IPPS for FY 2004 in the August 1, 2003, IPPS (68 FR 27226) which
are equally applicable to the LTCH PPS. We did not revise the labor-
related share under the IPPS based on the revised and rebased FY 1997
hospital market basket and the excluded hospital market basket because
of data and methodological concerns. We indicated that we would conduct
further analysis to determine the most appropriate methodology and data
for determining the labor-related share. Section 403 of the Medicare
Prescription Drug and Modernization Act of 2003 (enacted December 8,
2003, Pub. L. 108-173) amends section 1886(d) of the Act to provide
that for discharges occurring on or after October 1, 2004, the labor-
related share under the IPPS is reduced to 62 percent if such a change
would result in higher total payments to the hospital. While the
statute provides the option to hospitals of using an alternative to the
current IPPS labor-related share (71 percent), the statute does not
address updating the current IPPS labor-related share. We intend to
discuss the details of implementing this provision in the IPPS proposed
rule for FY 2005.
Although section 403 of Pub. L. 108-173 provides for an alternative
labor share percentage, this alternative only applies to hospitals paid
under the IPPS and not to LTCHs. Consequently, since we have not yet
implemented a change in the labor-share methodology used under the
IPPS, and the alternative provided at section 403 does not apply to
LTCHs, we are not proposing to change the LTCH PPS labor-share at this
time.
Accordingly, we are not proposing to update the labor-related share
for the 2005 LTCH PPS rate year; it would remain at 72.885 percent. As
is the case under the IPPS, once our research on the labor-related
share is complete, any future revisions to the LTCH PPS labor-related
share will be proposed and subject to public comment.
2. Proposed Adjustment for Cost-of-Living in Alaska and Hawaii
Under Sec. 412.525(b), we make a cost-of-living adjustment (COLA)
for LTCHs located in Alaska and Hawaii to account for the higher costs
incurred in those States. For the 2005 LTCH PPS rate year, we are
proposing to make a COLA to payments for LTCHs located in Alaska and
Hawaii by multiplying the standard Federal payment rate by the
appropriate factor listed in Table I. below. These factors are obtained
from the U.S. Office of Personnel Management (OPM) and are currently
used under the IPPS. In addition, in this proposed rule, we are
proposing that if OPM releases revised COLA factors before March 1,
2004, we would use them for the development of payments and publish
them in the LTCH PPS final rule.
Table I.--Proposed Cost-of-Living Adjustment Factors for Alaska and
Hawaii Hospitals for the 2005 LTCH PPS Rate Year
------------------------------------------------------------------------
------------------------------------------------------------------------
Alaska: All areas 1.25
Hawaii:
Honolulu County.............................................. 1.25
Hawaii County................................................ 1.165
Kauai County................................................. 1.2325
Maui County.................................................. 1.2375
Kalawao County............................................... 1.2375
------------------------------------------------------------------------
3. Proposed Adjustment for High-Cost Outliers
a. Background
Under Sec. 412.525(a), we make an adjustment for additional
payments for outlier cases that have extraordinarily high costs
relative to the costs of most discharges. Providing additional payments
for outliers strongly improves the accuracy of the LTCH PPS in
determining resource costs at the patient and hospital level. These
additional payments reduce the financial losses that would otherwise be
caused by treating patients who require more costly care and,
therefore, reduce the incentives to underserve these patients. We set
the outlier threshold before the beginning of the applicable rate year
so that total outlier payments are projected to equal 8 percent of
total payments under the LTCH PPS. Outlier payments
[[Page 4766]]
under the LTCH PPS are determined consistent with the IPPS outlier
policy.
Under section 412.525(a), we make outlier payments for any
discharges if the estimated cost of a case exceeds the adjusted LTCH
PPS payment for the LTC-DRG plus a fixed-loss amount. The fixed-loss
amount is the amount used to limit the loss that a hospital will incur
under an outlier policy. This results in Medicare and the LTCH sharing
financial risk in the treatment of extraordinarily costly cases. The
LTCH's loss is limited to the fixed-loss amount and the percentage of
costs above the marginal cost factor. We calculate the estimated cost
of a case by multiplying the overall hospital cost-to-charge ratio by
the Medicare allowable covered charge. In accordance with section
412.525(a), we pay outlier cases 80 percent of the difference between
the estimated cost of the patient case and the outlier threshold (the
sum of the adjusted Federal prospective payment for the LTC-DRG and the
fixed-loss amount).
We determine a fixed-loss amount, that is, the maximum loss that a
LTCH can incur under the LTCH PPS for a case with unusually high costs
before the LTCH will receive any additional payments. We calculate the
fixed-loss amount by simulating aggregate payments with and without an
outlier policy. The fixed-loss amount would result in estimated total
outlier payments being projected to be equal to 8 percent of projected
total LTCH PPS payments.
Currently, under both the LTCH PPS and the IPPS, only a maximum
cost-to-charge ratio threshold (ceiling) is applied to a hospital's
cost-to-charge ratio and, as discussed in the June 9, 2003, high-cost
outlier final rule (68 FR 34506-34507) for discharges occurring on or
after August 8, 2003, a minimum cost-to-charge ratio threshold (floor)
is no longer applicable. Thus, if a LTCH's cost-to-charge ratio is
above the ceiling, the applicable statewide average cost-to-charge
ratio is assigned to the LTCH. In addition, for LTCHs for which we are
unable to compute a cost-to-charge ratio, we also assign the applicable
statewide average cost-to-charge ratio. Currently, MedPAR claims data
and cost-to-charge ratios based on the latest available cost report
data from Hospital Cost Report Information System (HCRIS) and
corresponding MedPAR claims data are used to establish a fixed-loss
threshold amount under the LTCH PPS.
In the June 9, 2003, high-cost outlier final rule (68 FR 34507),
consistent with the outlier policy changes for acute care hospitals
under the IPPS discussed in that same final rule, we no longer assign
the applicable statewide average cost-to-charge ratio when a LTCH's
cost-to-charge ratio falls below the minimum cost-to-charge ratio
threshold (floor). We made this policy change because, as is the case
for acute care hospitals, we believe LTCHs could arbitrarily increase
their charges in order to maximize outlier payments. Even though this
arbitrary increase in charges should result in a lower cost-to-charge
ratio in the future (due to the lag time in cost report settlement),
previously when a LTCH's actual cost-to-charge ratio fell below the
floor, the LTCH's cost-to-charge ratio was raised to the applicable
statewide average cost-to-charge ratio. This application of the
statewide average resulted in inappropriately higher outlier payments.
Accordingly, for LTCH PPS discharges occurring on or after August 8,
2003, in making outlier payments under Sec. 412.525 (and short-stay
outlier payments under Sec. 412.529), we apply the LTCH's actual cost-
to-charge ratio to determine the cost of the case, even where the
LTCH's actual cost-to-charge ratio falls below the floor.
Also, in the June 9, 2003, high-cost outlier final rule (68 FR
34507), consistent with the policy change for acute care hospitals
under the IPPS, under Sec. 412.525(a)(4), by cross-referencing Sec.
412.84(i), we established that we will continue to apply the applicable
statewide average cost-to-charge ratio when a LTCH's cost-to-charge
ratio exceeds the maximum cost-to-charge ratio threshold (ceiling) by
adopting the policy at Sec. 412.84(i)(3)(ii). As we explained in that
same final rule, cost-to-charge ratios above this range are probably
due to faulty data reporting or entry. Therefore, these cost-to-charge
ratios should not be used to identify and make payments for outlier
cases because such data are clearly errors and should not be relied
upon. In addition, we made a similar change to the short-stay outlier
policy at Sec. 412.529. Since cost-to-charge ratios are also used in
determining short-stay outlier payments, the rationale for that change
mirrors that for high-cost outliers.
b. Establishment of the Proposed Fixed-Loss Amount
In the June 6, 2003, final rule (68 FR 34144), for the 2004 LTCH
PPS rate year, we used the March 2002 update of the FY 2001 MedPAR
claims data to determine a fixed-loss threshold that would result in
outlier payments projected to be equal to 8 percent of total payments,
based on the policies described in that final rule, because these data
were the best data available. We calculated cost-to-charge ratios for
determining the fixed-loss amount based on the latest available cost
report data in HCRIS and corresponding MedPAR claims data from FYs
1998, 1999, and 2000.
In that same final rule, in determining the fixed-loss amount for
the 2004 LTCH PPS rate year (using the outlier policy under Sec.
412.525(a) in effect on July 1, 2003), we used the current combined
operating and capital cost-to-charge ratio floor and ceiling under the
IPPS of 0.206 and 1.421, respectively (as explained in the IPPS final
rule (67 FR 50125, August 1, 2002)). As we discussed in the June 9,
2003, high-cost outlier final rule (68 FR 34508), we concluded that it
was not necessary to recalculate a new fixed-loss amount once the
changes to the outlier policy discussed in that final rule became
effective because the difference between the fixed-loss amount
determined with or without the application of the floor would be
negligible.
If a LTCH's cost-to-charge ratio was below this floor or above this
ceiling, we assigned the applicable IPPS statewide average cost-to-
charge ratio. We also assigned the applicable statewide average for
LTCHs for which we are unable to compute a cost-to-charge ratio, such
as for new LTCHs. Therefore, based on the methodology and data
described above, in the June 6, 2003, final rule (68 FR 34144), for the
2004 LTCH PPS rate year, we established a fixed-loss amount of $19,590.
Thus, during the 2004 LTCH PPS rate year, we pay an outlier case 80
percent of the difference between the estimated cost of the case and
the outlier threshold (the sum of the adjusted Federal LTCH payment for
the LTC-DRG and the fixed-loss amount of $19,590).
Also, in the June 6, 2003, final rule (68 FR 34145), we established
that beginning with the 2004 LTCH PPS rate year, we will calculate a
single fixed-loss amount for each LTCH PPS rate year based on the
version of the GROUPER that is in effect as of the beginning of the
LTCH PPS rate year (that is, July 1, 2003, for the 2004 LTCH PPS rate
year). Therefore, for the 2004 LTCH PPS rate year, we established a
single fixed-loss amount based on the Version 20.0 of the GROUPER,
which was in effect at the start of the 2004 LTCH PPS rate year (July
1, 2003). As we noted above, the fixed-loss amount for the 2004 LTCH
PPS rate year is $19,590.
In calculating the proposed fixed-loss amount for the 2005 LTCH PPS
rate year, we applied the current outlier policy under Sec. 412.525(a);
that is, we assigned the applicable statewide average cost-to-charge
ratio only to
[[Page 4767]]
LTCHs whose cost-to-charge ratios exceeded the ceiling (and not when
they fell below the floor). Accordingly, we used the current IPPS
combined operating and capital cost-to-charge ratio ceiling of 1.366
(as explained in the IPPS final rule (68 FR 45478, August 1, 2003)). We
believed that using the current combined IPPS operating and capital
cost-to-charge ratio ceiling for LTCHs is appropriate for the same
reasons we stated above regarding the use of the current combined
operating and capital cost-to-charge ratio ceiling under the IPPS.
In this proposed rule, for the 2005 LTCH PPS rate year, we used the
December 2002 update of the FY 2002 MedPAR claims data to determine a
proposed fixed-loss amount that would result in outlier payments
projected to be equal to 8 percent of total payments, based on the
policies described in this proposed rule, because these data are the
best LTCH data available. We considered using claims data from the
September 2003 update of the FY 2003 MedPAR to determine the proposed
fixed-loss amount (and the budget neutrality offset discussed below in
section IV.C.6.) for the 2005 LTCH PPS rate year. However, initial
analysis has shown that the FY 2003 MedPAR data contain coding errors.
As in the case with the FY 2002 MedPAR, we have learned that a large
hospital chain of LTCHs has continued to consistently code diagnoses
inaccurately on the claims it submitted, and these coding errors are
reflected in the FY 2003 MedPAR data. The coding inaccuracies in the
MedPAR claims data can cause significant skewing of the fixed-loss
amount and would impact the determination of the budget neutrality
offset. While we have corrected the coding inaccuracies in the FY 2002
MedPAR, we were unable to correct the coding errors in the FY 2003
MedPAR in time for publication of this proposed rule since the
correction process requires extensive programming work. Accordingly, we
are using the December 2002 update of the FY 2002 MedPAR claims data to
determine a proposed fixed-loss amount for the 2005 LTCH PPS rate year
for this proposed rule. We expect to be able to use the corrected FY
2003 MedPAR to calculate a revised fixed-loss amount for the final
rule. Furthermore, as noted above, we determined the proposed fixed-
loss amount based on the version of the GROUPER that would be in effect
as of the beginning of the 2005 LTCH PPS rate year (July 1, 2004), that
is, Version 21.0 of the LTCH PPS GROUPER (68 FR 45374-45385). We also
computed cost-to-charge ratios for determining the proposed fixed-loss
amount for the 2005 LTCH PPS rate year based on the latest available
cost report data in HCRIS and corresponding MedPAR claims data from FYs
1999, 2000, and 2001. As we explained above, the current applicable
IPPS statewide average cost-to-charge ratios were applied when a LTCH's
cost-to-charge ratio exceeded the ceiling (1.366). In addition, we
assigned the applicable statewide average to LTCHs for which we were
unable to compute a cost-to-charge ratio. (Currently, the applicable
IPPS statewide averages can be found in Tables 8A and 8B of the August
1, 2003, IPPS final rule (68 FR 45637-45638).)
Accordingly, based on the data and policies described above, we are
proposing a fixed-loss amount of $21,864 for the 2005 LTCH PPS rate
year. Thus, we would pay an outlier case 80 percent of the difference
between the estimated cost of the case and the proposed outlier
threshold (the sum of the adjusted proposed Federal LTCH payment for
the LTC-DRG and the proposed fixed-loss amount of $21,864).
c. Reconciliation of Outlier Payments Upon Cost Report Settlement
In the June 9, 2003, high-cost outlier final rule (68 FR 34508-
34512), we made changes to the LTCH outlier policy consistent with
those made for acute care hospitals under the IPPS because, as we
discussed in that same final rule, we became aware that payment
vulnerabilities existed in the previous IPPS outlier policy. Because
the LTCH PPS high-cost outlier and short-stay policies are modeled
after the outlier policy in the IPPS, we believe they were susceptible
to the same payment vulnerabilities and, therefore, also merited
revision. Consistent with the change made for acute care hospitals
under the IPPS at Sec. 412.84(m), we established under Sec.
412.525(a)(4)(ii), by cross-referencing Sec. 412.84(m), that effective
for LTCH PPS discharges occurring on or after August 8, 2003, any
reconciliation of outlier payments may be made upon cost report
settlement to account for differences between the actual cost-to-charge
ratio and the estimated cost-to-charge ratio for the period during
which the discharge occurs. As is the case with the changes made to the
outlier policy for acute care hospitals under the IPPS, the
instructions for implementing these regulations are discussed in
further detail in Program Memorandum Transmittal A-03-058. In addition,
in that same final rule (68 FR 34513), we established a similar change
to the short-stay outlier policy at Sec. 412.529(c)(5)(ii).
We also discussed in the June 9, 2003, IPPS high-cost outlier final
rule (68 FR 34507-34512) that only using cost-to-charge ratios based on
the latest settled cost report does not reflect any dramatic increases
in charges during the payment year when making outlier payments.
Because a LTCH has the ability to increase its outlier payments through
a dramatic increase in charges and because of the lag time in the data
used to calculate cost-to-charge ratios, in that same final rule (68 FR
34494-34515), consistent with the policy change for acute care
hospitals under the IPPS at Sec. 412.84(i)(2), we established that, for
LTCH PPS discharges occurring on or after October 1, 2003, fiscal
intermediaries will use more recent data when determining a LTCH's
cost-to-charge ratio. Therefore, by cross-referencing Sec. 412.84(i)(2)
under Sec. 412.525(a)(4)(iii), we established that fiscal
intermediaries will use either the most recent settled cost report or
the most recent tentative settled cost report, whichever is from the
later period. In addition, in that same final rule, we established a
similar change to the short-stay outlier policy at Sec.
412.529(c)(5)(iii).
d. Application of Outlier Policy to Short-Stay Outlier Cases
As we discussed in the August 30, 2002, final rule (67 FR 56026),
under some rare circumstances, a LTCH discharge could qualify as a
short-stay outlier case (as defined under Sec. 412.529 and discussed in
section IV.B.4.b. of this preamble) and also as a high-cost outlier
case. In such a scenario, a patient could be hospitalized for less than
five-sixths of the geometric average length of stay for the specific
LTC-DRG, and yet incur extraordinarily high treatment costs. If the
costs exceeded the outlier threshold (that is, the short-stay outlier
payment plus the fixed-loss amount), the discharge would be eligible
for payment as a high-cost outlier. Thus, for a short-stay outlier case
in the 2005 LTCH PPS rate year, the high-cost outlier payment would be
80 percent of the difference between the estimated cost of the case and
the outlier threshold (the sum of the proposed fixed-loss amount of
$21,864 and the amount paid under the short-stay outlier policy).
4. Proposed Adjustments for Special Cases
a. General
As discussed in the August 30, 2002, final rule (67 FR 55995),
under section 123 of Pub. L. 106-113, the Secretary
[[Page 4768]]
generally has broad authority in developing the PPS for LTCHs,
including whether (and how) to provide for adjustments to reflect
variations in the necessary costs of treatment among LTCHs.
Generally, LTCHs, as described in section 1886(d)(1)(B)(iv) of the
Act, are distinguished from other inpatient hospital settings by
maintaining an average inpatient length of stay of greater than 25
days. However, LTCHs may have cases that have stays of considerably
less than the average length of stay and that receive significantly
less than the full course of treatment for a specific LTC-DRG. As we
explained in the August 30, 2002, final rule (67 FR 55995), such cases
would be paid inappropriately if the hospital were to receive the full
LTC-DRG payment. Below we discuss the payment methodology for these
special cases as implemented in the August 30, 2002, final rule (67 FR
55955-56010).
b. Proposed Adjustment for Short-Stay Outlier Cases
A short-stay outlier case may occur when a beneficiary receives
less than the full course of treatment at the LTCH before being
discharged. These patients may be discharged to another site of care or
they may be discharged and not readmitted because they no longer
require treatment. Furthermore, patients may expire early in their LTCH
stay.
As noted above, generally LTCHs are defined by statute as having an
average inpatient length of stay of greater than 25 days. We believe
that a payment adjustment for short-stay outlier cases results in more
appropriate payments, because these cases most likely would not receive
a full course of treatment in such a short period of time and a full
LTC-DRG payment may not always be appropriate. Payment-to-cost ratios
simulated for LTCHs, for the cases described above, show that if LTCHs
receive a full LTC-DRG payment for those cases, they would be
significantly ``overpaid'' for the resources they have actually
expended.
Under Sec. 412.529, in general, we adjust the per discharge payment
to the least of 120 percent of the cost of the case, 120 percent of the
LTC-DRG specific per diem amount multiplied by the length of stay of
that discharge, or the full LTC-DRG payment, for all cases with a
length of stay up to and including five-sixths of the geometric average
length of stay of the LTC-DRG.
As we noted in section IV.C.3. of this preamble, in the June 9,
2003, high-cost outlier final rule (68 FR 34494-34515), we revised the
methodology for determining cost-to-charge ratios for acute care
hospitals under the IPPS because we became aware that payment
vulnerabilities existed in the previous IPPS outlier policy. As we also
explained in that same final rule, because the LTCH PPS high-cost
outlier and short-stay outlier policies are modeled after the outlier
policy in the IPPS, we believe they were susceptible to the same
payment vulnerabilities and, therefore, merited revision. Consistent
with the policy established for acute care hospitals under the IPPS at
Sec. 412.84(i) and (m) in the June 9, 2003, high-cost outlier final
rule (68 FR 34515), and similar to the policy change described above
for LTCH PPS high-cost outlier payments at Sec. 412.525(a)(4)(ii), we
established under Sec. 412.529(c)(5)(ii) that for discharges on or
after August 8, 2003, short-stay outlier payments are subject to the
provisions in the regulations at Sec. 412.84(i)(1), (i)(3) and (i)(4),
and (m). In addition, short-stay outlier payments are subject to the
provisions in the regulations at Sec. 412.84(i)(2) for discharges on or
after October 1, 2003, in accordance with Sec. 412.529(c)(5)(iii).
Therefore, in the June 9, 2003, high-cost outlier final rule (68 FR
34548-34513), under Sec. 412.529(c)(5)(ii), by cross-referencing
proposed Sec. 412.84(i)(2), we established that fiscal intermediaries
will use either the most recent settled cost report or the most recent
tentative settled cost report, whichever is from the later period, in
determining a LTCH's cost-to-charge ratio.
In addition, by cross-referencing Sec. 412.84(i), we established
that the applicable statewide average cost-to-charge ratio is only
applied when a LTCH's cost-to-charge ratio exceeds the ceiling. Thus,
the applicable statewide average cost-to-charge ratio is no longer
applied when a LTCH's cost-to-charge ratio falls below the floor.
Furthermore, by cross-referencing Sec. 412.84(i)(4), we established
that any reconciliation of payments for short-stay outliers may be made
upon cost report settlement to account for differences between the
estimated cost-to-charge ratio and the actual cost-to-charge ratio for
the period during which the discharge occurs. As noted above, in the
discussion of the high-cost outlier policy in section IV.C.3. of this
preamble, the instructions for implementing these regulations are
discussed in further detail in Program Memorandum Transmittal A-03-058.
In the June 6, 2003, final rule (68 FR 34146-34148), for certain
hospitals that qualify as LTCHs under section 1886(d)(1)(B)(iv)(II) of
the Act (``subclause (II)'' LTCHs) as added by section 4417(b) of Pub.
L. 105-33, and implemented in Sec. 412.23(e)(2)(ii), we established a
temporary adjustment to the short-stay outlier policy during the 5-year
transition period. Under Sec. 412.529(c)(4), effective for discharges
from a ``subclause (II)'' LTCH occurring on or after July 1, 2003, the
short-stay outlier percentage is 195 percent during the first year of
the hospital's 5-year transition. For the second cost reporting period,
the short-stay outlier percentage is 193 percent; for the third cost
reporting period, the percentage is 165 percent; for the fourth cost
reporting period, the percentage is 136 percent; and for the final cost
reporting period of the 5-year transition (and future cost reporting
periods), the short-stay outlier percentage is 120 percent, that is,
the same as it is for all other LTCHs under the LTCH PPS.
As we discussed in the June 6, 2003, final rule (68 FR 34147), we
established this formula with the expectation that an adjustment to
short-stay outlier payments during the transition will result in
reducing the difference between payments and costs for a ``subclause
(II)'' LTCH for the period of July 1, 2003, through the end of the
transition period, when the LTCH PPS will be fully phased-in.
As we stated in that same final rule, we also expect that during
this 5-year period, ``subclause (II)'' LTCHs will make every attempt to
adopt the type of efficiency enhancing policies that generally result
from the implementation of prospective payment systems in other health
care settings. We are not proposing any changes to the short-stay
outlier policy in this proposed rule.
c. Proposed Extension of the Interrupted Stay Policy
At existing Sec. 412.531(a), we define an ``interruption of a
stay'' as a stay at a LTCH during which a Medicare inpatient is
transferred upon discharge to an acute care hospital, an IRF, or a SNF
for treatment or services that are not available in the LTCH and
returns to the same LTCH within applicable fixed-day periods. (We also
include transfers to swing beds under this interrupted stay policy for
LTCH payment policy determinations, consistent with the SNF PPS payment
policy. That is, a readmission to a LTCH from post-hospital SNF care
being provided in a swing bed that is located either in the LTCH itself
or in another onsite Medicare provider has the same policy consequence
as a readmission to the LTCH from an onsite SNF (June 6, 2003, 68 FR
34149).)
As defined above, an interrupted stay is treated as one discharge
from the
[[Page 4769]]
LTCH. The day-count of the applicable fixed-day period of an
interrupted stay begins on the day of discharge from the LTCH (which is
also the day of admission to the other site of care). For a discharge
to an acute care hospital, the applicable fixed-day period is 9 days,
for an IRF, 27 days, and for a SNF 45 days. The counting of the days
begins on the day of discharge from the LTCH and ends on the 9th, 27th,
or 45th day for an acute care hospital, an IRF, or a SNF, respectively,
after the discharge.
If the patient is readmitted to the LTCH within the fixed-day
threshold, return to the LTCH is considered part of the first admission
and only a single LTCH PPS payment will be made. For example, if a LTCH
patient is discharged to an acute hospital and is readmitted to the
LTCH on any day up to and including the 9th day following the original
day of discharge from the LTCH, one LTC-DRG payment will be made. If
the patient is readmitted to the LTCH from the acute care hospital on
the 10th day after the original discharge or later, Medicare will pay
for the second admission as a separate stay with an additional LTC-DRG
assignment. In implementing this policy, we provide that, in the event
a Medicare inpatient is discharged from a LTCH and is readmitted and
the stay qualifies as an interrupted stay, the provider should cancel
the claim generated by the original stay in the LTCH and submit one
claim for the entire stay. (For further details, see Medicare Program
Memorandum Transmittal A-02-093, September 2002.)
On the other hand, if the patient stay exceeds the total fixed-day
threshold outside of the LTCH at another facility before being
readmitted, two separate payments would be made. One would be based on
the principal diagnosis and length of stay for the first admission and
the other based on the principal diagnosis and length of stay for the
second admission. Depending upon their lengths of stay, both stays
could result in payments as a short-stay outlier (Sec. 412.529), a full
LTC-DRG, or even a high-cost outlier. Further, if the principal
diagnosis is the same for both admissions, the hospital could receive
two similar payments.
When we introduced the interrupted stay policy for LTCHs in the
August 30, 2002, final rule (67 FR 56002-56006), we noted that we would
consider expanding or revising the policy based on information received
from the provider community or information gained from our ongoing
monitoring activities. During the first year of the LTCH PPS, it has
come to our attention, from both of these sources, that certain LTCHs
are discharging patients during the course of their treatment for the
sole purpose of receiving specific tests or procedures from another
facility (that should have been furnished under arrangements by the
LTCHs), and then readmitting the patient to the LTCH following the
administration of the test or procedure. In other words, these patients
do not stop receiving medical care that should be considered LTCH
inpatient services during the period between their discharge from and
readmission to the LTCH. On the contrary, they continue to receive
care, often of a highly specialized type, from the other facility
before being readmitted for further inpatient care at the LTCH. This
sequence of care suggests that the original discharge from the LTCH may
be motivated by financial considerations rather than by clinical
judgment and, therefore, would be inappropriate.
Existing regulations at Sec. 412.509(c) require a LTCH to furnish
all necessary covered services for a Medicare beneficiary who is an
inpatient of the hospital either directly or under arrangements (as
defined in Sec. 409.3). Under Sec. 409.3, when services are furnished
under arrangements, Medicare payments made to the provider that
arranged for the services discharges the liability of the beneficiary
or any other person to pay for those services. The ``under
arrangements'' policy set forth in Sec. 412.509 for LTCHs derives from
the regulations at Sec. 411.15(m), which implement section 1862(a)(14)
of the Act. Section 1862(a) of the Act specifies the services for which
no payment may be made under Medicare Part A and Part B. Section
1862(a)(14) of the Act specifies the exception for certain services to
be furnished ``under arrangements'' by providers.
If a LTCH obtains, from another facility ``under arrangements,'' a
specific test or procedure for one of its inpatients that is not
available on the LTCH's premises, as contemplated by Sec. 412.509, a
discharge and a subsequent readmission would be unnecessary and
inappropriate. This is true even if it is necessary to transport the
patient to another facility to receive the arranged-for service.
Furthermore, no additional claim should be submitted to Medicare by the
other entity that actually furnished the test or procedure because,
under Sec. 412.509(c), the LTCH must furnish all necessary covered
services to the Medicare beneficiary who is an inpatient of the
hospital either directly or under arrangements. In such a situation,
generally, the LTCH would include the medically necessary test or
procedure on its patient claim to Medicare (which could have an effect
on the assignment of the LTC-DRG and thus the Medicare payment to the
LTCH) and the LTCH would be responsible for paying the provider
directly for the test or procedure.
Patient discharges from the LTCH for tests or procedures that
should have been provided under arrangements, followed by LTCH
readmission, result in an inappropriate increase in Medicare costs in
three ways:
First, the Medicare payment associated with the LTC-DRG that would
be assigned to the patient's stay will typically already include the
costs of the test or procedure. (The August 30, 2002, LTCH PPS final
rule (67 FR 55977-55985), includes an in-depth description of the
derivation of LTC-DRGs from ICD-9-CM codes on Medicare claims and a
discussion of the development and calculation of LTC-DRG relative
weights.) Second, the intervening provider will bill Medicare
separately for the test or procedure. Thus, if services that should
have been furnished directly or under arrangements by the LTCH are
instead unbundled and billed separately, Medicare would pay the other
provider for the service that should have been paid for ``under
arrangements'' by the LTCH under Sec. 412.509.
Third, a discharge for outpatient services and a subsequent
readmission to the LTCH is not currently covered under the interrupted
stay policy at existing Sec. 412.531. Section 412.531(a) only includes
discharges from a LTCH to an acute care hospital, an IRF, and a SNF for
treatment or services not available in the LTCH and subsequent
readmission to the same LTCH. If a patient is discharged and readmitted
to the LTCH following an outpatient test or procedure, under current
policy, after making a LTCH PPS payment for the first discharge, there
would be a second Medicare payment to the LTCH when the patient is
finally discharged.
In order to address these concerns, we are proposing to revise the
definition of an interruption of a stay under Sec. 412.531 to add
situations in which a patient is discharged from the LTCH and
readmitted to the same LTCH within 3 days of the discharge (proposed
revised Sec. 412.531(a)(1)). We believe that if a patient is discharged
from a LTCH for any reason and is then readmitted within 3 days, in
general, the patient's original admitting diagnoses would not change
significantly during those 3 days. Therefore, such a readmission would
not constitute a new episode of care. We question whether a patient
[[Page 4770]]
who was discharged and then returned to the same LTCH within 3 days
should have been discharged in the first place. Since LTCHs are
designed to treat patients with a high level of acuity and
multicomorbidities, we believe that a 3-day period is a reasonable
window during which necessary offsite medical care might be delivered,
under arrangements, as contemplated under Sec. 412.509, without an
appreciable change in the original admitting diagnoses. Moreover, this
3-day period is consistent with the interrupted stay policy under the
IRF PPS under which the maximum period of time that a patient could be
away from the IRF is 3 days before a new patient assessment is
required. Therefore, under our proposal, if a patient were discharged
on Monday, and readmitted either on that Monday (the first day),
Tuesday (the second day), or Wednesday (the third day), the subsequent
readmission would not be considered a new admission and Medicare would
pay the LTCH for only one discharge based on the combined length of
stay for the period prior to and after the absence from the LTCH.
We are further proposing that, under the proposed revision of the
interruption of stay policy for LTCHs, any treatment or medical
services furnished to the individual during the 3-day (or less) absence
from the LTCH could not be billed separately to the Medicare program or
to the beneficiary, but would be paid as ``under arrangements''
services to the LTCH. We calculate payments under the LTCH PPS using
base year costs that include the numerous tests and procedures typical
of the complicated medical conditions that characterize LTCH patients,
including those furnished by other providers. Therefore, we believe
that a readmission to the LTCH that triggers the proposed 3-day
interrupted stay policy should be treated as a continuation of the
episode of care that occasioned the first admission. Further, we
believe that the readmission to the LTCH within 3 days establishes the
presumption that any treatment or services furnished during the
intervening 3 (or less) days should have been provided by the LTCH
``either directly or under arrangements'' (Sec. 412.509(b)). The entire
stay would generate one LTC-DRG payment under the LTCH PPS, which would
be ``payment in full for all inpatient hospital services, as defined in
Sec. 409.10.'' (Sec. 412.509(a)) Under Sec. 409.10(a) inpatient
hospital services means the following services furnished to an
inpatient of a qualified hospital: (1) Bed and board; (2) nursing
services and other related services; (3) use of hospital or CAH
facilities; (4) medical social services; (5) drugs, biologicals,
supplies, appliances, and equipment; (6) certain other diagnostic or
therapeutic services; (7) medical or surgical services provided by
certain interns or residents-in-training; and (8) transportation
services, including transport by ambulance.
As explained above, we are proposing that a readmittance to the
LTCH within 3 days after a discharge will result in one LTC-DRG payment
for the entire stay. Since we are treating both parts of the stay as
one episode of care, we are proposing that treatment or care provided
during the ``interruption'' be considered to have occurred during that
episode of care and that payment for such services are included in the
LTC-DRG payment. We are also proposing to include the days of the 3-day
interruption of stay in counting LTCH days to determine the total
length of stay of the patient at the LTCH if medical treatment or care
were provided during the 3 days because these services will be
considered to have been paid for as part of the total LTCH stay
(proposed Sec. 412.531(b)(1)(iii)). We are further proposing that if a
patient is discharged home, and within a 3-day period received no
additional medical treatment or service, but is readmitted to the LTCH,
the days away from the LTCH would not be included in the length of stay
calculation. This is presently the day count methodology that we use in
the existing interrupted stay policy at Sec. 412.531(b)(1) as applied
to acute care hospitals, IRFs, and SNFs.
We are proposing that this policy be applicable to all services or
procedures provided to the patient either under Medicare Part A, or
Part B, except for the services which are expressly excluded from
bundling under section 1886(a)(1)(H)(i) of the Act and Sec. 411.15(m),
such as services furnished by physicians under Sec. 415.102(a) and
other specific health professionals. Failure to comply with this
bundling requirement could lead to sanctions such as termination of the
LTCH's Medicare provider agreement or civil money penalties (under
section 1866(a)(1)(H)(i) of the Act).
Although we understand that, in good faith, a patient could be
discharged from a LTCH, return home for a day or two, experience a
setback, and then be readmitted to the LTCH, we believe that such a
readmission to the LTCH should be considered an extension of the
original hospitalization and that Medicare should not pay for two
claims for what was, in effect, one episode of care. The proposed 3-day
interrupted stay policy takes into account the profile of most LTCH
patients, as typically very sick individuals with multicomorbidities.
We believe that it is reasonable to presume that, should this type of
patient be discharged and then readmitted to a LTCH with 3 days the
readmission signifies a continuation of the original hospital stay and
not a new episode of care. Furthermore, we are concerned about reports
of LTCHs discharging and readmitting patients who are still undergoing
active treatment rather than obtaining services for these patients
``under arrangements'' in accordance with section 1862(a)(14) of the
Act and the regulations at Sec. 412.509.
If the policy is finalized, we intend to collect data on any
Medicare claims for outpatient services as well as inpatient services
furnished during the time that the patients are away from the LTCH
under the proposed 3-day interrupted stay policy. We would review data
to determine whether we should expand the 3-day time period and we will
consider proposing such a change in a future rule. Further, if it
appears that additional patients are being discharged for the purpose
of receiving tests or procedures at other Medicare settings, and then
readmitted to the LTCH, in order for the LTCH to avoid paying for the
procedure ``under arrangements,'' we may find it appropriate for our
Quality Improvement Organizations (QIO) to evaluate the medical basis
for the original discharge. A patient discharge that is not clinically
justifiable could constitute potential violation of the LTCH's
conditions of participation in the Medicare program for inadequate
discharge planning or an inappropriate discharge from the LTCH under
Sec. 482.43. Moreover, as noted above, if a separate bill is submitted
by an entity other than the LTCH for services furnished during this
period, this could also be a violation of the LTCH's provider agreement
obligation regarding bundled services.
In proposing this policy, we are not attempting to restrict a LTCH
from pursuing necessary or more appropriate clinical care from another
facility. As we designed the PPS for LTCHs, the original interrupted
stay policy was created for situations where sound clinical judgment
could suggest a different treatment setting for LTCH patients: a
patient requiring emergency surgery at an acute care hospital; a
patient who would appear to benefit from a specific therapy regimen at
an IRF; or a patient who had improved and, therefore, could be
appropriately cared for at a SNF. The policy accounted for
[[Page 4771]]
a readmission to the LTCH after the emergency care or in the event of a
change in the patient's condition, that is, for sound clinical reasons.
Fundamentally, the interrupted stay policy resulted from our
determination to allow considerable latitude to medical personnel in
this regard without untoward payment consequences for the Medicare
program.
We are proposing a revision to the existing interrupted stay policy
because we believe that 3 days in most instances represents an
appropriate interval for establishing whether or not the reason for the
patient's readmission is directly connected to the original episode of
care and whether or not Medicare-covered services were obtained during
the interruption that should have otherwise been provided ``under
arrangements'' by the LTCH.
All inpatient services, under Medicare, fall within the purview of
the requirement of section 1862(a)(14) of the Act, and, therefore, what
we have proposed is not a departure from existing policy. Under section
1862(a)(14) of the Act, notwithstanding any other provision of this
title, ``no payment may be made under Part A or Part B for any expenses
incurred for items or services which are other than physicians'
services (as defined in regulations promulgated specifically for
purposes of this paragraph), services described by section
1861(s)(2)(K) of the Act (certified nurse-midwife services, qualified
psychologist services, and services of a certified registered nurse
anesthetist) and which are furnished to an individual who is a patient
of a hospital or critical access hospital by an entity other than the
hospital or critical access hospital unless the services are furnished
under arrangements (as defined in section 1861(w)(1) of the Act with
the entity made by the hospital or critical access hospital.'' Section
1861(w)(1) of the Act states that ``[t]he term `arrangements' is
limited to arrangements under which receipt of payment by the hospital,
critical access hospital, skilled nursing facility, home health agency,
or hospice program (whether in its own right or as agent), with respect
to services for which an individual is entitled to have payment made
under this title, discharges the liability of such individual or any
other person to pay for the services.'' We believe the objective of
these statutory provisions, which were implemented for inpatient acute
care hospitals in regulations at Sec. 411.15(m) and subsequently at
Sec. 412.509 for LTCHs, was to discharge financial liability for
inpatients who may have received additional care off-premises and to
assign payment responsibility for such care to the hospital that is
being paid for that beneficiary's total care for that spell of illness.
The total care delivered by the hospital may be provided ``directly''
or ``under arrangements'' with other facilities (Sec. 412.509(c)) and
was included in Medicare's payment to the hospital. Over the years, we
have often referred to this as the ``prohibition against unbundling''
for purposes of emphasizing that if a Medicare provider ``unbundles''
specific components of a beneficiary's total inpatient care (provided
either ``directly'' or ``under arrangements'') and sends separate
claims to Medicare for those tests or treatments, the provider would be
acting in violation of the statute and applicable regulations. Since
LTCHs treat patients with multicomorbidities who are often in need of a
wide range of diagnostic and treatment modalities and lengthy
hospitalizations, we believe that in this particular setting, this
statutory requirement is particularly vulnerable to gaming. For that
reason, we are taking this opportunity to clarify the existing general
unbundling prohibition and to propose specific language on the
unbundling prohibition as it applies to the interrupted stay policy
under the LTCH PPS and are proposing to codify it in regulations. As
noted above, we are concerned that LTCH patients, under active
treatment, are being inappropriately discharged to other treatment
sites, receiving tests or procedures related to one of the diagnoses
for which the patient is being hospitalized and which otherwise should
have been provided at the LTCH either directly or under arrangements
under Sec. 412.509 and then readmitted to the LTCH. Another claim is
also being submitted to Medicare by the other treatment site for those
tests or procedures. As stated earlier, under the LTCH PPS, payments
associated with specific LTC-DRGs include all costs associated with
rendering care to the type of patients treated in LTCHs and, therefore,
additional Medicare payments for such services would be inappropriate.
We understand that during a particular hospitalization, a typical
LTCH patient, with multicomorbidities, could suddenly require emergency
care at an acute care hospital. This would be the case, for example, if
a patient who was admitted to the LTCH with a principal diagnosis of
chronic obstructive pulmonary disease and respirator dependence, with
secondary diagnoses of hypertension, Type II diabetes mellitus, history
of coronary artery disease, and history of bladder cancer suddenly
exhibits symptoms consistent with a pneumothorax (lung collapse) and
requires treatment that is beyond the scope of the LTCH. Services
obtained at an acute care hospital, under the proposed policy would be
considered related to the original diagnoses and submission of a
separate claim by the acute hospital should be considered a violation
of the unbundling requirement established by section 1862(a)(14) of the
Act. Payment to the acute hospital for any services delivered would be
the responsibility of the LTCH since the critical episode was directly
related to the hospitalization at the LTCH. Conversely, if the same
patient had instead suddenly suffered a myocardial infarction (heart
attack) that requires a cardiac workup, evaluation, and possible
implantation of a cardiac stent, it may be appropriate to discharge
this patient for admission to an acute care facility for appropriate
evaluation and the invasive cardiac procedure. Under these
circumstances, the admission to the acute hospital was totally
unrelated to the patient's diagnoses in the LTCH and arguably there may
be no need to bundle the services. A discharge from the LTCH and a
readmission following the procedure at the acute hospital in order to
resume the treatment provided by the LTCH, for which the patient was
originally hospitalized, could be entirely appropriate.
(Notwithstanding the necessity of the discharge, under the proposed 3-
day interrupted stay policy, there would be no additional LTC-DRG
payment generated to the LTCH if the patient returns to the LTCH within
the 3-day period.) It could be argued that in this type of a subsequent
admission to the acute hospital, the acute care hospital should be able
to submit a claim to Medicare for the procedure. (This payment to the
acute hospital may be subject to the postacute care policy at Sec.
412.4, depending upon the DRG to which it is assigned (68 FR 45404 and
45412, August 1, 2003).)
We are aware that there may be exceptions, and that in the example
cited above, sound medical judgment could have dictated that the
patient who needed the cardiac stent should first be discharged to the
acute hospital and then readmitted to the LTCH within 3-days in order
to continue necessary treatment at the LTCH. In such a case,
notwithstanding our proposed 3-day interrupted stay policy, it is
arguable that the implantation of the cardiac stent does not fall
within the category of services that should be paid for by the LTCH
under arrangements, and that the
[[Page 4772]]
acute hospital should be able to submit a claim to Medicare.
Accordingly, while, arguably, it may be appropriate to attempt to
limit the proposed unbundling requirement that services be provided
under arrangement to those that are ``related'' to the admitting
diagnoses of the LTCH patient, we have not been able to develop a
methodology that would be administratively feasible and not subject to
gaming, given the multiple comorbidities typical of LTCH patients. The
prospective payment system for this particular setting was designed to
capture all costs associated with treating these highly complicated
cases and we believe that it will difficult to distinguish whether a
particular critical episode can been seen as arising from one of the
patient's many medical conditions for which the patient is presently at
the LTCH. We are soliciting comments and suggestions that are
consistent with the stated policy goals described above and that would
be administratively feasible.
We understand that any policy that is adopted in the final
regulation would need to be issued with detailed instructions to fiscal
intermediaries on implementation procedures to ensure a correct and
consistent interpretation of our policy objectives.
d. Onsite Discharges and Readmittances
Under Sec. 412.532, generally, if more than 5 percent of all
Medicare discharges during a cost reporting period are patients who are
discharged to an onsite SNF, IRF, or psychiatric facility, or to an
onsite acute care hospital and who are then directly readmitted to the
LTCH, only one LTC-DRG payment will be made to the LTCH for these type
of discharges and readmittances during the LTCH's cost reporting
period. Therefore, payment for the entire stay will be paid either as
one full LTC-DRG payment or a short-stay outlier, depending on the
duration of the entire LTCH stay.
In applying the 5-percent threshold, we apply one threshold for
discharges and readmittances with a co-located acute care hospital.
There is also a separate 5-percent threshold for all discharges and
readmittances with co-located SNFs, IRFs, and psychiatric facilities.
In the case of a LTCH that is co-located with an acute care hospital,
an IRF, or a SNF, the interrupted stay policy at Sec. 412.531 applies
until the 5-percent threshold is reached. However, once the applicable
threshold is reached, all such discharges and readmittances to the
applicable site(s) for that cost reporting period are paid as one
discharge pursuant to Sec. 412.532. This means that even if a
discharged LTCH Medicare patient was readmitted to the LTCH following a
stay in an acute care hospital of greater than 9 days, if the
facilities share a common location and the 5-percent threshold were
exceeded, the subsequent discharge from the LTCH will not represent a
separate hospitalization for payment purposes. Only one LTC-DRG payment
will be made for all such discharges during a cost reporting period to
the acute care hospital, regardless of the length of stay at the acute
care hospital, that are followed by readmittances to the onsite LTCH.
Similarly, if the LTCH has exceeded its 5-percent threshold for all
discharges to an onsite IRF, SNF, or psychiatric hospital or unit, with
readmittances to the LTCH, the subsequent LTCH discharge for patients
from any of those sites for the entire cost reporting period will not
be treated as a separate discharge for Medicare payment purposes. (As
under the interrupted stay policy, payment to an acute care hospital
under the IPPS, to an IRF under the IRF PPS, and to a SNF under the SNF
PPS, will not be affected. Payments to the psychiatric facility also
will not be affected.)
5. Other Payment Adjustments
As indicated earlier, we have broad authority under section 123 of
Public Law 106-113, including whether (and how) to provide for
adjustments to reflect variations in the necessary costs of treatment
among LTCHs. Thus, in the August 30, 2002, final rule (67 FR 56014-
56027), we discussed our extensive data analysis and rationale for not
implementing an adjustment for geographic reclassification, rural
location, treating a disproportionate share of low-income patients
(DSH), or indirect medical education (IME) costs. In that same final
rule, we stated that we would collect data and reevaluate the
appropriateness of these adjustments in the future once more LTCH data
become available after the LTCH PPS is implemented. Because the LTCH
PPS has only been implemented for less than 2 years and the lag-time in
data availability, sufficient new data have still not yet been
generated that would enable us to conduct a comprehensive reevaluation
of these payment adjustments. Nonetheless, we have reviewed the limited
data that are available and found no evidence to support additional
proposed policy changes. Therefore, in this proposed rule, we are not
proposing an adjustment for geographic reclassification, rural
location, DSH, or IME at this time. However, we will continue to
collect and interpret new data as they become available in the future
to determine if these data support proposing any additional payment
adjustments.
6. Proposed Budget Neutrality Offset To Account for the Transition
Methodology
Under Sec. 412.533, we implemented a 5-year transition period from
reasonable cost-based payment to prospective payment, during which a
LTCH will be paid an increasing percentage of the LTCH PPS rate and a
decreasing percentage of its payments under the reasonable cost-based
payment methodology for each discharge. Furthermore, we allow a LTCH to
elect to be paid based on 100 percent of the standard Federal rate in
lieu of the blended methodology.
The standard Federal rate was determined as if all LTCHs will be
paid based on 100 percent of the standard Federal rate. As stated
earlier, we provide for a 5-year transition period that allows LTCHs to
receive payments based partially on the reasonable cost-based
methodology. In order to maintain budget neutrality as required by
section 123(a)(1) of the Pub. L. 106-113 and Sec. 412.523(d)(2) during
the 5-year transition period, we reduce all LTCH Medicare payments
(whether a LTCH elects payment based on 100 percent of the Federal rate
or whether a LTCH is being paid under the transition blend
methodology). Specifically, we reduce all LTCH Medicare payments during
the 5-year transition by a factor that is equal to 1 minus the ratio of
the estimated TEFRA reasonable cost-based payments that would have been
made if the LTCH PPS had not been implemented, to the projected total
Medicare program PPS payments (that is, payments made under the
transition methodology and the option to elect payment based on 100
percent of the Federal rate).
In the June 6, 2003, final rule (68 FR 34512), based on the best
available data, we projected that a certain percentage of LTCHs would
elect to be paid based on 100 percent of the standard Federal rate
rather than receive payment based on the transition blend methodology.
As discussed in that same final rule, using the same methodology
established in the August 30, 2002, final rule (67 FR 56034), this
projection was based on our estimate that either: (1) a LTCH has
already elected payment based on 100 percent of the Federal rate prior
to the beginning of the 2004 LTCH PPS rate year (July 1, 2003); or (2)
a LTCH will receive higher payments based on 100 percent of the
standard Federal rate compared to the payments they would receive under
the transition blend
[[Page 4773]]
methodology. Similarly, we projected that the remaining LTCHs would
choose to be paid based on the transition blend methodology at Sec.
412.533 because those payments would be higher than if they were paid
based on 100 percent of the standard Federal rate.
In the June 6, 2003, final rule (68 FR 34513), we projected that
the full effect of the remaining 4 years of the transition period,
including the election option, will result in a cost to the Medicare
program of $310 million. Specifically, for the 2005 LTCH PPS rate year,
we estimated that the cost of the transition would be $100 million.
This cost would have necessitated an estimated budget neutrality offset
of 4.6 percent (0.954) for payments to LTCHs in the 2005 rate year.
Furthermore, in order to maintain budget neutrality, we indicated that,
in the future, we would propose a budget neutrality offset for each of
the remaining years of the transition period to account for the
estimated payments for the respective fiscal year.
For the proposed 2005 LTCH PPS rate year, based on the best
available data, we are projecting that approximately 69 percent of
LTCHs would be paid based on 100 percent of the proposed standard
Federal rate rather than receive payment under the transition blend
methodology. Using the same methodology described in the August 30,
2002, final rule (67 FR 56034), this projection, which uses updated
data and inflation factors, is based on our estimate that either--(1) a
LTCH has already elected payment based on 100 percent of the Federal
rate prior to the start of the 2005 LTCH PPS rate year (July 1, 2004);
or (2) a LTCH would receive higher payments based on 100 percent of the
proposed 2005 LTCH PPS rate year standard Federal rate compared to the
payments it would receive under the transition blend methodology.
Similarly, we are projecting that the remaining 31 percent of LTCHs
would choose to be paid based on the applicable transition blend
methodology (as set forth under Sec. 412.533(a)) because they would
receive higher payments than if they were paid based on 100 percent of
the proposed 2005 LTCH PPS rate year standard Federal rate. The
applicable transition blend percentage is applicable for a LTCH's
entire cost reporting period beginning on or after October 1 (unless
the LTCH elects payment based on 100 percent of the Federal rate).
In this proposed rule, based on the best available data and the
proposed policy revisions described above, we project that the full
effect of the remaining 4 years of the transition period (including the
election option) would result in a cost to the Medicare program of $170
million as follows:
------------------------------------------------------------------------
Estimated cost
LTCH PPS rate year (in millions)
------------------------------------------------------------------------
2005.................................................. $80
2006.................................................. 50
2007.................................................. 30
2008.................................................. 10
------------------------------------------------------------------------
We note that although the transition period will have ended for
most LTCHs by the 2008 LTCH PPS rate year, a small cost is projected
for the 2008 LTCH PPS rate year (July 1, 2007, through June 30, 2008)
because the applicable transition period percentages are based on a
LTCH's individual cost reporting period and not the LTCH PPS rate year
(July 1 through June 30). Specifically, LTCHs with cost reporting
periods beginning July 1, 2006, through October 1, 2006 (during the 4th
year of the transition period), where the applicable transition blend
percentages are 20 percent based on reasonable cost and 80 percent
based on the Federal rate (see Sec. 412.533), will end during the first
3 months of the 2008 LTCH PPS rate year (July 1, 2007, through
September 30, 2007). Therefore, a small cost is projected for the 2008
LTCH PPS rate year to account for those LTCHs that will still be
receiving blended transition payments for a portion of the 2008 LTCH
PPS rate year.
Accordingly, using the methodology established in the August 30,
2002, final rule (67 FR 56034) based on updated data and the proposed
policies and rates discussed in this proposed rule, we are proposing a
3.0 percent reduction (0.970) to all LTCHs' payments for discharges
occurring on or after July 1, 2004, and through June 30, 2005, to
account for the estimated cost of the transition period methodology
(including the option to elect payment based on 100 percent of the
Federal rate) of the $80 million for the 2005 LTCH PPS rate year.
This offset of 3.0 percent has decreased relative to the estimate
of 4.6 percent for several reasons. For this proposed rule, we have
used data from more recent cost reports and were able to obtain data
from more LTCHs (211 LTCHs as compared to 194 LTCHs in the June 6,
2003, final rule). In addition, in projecting the percentage of
hospitals that would elect to be paid based on 100 percent of the
proposed 2005 LTCH PPS rate year standard Federal rate, we used the
Provider Specific File (PSF) in which LTCHs indicated whether they
opted to be paid based on 100 percent of standard Federal rate or the
transition blend methodology for the FY 2003 LTCH PPS payment year.
However, based on information obtained from the PSF, we learned that,
for those LTCHs that we projected would choose payment for FY 2003
based on 100 percent of the standard Federal rate (where payment based
on the full Federal rate would be expected to be higher for those LTCHs
than payment under the transition blend methodology), a significant
number of those LTCHs chose to be paid under the transition blend
methodology that is projected to result in payment lower than that
using 100 percent of the standard Federal rate.
Similarly, a significant number of those LTCHs that we expected
would choose payment under the transition blend methodology (where
payment under the transition blend for those LTCHs would be expected to
be higher than payment based on 100 percent of the standard Federal
rate) chose to be paid using 100 percent of the standard Federal rate,
which is projected to result in payment lower than that under the
transition blend methodology. Since a number of LTCHs opted to be paid
based on a methodology in which they would receive lower payments, we
assume that the overall cost of $100 million to the Medicare program of
the transition period would be less than what was projected in the June
6, 2003, final rule for the proposed 2005 LTCH PPS rate year. Thus, in
the June 6, 2003, final rule, in estimating the $100 million cost to
the transition, which would have necessitated a 4.6 percent reduction
to all LTCHs' payments for the 2005 LTCH PPS rate year, we overstated
our assumptions of the cost of the transition period. Accordingly, to
account for the projected lower cost of the transition period due to
those LTCHs that chose to be paid based on a methodology in which they
would receive lower payments in FY 2003, for this proposed rule, we are
proposing a 3.0 percent (0.970) reduction to all LTCHs' payments during
the 2005 LTCH PPS rate year. We note that the proposed 0.970 transition
period budget neutrality factor for the 2005 LTCH PPS rate year is 3
percentage points lower than the transition period budget neutrality
factor for the 2004 LTCH PPS rate year (0.940). This smaller budget
neutrality offset contributes to greater LTCH payment increases between
the 2004 and 2005 LTCH PPS rate years compared to the increases seen
between FY 2003 and the 2004 LTCH PPS rate year. We do not expect to
see these large payment per discharge increases in future years as the
majority of LTCHs will have transitioned fully to the LTCH PPS and,
therefore, the transition period
[[Page 4774]]
budget neutrality factor should remain more stable.
As noted above, in order to maintain budget neutrality, we
indicated that we would propose a budget neutrality offset for each of
the remaining years of the transition period to account for the
estimated costs for the respective LTCH PPS rate years. In this
proposed rule, based on the best available data, we are proposing the
following budget neutrality offsets to the LTCH PPS during the
remaining years of the transition period: 2.2 percent (0.978) for the
2006 LTCH PPS rate year, 1.1 percent (0.989) for the 2007 LTCH PPS rate
year, and 0.1 percent (0.990) for the 2008 LTCH PPS rate year. As noted
above, the small offset in the 2008 LTCH PPS rate year accounts for
those LTCHs whose blended transition period payments will be concluding
in the first 3 months of the 2008 LTCH PPS rate year (that is, July 1,
2007, through September 30, 2007).
As we discussed in the August 30, 2002, final rule (67 FR 56036),
consistent with the statutory requirement for budget neutrality in
section 123(a)(1) of Public Law 106-113, we intended for estimated
aggregate payments under the LTCH PPS to equal the estimated aggregate
payments that would be made if the LTCH PPS was not implemented. Our
methodology for estimating payments for purposes of the budget
neutrality calculations use the best available data at that time and
necessarily reflect assumptions. As the LTCH PPS progresses, we are
monitoring payment data and will evaluate the ultimate accuracy of the
assumptions used in the budget neutrality calculations (for example,
inflation factors, intensity of services provided, or behavioral
response to the implementation of the LTCH PPS) described in the August
30, 2002, final rule (67 FR 56027-56037). To the extent these
assumptions significantly differ from actual experience, the aggregate
amount of actual payments may turn out to be significantly higher or
lower than the estimates on which the budget neutrality calculations
were based.
Section 123 of Pub. L. 106-113 and section 307 of Pub. L. 106-554
provide broad authority to the Secretary in developing the LTCH PPS,
including the authority for appropriate adjustments. Under this broad
authority, as implemented in the regulations at Sec. 412.523(d)(3), we
have provided for the possibility of making a one-time prospective
adjustment to the LTCH PPS rates by October 1, 2006, so that the effect
of any significant difference between actual payments and estimated
payments for the first year of the LTCH PPS would not be perpetuated in
the LTCH PPS rates for future years.
In the June 6, 2003, final rule (67 FR 34153), we estimated that
total Medicare program payments for LTCH services over the next 5 LTCH
PPS rate years would be $2.17 billion for the 2004 LTCH PPS rate year;
$2.29 billion for the 2005 LTCH PPS rate year; $2.42 billion for the
2006 LTCH PPS rate year; $2.56 billion for the 2007 LTCH PPS rate year;
and $2.71 billion for the 2008 LTCH PPS rate year.
Consistent with the methodology discussed in the June 6, 2003,
final rule (68 FR 34138), in this proposed rule, based on the most
recent available data, we estimate that total Medicare program payments
for LTCH services for the next 5 LTCH PPS rate years would be as
follows:
------------------------------------------------------------------------
Estimated
LTCH PPS rate year payments ($ in
billions)
------------------------------------------------------------------------
2005.................................................. $2.33
2006.................................................. 2.48
2007.................................................. 2.64
2008.................................................. 2.79
2009.................................................. 2.96
------------------------------------------------------------------------
As noted above, in accordance with the methodology established in
the August 30, 2002, final rule (67 FR 56037), these estimates are
based on the projection that 69 percent of LTCHs would elect to be paid
based on 100 percent of the proposed 2005 LTCH PPS rate year standard
Federal rate rather than the applicable transition blend, and our
estimate of 2005 LTCH PPS rate year payments to LTCHs using our Office
of the Actuary's most recent estimate of the excluded hospital with
capital market basket of 2.9 percent for the 2005 LTCH PPS rate year,
3.2 percent for the 2006 LTCH PPS rate year, 3.1 percent for the 2007
LTCH PPS rate year, 3.0 percent for the 2008 LTCH PPS rate year, and
3.2 percent for the 2009 LTCH PPS rate year. We also took into account
our Office of the Actuary's projection that there would be an increase
in Medicare beneficiary enrollment of 2.1 percent in the 2005 LTCH PPS
rate year, 2.4 percent in the 2006 LTCH PPS rate year, 2.1 percent in
the 2007 LTCH PPS rate year, 2.0 percent in the 2008 LTCH PPS rate
year, and 2.1 percent in the 2009 LTCH PPS rate year.
Because the LTCH PPS has only been implemented for less than 2
years, sufficient new data have not been generated that would enable us
to conduct a comprehensive reevaluation of our budget neutrality
calculations. Therefore, in this proposed rule, we are not proposing to
make a one-time adjustment under Sec. 412.523(d)(3) so that the effect
of any significant difference between actual payments and estimated
payments for the first year of the LTCH PPS is not perpetuated in the
PPS rates for future years. However, we will continue to collect and
interpret new data as the data become available in the future to
determine if such an adjustment should be proposed.
7. Proposed Changes in the Procedure for Counting Days in the Average
Length of Stay Calculation
Prior to the implementation of the PPS for LTCHs, Medicare paid
LTCHs under the reasonable cost methodology subject to limitations on
payments. Both the BBRA and BIPA required the development and
implementation of a per discharge PPS for LTCHs based on DRGs for cost
reporting periods beginning on or after October 1, 2002 (67 FR 55954,
August 30, 2002).
Under the reasonable cost-based reimbursement system, the number of
patient days that occurred during a cost reporting period and the costs
associated with those days were reported on the hospital's cost report
(Hospital and Hospital Health Care Complex Cost Report, CMS Form 2552-
96), as were the number of patient discharges that occurred during that
same period. This method of reporting and reimbursement did not require
that all of the days of care to a patient be counted as occurring in
the cost reporting period during which the patient was discharged.
Under this method of reporting and reimbursement the days of care to a
patient are counted in the cost reporting period in which it occurred.
With the FY 2003 implementation of the LTCH PPS, as in other
discharge-based PPS'', such as those for acute care hospitals and for
IRFs, all days of the patient's stay, even those occurring prior to the
cost reporting period in which the discharge occurs are counted for
payment purposes as occurring in the cost reporting period of the
patient's discharge. An example of this distinction is as follows: A
LTCH has a January 1 through December 31 cost reporting period; a
Medicare patient is admitted on December 15 and discharged on February
5, 2004. Prior to the LTCH PPS, under the reasonable cost-based
reimbursement system, costs and patient days occurring in December 2003
would be included in the January 1 through December 31, 2003, cost
reporting period, even though the patient was not discharged until
February of the next cost reporting period that began January 1, 2004.
Those patient days occurring in January
[[Page 4775]]
and February would be counted in the next cost reporting period (2004)
in which the discharge occurred. Since the implementation of the LTCH
PPS, for payment purposes, all patient days for this stay would be
reported in the cost reporting period in which the discharge occurred.
In the above example, therefore, all of the patient stay would be
counted in the next cost reporting period which is the 2004 cost
reporting period. Even if a LTCH is transitioning into fully Federal
payments and a percentage of its payments is based upon what would have
been paid under the former reasonable cost-based reimbursement system,
under Sec.Sec. 412.500 and 412.533, payment policy is governed by the
LTCH PPS. At cost report settlement, payment is discharge-based.
Therefore, once a LTCH is subject to the LTCH PPS, that is, for its
first cost reporting period starting on or after October 1, 2002, the
``days follow the discharge,'' which means that both days and costs are
linked to the patient's discharge, even when the days occurred in a
previous cost reporting period.
In the August 30, 2002, final rule (67 FR 55972), which established
the policies of the LTCH PPS, we stated that ``[t]he procedure by which
a LTCH will be evaluated by its fiscal intermediary to determine
whether it will qualify as a LTCH * * * is the same procedure currently
employed under the TEFRA system.'' Currently, for determining whether a
hospital meets the greater than 25 day average Medicare inpatient
length of stay criterion, in the case of a Medicare patient who was
admitted during one cost reporting period, but was discharged in a
following cost reporting period, both covered and uncovered days are
counted in the cost reporting period in which they occurred and not
linked to the cost reporting period in which the patient is discharged.
Therefore, presently, for a LTCH with a January 1 through December
31 cost reporting period, if a patient was admitted on December 1,
2002, and discharged on January 15, 2003, patient days would be counted
one way for payment purposes and another way for purposes of counting
the average length of stay. For payment purposes, all 46 days of the
stay and the costs associated with them would be reported during the
cost reporting period that the discharge occurred, that is, January 1,
2003, through December 31, 2003. For purposes of determining whether a
hospital meets the greater than 25 day length of stay criterion, under
Sec. 412.23(e)(2)(i), however, for the same patient, the 31 days in
December would be counted as occurring during the January 1, 2002, to
December 31, 2002, cost reporting period and the 15 days in January
2003 would be counted, along with the discharge, during the January 1,
2003, through December 31, 2003, cost reporting period.
We have received numerous inquiries from providers and fiscal
intermediaries indicating that our two different ways of counting days
under the LTCH PPS for payment and for average length of stay
calculations have created considerable confusion. Therefore, in
response to these inquiries and consistent with the payment system
already in place for LTCHs as discussed above, in this proposed rule,
we are proposing to revise Sec. 412.23(e)(3)(i) of the regulations to
specify that if a patient's stay includes days of care furnished during
two or more separate consecutive cost reporting periods, the total days
of a patient's stay would be reported in the cost reporting period
during which the patient is discharged in calculating the average
length of stay for hospitals that qualify as LTCHs under both Sec.
412.23(e)(2)(i) and (ii). We are not proposing any changes to the
formula of dividing the number of total days for Medicare patients by
discharges for LTCHs in order to determine whether a hospital qualifies
as a LTCH under Sec. 412.23(e)(2)(i) or in the formula of dividing
total days for all patients by discharges for LTCHs to qualify under
Sec. 412.23(e)(2)(ii).
In the August 1, 2003, final rule for the IPPS (68 FR 45464), we
discussed the inability of the present cost report (Hospital and
Hospital Health Care Complex Cost Report, CMS Form 2552-96) to capture
total days for Medicare patients as required under Sec.Sec.
412.23(e)(2) and (e)(3) for hospitals qualifying under Sec.
412.23(e)(2)(i) and our present use of census data gathered from the
Medicare provider analysis and review (MedPAR) files for this purpose.
Prior to the October 1, 2002, implementation of the LTCH PPS, we relied
on data from the most recently submitted hospital cost report in order
to determine whether or not a hospital qualified as a LTCH. We would
continue to utilize patient days and discharge data from MedPAR files
for the qualification calculation under the proposed revised Sec.
412.23(e)(3)(i) until the cost reporting form is revised to capture
total days for Medicare inpatients.
As discussed earlier, for a hospital to qualify as a LTCH under
Sec. 412.23(e)(2)(i), it must demonstrate that the Medicare inpatients
require care for an average Medicare inpatient length of stay of
greater than 25 days for the hospital's most recent cost reporting
period. Alternatively, for cost reporting periods beginning on or after
August 5, 1997, a hospital that was first excluded from the PPS in
1986, and can demonstrate that at least 80 percent of its annual
Medicare inpatient discharges in the 12-month cost reporting period
ending in FY 1997 have a principal diagnosis that reflects a finding of
neoplastic disease must have an average inpatient length of stay for
all patients, including both Medicare and non-Medicare inpatients, of
greater than 20 days (Sec. 412.23(e)(2)(ii)). As described above, under
the previous reasonable cost-based reimbursement system to determine
whether or not a hospital met this requirement, total days for all
patients were divided by the total number of discharges that occurred
during a cost reporting period. When we implemented the LTCH PPS on
October 1, 2002, we limited this calculation to only Medicare patients
for hospitals to qualify under Sec. 412.23(e)(2)(i), but did not change
the calculation for hospitals to qualify under Sec. 412.23(e)(2)(ii).
As we noted in the August 30, 2002, final rule, ``[w]e believe that
excluding non-Medicare patients in determining the average inpatient
length of stay for purposes of subclause (I) would be more appropriate
in identifying the hospitals that warrant exclusion under the general
definition of LTCH in subclause (I). However in enacting subclause
(II), the Congress provided an exception to the general definition of
LTCH under subclause (I), and we have no reason to believe that the
change in methodology for determining the average inpatient length of
stay would better identify the hospitals that the Congress intended to
exclude under subclause (II) (67 FR 55974). These hospitals will
continue to have their greater than 20 days average length of stay
calculated based on all days for all patients, whether Medicare or non-
Medicare patients, and will continue to be determined based on the days
of care provided during the cost reporting period and not based solely
on the count of days for the patients discharged during the cost
reporting period.
8. Clarification of the Requirements for a Satellite Facility or a
Remote Location To Qualify as a LTCH and Proposed Changes to the
Requirements for Certain Satellite Facilities and Remote Locations
a. Proposed Policy Change
In Sec. 412.22(h)(1), we define a satellite as ``a part of a
hospital that provides inpatient services in a building also used by
another hospital, or in one or more entire buildings located on the
[[Page 4776]]
same campus as buildings used by another hospital.'' Satellite
arrangements exist when a IPPS excluded hospital is either a
freestanding hospital or a hospital-within-a-hospital under Sec.
412.22(e) that establishes an additional location by sharing space in a
building also used by another hospital, or in one or more entire
buildings located on the same campus as buildings used by another
hospital. A detailed discussion of our policies regarding Medicare
payments for satellite facilities of hospitals excluded from the IPPS
was set forth in the IPPS final rules published on July 30, 1999 (64 FR
41532-41534), and August 1, 2003 (67 FR 49982).
We established Medicare regulations regarding satellite facilities
for several reasons. First, we believe that whenever a facility that is
co-located with an acute care hospital is presented as part of another
IPPS-excluded hospital, it is necessary to ensure that the facility is,
in fact, organized and operated as part of the IPPS-excluded hospital
and is not simply a unit of the acute hospital with which it is co-
located. Although we recognize that the co-location of Medicare
providers, in the form of satellite facilities, hospitals-within-
hospitals, and excluded units, may have some legitimate advantages from
the standpoint of clinical care as well as medical efficiency, we
continue to believe that the physical proximity inherent in such
arrangements also has considerable potential for Medicare program
payment abuse in that it may facilitate patient shifting for reasons
related to payment rather than clinical benefits. In existing
regulations at Sec. 412.22(e) for hospitals-within-hospitals (59 FR
45330, September 1, 1994), at Sec. 412.23(h) for hospital satellites
(64 FR 41532-41534, July 30, 1999, and 67 FR 49982, August 1, 2002),
and Sec. 412.25(e) for satellite facilities, we promulgated
``separateness and control'' requirements governing the relationships
between these facilities and their host hospitals.
Research by the Urban Institute on the universe of LTCHs that was
used in developing the LTCH PPS pointed to the considerable growth of
new LTCHs (or LTCH beds, as in the case of satellite facilities) that
were co-located with other Medicare providers. Our more recent data
confirm that this trend has continued. Even though our existing
regulations governing hospitals-within-hospitals and satellite
facilities established certain functional boundaries between these
entities and their hosts, we instituted a policy under the LTCH
regulations at Sec. 412.532 to discourage inappropriate patient
discharges and readmissions among co-located Medicare providers (67 FR
56007-56010, August 30, 2002). Furthermore, in the June 6, 2003, LTCH
PPS final rule (68 FR 34157), we noted that we are monitoring the
movement of patients among onsite providers for the purpose of
determining whether we should consider proposing further changes to
LTCH coverage and payment policy.
LTCH hospitals-within-hospitals and LTCH satellite facilities are
similar in that both are located on the same campus or in the same
building as another hospital, and many of the same separateness and
control regulations exist for both types of facilities. However, there
is an important distinction between them. A LTCH that is co-located
with another Medicare hospital (generally an acute care hospital) is
itself a distinct hospital (Sec. 412.22(e)). Section 412.23(e)(1)
requires a LTCH to have a provider agreement as described under 42 CFR
Part 489 to participate as a hospital. A satellite facility of a LTCH,
like all satellite facilities of hospitals excluded from the IPPS (Sec.
412.22(h)), is not itself a separate hospital, but a ``part of a
hospital that provides inpatient services in a building also used by
another hospital * * *'' Consistent with its status as another
hospital, a hospital-within-a-hospital has its own Medicare provider
number. A satellite facility shares the provider number of the parent
hospital.
Because a satellite facility is not considered a separate hospital
under Medicare, if a LTCH with a satellite facility is interested in
``spinning off'' the satellite facility and establishing the previous
satellite facility as an independent LTCH, the satellite must first be
separately licensed by the State. The facility must further demonstrate
compliance with the Medicare conditions of participation (COPS) under
part 482 and other requirements for establishing a provider agreement
under parts 482 and 489 to participate under Medicare as a hospital
(Sec. 412.23(e)(1)). (Compliance with the COPS may be either
demonstrated by a State agency survey or based on accreditation as a
hospital by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO or the American Osteopathic Association (AOA)
(section 1865 of the Act).) Second, if the newly established hospital
meets the provider agreement requirements under 42 CFR part 489, it
must demonstrate that it has an average Medicare inpatient length of
stay of greater than 25 days (Sec. 412.23(e)(2)(i)) by providing data
of a period of at least 5 months of the preceding 6-month period (Sec.
412.22(e)(3)(ii) and (iii)). The data used by the fiscal intermediary
to calculate the average length of stay would be from discharges from
the newly established hospital and not from discharges attributable to
stays at the previous satellite facility for the period prior to its
participation as a separate hospital.
Although we believe that these requirements, under existing Sec.
412.23(e)(1) and (2), are clear and unambiguous, we have been informed
that due to misinterpretation, in some circumstances, application of
this policy has been inconsistent. Therefore, some facilities operating
as LTCH satellite facilities have been inappropriately granted
autonomous status that has resulted in the assignment of their own
Medicare provider numbers as LTCHs without first obtaining provider
agreements to participate in Medicare as hospitals, under Sec.
412.23(e)(1). Apparently, in these cases, the satellite facilities were
able to demonstrate that as satellite facilities of LTCHs, Medicare
patients at their location had an average length of stay of greater
than 25 days, in compliance with Sec. 412.22(h)(2)(ii) which required
satellite facilities of hospitals excluded from the IPPS to comply with
specific requirements for their provider category. In other situations,
we understand that fiscal intermediaries correctly refused to accept
data from LTCH satellite facilities for purposes of qualification as an
autonomous LTCH and instead required the satellites to satisfy criteria
for designation as a hospital, under Sec. 412.23(e)(1). In these cases,
the fiscal intermediary evaluated average length of stay data dating
from that hospital designation forward, as required by Sec.
412.23(e)(2).
We believe consistency in the application of this policy is needed,
in compliance with existing regulations at Sec. 412.23(e)(1) and
(e)(2). We are emphasizing that a LTCH satellite facility that is ``a
part of a hospital that provides inpatient services in a building also
used by another hospital * * *'' that is seeking to become an
independent LTCH, must comply with the requirements set forth in the
definition of a new LTCH in existing Sec. 412.23(e)(4). Therefore, we
are proposing to revise Sec. 412.23(e)(4) to include a new paragraph
(e)(4)(ii) that specifies that only data reflecting the average length
of stay for Medicare patients in the newly established hospital will be
utilized in the qualifying calculation at Sec. 412.23(e)(2). Thus, we
are proposing clarifying language that emphasizes that if a
[[Page 4777]]
satellite facility is reorganized as a separately participating
hospital under Medicare with or without a concurrent change of
ownership, the new hospital cannot be paid under Medicare as a LTCH
until it demonstrates that it has an average Medicare inpatient length
of stay in excess of 25 days based on discharges occurring on or after
its effective date of participation as a hospital and not based on
discharges at the satellite facility site when it was part of another
hospital (proposed Sec. 412.23(e)(4)(ii)).
This proposed policy clarification would also be applicable to
remote locations of LTCHs that are being voluntarily separated from the
parent LTCHs or sold and are seeking status as independent LTCHs. A
remote location of a hospital (as defined at Sec. 413.65(a)(2)) is
similar to a satellite facility because it does not participate in
Medicare as a separate hospital, but only as an integral and
subordinate part of another hospital. However, unlike a satellite
facility, a remote location is not one that is in the same building or
on the same campus as another hospital. (Because a remote location has
no ``host'' hospital, it is not required to meet the separateness
criteria as hospitals-within-hospitals in Sec. 412.22(e) that would
arise for satellite facilities that become independent LTCHs, as
discussed above.) Since the hospital would not be a LTCH until the
fiscal intermediary reviews its documentation and determines that it
qualifies, during those initial months, the hospital would be paid
under the IPPS.
We emphasize that notwithstanding the fact that satellite
facilities of LTCHs are required to independently meet the average
Medicare inpatient length of stay requirement of greater than 25 days
under Sec. 412.22(h)(2)(ii)(D), we are proposing to evaluate length of
stay data only from discharges occurring after the facility has become
a hospital. This is the case as the prerequisite to designation as a
LTCH is a provider agreement under part 489 of chapter IV to
participate as a hospital in the Medicare program (Sec. 412.23(e)(1)).
The requirement that a satellite facility independently meets the
length of stay criterion was never intended as an alternative method of
qualifying as a separate excluded hospital. Under Sec.
412.23(h)(2)(ii), satellite facilities of psychiatric, rehabilitation,
and children's hospitals, as well as LTCHs, are required to meet
specific requirements for their provider category because we believed
that it was essential to ensure that satellite facilities of excluded
hospitals actually delivered the specialized care for which Medicare
was paying (Sec. 412.23(h)(2)(ii)). Furthermore, those regulations were
designed to ensure that there is both an appropriate financial and
administrative linkage between the satellite facility and the parent
hospital, and a clear separation of the satellite facility from the
host hospital. These policies are set forth in the July 30, 1999, IPPS
final rule (64 FR 41534). In the case of a LTCH, we believe that our
existing requirement that a satellite facility independently meet the
greater than 25-day average Medicare inpatient length of stay
requirement is consistent with the guiding principles of the LTCH PPS.
We do not believe patients who do not require long-term hospital-level
care should be admitted to either a LTCH or its satellite facility. In
addition, we were concerned that, without requiring separate
compliance, shorter lengths of stay at either the LTCH or its satellite
facility could be balanced by longer stays at the other. By
establishing these distinct standards for satellite facilities of
excluded hospitals, we also wanted to safeguard against the possibility
of these facilities functioning as a part of an acute care hospital. In
the case of a LTCH, that result would be inconsistent with section
1886(d)(1)(B) of the Act, which provides for excluded rehabilitation
and psychiatric units to be established in acute care hospitals, but
not long-term care units.
There is another situation that must be distinguished from the
scenario discussed above in which a LTCH is voluntarily separating from
or selling its satellite facility or remote location with the intent of
the satellite facility or remote location converting into an
independent hospital and eventually a LTCH. Our recent provider-based
regulations under Sec. 413.65 require a remote location of a hospital
that fails to meet certain requirements at Sec. 413.65(e)(3) to seek
status as a separate hospital if it is to continue functioning and
being paid by Medicare. Satellite facilities of excluded hospitals,
such as LTCHs, may also be affected by these new provider-based
requirements and, in those cases, the following procedure would also be
applicable.
Under the provider-based regulations, which became effective for
the main providers as defined in Sec. 413.65(a)(2), for cost reporting
periods beginning on or after July 1, 2003, certain facilities that
were formerly treated for payment purposes by Medicare as remote
locations or satellite facilities of hospitals, are now precluded from
continuing in that status because they do not meet the ``common service
area'' location requirement for provider-based facilities under Sec.
413.65(e)(3) (67 FR 50078, August 1, 2002). It has come to our
attention that certain satellite facilities and remote locations of
LTCHs are being affected by this preclusion. Due to the compulsory
nature of this separation requirement, we are proposing an exception
for these affected satellite facilities and remote locations of LTCHs
that will allow them to utilize length of stay data from the 5 months
of the previous 6 months prior to when they were compelled to separate
from their main provider under Sec. 413.65(e)(3) (proposed Sec.
412.23(e)(4)(iii)).
We want to emphasize that the only distinction that we are
proposing between requirements proposed under Sec. 412.23(e)(4)(ii),
for satellite facilities and remote locations that voluntarily separate
from their parent LTCHs and requirements in proposed Sec.
412.23(e)(4)(iii) that apply to satellite facilities and remote
locations compelled by provider-based location requirements at Sec.
413.65(e)(3) to terminate their link to their main providers, is that
we are proposing to allow the latter group to utilize data gathered
prior to establishing themselves as distinct hospitals. Furthermore,
this distinction only exists for satellite facilities and remote
locations of LTCHs that are affected by (Sec. 413.65(e)(3)) and which
were in existence prior to the effective date of the provider-based
location requirements (July 1, 2003). Under the regulations at Sec.
413.65(e)(3), we would not permit these entities to be established more
than 35 miles from the main providers after June 30, 2003. We would
assign new Medicare provider numbers to former remote locations of LTCH
hospitals or satellite facilities that fail the new location
requirement in Sec. 413.65(e)(3), but want to become new LTCHs, if the
following conditions are satisfied in proposed Sec. 412.23(e)(4)(iii):
The facility meets all Medicare COPs in 42 CFR
Part 482 and other participation requirements set forth in 42 CFR Part
489.
The facility provides data to its fiscal
intermediary indicating that during 5 of the immediate 6 months
preceding its separation from the main hospital, it has independently
met the greater than 25-day average length of stay requirement for its
Medicare patients (Sec. 412.23(e)(3)).
b. Technical Correction
In the August 30, 2002, LTCH PPS final rule (67 FR 56053), we
issued regulations at Sec. 412.532(i) that require a LTCH or a
satellite of a LTCH to notify its fiscal intermediary and CMS in
writing of its co-location and any
[[Page 4778]]
changes in co-location status. In Sec. 412.532(i), we include a cross-
reference to the Medicare regulations that contain the requirements for
a satellite facility to be paid under Medicare. We made an
unintentional error in specifying this cross-reference as paragraphs
(h)(1) through (h)(4) of Sec. 412.532. The correct cross-reference to
the requirements for satellite facilities is Sec. 412.22(h)(1) through
(h)(4). Therefore, we are proposing to revise Sec. 412.532(i) to
include the correct cross-reference to Sec. 412.22(h)(1) through
(h)(4).
V. Computing the Proposed Adjusted Federal Prospective Payments for the
2005 LTCH PPS Rate Year
(If you choose to comment on issues in this section, please include
the caption ``COMPUTING THE PROPOSED ADJUSTED FEDERAL PROSPECTIVE
PAYMENTS'' at the beginning of your comments.)
In accordance with Sec. 412.525 and as discussed in section IV.C.
of this proposed rule, the proposed standard Federal rate is adjusted
to account for differences in area wages by multiplying the labor-
related share of the proposed standard Federal rate by the appropriate
proposed LTCH PPS wage index (as shown in Tables 1 and 2 of the
Addendum to this proposed rule). The proposed standard Federal rate is
also adjusted to account for the higher costs of hospitals in Alaska
and Hawaii by multiplying the nonlabor-related share of the proposed
standard Federal rate by the appropriate proposed cost-of-living factor
(shown in Table I in section IV.C.2. of this preamble). In this
proposed rule, as discussed in section IV.B. of this preamble, we are
proposing a standard Federal rate of $36,762.24 for the 2005 LTCH PPS
rate year. We illustrate the methodology used to adjust the proposed
Federal prospective payments in the following example:
During the 2005 LTCH PPS rate year, a Medicare patient is in a LTCH
located in Chicago, Illinois (MSA 1600) with a proposed two-fifths wage
index value of 1.0357 (see Table 1 in the Addendum to this proposed
rule). The Medicare patient is classified into LTC-DRG 9 (Spinal
Disorders and Injuries), which has a relative weight of 1.5025 (see
Table 3 of the Addendum to this proposed rule). To calculate the LTCH's
total adjusted proposed Federal prospective payment for this Medicare
patient, we compute the wage-adjusted proposed Federal prospective
payment amount by multiplying the unadjusted proposed standard Federal
rate ($36,762.24) by the labor-related share (72.885 percent) and the
proposed wage index value (1.0357). (We note that the LTCH in this
example is in the second year of the wage index phase-in, thus, the
two-fifths wage index value is applicable.) This wage-adjusted amount
is then added to the nonlabor-related portion of the unadjusted
proposed standard Federal rate (27.115 percent; adjusted for cost of
living, if applicable) to determine the adjusted proposed Federal rate,
which is then multiplied by the LTC-DRG relative weight (1.5025) to
calculate the total adjusted proposed Federal prospective payment for
the 2005 LTCH PPS rate year ($56,672.48). In addition, as discussed in
section IV.C.6. of this preamble, for the 2005 LTCH PPS rate year, we
are proposing to reduce the LTCH PPS payment by 3.0 percent for the
budget neutrality offset to account for the costs of the transition
methodology. The following illustrates the components of the
calculations in this example:
------------------------------------------------------------------------
------------------------------------------------------------------------
Unadjusted Proposed Standard Federal Prospective Payment $36,762.24
Rate...................................................
Labor-Related Share..................................... x0.72885
---------------
Labor-Related Portion of the Proposed Federal Rate...... =$26,794.16
Proposed \2/5\th Wage Index (MSA 1600).................. x1.0357
---------------
Wage-Adjusted Labor Share of Proposed Federal Rate...... =$27,750.71
Nonlabor-Related Portion of the Proposed Federal Rate +$ 9,968.08
($36,762.24 x 0.27115)...............................
Adjusted Proposed Federal Rate Amount................... =$37,718.79
LTC-DRG 4 Relative Weight............................... x1.5025
Total Adjusted Proposed Federal Prospective Payment =$56,672.48
(Before the Proposed Budget Neutrality Offset).........
Proposed Budget Neutrality Offset....................... x0.970
---------------
Total Proposed Federal Prospective Payment (Including =$54,972.31
the Proposed Budget Neutrality Offset).................
------------------------------------------------------------------------
VI. Transition Period
(If you choose to comment on issues in this section, please include
the caption ``TRANSITION PERIOD'' at the beginning of your comments.)
To provide a stable fiscal base for LTCHs, under Sec. 412.533, we
implemented a 5-year transition period from reasonable cost-based
reimbursement under the TEFRA system to a prospective payment based on
industry-wide average operating and capital-related costs. Under the
average pricing system, payment is not based on the experience of an
individual hospital. As discussed in the August 30, 2002 final rule (67
FR 56038), we believe that a 5-year phase-in provides LTCHs time to
adjust their operations and capital financing to the LTCH PPS, which is
based on prospectively determined Federal payment rates. Furthermore,
we believe that the 5-year phase-in of the LTCH PPS also allows LTCH
personnel to develop proficiency with the LTC-DRG coding system, which
will result in improvement in the quality of the data used for
generating our annual determination of relative weights and payment
rates.
In accordance with Sec. 412.533, the transition period for all
hospitals subject to the LTCH PPS begins with the hospital's first cost
reporting period beginning on or after October 1, 2002, and extends
through the hospital's last cost reporting period beginning before
October 1, 2006. During the 5-year transition period, a LTCH's total
payment under the LTCH PPS is based on two payment percentages--one
based on reasonable cost-based (TEFRA) payments and the other based on
the standard Federal prospective payment rate. The percentage of
payment based on the LTCH PPS Federal rate increases by 20 percentage
points each year, while the reasonable cost-based payment rate
percentage decreases by 20 percentage points each year, for the next 3
fiscal years. For cost reporting periods beginning on or after October
1, 2006, Medicare payment to LTCHs will be determined entirely under
the Federal PPS methodology. The blend percentages as set forth in Sec.
412.533(a) are as follows:
[[Page 4779]]
------------------------------------------------------------------------
Reasonable cost
Cost reporting periods Federal rate principles rate
beginning on or after percentage percentage
------------------------------------------------------------------------
October 1, 2002............... 20 80
October 1, 2003............... 40 60
October 1, 2004............... 60 40
October 1, 2005............... 80 20
October 1, 2006............... 100 0
------------------------------------------------------------------------
For cost reporting periods that begin on or after October 1, 2003,
and before October 1, 2004 (FY 2004), the total payment for a LTCH is
60 percent of the amount calculated under reasonable cost principles
for that specific LTCH and 40 percent of the Federal prospective
payment amount. For cost reporting periods that begin on or after
October 1, 2004, and before October 1, 2005 (FY 2005), the total
payment for a LTCH will be 40 percent of the amount calculated under
reasonable cost principles for that specific LTCH and 60 percent of the
Federal prospective payment amount. As we noted in the June 6, 2003,
final rule (68 FR 34155), the change in the effective date of the
annual LTCH PPS rate update from October 1 to July 1 has no effect on
the LTCH PPS transition period as set forth in Sec. 412.533(a). That
is, LTCHs paid under the transition blend under Sec. 412.533(a) will
receive those blend percentages for the entire 5-year transition period
(unless they elect payments based on 100 percent of the Federal rate).
Furthermore, LTCHs paid under the transition blend will receive the
appropriate blend percentages of the Federal and reasonable cost-based
rate for their entire cost reporting period as prescribed in Sec.
412.533(a)(1) through (a)(5).
The reasonable cost-based rate percentage is a LTCH specific amount
that is based on the amount that the LTCH would have been paid (under
TEFRA) if the PPS were not implemented. Medicare fiscal intermediaries
will continue to compute the LTCH reasonable cost-based payment amount
according to Sec. 412.22(b) of the regulations and sections 1886(d) and
(g) of the Act.
In implementing the PPS for LTCHs, one of our goals is to
transition hospitals to full prospective payments as soon as
appropriate. Therefore, under Sec. 412.533(c), we allow a LTCH, which
is subject to a blended rate, to elect payment based on 100 percent of
the Federal rate at the start of any of its cost reporting periods
during the 5-year transition period rather than incrementally shifting
from reasonable cost-based payments to prospective payments. Once a
LTCH elects to be paid based on 100 percent of the Federal rate, it
will not be able to revert to the transition blend. For cost reporting
periods that began on or after December 1, 2002, and for the remainder
of the 5-year transition period, a LTCH must notify its fiscal
intermediary in writing of its election on or before the 30th day prior
to the start of the LTCH's next cost reporting period. For example, a
LTCH with a cost reporting period that begins on May 1, 2004, must
notify its fiscal intermediary in writing of an election before April
1, 2004.
Under Sec. 412.533(c)(2)(i), the notification by the LTCH to make
the election must be made in writing to the Medicare fiscal
intermediary. Under Sec.Sec. 412.533(c)(2)(ii) and (c)(2)(iii), the
intermediary must receive the request on or before the specified date
(that is, on or before the 30th day before the applicable cost
reporting period begins for cost reporting periods beginning on or
after December 1, 2002 through September 30, 2006), regardless of any
postmarks or anticipated delivery dates.
Notifications received, postmarked, or delivered by other means
after the specified date will not be accepted. If the specified date
falls on a day that the postal service or other delivery sources are
not open for business, the LTCH will be responsible for allowing
sufficient time for the delivery of the request before the deadline. If
a LTCH's notification is not received timely, payment will be based on
the transition period blend percentages.
VII. Payments to New LTCHs
(If you choose to comment on issues in this section, please include the
caption ``PAYMENTS TO NEW LTCHs'' at the beginning of your comments.)
Under Sec. 412.23(e)(4), for purposes of Medicare payment under the
LTCH PPS, we define a new LTCH as a provider of inpatient hospital
services that otherwise meets the qualifying criteria for LTCHs, set
forth in Sec. 412.23(e)(1) and (e)(2), under present or previous
ownership (or both), and its first cost reporting period as a LTCH
begins on or after October 1, 2002. We also specify in Sec. 412.500
that the LTCH PPS is applicable to hospitals with a cost reporting
period that began on or after October 1, 2002. (In section I.B.3. of
this proposed rule, we clarify existing policy for the time frame for
calculating the average length of stay of a new LTCH as it relates to a
satellite facility or remote location of a LTCH that voluntarily seeks
to become a separate LTCH. We are also proposing a policy for the time
frame for calculating the average length of stay as it relates to a
remote location of a hospital that fails to meet certain requirements
at Sec. 413.65 and is required to seek status as a separate LTCH.)
As we discussed in the August 30, 2002, final rule (67 FR 56040),
this definition of new LTCHs should not be confused with those LTCHs
first paid under the TEFRA payment system for discharges occurring on
or after October 1, 1997, described in section 1886(b)(7)(A) of the
Act, as added by section 4416 of Public Law 105-33. As stated in Sec.
413.40(f)(2)(ii), for cost reporting periods beginning on or after
October 1, 1997, the payment amount for a ``new'' (post-FY 1998) LTCH
is the lower of the hospital's net inpatient operating cost per case or
110 percent of the national median target amount payment limit for
hospitals in the same class for cost reporting periods ending during FY
1996, updated to the applicable cost reporting period (see 62 FR 46019,
August 29, 1997). Under the LTCH PPS, those ``new'' LTCHs that meet the
definition of ``new'' under Sec. 413.40(f)(2)(ii) and that have their
first cost reporting period as a LTCH beginning prior to October 1,
2002, will be paid under the transition methodology described in Sec.
412.533.
As noted above and in accordance with Sec. 412.533(d), new LTCHs
will not participate in the 5-year transition from reasonable cost-
based reimbursement to prospective payment. As we discussed in the
August 30, 2002, final rule (67 FR 56040), the transition period is
intended to provide existing LTCHs time to adjust to payment under the
new system. Since these new LTCHs with cost reporting periods beginning
on or after October 1, 2002, would not have received payment under
reasonable cost-based reimbursement for the delivery of LTCH services
prior to the effective date of the LTCH PPS, we do not believe that
those new LTCHs require a transition period
[[Page 4780]]
in order to make adjustments to their operations and capital financing,
as will LTCHs that have been paid under the reasonable cost-based
methodology.
VIII. Method of Payment
(If you choose to comment on issues in this section, please include the
caption ``METHOD OF PAYMENT'' at the beginning of your comments.)
Under Sec. 412.513, a Medicare LTCH patient is classified into a
LTC-DRG based on the principal diagnosis, up to eight additional
(secondary) diagnoses, and up to six procedures performed during the
stay, as well as age, sex, and discharge status of the patient. The
LTC-DRG is used to determine the Federal prospective payment that the
LTCH will receive for the Medicare-covered Part A services the LTCH
furnished during the Medicare patient's stay. Under Sec. 412.541(a),
the payment is based on the submission of the discharge bill. The
discharge bill also provides data to allow for reclassifying the stay
from payment at the full LTC-DRG rate to payment for a case as a short-
stay outlier (under Sec. 412.529) or as an interrupted stay (under Sec.
412.531), or to determine if the case will qualify for a high-cost
outlier payment (under Sec. 412.525(a)).
Accordingly, the ICD-9-CM codes and other information used to
determine if an adjustment to the full LTC-DRG payment is necessary
(for example, length of stay or interrupted stay status) are recorded
by the LTCH on the Medicare patient's discharge bill and submitted to
the Medicare fiscal intermediary for processing. The payment represents
payment in full, under Sec. 412.521(b), for inpatient operating and
capital-related costs, but not for the costs of an approved medical
education program, bad debts, blood clotting factors, anesthesia
services by hospital-employed nonphysician anesthetists or obtained
under arrangement, or the costs of photocopying and mailing medical
records requested by a QIO, which are costs paid outside the LTCH PPS.
As under the previous reasonable cost-based payment system, under
Sec. 412.541(b) a LTCH may elect to be paid using the periodic interim
payment (PIP) method described in Sec. 413.64(h) and may be eligible to
receive accelerated payments as described in Sec. 413.64(g).
For those LTCHs that are paid during the 5-year transition based on
the blended transition methodology in Sec. 412.533(a) for cost
reporting periods that began on or after October 1, 2002, and before
October 1, 2006, the PIP amount is based on the transition blend. For
those LTCHs that are paid based on 100 percent of the standard Federal
rate, the PIP amount is based on the estimated prospective payment for
the year rather than on the estimated reasonable cost-based
reimbursement. We exclude high-cost outlier payments that are paid upon
submission of a discharge bill from the PIP amounts. In addition, Part
A costs that are not paid for under the LTCH PPS, including Medicare
costs of an approved medical education program, bad debts, blood
clotting factors, anesthesia services by hospital-employed nonphysician
anesthetists or obtained under arrangement, and the costs of
photocopying and mailing medical records requested by a QIO, are
subject to the interim payment provisions (Sec. 412.541(c)).
Under Sec. 412.541(d), LTCHs with unusually long lengths of stay
and that are not receiving payment under the PIP method may bill on an
interim basis (60 days after an admission and at intervals of at least
60 days after the date of the first interim bill) and should include
any high-cost outlier payment determined as of the last day for which
the services have been billed.
IX. Monitoring
(If you choose to comment on issues in this section, please include
the caption ``MONITORING'' at the beginning of your comments.)
In the August 30, 2002, final rule (67 FR 56014), we discussed our
intent to develop a monitoring system that will assist us in evaluating
the LTCH PPS. Specifically, we discussed the monitoring of the various
policies that we believe would provide equitable payment for stays that
reflect less than the full course of treatment and reduce the
incentives for inappropriate admissions, transfers, or premature
discharges of patients that are present in a discharge-based
prospective payment system. We also stated our intent to collect and
interpret data on changes in average lengths of stay under the LTCH PPS
for specific LTC-DRGs and the impact of these changes on the Medicare
program. We stated that if our data indicates that changes might be
warranted, we may revisit these issues and consider proposing revisions
to these policies in the future. To this end, we have designed system
features utilizing MedPAR data that will enable CMS and the fiscal
intermediary to track beneficiary movement to and from a LTCH and to
and from another Medicare provider. As we discussed in the June 6,
2003, final rule (68 FR 34157), the MedPAC has endorsed this monitoring
activity and is pursuing an independent research initiative that will
evaluate all aspects of LTCHs, including the accuracy of data
reporting, provision of equivalent services by other providers, growth
in the number of LTCHs, and clinical outcomes. We are particularly
concerned with the recent significant growth in the number of LTCHs.
Since the implementation of LTCH PPS we have observed a growth of
nearly 50 percent in the number of LTCHs, and that growth is almost
exclusively in the number of LTCH that are hospitals within hospitals.
We intend to focus our monitoring on this growth and the potential for
gaming the IPPS by the co-located acute care hospital and the LTCH PPS
by the LTC hospital within a hospital. Based on the outcome of that
monitoring activity we may need to address either the criteria for
qualifying for LTCH PPS payments for hospitals within hospitals, the
payment rates for patients that are discharged from acute care
hospitals and admitted to a co-located LTCH or other policy issues that
may arise as a result of our monitoring activity.
Also, in the June 6, 2003, final rule (68 FR 34157), we explained
that, given that the only unique requirement that distinguishes a LTCH
from other acute care hospitals is an average inpatient length of stay
of greater than 25 days, we continue to be concerned about the extent
to which LTCH services and patients differ from those services and
patients treated in other Medicare covered settings (for example, SNFs
and IRFs) and how the LTCH PPS will affect the access, quality, and
costs across the health care continuum. Thus, we will monitor trends in
the supply and utilization of LTCHs and Medicare's costs in LTCHs
relative to other Medicare providers. For example, we may conduct
medical record reviews of Medicare patients to monitor changes in
service use (for example, ventilator use) over a LTCH episode of care
and to assess patterns in the average length of stay at the facility
level.
We also are collecting data on patients staying for periods of 6
months or longer in LTCHs and may involve QIOs in evaluating whether or
not such extensive stays may be indicative of LTCH patients who could
be more appropriately served at a SNF.
Existing policy at Sec. 412.509(c) provides that the LTCH must
``furnish all necessary covered services to the Medicare beneficiary
who is an inpatient of the hospital either directly or under
arrangements.'' In this proposed rule we are proposing to expand our
interrupted stay policy, at Sec. 412.531, to include LTCH discharges
[[Page 4781]]
and readmissions within a period of 3 days.
We believe that such behavior by certain LTCHs may constitute
gaming of the Medicare system, circumventing existing Medicare policy,
and generating unnecessary Medicare payments. Therefore, we are
proposing an expansion of our interrupted stay policy at Sec. 412.531
to address this situation. (See section IV.C.4.c. of this proposed rule
for additional information regarding the proposed expansion of our
interrupted stay policy.)
X. Collection of Information Requirements
(If you choose to comment on issues in this section, please include
the caption ``COLLECTION OF INFORMATION REQUIREMENTS'' at the beginning
of your comments.)
Under the Paperwork Reduction Act (PRA) of 1995, we are required to
provide 60-day 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 PRA 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.
Therefore, we are soliciting public comments on each of these
issues for the information collection requirements discussed below.
The following information collection requirements and associated
burdens are subject to the PRA:
Sec. 412.23 Excluded Hospitals: Classifications
Section 412.23(e)(3) proposes revisions to the procedure for
calculating the average length of stay for purposes of qualifying as a
LTCH, so that the ``days follow discharge.'' Therefore, the total
number of inpatient days for Medicare patients under paragraph
(e)(2)(i), and the total number of days for all patients (both Medicare
and non-Medicare) under paragraph (e)(2)(ii), would be divided by the
discharges for the hospital's most recent cost reporting period. If the
days of a stay involve admission during one cost reporting period and
discharge in a second consecutive cost reporting period, the total days
of the stay are considered to have occurred in the cost reporting
period during which the patient was discharged. Since this data was not
captured on the cost reporting form, for cost reporting periods
beginning on or after October 1, 2002, CMS retrieved data for the
average length of stay calculation from MedPAR files for use by the
fiscal intermediaries. If the days-follow-the-discharge policy is
finalized, it may be possible to revise the cost reporting form and,
thus, enable fiscal intermediaries to use the Medicare cost report for
this calculation, as they did prior to the implementation of the LTCH
PPS. We are presently analyzing whether use of the MedPAR for this
purpose or revising the cost reporting form to capture all inpatient
days for Medicare patients would be more appropriate. If we revert to
using the cost report for this purpose, the task would require one
calculation annually by fiscal intermediaries for each hospital: the
division of the number of days by the number of discharges. We estimate
that it would take approximately 5 minutes for each of the fiscal
intermediaries to evaluate whether each of the 300 facilities meet the
average length of stay requirement for a total one-time burden of 25
hours.
Section 412.23(e)(4)(ii) states that except as specified in
paragraph (e)(4)(iii) of this section, a satellite facility (as defined
in Sec. 412.22(h)) or a remote location of a hospital (as defined in
Sec. 412.65(a)(2)) that voluntarily reorganizes as a separate Medicare
participating hospital, with or without a concurrent change in
ownership, and that seeks to qualify as a new long-term care hospital
for Medicare payment purposes must demonstrate through documentation
that it meets the average length of stay requirement specified under
paragraphs (e)(2)(i) or (e)(2)(ii) of this section.
The burden associated with this requirement is the time required to
maintain documentation to demonstrate that a satellite facility or a
remote location of a hospital has an average length of stay as
specified by this section. Since this requirement is a voluntary
decision that is made by each facility, we do not know the number of
facilities and remote locations that will seek to become new LTCHs.
However, the information to be documented is currently being collected
and maintained on each facility's cost report; therefore, this
information collection requirement is currently approved under OMB
control number 0938-0050.
Section 412.23(e)(4)(iii) states that satellite facilities and
remote locations of hospitals that became subject to the provider-based
status rules under Sec. 412.65 as of July 1, 2003, that become
separately participating hospitals, and that seek to qualify as long-
term care hospitals for Medicare payment purposes may submit to the
fiscal intermediary discharge data gathered during 5 months of the
immediate 6 months preceding the facility's separation from the main
hospital for calculation of the greater than 25-day average Medicare
inpatient length of stay requirement specified under paragraph (e)(2)
of this section.
The burden associated with this requirement is the time required of
the satellite facilities and remote locations of hospitals that became
subject to the provider-based status rules under as of July 1, 2003, to
submit discharge data to the fiscal intermediary. We estimate that it
will take approximately 5 minutes for each of the 300 facilities to
submit the required information for a total one-time burden of 25
hours.
We have submitted a copy of this proposed rule to OMB for its
review of the information collection requirements described above.
These requirements are not effective until they have been approved by
OMB.
If you comment on any of these information collection and record
keeping requirements, please mail copies directly to the following:
Centers for Medicare & Medicaid Services, Office of Strategic
Operations and Regulatory Affairs, Regulations Development and
Issuances Group, Attn: Dawn Willinghan, CMS-1263-P, Room C5-14-03, 7500
Security Boulevard, Baltimore, MD 21244-1850; and
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 10235, New Executive Office Building, Washington, DC
20503, Attn: Brenda Aguilar, CMS Desk Officer.
Comments submitted to OMB may also be emailed to the following
address: email: baguilar@omb.eop.gov; or faxed to OMB at (202) 395-
6974.
XI. Regulatory Impact Analysis
(If you choose to comment on issues in this section, please include the
caption ``REGULATORY IMPACT ANALYSIS'' at the beginning of your
comments.)
A. Introduction
We have examined the impact of this proposed rule as required by
Executive
[[Page 4782]]
Order 12866 (September 1993, Regulatory Planning and Review), the
Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96-354),
section 1102(b) of the Social Security Act (the Act), the Unfunded
Mandates Reform Act of 1995 (UMRA) (Pub. L. 104-4), and Executive Order
13132.
1. Executive Order 12866
Executive Order 12866 (as amended by Executive Order 13258, which
merely assigns responsibility of duties) 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 one
year). In this proposed rule, we are using the most recent estimate of
the LTCH PPS market basket and updated wage index values to estimate
proposed payments for the 2005 LTCH PPS rate year. Based on the best
available data for 211 LTCHs, we estimate that the proposed 2.9 percent
increase in the standard Federal rate for the 2005 LTCH PPS rate year,
in conjunction with the proposed decrease in the budget neutrality
offset to account for the transition methodology (discussed in section
IV.C.6. of this preamble), would result in an increase in payments from
the 2004 LTCH PPS rate year of $118 million for the 211 LTCHs. (Section
IV.C.6. of this preamble includes an estimate of Medicare program
payments for LTCH services.) Because the combined distributional
effects and costs to the Medicare program are greater than $100
million, this proposed rule is considered a major economic rule, as
defined above.
2. Regulatory Flexibility Act (RFA)
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and government agencies.
Most hospitals and most other providers and suppliers are small
entities, either by nonprofit status or by having revenues of $26
million or less in any 1 year. For purposes of the RFA, all hospitals
are considered small entities according to the Small Business
Administration's latest size standards with total revenues of $26
million or less in any 1 year (for further information, see the Small
Business Administration's regulation at 65 FR 69432, November 17,
2000). Because we lack data on individual hospital receipts, we cannot
determine the number of small proprietary LTCHs. Therefore, we assume
that all LTCHs are considered small entities for the purpose of the
analysis that follows. Medicare fiscal intermediaries are not
considered to be small entities. Individuals and States are not
included in the definition of a small entity.
The provisions of this proposed rule represent a 5.4 percent
increase in estimated payments in the 2005 LTCH PPS rate year (as shown
in Table II below). We do not expect an incremental increase of 5.4
percent to the Medicare payment rates to have a significant effect on
the overall revenues of most LTCHs. In addition, LTCHs also provide
services to (and generate revenue from) patients other than Medicare
beneficiaries. Accordingly, we certify that this proposed rule would
not have a significant impact on a substantial number of small
entities, in accordance with RFA.
3. Impact on Rural Hospitals
Section 1102(b) of the Social Security Act requires us to prepare a
regulatory impact analysis if a proposed or final rule 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 604 of the RFA. For purposes of section 1102(b) of the Act, we
define a small rural hospital as a hospital that is located outside of
a Metropolitan Statistical Area and has fewer than 100 beds. As
discussed in detail below, the rates and policies set forth in this
proposed rule would not have a substantial impact on the 8 rural
hospitals for which data were available that have fewer than 100 beds
and that are located in rural areas.
4. Unfunded Mandates
Section 202 of the UMRA requires that agencies assess anticipated
costs and benefits before issuing any rule that may result in
expenditure in any one year by State, local, or tribal governments, in
the aggregate, or by the private sector, of $110 million or more. This
proposed rule would not mandate any requirements for State, local, or
tribal governments, nor would it result in expenditures by the private
sector of $110 million or more in any one year.
5. Federalism
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications.
We have examined this proposed rule under the criteria set forth in
Executive Order 13132 and have determined that, based on the 20 State
and local LTCHs in our database, this proposed rule would not have any
significant impact on the rights, roles, and responsibilities of State,
local, or tribal governments or preempt State law.
B. Anticipated Effects of Proposed Payment Rate Changes
We discuss the impact of the proposed payment rate changes in this
proposed rule below in terms of their fiscal impact on the Medicare
budget and on LTCHs.
1. Budgetary Impact
Section 123(a)(1) of Medicare, Medicaid and State Child Health
Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999 (BBRA)
(Pub. L. 106-113) requires us to set the proposed payment rates
contained in this proposed rule such that total payments under the LTCH
PPS are projected to equal the amount that would have been paid if this
PPS had not been implemented. However, as discussed in greater detail
in the August 30, 2002, final rule (67 FR 56033-56036), the FY 2003
standard Federal rate ($34,956.15) was calculated as though all LTCHs
will be paid based on 100 percent of the standard Federal rate in FY
2003. As discussed in section IV.C.6. of this proposed rule, we would
apply a proposed budget neutrality offset to payments to account for
the monetary effect of the 5-year transition period and the policy to
permit LTCHs to elect to be paid based on 100 percent of the proposed
standard Federal rate rather than a blend of proposed Federal
prospective payments and reasonable cost-based payments during the
transition. The amount of the proposed offset is equal to 1 minus the
ratio of the estimated reasonable cost-based payments that would have
been made if the LTCH PPS had not been implemented, to the projected
total Medicare program payments that would be made under the transition
methodology and the option to elect payment based on 100 percent of the
Federal prospective payment rate.
2. Impact on Providers
The basic methodology for determining a LTCH PPS payment is set
forth in the regulations at Sec. 412.515 through Sec. 412.525. In
addition to the basic LTC-DRG payment (standard Federal rate x LTC-DRG
relative
[[Page 4783]]
weight), we make adjustments for differences in area wage levels, cost-
of-living adjustment for Alaska and Hawaii, and short-stay outliers. In
addition, LTCHs may also receive high-cost outlier payments for those
cases that qualify under the threshold established each rate year.
Section 412.533 provides for a 5-year transition to fully prospective
payments from payment based on reasonable cost-based methodology.
During the 5-year transition period, payments to LTCHs are based on an
increasing percentage of the LTCH PPS Federal rate and a decreasing
percentage of payment based on reasonable cost-based methodology.
Section 412.533(c) provides for a one-time opportunity for LTCHs to
elect payments based on 100 percent of the LTCH PPS Federal rate.
In order to understand the impact of the changes to the LTCH PPS
discussed in this proposed rule on different categories of LTCHs for
the 2005 LTCH PPS rate year, it is necessary to estimate payments per
discharge under the LTCH PPS rates and factors for the 2004 LTCH PPS
rate year (see the June 6, 2003, final rule; 68 FR 34122-34190) and
payments per discharge that would be made under the LTCH PPS rates and
factors for the 2005 LTCH PPS rate year as discussed in the preamble of
this proposed rule. We also evaluated the percent change in payments
per discharge of estimated 2004 LTCH PPS rate year payments to
estimated 2005 LTCH PPS rate year payments for each category of LTCHs.
Hospital groups were based on characteristics provided in the
Online Survey Certification and Reporting (System) (OSCAR) data and FYs
1999 through 2001 cost report data. Hospitals with incomplete
characteristics were grouped into the ``unknown'' category. Hospital
groups include:
Location: Large Urban/Other Urban/Rural;
Participation Date;
Ownership Control;
Census Region;
Bed Size.
To estimate the impacts among the various categories of providers
during the transition period, it is imperative that reasonable cost-
based methodology payments and prospective payments contain similar
inputs. More specifically, in the impact analysis showing the impact
reflecting the applicable transition blend percentages of proposed
prospective payments and reasonable cost-based methodology payments and
the option to elect payment based on 100 percent of the proposed
Federal rate (Table III below), we estimated payments only for those
providers for whom we are able to calculate payments based on
reasonable cost-based methodology. For example, if we did not have at
least 2 years of historical cost data for a LTCH, we were unable to
determine an update to the LTCH's target amount to estimate payment
under reasonable cost-based methodology.
Using LTCH cases from the FY 2002 MedPAR file and cost data from
FYs 1996 through 2001 to estimate payments under the current reasonable
cost-based principles, we have both case-mix and cost data for 211
LTCHs. Thus, for the impact analyses reflecting the applicable
transition blend percentages of proposed prospective payments and
reasonable cost-based methodology payments and the option to elect
payment based on 100 percent of the proposed Federal rate (see Table II
below), we used data from 211 LTCHs. While currently there are
approximately 300 LTCHs, the most recent growth is predominantly in
for-profit LTCHs that provide respiratory and ventilator-dependent
patient care. We believe that the discharges from the MedPAR data for
the 211 LTCHs in our database provide sufficient representation in the
LTC-DRGs containing discharges for patients who received respiratory
and ventilator-dependent care. However, using cases from the FY 2002
MedPAR file, we had case-mix data for 272 LTCHs. Cost data to determine
current payments under reasonable cost-based methodology payments are
not needed to simulate payments based on 100 percent of the proposed
Federal rate. Therefore, for the impact analyses reflecting fully
phased-in prospective payments (see Table III below), we used data from
272 LTCHs.
These impacts reflect the estimated ``losses'' or ``gains'' among
the various classifications of providers for the 2004 LTCH PPS rate
year (July 1, 2003, through June 30, 2004) compared to the 2005 LTCH
PPS rate year (July 1, 2004, through June 30, 2005). Prospective
payments for the 2004 LTCH rate year were based on the standard Federal
rate of $35,726.18 and the hospital's estimated case-mix based on FY
2002 claims data. Prospective payments for the 2005 LTCH PPS rate year
were based on the proposed standard Federal rate of $36,762.24 and the
same FY 2002 claims data.
3. Calculation of Prospective Payments
To estimate payments under the LTCH PPS, we simulated payments on a
case-by-case basis by applying the existing payment policy for short-
stay outliers (as described in section IV.C.4.b. of this proposed rule)
and the existing adjustments for area wage differences (as described in
section IV.C.1. of this proposed rule) and for the cost-of-living for
Alaska and Hawaii (as described in section IV.C.2. of this proposed
rule). Additional payments would also be made for high-cost outlier
cases (as described in section IV.C.3. of this proposed rule). As noted
in section IV.C.5. of this proposed rule, we are not making adjustments
for rural location, geographic reclassification, indirect medical
education costs, or a disproportionate share of low-income patients.
We adjusted for area wage differences for estimated 2004 LTCH PPS
rate year payments by computing a weighted average of a LTCH's
applicable wage index during the period from July 1, 2003, through June
30, 2004, because some providers may experience a change in the wage
index phase-in percentage during that period. For cost reporting
periods beginning on or after October 1, 2002, and before September 30,
2003, the labor portion of the Federal rate is adjusted by one-fifth of
the applicable ``LTCH PPS wage index'' (that is, the FY 2004 IPPS wage
index data without geographic reclassification, under sections
1886(d)(8) and (d)(10)) of the Act. For cost reporting periods
beginning on or after October 1, 2003, and before September 30, 2004,
the labor portion of the Federal rate is adjusted by two-fifths of the
applicable LTCH PPS wage index. Therefore, a provider with a cost
reporting period that began October 1, 2003, will have 3 months of
payments under the one-fifth wage index value and 9 months of payment
under the two-fifths wage index value. For this provider, we computed a
blended wage index of 25 percent (3 months/12 months) of the one-fifth
wage index value and 75 percent (9 months/12 months) of the two-fifths
wage index value. Similarly, we adjusted for area wage differences for
estimated 2005 LTCH PPS rate year payments by computing a weighted
average of a LTCH's applicable wage index during the period from July
1, 2004, through June 30, 2005, because some providers may experience a
change in the wage index phase-in percentage during that period. For
cost reporting periods beginning on or after October 1, 2003, and
before September 30, 2004, the labor portion of the Federal rate is
adjusted by two-fifths of the applicable LTCH PPS wage index. For cost
reporting periods beginning on or after October 1, 2004, and before
September 30, 2005, the labor portion of the Federal rate is adjusted
by three-fifths of the applicable LTCH PPS wage index. The applicable
proposed LTCH
[[Page 4784]]
PPS wage index values for the 2005 LTCH PPS rate year are shown in
Tables 1 and 2 of the Addendum to this proposed rule.
We also calculated payments using the applicable transition blend
percentages. During the 2004 LTCH PPS rate year, based on the
transition blend percentages set forth in Sec. 412.533(a), some
providers may experience a change in the transition blend percentage
during the period from July 1, 2003, through June 30, 2004. That is,
during the period from July 1, 2003, through June 30, 2004, a provider
with a cost reporting period beginning on October 1, 2002 (which is
paid under the 80/20 transition blend (80 percent of payments based on
reasonable cost-based methodology and 20 percent of payments under the
LTCH PPS), beginning October 1, 2002) had 3 months (July 1, 2003,
through September 30, 2003) under the 80/20 blend and 9 months (October
1, 2003, through June 30, 2004) of payment under the 60/40-transition
blend (60 percent of payments based on reasonable cost-based
methodology and 40 percent of payments under the LTCH PPS). (The 60
percent/40 percent blend would continue until the provider's cost
reporting period beginning on October 1, 2004.)
Similarly, during the 2005 LTCH PPS rate year, based on the
transition blend percentages set forth in Sec. 412.533(a), some
providers may experience a change in the transition blend percentage
during the period from July 1, 2004, through June 30, 2005. That is,
during the period from July 1, 2004, through June 30, 2005, a provider
with a cost reporting period beginning on October 1, 2003 (which is
paid under the 60/40 transition blend), had 3 months (July 1, 2004,
through September 30, 2004) under the 60/40 blend and 9 months (October
1, 2004, through June 30, 2005) of payment under the 40/60-transition
blend (40 percent of payments based on reasonable cost-based
methodology and 60 percent of payments under the LTCH PPS). (The 40
percent/60 percent blend would continue until the provider's cost
reporting period beginning on October 1, 2005.)
In estimating blended transition payments, we estimated payments
based on reasonable cost-based methodology in accordance with the
methodology in section 1886(b) of the Act. We compared the estimated
blended transition payment to the LTCH's estimated payment if it would
elect payment based on 100 percent of the Federal rate. If we estimated
that a LTCH would be paid more based on 100 percent of the Federal
rate, we assumed that it would elect to bypass the transition
methodology and to receive immediate prospective payments.
Then we applied the 6.0 percent budget neutrality reduction to
payments to account for the effect of the 5-year transition methodology
and election of payment based on 100 percent of the Federal rate on
Medicare program payments established in the June 6, 2003, final rule
(68 FR 34153) to each LTCH's estimated payments under the LTCH PPS for
the 2004 LTCH PPS rate year. Similarly, we applied the proposed 3.0
percent budget neutrality reduction to payment to account for the
effect of the 5-year transition methodology and election of payment
based on 100 percent of the proposed Federal rate on Medicare program
payments (see section IV.C.6. of this proposed rule) to each LTCH's
estimated payments under the LTCH PPS for the 2005 LTCH PPS rate year.
The impact based on our projection of whether a LTCH would be paid
based on the transition blend methodology or would elect payment based
on 100 percent of the Federal rate is shown below in Table II.
In Table III below, we also show the impact if the LTCH PPS were
fully implemented; that is, as if there were an immediate transition to
fully Federal prospective payments under the LTCH PPS for the 2004 LTCH
PPS rate year and the 2005 LTCH PPS rate year. Accordingly, the 6.0
percent budget neutrality reduction to account for the 5-year
transition methodology on LTCHs' Medicare program payments for the 2004
LTCH PPS rate year and the proposed 3.0 percent budget neutrality
reduction to account for the 5-year transition methodology on LTCHs'
Medicare program payments established for the 2005 LTCH PPS rate year
were not applied to LTCHs' estimated payments under the PPS.
Tables II and III below illustrate the aggregate impact of the
payment system among various classifications of LTCHs.
The first column, LTCH Classification,
identifies the type of LTCH.
The second column lists the number of LTCHs of
each classification type.
The third column identifies the number of long-
term care cases.
The fourth column shows the estimated payment
per discharge for the 2004 LTCH PPS rate year.
The fifth column shows the estimated payment per
discharge for the 2005 LTCH PPS rate year.
The sixth column shows the percent change of
2004 LTCH PPS rate year compared to the 2005 LTCH PPS rate year.
Table II.--Projected Impact Reflecting Applicable Transition Blend Percentages of Proposed Prospective Payments
and Reasonable Cost-Based (TEFRA) Payments and Option To Elect Payment Based on 100 Percent of the Federal Rate
1
[2004 LTCH PPS Rate Year Payments Compared to Proposed 2005 LTCH Prospective Payment System Rate Year]
----------------------------------------------------------------------------------------------------------------
Average
proposed 2005
Average 2004 LTCH
Number of Number of LTCH LTCH PPS rate prospective
LTCH classification LTCHs cases year payment payment system Percent change
per case 2 rate year
payment per
case 3
----------------------------------------------------------------------------------------------------------------
All Providers................... 211 81,431 26,672.42 28,120.97 5.4
By location:
Rural....................... 8 2,476 21,055.14 22,167.94 5.3
Urban....................... 203 78,955 26,848.58 28,307.66 5.4
Large................... 108 45,078 27,001.83 28,594.50 5.9
Other................... 95 33,877 26,644.66 27,925.98 4.8
By Participation Date:
After October 1993.......... 148 52,146 27,162.64 28,566.47 5.2
Before October 1983......... 16 7,985 20,472.43 22,910.93 11.9
[[Page 4785]]
October 1983--September 1993 45 20,824 27,561.37 28,734.45 4.3
Unknown..................... 2 476 38,085.50 39,877.49 4.7
By Ownership Control:
Voluntary................... 54 21,723 24,589.76 26,297.41 6.9
Proprietary................. 149 57,690 27,484.50 28,863.61 5.0
Government.................. 8 2,018 25,876.08 26,520.63 2.5
By Census Region:
New England................. 12 9,603 20,505.41 23,280 13.5
Middle Atlantic............. 11 4,253 27,252.20 28,405.28 4.2
South Atlantic.............. 22 7,439 31,663.08 32,403.26 2.3
East North Central.......... 40 10,781 29,094.38 30,485.73 4.8
East South Central.......... 12 3,678 28,447.45 29,194.17 2.6
West North Central.......... 14 3,653 27,235.20 29,108.58 6.9
West South Central.......... 71 32,839 25,375.16 26,629.22 4.9
Mountain.................... 17 3,610 27,193.75 28,510.11 4.8
Pacific..................... 12 5,575 31,274.04 33,135.55 6.0
By Bed Size:
Beds: 0-24.................. 18 2,342 27,880.61 29,462.25 5.7
Beds: 25-49................. 97 24,920 27,199.38 28,666.55 5.4
Beds: 50-74................. 33 11,778 27,470.38 28,694.19 4.5
Beds: 75-124................ 32 13,657 27,374.27 28,554.40 4.3
Beds: 125-199............... 22 19,130 25,168.06 26,784.95 6.4
Beds: 200+.................. 9 9,604 26,030.39 27,720.14 6.5
Unknown..................... 0 0 0 0 0.0
----------------------------------------------------------------------------------------------------------------
1 These calculations take into account that some providers may experience a change in the blend percentage
changes during the 2004 and 2005 LTCH PPS rate years. For example, during the period of July 1, 2003, through
June 30, 2004, a provider with a cost reporting period beginning October 1 would have 3 months (July 1, 2003,
through September 30, 2003) of payments under the 80/20 blend and 9 months (October 1, 2003, through June 30,
2004) of payment under the 60/40 blend.
2 Average payment per case for the 12-month period of July 1, 2003, through June 30, 2004.
3 Average payment per case for the 12-month period of July 1, 2004, through June 30, 2005.
Table III.--Projected Impact Reflecting the Fully Phased-In Proposed Prospective Payments
[2004 LTCH PPS Rate Year Payments Compared to Proposed 2005 LTCH Prospective Payment System Rate Year Payments]
----------------------------------------------------------------------------------------------------------------
Average
proposed 2005
Average 2004 LTCH
Number of Number of LTCH LTCH PPS rate prospective
LTCH classification LTCHs cases year payment payment system Percent change
per case 1 rate year
payment per
case 2
----------------------------------------------------------------------------------------------------------------
All Providers................... 272 96,104 26,955.97 27,499.11 2.0
By Location:
Rural....................... 20 7,114 21,361.01 21,774.57 1.9
Urban....................... 252 88,990 27,403.24 27,956.74 2.0
Large................... 129 49,215 27,624.32 28,325.67 2.5
Other................... 123 39,775 27,129.69 27,500.24 1.4
By Participation Date:
After October 1993.......... 200 64,968 27,376.79 27,878.10 1.8
Before October 1983......... 17 8,038 21,542.46 23,435.89 8.8
October 1983--September 1993 48 21,622 27,615.27 27,797.35 0.7
Unknown..................... 7 1,476 28,255.89 28,575.78 1.1
By Ownership Control:
Voluntary................... 62 23,427 25,183.86 26,444.67 5.0
Proprietary................. 169 62,914 27,937.26 28,371.37 1.6
Government.................. 20 6,998 25,497.90 24,712.39 -3.1
By Census Region:
New England................. 14 9,835 21,856.33 24,089.72 10.2
Middle Atlantic............. 18 5,454 26,816.54 27,386.99 2.1
South Atlantic.............. 27 8,028 32,480.27 31,363.84 -3.4
[[Page 4786]]
East North Central.......... 53 13,354 29,429.54 29,810.95 1.3
East South Central.......... 15 4,169 30,028.46 29,916.90 -0.4
West North Central.......... 17 4,355 28,596.20 29,832.89 4.3
West South Central.......... 94 40,775 25,234.32 25,781.35 2.2
Mountain.................... 21 4,335 26,659.53 27,096.15 1.6
Pacific..................... 13 5,799 31,278.68 31,601.47 1.0
By Bed Size:
Beds: 0-24.................. 23 3,105 27,760.33 28,478.85 2.6
Beds: 25-49................. 115 29,060 28,131.57 28,808.02 2.4
Beds: 50-74................. 33 11,778 27,599.01 28,175.22 2.1
Beds: 75-124................ 34 14,270 28,116.29 27,657.35 -1.6
Beds: 125-199............... 24 19,451 25,851.29 26,930.75 4.2
Beds: 200+.................. 10 9,657 26,826.41 27,405.20 2.2
Unknown..................... 33 8,783 22,623.37 23,020.17 1.8
----------------------------------------------------------------------------------------------------------------
1 Average payment per case for the 12-month period of July 1, 2003, through June 30, 2004.
2 Average payment per case for the 12-month period of July 1, 2004, through June 30, 2005.
4. Results
We have prepared the following summary of the impact (as shown in
Table II) of the LTCH PPS set forth in this proposed rule.
a. Location
The majority of LTCHs are in urban areas. Approximately 4 percent
of the LTCHs are identified as being located in a rural area, and
approximately 3 percent of all LTCH cases are treated in these rural
hospitals. Impact analysis in Table II shows that the percent change in
estimated payments per discharge for the 2004 LTCH PPS rate year
compared to the 2005 LTCH PPS rate year for rural LTCHs would be 5.3
percent, and would be 5.4 percent for urban LTCHs. Large urban LTCHs
are projected to experience a 5.9 percent increase in payments per
discharge from the 2004 LTCH PPS rate year compared to the 2005 LTCH
PPS rate year, while other urban LTCHs projected to experience a 4.8
percent increase in payments per discharge from the 2004 LTCH PPS rate
year compared to the 2005 LTCH PPS rate year. (See Table II.)
b. Participation Date
LTCHs are grouped by participation date into three categories: (1)
Before October 1983; (2) between October 1983 and September 1993; and
(3) after October 1993. We did not have sufficient OSCAR data on two
LTCHs, which we labeled as an ``Unknown'' category. The majority,
approximately 64 percent, of the LTCH cases are in hospitals that began
participating after October 1993 and are projected to experience a 5.2
percent increase in payments per discharge from the 2004 LTCH PPS rate
year compared to the 2005 LTCH PPS rate year. Approximately 10 percent
of the cases are in LTCHs that began participating in Medicare before
October 1983 and are projected to experience a 11.9 percent increase in
payments per discharge from the 2004 LTCH PPS rate year compared to the
2005 LTCH PPS rate year. This relatively large increase in payments for
the 2005 LTCH PPS rate year may be attributable to the fact that many
of these LTCHs that began participating in Medicare prior to October
1983 are located in the New England census region (as explained below).
In addition to the update in the standard Federal rate, these LTCHs are
experiencing increases in payments because of an increasing wage index
adjustment, which is two-fifths of the applicable LTCH PPS wage index
for cost reporting periods beginning on or after October 1, 2003, and
three-fifths of the applicable wage index for cost reporting periods
beginning on or after October 1, 2004. In addition, as we discuss in
section IV.C.6. of the preamble of this proposed rule, we are proposing
a 3.0 percent budget neutrality reduction (0.970) to payments in the
2005 LTCH PPS rate year to account for the effect of the 5-year
transition methodology. The proposed 0.970 transition period budget
neutrality factor for the 2005 LTCH PPS rate year is 3 percentage
points lower than the transition period budget neutrality factor for
the 2004 LTCH PPS rate year (0.940). This smaller budget neutrality
offset contributes to greater LTCH payment increases between the 2004
and 2005 LTCH PPS rate years compared to the increases seen between FY
2003 and the 2004 LTCH PPS rate year. We do not expect to see these
large payment per discharge increases in future years as the majority
of LTCHs will have transitioned fully to the LTCH PPS and, therefore,
the transition period budget neutrality factor should remain more
stable.
LTCHs that began participating between October 1983 and September
1993 are projected to experience a 4.3 percent increase in payments per
discharge from the 2004 LTCH PPS rate year compared to the 2005 LTCH
PPS rate year. (See Table II.)
c. Ownership Control
LTCHs are grouped into three categories based on ownership control
type--(1) voluntary; (2) proprietary; and (3) government.
Approximately 4 percent of LTCHs are government run and we expect
that they would ``gain'' from the changes based on our projection that
they would experience a 2.5 percent increase in payments per discharge
from the 2004 LTCH PPS rate year compared to the 2005 LTCH PPS rate
year. Voluntary and proprietary LTCHs are projected to experience a 6.9
percent and 5.0 percent increase in payments per discharge from the
2004 LTCH PPS rate year compared to the 2005 LTCH PPS rate year,
respectively. (See Table II.)
[[Page 4787]]
d. Census Region
LTCHs located in all regions are expected to experience an increase
in payments per discharge from the 2004 LTCH PPS rate year compared to
the 2005 LTCH PPS rate year. Specifically, of the nine census regions,
we expect that LTCHs in the New England region would experience the
largest percent increase in payments per discharge from the 2004 LTCH
PPS rate year compared to the 2005 LTCH PPS rate year (13.5 percent).
As explained above, under section B.4.b. (Participation Date), this
relatively large increase in payments for the 2005 LTCH PPS rate year
may be attributable to the update in the standard Federal rate, and the
fact that these LTCHs are experiencing increases in payments because of
an increasing wage index adjustment, which is two-fifths of the
applicable LTCH PPS wage index for cost reporting periods beginning on
or after October 1, 2003, and three-fifths of the applicable wage index
for cost reporting periods beginning on or after October 1, 2004. In
addition, as we discuss in section IV.C.6. of the preamble of this
proposed rule, we are proposing a 3.0 percent budget neutrality
reduction (0.970) to payments in the 2005 LTCH PPS rate year to account
for the effect of the 5-year transition methodology. The proposed 0.970
transition period budget neutrality factor for the 2005 LTCH PPS rate
year is 3 percentage points lower than the transition period budget
neutrality factor for the 2004 LTCH PPS rate year (0.940). This smaller
budget neutrality offset contributes to greater LTCH payment increases
between the 2004 and 2005 LTCH PPS rate years compared to the increases
seen between FY 2003 and the 2004 LTCH PPS rate year. We do not expect
to see these large payment per discharge increases in future years as
the majority of LTCHs will have transitioned fully to the LTCH PPS and,
therefore, the transition period budget neutrality factor should remain
more stable.
We expect LTCHs in the South Atlantic region would experience the
smallest percent increase in payments per discharge from the 2004 LTCH
PPS rate year compared to the 2005 LTCH PPS rate year (2.3 percent).
(See Table II.)
e. Bed Size
LTCHs were grouped into six categories based on bed size--0-24
beds, 25-49 beds, 50-74 beds, 75-124 beds, 125-199 beds, and 200+ beds.
The percent increase in payments per discharge from the 2004 LTCH
PPS rate year compared to the 2005 LTCH PPS rate year are projected to
increase for all bed size categories.
Most LTCHs were in bed size categories where the percent increase
in payments per discharge from the 2004 LTCH PPS rate year compared to
the 2005 LTCH PPS rate year is estimated to be greater than 5.4
percent. LTCHs with 200 or more beds have the highest estimated percent
change in payments per discharge from the 2004 LTCH PPS rate year
compared to the 2005 LTCH PPS rate year (6.5 percent), while LTCHs with
75-124 beds have the lowest projected increase in the percent change in
payments per discharge from the 2004 LTCH PPS rate year compared to the
2005 LTCH PPS rate year (4.3 percent). (See Table II.)
5. Effect on the Medicare Program
Based on actuarial projections, we estimate that Medicare spending
(total Medicare program payments) for LTCH services over the next 5
years will be as follows:
------------------------------------------------------------------------
Estimated
LTCH PPS rate year payments ($ in
billions)
------------------------------------------------------------------------
2005.................................................. $2.33
2006.................................................. 2.48
2007.................................................. 2.64
2008.................................................. 2.79
2009.................................................. 2.96
------------------------------------------------------------------------
These estimates are based on the current estimate of increase in
the excluded hospital with capital market basket of 2.9 percent for the
2005 LTCH PPS rate year, 3.2 percent for the 2006 LTCH PPS rate year,
3.1 percent for the 2007 LTCH PPS rate year, 3.0 percent for the 2008
LTCH PPS rate year, and 3.2 percent for the 2009 LTCH PPS rate year. We
estimate that there would be an increase in Medicare beneficiary
enrollment of 2.1 percent in the 2005 LTCH PPS rate year, 2.4 percent
in the 2006 LTCH PPS rate year, 2.1 percent in 2007 LTCH PPS rate year,
2.0 percent in the 2008 LTCH PPS rate year, 2.1 percent in the 2009
LTCH PPS rate year, and an estimated increase in the total number of
LTCHs.
Consistent with the statutory requirement for budget neutrality, we
intend for estimated aggregate payments under the LTCH PPS in FY 2003
to equal the estimated aggregate payments that will be made if the LTCH
PPS were not implemented. Our methodology for estimating payments for
purposes of the budget neutrality calculations uses the best available
data and necessarily reflects assumptions. As we collect data from
LTCHs, we will monitor payments and evaluate the ultimate accuracy of
the assumptions used to calculate the budget neutrality calculations
(that is, inflation factors, intensity of services provided, or
behavioral response to the implementation of the LTCH PPS).
Section 123 of BBRA and section 307 of BIPA provide the Secretary
with extremely broad authority in developing the LTCH PPS, including
the authority for appropriate adjustments. In accordance with this
broad authority, we may discuss in a future proposed rule a possible
one-time prospective adjustment to the LTCH PPS rates to maintain
budget neutrality so that the effect of the difference between actual
payments and estimated payments for the first year of LTCH PPS is not
perpetuated in the PPS rates for future years. Because the LTCH PPS was
only recently implemented, we do not yet have sufficient complete data
to determine whether such an adjustment is warranted.
6. Effect on Medicare Beneficiaries
Under the LTCH PPS, hospitals receive payment based on the average
resources consumed by patients for each diagnosis. We do not expect any
changes in the quality of care or access to services for Medicare
beneficiaries under the LTCH PPS, but we expect that paying
prospectively for LTCH services will enhance the efficiency of the
Medicare program.
C. Impact of Proposed Policy Changes
1. Proposed Requirements for Satellite Facilities and Remote Locations
of Hospitals To Qualify as Long-Term Care Hospitals
Under section I.B.3. of the preamble of this proposed rule, we
discuss our proposal to clarify the procedures under which a satellite
facility or a remote location of a hospital must meet the statutory and
regulatory requirements to qualify as a distinct LTCH. Specifically, we
are proposing to present in regulations the procedure for determining
the period from which the fiscal intermediaries will use discharge data
in calculating the average Medicare inpatient length of stay
requirement for a new, separately participating hospital that seeks
classification as a LTCH.
In this proposed rule, we are restating in regulations our existing
policy that a satellite facility or remote location of a hospital
(except for those that are subject to the location requirement under
the provider-based rules at Sec. 413.65) that voluntarily reorganizes
itself as a separate hospital and meets the provider agreement
requirements of 42 CFR part 489 and the Medicare conditions of
participation under 42 CFR part 482 would have its average
[[Page 4788]]
Medicare inpatient length of stay calculated based on discharges that
occur after the satellite facility or remote location is established as
a separate participating hospital.
The policy that we are proposing to incorporate in the regulations
is already in existence. Therefore, complying with the proposed
regulation amendments would pose no additional burden on LTCHs.
We are proposing to incorporate in regulations that govern
requirements for LTCHs a provision that the average Medicare inpatient
length of stay for satellite facilities and remote locations of
hospitals that became subject to the revised location-based provider-
based requirements on July 1, 2003, that reorganize as separate
participating hospitals, and that seek classification as LTCHs, would
continue to be based on discharge data during the 5 months of the
immediate 6 months preceding the facility's separation from the main
hospital. This proposed amendment to the regulation text would
incorporate procedures that are already established under the
regulations governing provider-based entities, but whose implementation
applicable to LTCH classifications were not expounded in the specific
regulations governing LTCHs. The proposed regulations apply only to
those facilities or locations that became subject to the revised
provider-based location rules on July 1, 2003, and that seek
classification as LTCHs for Medicare payment purposes. Therefore, we
are unable to quantify how many or when a facility or location would
seek LTCH classification.
These proposed amendments to the regulations would not impose any
additional requirements on providers. The data used in the calculation
of the average length of stay are already being collected. The existing
procedure for application of the discharge data in calculating the
average length of stay in both circumstances is consistent with
existing statutory and regulatory requirements.
2. Proposed Change in Policy on Interruption of a Stay in a LTCH
Under section IV.C.4.c. of the preamble of this proposed rule, we
are proposing to expand the definition of an interruption of a stay to
include an interruption in which the patient is discharged from the
LTCH, and returns to the LTCH within 3 days of the original discharge.
We have found, through monitoring activities and other sources, that
certain LTCHs are discharging patients during the course of their
treatment for the sole purpose of the patient receiving specific tests
or procedures and then readmitting the patient following the
administration of the test or procedure. We believe these situations
are resulting in improper increases in Medicare costs through separate
billings for services that are already included in the LTC-DRG payment
made to the LTCH. The proposed regulation change would prevent these
inappropriate Medicare payments. However, we do not have sufficient
data at this time to quantify either the number of providers that would
be affected by the proposed change nor the savings to the Medicare
program.
3. Proposed Change in Procedure for Counting Covered and Noncovered
Days in a Stay That Crosses Two Consecutive Cost Reporting Periods
Under section I.B.2. of the preamble to this proposed rule, we are
proposing to specify the procedure for calculating a hospital's
inpatient average length of stay for purposes of classification as a
LTCH when covered and noncovered days of the stay involve admission in
one cost reporting period and discharge in a second consecutive cost
reporting period. Under this circumstance, we are proposing to count
the total number of days of the stay in the cost reporting period
during which the inpatient was discharged. We are proposing this
revised procedure to make it consistent with reporting and payment
procedures already in place for discharge-based payment systems that
link patient days to discharges.
The proposed regulation imposes no additional requirements on
providers. The discharge data are already being collected and the
proposed revision would merely change the procedure for reporting it.
D. Executive Order 12866
In accordance with the provisions of Executive Order 12866, this
proposed rule was reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare,
Puerto Rico, Reporting and recordkeeping requirements.
In accordance with the discussion in this preamble, the Centers for
Medicare & Medicaid Services is proposing to amend 42 CFR chapter IV,
part 412, as set forth below:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
1. The authority citation for part 412 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 412.23 is amended by--
A. Revising paragraphs (e)(3)(i) and (e)(3)(ii).
B. In paragraph (e)(3)(iii), removing the phrase ``required
Medicare average length of stay,'' and adding in its place the phrase
``required average length of stay,''.
C. Revising paragraph (e)(4).
The revisions and additions read as follows:
Sec. 412.23 Excluded hospitals: classifications.
* * * * *
(e) Long-term care hospitals. * * *
(3) Calculation of average length of stay. (i) Subject to the
provisions of paragraphs (e)(3)(ii) and (e)(3)(iii) of this section,
the average Medicare inpatient length of stay specified under paragraph
(e)(2)(i) of this section is calculated by dividing the total number of
covered and noncovered days of stay of Medicare inpatients (less leave
or pass days) by the number of total Medicare discharges for the
hospital's most recent complete cost reporting period. The average
inpatient length of stay specified under paragraph (e)(2)(ii) of this
section is calculated by dividing the total number of days for all
patients, including both Medicare and non-Medicare inpatients (less
leave or pass days) by the number of total discharges for the
hospital's most recent complete cost reporting period. If the days of a
stay of an inpatient involve an admission during one cost reporting
period and a discharge in a second consecutive cost reporting period,
the total number of days of the stay are considered to have occurred in
the cost reporting period during which the inpatient was discharged.
(ii) If a change in a hospital's average length of stay specified
under paragraph (e)(2)(i) or paragraph (e)(2)(ii) of this section is
indicated, the calculation is made by the same method for the period of
at least 5 months of the immediately preceding 6-month period.
* * * * *
(4) Rules applicable to new long-term care hospitals--(i)
Definition. For purposes of payment under the long-term care hospital
prospective payment system under subpart O of this part, a new long-
term care hospital is a provider of inpatient hospital services that
meets the qualifying criteria in paragraphs (e)(1) and (e)(2) of this
section and, under present or previous ownership (or both), its first
cost reporting period as a LTCH begins on or after October 1, 2002.
[[Page 4789]]
(ii) Satellite facilities and remote locations of hospitals seeking
to become new long-term care hospitals. Except as specified in
paragraph (e)(4)(iii) of this section, a satellite facility (as defined
in Sec. 412.22(h)) or a remote location of a hospital (as defined in
Sec. 413.65(a)(2)) that voluntarily reorganizes as a separate Medicare
participating hospital, with or without a concurrent change in
ownership, and that seeks to qualify as a new long-term care hospital
for Medicare payment purposes must demonstrate through documentation
that it meets the average length of stay requirement as specified under
paragraphs (e)(2)(i) or (e)(2)(ii) of this section based on discharges
that occur on or after the effective date of its participation under
Medicare as a separate hospital.
(iii) Provider-based facility or organization identified as a
satellite facility and remote location of a hospital prior to July l,
2003. Satellite facilities and remote locations of hospitals that
became subject to the provider-based status rules under Sec. 413.65 as
of July l, 2003, that become separately participating hospitals, and
that seek to qualify as long-term care hospitals for Medicare payment
purposes may submit to the fiscal intermediary discharge data gathered
during 5 months of the immediate 6 months preceding the facility's
separation from the main hospital for calculation of the average length
of stay specified under paragraph (e)(2)(i) or paragraph (e)(2)(ii) of
this section.
* * * * *
3. Section 412.531 is amended by--
A. Revising paragraph (a).
B. Revising paragraph (b)(1).
The revisions and additions read as follows:
Sec. 412.531 Special payment provisions when an interruption of a stay
occurs in a long-term care hospital.
(a) Interruption of a stay defined. ``Interruption of a stay''
means--
(1) A stay at a long-term care hospital during which a Medicare
inpatient is discharged from the long-term care hospital and returns to
the same long-term care hospital within 3 consecutive days under
conditions other than those specified in paragraph (a)(2)(i) through
(a)(2)(iii) of this section. The duration of the interruption of the
stay of 3 consecutive days begins with the date of discharge from the
long-term care hospital and ends at midnight of the third day.
(2) A stay in a long-term care hospital during which a Medicare
inpatient is discharged from the long-term care hospital to an acute
care hospital, an IRF, or a SNF and returns to the same long-term care
hospital within the applicable fixed day period specified in paragraphs
(a)(2)(i) through (a)(2)(iii) of this section.
(i) For a discharge to an acute care hospital, the applicable fixed
day period is 9 days. The counting of the days begins on the date of
discharge from the long-term care hospital and ends on the 9th date
after the discharge.
(ii) For a discharge to an IRF, the applicable fixed day period is
27 days. The counting of the days begins on the day of discharge from
the long-term care hospital and ends on the 27th day after discharge.
(iii) For a discharge to a SNF, the applicable fixed day period is
45 days. The counting of the days begins on the day of discharge from
the long-term care hospital and ends on the 45th day after the
discharge.
(b) Methods of determining payments. (1) In determining payments,
the following provisions apply:
(i) For purposes of determining a Federal prospective payment, any
stay in a long-term care hospital that involves an interruption of the
stay will be paid as a single discharge from the long-term care
hospital. CMS will make only one LTC-DRG payment for all portions of a
long-term care stay that involves an interruption of stay.
(ii) Except as specified in paragraph (b)(1)(iii) of this section,
the number of days that a beneficiary spends away from the long-term
care hospital during a 3-day interruption of stay, as defined in
paragraph (a)(1) of this section, is not included in determining the
length of stay of the patient at the long-term care hospital when there
is no medical care or treatment that is considered a covered service
delivered to the beneficiary.
(iii) The number of days that a beneficiary spends away from a
long-term care hospital during an interruption of stay defined under
paragraph (a)(1) of this section during which the beneficiary receives
medical care or treatment that is considered a covered service and
returns to the long-term care hospital within 3 consecutive days or
less after a discharge is counted in determining the length of stay of
the patient at the long-term care hospital.
(iv) In accordance with Sec. 412.509, CMS will not make any payment
other than the LTC-DRG payment as specified under paragraph (b)(1)(i)
of this section for covered services that should have been furnished by
the long-term care hospital during a 3-day interruption of stay, as
defined in paragraph (a)(1) of this section.
(v) In accordance with Sec. 412.513(b), payment will be based on
the patient's LTC-DRG that would be determined by the principal
diagnosis, which is the condition established after study to be chiefly
responsible for occasioning the first admission of the patient to the
hospital for care.
* * * * *
Sec. 412.532 [Amended]
4. In Sec. 412.532(i), the reference ``paragraphs (h)(1) through
(h)(4) of this section'' is revised to read ``Sec. 412.22(h)(1) through
(h)(4)''.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance.)
Dated: December 14, 2003.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
Dated: January 21, 2004.
Tommy G. Thompson,
Secretary.
Addendum
This addendum contains the tables referred to throughout the
preamble to this proposed rule. The tables presented below are as
follows:
Table 1.--Long-Term Care Hospital Proposed Wage Index for Urban
Areas for Discharges Occurring from July 1, 2004 through June 30,
2005;
Table 2.--Long-Term Care Hospital Proposed Wage Index for Rural
Areas for Discharges Occurring from July 1, 2004 through June 30,
2005;
Table 3.--FY 2004 LTC-DRG Relative Weights, Geometric Mean
Length of Stay, and Short-Stay Five-Sixths Average Length of Stay
for Discharges Occurring from July 1, 2004 through September 30,
2004.
(Note: This is the same information provided in Table 11 of the
August 1, 2003, IPPS final rule (68 FR 45650-45658), which has been
reprinted here for convenience.)
[[Page 4790]]
Table 1.--Long-Term Care Hospital Proposed Wage Index for Urban Areas for Discharges Occurring From July 1, 2004
Through June 30, 2005
----------------------------------------------------------------------------------------------------------------
Urban area (constituent Full wage 1/5th wage 2/5ths wage 3/5ths wage
MSA counties) index \1\ index \2\ index \3\ index \4\
----------------------------------------------------------------------------------------------------------------
0040............ Abilene, TX................... 0.7627 0.9525 0.9051 0.8576
Taylor, TX
0060............ Aguadilla, PR................. 0.4306 0.8861 0.7722 0.6584
Aguada, PR
Aguadilla, PR
Moca, PR
0080............ Akron, OH..................... 0.9246 0.9849 0.9698 0.9548
Portage, OH
Summit, OH
0120............ Albany, GA.................... 1.0863 1.0173 1.0345 1.0518
Dougherty, GA
Lee, GA
0160............ Albany-Schenectady-Troy, NY... 0.8489 0.9698 0.9396 0.9093
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200............ Albuquerque, NM............... 0.9300 0.9860 0.9720 0.9580
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220............ Alexandria, LA................ 0.8019 0.9604 0.9208 0.8811
Rapides, LA
0240............ Allentown-Bethlehem-Easton, PA 0.9721 0.9944 0.9888 0.9833
Carbon, PA
Lehigh, PA
Northampton, PA
0280............ Altoona, PA................... 0.8806 0.9761 0.9522 0.9284
Blair, PA
0320............ Amarillo, TX.................. 0.8986 0.9797 0.9594 0.9392
Potter, TX
Randall, TX
0380............ Anchorage, AK................. 1.2216 1.0443 1.0886 1.1330
Anchorage, AK
0440............ Ann Arbor, MI................. 1.1074 1.0215 1.0430 1.0644
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450............ Anniston, AL.................. 0.8090 0.9618 0.9236 0.8854
Calhoun, AL
0460............ Appleton-Oshkosh-Neenah, WI... 0.9035 0.9807 0.9614 0.9421
Calumet, WI
Outagamie, WI
Winnebago, WI
0470............ Arecibo, PR................... 0.4155 0.8831 0.7662 0.6493
Arecibo, PR
Camuy, PR
Hatillo, PR
0480............ Asheville, NC................. 0.9720 0.9944 0.9888 0.9832
Buncombe, NC
Madison, NC
0500............ Athens, GA.................... 0.9818 0.9964 0.9927 0.9891
Clarke, GA
Madison, GA
Oconee, GA
0520............ Atlanta, GA................... 1.0130 1.0026 1.0052 1.0078
Barrow, GA
Bartow, GA
Carroll, GA
Cherokee, GA
Clayton, GA
Cobb, GA
Coweta, GA
DeKalb, GA
Douglas, GA
Fayette, GA
Forsyth, GA
Fulton, GA
[[Page 4791]]
Gwinnett, GA
Henry, GA
Newton, GA
Paulding, GA
Pickens, GA
Rockdale, GA
Spalding, GA
Walton, GA
0560............ Atlantic-Cape May, NJ......... 1.0795 1.0159 1.0318 1.0477
Atlantic, NJ
Cape May, NJ
0580............ Auburn-Opelika, AL............ 0.8494 0.9699 0.9398 0.9096
Lee, AL
0600............ Augusta-Aiken, GA-SC.......... 0.9625 0.9925 0.9850 0.9775
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640............ Austin-San Marcos, TX......... 0.9609 0.9922 0.9844 0.9765
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680............ Bakersfield, CA............... 0.9810 0.9962 0.9924 0.9886
Kern, CA
0720............ Baltimore, MD................. 0.9919 0.9984 0.9968 0.9951
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733............ Bangor, ME.................... 0.9904 0.9981 0.9962 0.9942
Penobscot, ME
0743............ Barnstable-Yarmouth, MA....... 1.2956 1.0591 1.1182 1.1774
Barnstable, MA
0760............ Baton Rouge, LA............... 0.8406 0.9681 0.9362 0.9044
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840............ Beaumont-Port Arthur, TX...... 0.8424 0.9685 0.9370 0.9054
Hardin, TX
Jefferson, TX
Orange, TX
0860............ Bellingham, WA................ 1.1757 1.0351 1.0703 1.1054
Whatcom, WA
0870............ Benton Harbor, MI............. 0.8871 0.9774 0.9548 0.9323
Berrien, MI
0875............ Bergen-Passaic, NJ............ 1.1692 1.0338 1.0677 1.1015
Bergen, NJ
Passaic, NJ
0880............ Billings, MT.................. 0.8961 0.9792 0.9584 0.9377
Yellowstone, MT
0920............ Biloxi-Gulfport-Pascagoula, MS 0.9029 0.9806 0.9612 0.9417
Hancock, MS
Harrison, MS
Jackson, MS
0960............ Binghamton, NY................ 0.8428 0.9686 0.9371 0.9057
Broome, NY
Tioga, NY
1000............ Birmingham, AL................ 0.9212 0.9842 0.9685 0.9527
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010............ Bismarck, ND.................. 0.7965 0.9593 0.9186 0.8779
[[Page 4792]]
Burleigh, ND
Morton, ND
1020............ Bloomington, IN............... 0.8662 0.9732 0.9465 0.9197
Monroe, IN
1040............ Bloomington-Normal, IL........ 0.8832 0.9766 0.9533 0.9299
McLean, IL
1080............ Boise City, ID................ 0.9209 0.9842 0.9684 0.9525
Ada, ID
Canyon, ID
1123............ Boston-Worcester-Lawrence- 1.1233 1.0247 1.0493 1.0740
Lowell-Brockton, MA-NH (NH
Hospitals).
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125............ Boulder-Longmont, CO.......... 1.0049 1.0010 1.0020 1.0029
Boulder, CO
1145............ Brazoria, TX.................. 0.8137 0.9627 0.9255 0.8882
Brazoria, TX
1150............ Bremerton, WA................. 1.0580 1.0116 1.0232 1.0348
Kitsap, WA
1240............ Brownsville-Harlingen-San 1.0303 1.0061 1.0121 1.0182
Benito, TX.
Cameron, TX
1260............ Bryan-College Station, TX..... 0.9019 0.9804 0.9608 0.9411
Brazos, TX
1280............ Buffalo-Niagara Falls, NY..... 0.9604 0.9921 0.9842 0.9762
Erie, NY
Niagara, NY
1303............ Burlington, VT................ 0.9704 0.9941 0.9882 0.9822
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310............ Caguas, PR.................... 0.4158 0.8832 0.7663 0.6495
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320............ Canton-Massillon, OH.......... 0.9071 0.9814 0.9628 0.9443
Carroll, OH
Stark, OH
1350............ Casper, WY.................... 0.9095 0.9819 0.9638 0.9457
Natrona, WY
1360............ Cedar Rapids, IA.............. 0.8874 0.9775 0.9550 0.9324
Linn, IA
1400............ Champaign-Urbana, IL.......... 0.9907 0.9981 0.9963 0.9944
Champaign, IL
1440............ Charleston-North Charleston, 0.9332 0.9866 0.9733 0.9599
SC.
Berkeley, SC
Charleston, SC
Dorchester, SC
1480............ Charleston, WV................ 0.8880 0.9776 0.9552 0.9328
Kanawha, WV
Putnam, WV
1520............ Charlotte-Gastonia-Rock Hill, 0.9760 0.9952 0.9904 0.9856
NC-SC.
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
[[Page 4793]]
1540............ Charlottesville, VA........... 1.0025 1.0005 1.0010 1.0015
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560............ Chattanooga, TN-GA............ 0.9086 0.9817 0.9634 0.9452
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580............ Cheyenne, WY.................. 0.8796 0.9759 0.9518 0.9278
Laramie, WY
1600............ Chicago, IL................... 1.0892 1.0178 1.0357 1.0535
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620............ Chico-Paradise, CA............ 1.0193 1.0039 1.0077 1.0116
Butte, CA
1640............ Cincinnati, OH-KY-IN.......... 0.9413 0.9883 0.9765 0.9648
Dearborn, IN
Ohio, IN
Boone, KY
Campbell, KY
Gallatin, KY
Grant, KY
Kenton, KY
Pendleton, KY
Brown, OH
Clermont, OH
Hamilton, OH
Warren, OH
1660............ Clarksville-Hopkinsville, TN- 0.8244 0.9649 0.9298 0.8946
KY.
Christian, KY
Montgomery, TN
1680............ Cleveland-Lorain-Elyria, OH... 0.9671 0.9934 0.9868 0.9803
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720............ Colorado Springs, CO.......... 0.9833 0.9967 0.9933 0.9900
El Paso, CO
1740............ Columbia, MO.................. 0.8695 0.9739 0.9478 0.9217
Boone, MO
1760............ Columbia, SC.................. 0.8902 0.9780 0.9561 0.9341
Lexington, SC
Richland, SC
1800............ Columbus, GA-AL............... 0.8694 0.9739 0.9478 0.9216
Russell, AL
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840............ Columbus, OH.................. 0.9648 0.9930 0.9859 0.9789
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880............ Corpus Christi, TX............ 0.8521 0.9704 0.9408 0.9113
Nueces, TX
San Patricio, TX
[[Page 4794]]
1890............ Corvallis, OR................. 1.1516 1.0303 1.0606 1.0910
Benton, OR
1900............ Cumberland, MD-WV (WV 0.8200 0.9640 0.9280 0.8920
Hospital).
Allegany, MD
Mineral, WV
1920............ Dallas, TX.................... 0.9974 0.9995 0.9990 0.9984
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950............ Danville, VA.................. 0.9035 0.9807 0.9614 0.9421
Danville City, VA
Pittsylvania, VA
1960............ Davenport-Moline-Rock Island, 0.8985 0.9797 0.9594 0.9391
IA-IL.
Scott, IA
Henry, IL
Rock Island, IL
2000............ Dayton-Springfield, OH........ 0.9518 0.9904 0.9807 0.9711
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020............ Daytona Beach, FL............. 0.9078 0.9816 0.9631 0.9447
Flagler, FL
Volusia, FL
2030............ Decatur, AL................... 0.8828 0.9766 0.9531 0.9297
Lawrence, AL
Morgan, AL
2040............ Decatur, IL................... 0.8161 0.9632 0.9264 0.8897
Macon, IL
2080............ Denver, CO.................... 1.0837 1.0167 1.0335 1.0502
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120............ Des Moines, IA................ 0.9106 0.9821 0.9642 0.9464
Dallas, IA
Polk, IA
Warren, IA
2160............ Detroit, MI................... 1.0101 1.0020 1.0040 1.0061
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180............ Dothan, AL.................... 0.7741 0.9548 0.9096 0.8645
Dale, AL
Houston, AL
2190............ Dover, DE..................... 0.9805 0.9961 0.9922 0.9883
Kent, DE
2200............ Dubuque, IA................... 0.8886 0.9777 0.9554 0.9332
Dubuque, IA
2240............ Duluth-Superior, MN-WI........ 1.0171 1.0034 1.0068 1.0103
St. Louis, MN
Douglas, WI
2281............ Dutchess County, NY........... 1.0934 1.0187 1.0374 1.0560
Dutchess, NY
2290............ Eau Claire, WI................ 0.9064 0.9813 0.9626 0.9438
Chippewa, WI
Eau Claire, WI
2320............ El Paso, TX................... 0.9196 0.9839 0.9678 0.9518
El Paso, TX
2330............ Elkhart-Goshen, IN............ 0.9783 0.9957 0.9913 0.9870
Elkhart, IN
[[Page 4795]]
2335............ Elmira, NY.................... 0.8377 0.9675 0.9351 0.9026
Chemung, NY
2340............ Enid, OK...................... 0.8559 0.9712 0.9424 0.9135
Garfield, OK
2360............ Erie, PA...................... 0.8601 0.9720 0.9440 0.9161
Erie, PA
2400............ Eugene-Springfield, OR........ 1.1456 1.0291 1.0582 1.0874
Lane, OR
2440............ Evansville-Henderson, IN-KY 0.8429 0.9686 0.9372 0.9057
(in hospitals).
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520............ Fargo-Moorhead, ND-MN......... 0.9797 0.9959 0.9919 0.9878
Clay, MN
Cass, ND
2560............ Fayetteville, NC.............. 0.8986 0.9797 0.9594 0.9392
Cumberland, NC
2580............ Fayetteville-Springdale- 0.8396 0.9679 0.9358 0.9038
Rogers, AR.
Benton, AR
Washington, AR
2620............ Flagstaff, AZ-UT.............. 1.1333 1.0267 1.0533 1.0800
Coconino, AZ
Kane, UT
2640............ Flint, MI..................... 1.0858 1.0172 1.0343 1.0515
Genesee, MI
2650............ Florence, AL.................. 0.7747 0.9549 0.9099 0.8648
Colbert, AL
Lauderdale, AL
2655............ Florence, SC.................. 0.8709 0.9742 0.9484 0.9225
Florence, SC
2670............ Fort Collins-Loveland, CO..... 1.0108 1.0022 1.0043 1.0065
Larimer, CO
2680............ Ft. Lauderdale, FL............ 1.0163 1.0033 1.0065 1.0098
Broward, FL
2700............ Fort Myers-Cape Coral, FL..... 0.9816 0.9963 0.9926 0.9890
Lee, FL
2710............ Fort Pierce-Port St. Lucie, FL 1.0008 1.0002 1.0003 1.0005
Martin, FL
St. Lucie, FL
2720............ Fort Smith, AR-OK............. 0.8424 0.9685 0.9370 0.9054
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750............ Fort Walton Beach, FL......... 0.8966 0.9793 0.9586 0.9380
Okaloosa, FL
2760............ Fort Wayne, IN................ 0.9585 0.9917 0.9834 0.9751
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800............ Forth Worth-Arlington, TX..... 0.9359 0.9872 0.9744 0.9615
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840............ Fresno, CA.................... 1.0094 1.0019 1.0038 1.0056
Fresno, CA
Madera, CA
2880............ Gadsden, AL................... 0.8206 0.9641 0.9282 0.8924
Etowah, AL
2900............ Gainesville, FL............... 0.9693 0.9939 0.9877 0.9816
Alachua, FL
2920............ Galveston-Texas City, TX...... 0.9279 0.9856 0.9712 0.9567
Galveston, TX
2960............ Gary, IN...................... 0.9410 0.9882 0.9764 0.9646
Lake, IN
Porter, IN
[[Page 4796]]
2975............ Glens Falls, NY............... 0.8475 0.9695 0.9390 0.9085
Warren, NY
Washington, NY
2980............ Goldsboro, NC................. 0.8622 0.9724 0.9449 0.9173
Wayne, NC
2985............ Grand Forks, ND-MN............ 0.8636 0.9727 0.9454 0.9182
Polk, MN
Grand Forks, ND
2995............ Grand Junction, CO............ 0.9633 0.9927 0.9853 0.9780
Mesa, CO
3000............ Grand Rapids-Muskegon-Holland, 0.9469 0.9894 0.9788 0.9681
MI.
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040............ Great Falls, MT............... 0.8809 0.9762 0.9524 0.9285
Cascade, MT
3060............ Greeley, CO................... 0.9372 0.9874 0.9749 0.9623
Weld, CO
3080............ Green Bay, WI................. 0.9461 0.9892 0.9784 0.9677
Brown, WI
3120............ Greensboro-Winston-Salem-High 0.9166 0.9833 0.9666 0.9500
Point, NC.
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150............ Greenville, NC................ 0.9098 0.9820 0.9639 0.9459
Pitt, NC
3160............ Greenville-Spartanburg- 0.9335 0.9867 0.9734 0.9601
Anderson, SC.
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180............ Hagerstown, MD................ 0.9172 0.9834 0.9669 0.9503
Washington, MD
3200............ Hamilton-Middletown, OH....... 0.9214 0.9843 0.9686 0.9528
Butler, OH
3240............ Harrisburg-Lebanon-Carlisle, 0.9164 0.9833 0.9666 0.9498
PA.
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283............ Hartford, CT.................. 1.1555 1.0311 1.0622 1.0933
Litchfield, CT
Middlesex, CT
Tolland, CT
3285............ Hattiesburg, MS............... 0.7307 0.9461 0.8923 0.8384
Forrest, MS
Lamar, MS
3290............ Hickory-Morganton-Lenoir, NC.. 0.9242 0.9848 0.9697 0.9545
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320............ Honolulu, HI.................. 1.1098 1.0220 1.0439 1.0659
Honolulu, HI
3350............ Houma, LA..................... 0.7748 0.9550 0.9099 0.8649
Lafourche, LA
Terrebonne, LA
3360............ Houston, TX................... 0.9834 0.9967 0.9934 0.9900
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
[[Page 4797]]
Waller, TX
3400............ Huntington-Ashland, WV-KY-OH.. 0.9595 0.9919 0.9838 0.9757
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440............ Huntsville, AL................ 0.9245 0.9849 0.9698 0.9547
Limestone, AL
Madison, AL
3480............ Indianapolis, IN.............. 0.9916 0.9983 0.9966 0.9950
Boone, IN
Hamilton, IN
Hancock, IN
Henricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500............ Iowa City, IA................. 0.9548 0.9910 0.9819 0.9729
Johnson, IA
3520............ Jackson, MI................... 0.8986 0.9797 0.9594 0.9392
3560............ Jackson, MS................... 0.8357 0.9671 0.9343 0.9014
Hinds, MS
Madison, MS
Rankin, MS
3580............ Jackson, TN................... 0.8984 0.9797 0.9594 0.9390
Madison, TN
Chester, TN
3600............ Jacksonville, FL.............. 0.9529 0.9906 0.9812 0.9717
Clay, FL
Duval, FL
Nasssau, FL
St. Johns, FL
3605............ Jacksonville, NC.............. 0.8544 0.9709 0.9418 0.9126
Onslow, NC
3610............ Jamestown, NY................. 0.7762 0.9552 0.9105 0.8657
Chautauqua, NY
3620............ Janesville-Beloit, WI......... 0.9282 0.9856 0.9713 0.9569
Rock, WI
3640............ Jersey City, NJ............... 1.1115 1.0223 1.0446 1.0669
Hudson, NJ
3660............ Johnson City-Kingsport- 0.8253 0.9651 0.9301 0.8952
Bristol, TN-VA.
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680............ Johnstown, PA................. 0.8158 0.9632 0.9263 0.8895
Cambria, PA
Somerset, PA
3700............ Jonesboro, AR................. 0.7794 0.9559 0.9118 0.8676
Craighead, AR
3710............ Joplin, MO.................... 0.8681 0.9736 0.9472 0.9209
Jasper, MO
Newton, MO
3720............ Kalamazoo-Battlecreek, MI..... 1.0500 1.0100 1.0200 1.0300
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740............ Kankakee, IL.................. 1.0419 1.0084 1.0168 1.0251
Kankakee, IL
3760............ Kansas City, KS-MO............ 0.9715 0.9943 0.9886 0.9829
Johnson, KS
Leavenworth, KS
[[Page 4798]]
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800............ Kenosha, WI................... 0.9761 0.9952 0.9904 0.9857
Kenosha, WI
3810............ Killeen-Temple, TX............ 0.9159 0.9832 0.9664 0.9495
Bell, TX
Coryell, TX
3840............ Knoxville, TN................. 0.8820 0.9764 0.9528 0.9292
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850............ Kokomo, In.................... 0.9045 0.9809 0.9618 0.9427
Howard, IN
Tipton, IN
3870............ La Crosse, WI-MN.............. 0.9247 0.9849 0.9699 0.9548
Houston, MN
La Crosse, WI
3880............ Lafayette, LA................. 0.8189 0.9638 0.9276 0.8913
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920............ Lafayette, IN................. 0.8584 0.9717 0.9434 0.9150
Clinton, IN
Tippecanoe, IN
3960............ Lake Charles, LA.............. 0.7841 0.9568 0.9136 0.8705
Calcasieu, LA
3980............ Lakeland-Winter Haven, FL..... 0.8811 0.9762 0.9524 0.9287
Polk, FL
4000............ Lancaster, PA................. 0.9282 0.9856 0.9713 0.9569
Lancaster, PA
4040............ Lansing-East Lansing, MI...... 0.9714 0.9943 0.9886 0.9828
Clinton, MI
Eaton, MI
Ingham, MI
4080............ Laredo, TX.................... 0.8091 0.9618 0.9236 0.8855
Webb, TX
4100............ Las Cruces, NM................ 0.8688 0.9738 0.9475 0.9213
Dona Ana, NM
4120............ Las Vegas, NV-AZ.............. 1.1528 1.0306 1.0611 1.0917
Mohave, AZ
Clark, NV
Nye, NV
4150............ Lawrence, KS.................. 0.8677 0.9735 0.9471 0.9206
Douglas, KS
4200............ Lawton, OK.................... 0.8267 0.9653 0.9307 0.8960
Comanche, OK
4243............ Lewiston-Auburn, ME........... 0.9383 0.9877 0.9753 0.9630
Androscoggin, ME
4280............ Lexington, KY................. 0.8685 0.9737 0.9474 0.9211
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320............ Lima, OH...................... 0.9522 0.9904 0.9809 0.9713
Allen, OH
Auglaize, OH
[[Page 4799]]
4360............ Lincoln, NE................... 1.0033 1.0007 1.0013 1.0020
Lancaster, NE
4400............ Little Rock-North Little Rock, 0.8923 0.9785 0.9569 0.9354
AR.
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420............ Longview-Marshall, TX......... 0.9113 0.9823 0.9645 0.9468
Gregg, TX
Harrison, TX
Upshur, TX
4480............ Los Angeles-Long Beach, CA.... 1.1795 1.0359 1.0718 1.1077
Los Angeles, CA
4520............ Louisville, KY-IN\1\.......... 0.9242 0.9848 0.9697 0.9545
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600............ Lubbock, TX................... 0.8272 0.9654 0.9309 0.8963
Lubbock, TX
4640............ Lynchburg, VA................. 0.9134 0.9827 0.9654 0.9480
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680............ Macon, GA..................... 0.8953 0.9791 0.9581 0.9372
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720............ Madison, WI................... 1.0264 1.0053 1.0106 1.0158
Dane, WI
4800............ Mansfield, OH................. 0.9180 0.9836 0.9672 0.9508
Crawford, OH
Richland, OH
4840............ Mayaguez, PR.................. 0.4795 0.8959 0.7918 0.6877
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880............ McAllen-Edinburg-Mission, TX.. 0.8381 0.9676 0.9352 0.9029
Hidalgo, TX
4890............ Medford-Ashland, OR........... 1.0772 1.0154 1.0309 1.0463
Jackson, OR
4900............ Melbourne-Titusville-Palm Bay, 0.9776 0.9955 0.9910 0.9866
FL.
Brevard, FL
4920............ Memphis, TN-AR-MS............. 0.9009 0.9802 0.9604 0.9405
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940............ Merced, CA.................... 0.9690 0.9938 0.9876 0.9814
Merced, CA
5000............ Miami, FL..................... 0.9894 0.9979 0.9958 0.9936
Dade, FL
5015............ Middlesex-Somerset-Hunterdon, 1.1366 1.0273 1.0546 1.0820
NJ.
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080............ Milwaukee-Waukesha, WI........ 0.9988 0.9998 0.9995 0.9993
Milwaukee, WI
Ozaukee, WI
[[Page 4800]]
Washington, WI
Waukesha, WI
5120............ Minneapolis-St. Paul, MN-WI... 1.1001 1.0200 1.0400 1.0601
Anoka, MN
Carver, MN
Chisago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherburne, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5140............ Missoula, MT.................. 0.8718 0.9744 0.9487 0.9231
Missoula, MT
5160............ Mobile, AL.................... 0.7994 0.9599 0.9198 0.8796
Baldwin, AL
Mobile, AL
5170............ Modesto, CA................... 1.1275 1.0255 1.0510 1.0765
Stanislaus, CA
5190............ Monmouth-Ocean, NJ............ 1.0956 1.0191 1.0382 1.0574
Monmouth, NJ
Ocean, NJ
5200............ Monroe, LA.................... 0.7922 0.9584 0.9169 0.8753
Ouachita, LA
5240............ Montgomery, AL................ 0.7907 0.9581 0.9163 0.8744
Autauga, AL
Elmore, AL
Montgomery, AL
5280............ Muncie, IN.................... 0.8775 0.9755 0.9510 0.9265
Delaware, IN
5330............ Myrtle Beach, SC.............. 0.9112 0.9822 0.9645 0.9467
Horry, SC
5345............ Naples, FL.................... 0.9790 0.9958 0.9916 0.9874
Collier, FL
5360............ Nashville, TN................. 0.9855 0.9971 0.9942 0.9913
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380............ Nassau-Suffolk, NY............ 1.3140 1.0628 1.1256 1.1884
Nassau, NY
Suffolk, NY
5483............ New Haven-Bridgeport-Stamford- 1.2385 1.0477 1.0954 1.1431
Waterbury, CT.
Danbury, CT
Fairfield, CT
New Haven, CT
5523............ New London-Norwich, CT........ 1.1631 1.0326 1.0652 1.0979
New London, CT
5560............ New Orleans, LA............... 0.9174 0.9835 0.9670 0.9504
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600............ New York, NY.................. 1.4018 1.0804 1.1607 1.2411
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
[[Page 4801]]
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640............ Newark, NJ.................... 1.1518 1.0304 1.0607 1.0911
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660............ Newburgh, NY-PA............... 1.1509 1.0302 1.0604 1.0905
Orange, NY
Pike, PA
5720............ Norfolk-Virginia Beach-Newport 0.8619 0.9724 0.9448 0.9171
News, VA-NC.
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
York, VA
5775............ Oakland, CA................... 1.4921 1.0984 1.1968 1.2953
Alameda, CA
Contra Costa, CA
5790............ Ocala, FL..................... 0.9728 0.9946 0.9891 0.9837
Marion, FL
5800............ Odessa-Midland, TX............ 0.9327 0.9865 0.9731 0.9596
Ector, TX
Midland, TX
5880............ Oklahoma City, OK............. 0.8984 0.9797 0.9594 0.9390
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910............ Olympia, WA................... 1.0963 1.0193 1.0385 1.0578
Thurston, WA
5920............ Omaha, NE-IA.................. 0.9745 0.9949 0.9898 0.9847
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945............ Orange County, CA............. 1.1372 1.0274 1.0549 1.0823
Orange, CA
5960............ Orlando, FL................... 0.9654 0.9931 0.9862 0.9792
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990............ Owensboro, KY................. 0.8374 0.9675 0.9350 0.9024
Daviess, KY
6015............ Panama City, FL............... 0.8202 0.9640 0.9281 0.8921
Bay, FL
6020............ Parkersburg-Marietta, WV-OH... 0.8039 0.9608 0.9216 0.8823
Washington, OH
Wood, WV
6080............ Pensacola, FL................. 0.8707 0.9741 0.9483 0.9224
Escambia, FL
Santa Rosa, FL
6120............ Peoria-Pekin, IL.............. 0.8734 0.9747 0.9494 0.9240
[[Page 4802]]
Peoria, IL
Tazewell, IL
Woodford, IL
6160............ Philadelphia, PA-NJ........... 1.0883 1.0177 1.0353 1.0530
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200............ Phoenix-Mesa, AZ.............. 1.0129 1.0026 1.0052 1.0077
Maricopa, AZ
Pinal, AZ
6240............ Pine Bluff, AR................ 0.7865 0.9573 0.9146 0.8719
Jefferson, AR
6280............ Pittsburgh, PA................ 0.8901 0.9780 0.9560 0.9341
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323............ Pittsfield, MA................ 1.0276 1.0055 1.0110 1.0166
Berkshire, MA
6340............ Pocatello, ID................. 0.9042 0.9808 0.9617 0.9425
Bannock, ID
6360............ Ponce, PR..................... 0.4708 0.8942 0.7883 0.6825
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403............ Portland, ME.................. 0.9949 0.9990 0.9980 0.9969
Cumberland, ME
Sagadahoc, ME
York, ME
6440............ Portland-Vancouver, OR-WA..... 1.1213 1.0243 1.0485 1.0728
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483............ Providence-Warwick-Pawtucket, 1.0977 1.0195 1.0391 1.0586
RI.
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520............ Provo-Orem, UT................ 0.9976 0.9995 0.9990 0.9986
Utah, UT
6560............ Pueblo, CO.................... 0.8778 0.9756 0.9511 0.9267
Pueblo, CO
6580............ Punta Gorda, FL............... 0.9510 0.9902 0.9804 0.9706
Charlotte, FL
6600............ Racine, WI.................... 0.8814 0.9763 0.9526 0.9288
Racine, WI
6640............ Raleigh-Durham-Chapel Hill, NC 0.9959 0.9992 0.9984 0.9975
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660............ Rapid City, SD................ 0.8806 0.9761 0.9522 0.9284
Pennington, SD
[[Page 4803]]
6680............ Reading, PA................... 0.9133 0.9827 0.9653 0.9480
Berks, PA
6690............ Redding, CA................... 1.1352 1.0270 1.0541 1.0811
Shasta, CA
6720............ Reno, NV...................... 1.0682 1.0136 1.0273 1.0409
Washoe, NV
6740............ Richland-Kennewick-Pasco, WA.. 1.0609 1.0122 1.0244 1.0365
Benton, WA
Franklin, WA
6760............ Richmond-Petersburg, VA....... 0.9349 0.9870 0.9740 0.9609
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780............ Riverside-San Bernardino, CA.. 1.1341 1.0268 1.0536 1.0805
Riverside, CA
San Bernardino, CA
6800............ Roanoke, VA................... 0.8700 0.9740 0.9480 0.9220
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820............ Rochester, MN................. 1.1739 1.0348 1.0696 1.1043
Olmsted, MN
6840............ Rochester, NY................. 0.9430 0.9886 0.9772 0.9658
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880............ Rockford, IL.................. 0.9666 0.9933 0.9866 0.9800
Boone, IL
Ogle, IL
Winnebago, IL
6895............ Rocky Mount, NC............... 0.9076 0.9815 0.9630 0.9446
Edgecombe, NC
Nash, NC
6920............ Sacramento, CA................ 1.1845 1.0369 1.0738 1.1107
El Dorado, CA
Placer, CA
Sacramento, CA
6960............ Saginaw-Bay City-Midland, MI.. 1.0032 1.0006 1.0013 1.0019
Bay, MI
Midland, MI
Saginaw, MI
6980............ St. Cloud, MN................. 0.9506 0.9901 0.9802 0.9704
Benton, MN
Stearns, MN
7000............ St. Joseph, MO................ 0.9757 0.9951 0.9903 0.9854
Andrew, MO
Buchanan, MO
7040............ St. Louis, MO-IL.............. 0.9033 0.9807 0.9613 0.9420
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
[[Page 4804]]
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080............ Salem, OR..................... 1.0482 1.0096 1.0193 1.0289
Marion, OR
Polk, OR
7120............ Salinas, CA................... 1.4339 1.0868 1.1736 1.2603
Monterey, CA
7160............ Salt Lake City-Ogden, UT...... 0.9913 0.9983 0.9965 0.9948
Davis, UT
Salt Lake, UT
Weber, UT
7200............ San Angelo, TX................ 0.8535 0.9707 0.9414 0.9121
Tom Green, TX
7240............ San Antonio, TX............... 0.8870 0.9774 0.9548 0.9322
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320............ San Diego, CA................. 1.1147 1.0229 1.0459 1.0688
San Diego, CA
7360............ San Francisco, CA............. 1.4514 1.0903 1.1806 1.2708
Marin, CA
San Francisco, CA
San Mateo, CA
7400............ San Jose, CA.................. 1.4626 1.0925 1.1850 1.2776
Santa Clara, CA
7440............ San Juan-Bayamon, PR.......... 0.4909 0.8982 0.7964 0.6945
Aguas Buenas, PR
Barceloneta, PR
Bayamon, PR
Canovanas, PR
Carolina, PR
Catano, PR
Ceiba, PR
Comerio, PR
Corozal, PR
Dorado, PR
Fajardo, PR
Florida, PR
Guaynabo, PR
Humacao, PR
Juncos, PR
Los Piedras, PR
Loiza, PR
Luguillo, PR
Manati, PR
Morovis, PR
Naguabo, PR
Naranjito, PR
Rio Grande, PR
San Juan, PR
Toa Alta, PR
Toa Baja, PR
Trujillo Alto, PR
Vega Alta, PR
Vega Baja, PR
Yabucoa, PR
7460............ San Luis Obispo-Atascadero- 1.1429 1.0286 1.0572 1.0857
Paso Robles, CA.
San Luis Obispo, CA
7480............ Santa Barbara-Santa Maria- 1.0441 1.0088 1.0176 1.0265
Lompoc, CA.
Santa Barbara, CA
7485............ Santa Cruz-Watsonville, CA.... 1.2942 1.0588 1.1177 1.1765
Santa Cruz, CA
7490............ Santa Fe, NM.................. 1.0653 1.0131 1.0261 1.0392
Los Alamos, NM
Santa Fe, NM
7500............ Santa Rosa, CA................ 1.2877 1.0575 1.1151 1.1726
Sonoma, CA
[[Page 4805]]
7510............ Sarasota-Bradenton, FL........ 0.9964 0.9993 0.9986 0.9978
Manatee, FL
Sarasota, FL
7520............ Savannah, GA.................. 0.9472 0.9894 0.9789 0.9683
Bryan, GA
Chatham, GA
Effingham, GA
7560............ Scranton-Wilkes-Barre- 0.8412 0.9682 0.9365 0.9047
Hazleton, PA.
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600............ Seattle-Bellevue-Everett, WA.. 1.1562 1.0312 1.0625 1.0937
Island, WA
King, WA
Snohomish, WA
7610............ Sharon, PA.................... 0.7751 0.9550 0.9100 0.8651
Mercer, PA
7620............ Sheboygan, WI................. 0.8624 0.9725 0.9450 0.9174
Sheboygan, WI
7640............ Sherman-Denison, TX........... 0.9700 0.9940 0.9880 0.9820
Grayson, TX
7680............ Shreveport-Bossier City, LA... 0.9083 0.9817 0.9633 0.9450
Bossier, LA
Caddo, LA
Webster, LA
7720............ Sioux City, IA-NE............. 0.8993 0.9799 0.9597 0.9396
Woodbury, IA
Dakota, NE
7760............ Sioux Falls, SD............... 0.9309 0.9862 0.9724 0.9585
Lincoln, SD
Minnehaha, SD
7800............ South Bend, IN................ 0.9821 0.9964 0.9928 0.9893
St. Joseph, IN
7840............ Spokane, WA................... 1.0901 1.0180 1.0360 1.0541
Spokane, WA
7880............ Springfield, IL............... 0.8944 0.9789 0.9578 0.9366
Menard, IL
Sangamon, IL
7920............ Springfield, MO............... 0.8457 0.9691 0.9383 0.9074
Christian, MO
Greene, MO
Webster, MO
8003............ Springfield, MA............... 1.0543 1.0109 1.0217 1.0326
Hampden, MA
Hampshire, MA
8050............ State College, PA............. 0.8740 0.9748 0.9496 0.9244
Centre, PA
8080............ Steubenville-Weirton, OH-WV 0.8398 0.9680 0.9359 0.9039
(WV Hospitals).
Jefferson, OH
Brooke, WV
Hancock, WV
8120............ Stockton-Lodi, CA............. 1.0404 1.0081 1.0162 1.0242
San Joaquin, CA
8140............ Sumter, SC.................... 0.8243 0.9649 0.9297 0.8946
Sumter, SC
8160............ Syracuse, NY.................. 0.9412 0.9882 0.9765 0.9647
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200............ Tacoma, WA.................... 1.1116 1.0223 1.0446 1.0670
Pierce, WA
8240............ Tallahassee, FL............... 0.8520 0.9704 0.9408 0.9112
Gadsden, FL
Leon, FL
8280............ Tampa-St. Petersburg- 0.9103 0.9821 0.9641 0.9462
Clearwater, FL.
Hernando, FL
Hillsborough, FL
Pasco, FL
[[Page 4806]]
Pinellas, FL
8320............ Terre Haute, IN............... 0.8325 0.9665 0.9330 0.8995
Clay, IN
Vermillion, IN
Vigo, IN
8360............ Texarkana, AR-Texarkana, TX... 0.8150 0.9630 0.9260 0.8890
Miller, AR
Bowie, TX
8400............ Toledo, OH.................... 0.9381 0.9876 0.9752 0.9629
Fulton, OH
Lucas, OH
Wood, OH
8440............ Topeka, KS.................... 0.9108 0.9822 0.9643 0.9465
Shawnee, KS
8480............ Trenton, NJ................... 1.0517 1.0103 1.0207 1.0310
Mercer, NJ
8520............ Tucson, AZ.................... 0.8981 0.9796 0.9592 0.9389
Pima, AZ
8560............ Tulsa, OK..................... 0.9185 0.9837 0.9674 0.9511
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600............ Tuscaloosa, AL................ 0.8212 0.9642 0.9285 0.8927
Tuscaloosa, AL
8640............ Tyler, TX..................... 0.9404 0.9881 0.9762 0.9642
Smith, TX
8680............ Utica-Rome, NY................ 0.8403 0.9681 0.9361 0.9042
Herkimer, NY
Oneida, NY
8720............ Vallejo-Fairfield-Napa, CA.... 1.3377 1.0675 1.1351 1.2026
Napa, CA
Solano, CA
8735............ Ventura, CA................... 1.1064 1.0213 1.0426 1.0638
Ventura, CA
8750............ Victoria, TX.................. 0.8184 0.9637 0.9274 0.8910
Victoria, TX
8760............ Vineland-Millville-Bridgeton, 1.0405 1.0081 1.0162 1.0243
NJ.
Cumberland, NJ
8780............ Visalia-Tulare-Porterville, CA 0.9794 0.9959 0.9918 0.9876
Tulare, CA
8800............ Waco, TX...................... 0.8394 0.9679 0.9358 0.9036
McLennan, TX
8840............ Washington, DC-MD-VA-WV....... 1.0904 1.0181 1.0362 1.0542
District of Columbia, DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Culpeper, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Fauquier, VA
Fredericksburg City, VA
King George, VA
Loudoun, VA
Manassas City, VA
Manassas Park City, VA
Prince William, VA
Spotsylvania, VA
Stafford, VA
Warren, VA
Berkeley, WV
Jefferson, WV
[[Page 4807]]
8920............ Waterloo-Cedar Falls, IA...... 0.8366 0.9673 0.9346 0.9020
Black Hawk, IA
8940............ Wausau, WI.................... 0.9692 0.9938 0.9877 0.9815
Marathon, WI
8960............ West Palm Beach-Boca Raton, FL 0.9798 0.9960 0.9919 0.9879
Palm Beach, FL
9000............ Wheeling, WV-OH............... 0.7494 0.9499 0.8998 0.8496
Belmont, OH
Marshall, WV
Ohio, WV
9040............ Wichita, KS................... 0.9238 0.9848 0.9695 0.9543
Butler, KS
Harvey, KS
Sedgwick, KS
9080............ Wichita Falls, TX............. 0.8341 0.9668 0.9336 0.9005
Archer, TX
Wichita, TX
9140............ Williamsport, PA.............. 0.8158 0.9632 0.9263 0.8895
Lycoming, PA
9160............ Wilmington-Newark, DE-MD...... 1.0882 1.0176 1.0353 1.0529
New Castle, DE
Cecil, MD
9200............ Wilmington, NC................ 0.9563 0.9913 0.9825 0.9738
New Hanover, NC
Brunswick, NC
9260............ Yakima, WA.................... 1.0372 1.0074 1.0149 1.0223
Yakima, WA
9270............ Yolo, CA...................... 0.9204 0.9841 0.9682 0.9522
Yolo, CA
9280............ York, PA...................... 0.9119 0.9824 0.9648 0.9471
York, PA
9320............ Youngstown-Warren, OH......... 0.9214 0.9843 0.9686 0.9528
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340............ Yuba City, CA................. 1.0196 1.0039 1.0078 1.0118
Sutter, CA
Yuba, CA
9360............ Yuma, AZ...................... 0.8895 0.9779 0.9558 0.9337
Yuma, AZ
----------------------------------------------------------------------------------------------------------------
\1\ Wage index calculated using the same wage data used to compute the wage index used by acute care hospitals
under the IPPS for Federal FY 2004 (that is, fiscal year 2000 audited acute care hospital inpatient wage data)
without regard to reclassification under section 1886(d)(8) or section 1886(d)(10) of the Act.
\2\ One-fifth of the proposed full wage index value, applicable for a LTCH's cost reporting period beginning on
or after October 1, 2002 through September 30, 2003 (Federal FY 2203). That is, for a LTCH's cost reporting
period that began during Federal FY 2003 and located in Chicago, Illinois (MSA 1600), the proposed 1/5th wage
index value is computed as (1.0892 + 4)/5 = 1.0178. For further details on the 5-year phase-in of the wage
index, see section IV.C.1.of this proposed rule.
\3\ Two-fifths of the proposed full wage index value, applicable for a LTCH's cost reporting period beginning on
or after October 1, 2003 through September 30, 2004 (Federal FY 2004). That is, for a LTCH's cost reporting
period that begins during Federal FY 2004 and located in Chicago, Illinois (MSA 1600), the proposed 2/5ths
wage index value is computed as ((2*1.0892) + 3))/5 = 1.0357. For further details on the 5-year phase-in of
the wage index, see section IV.C.1. of this proposed rule.
\4\ Three-fifths of the proposed full wage index value, applicable for a LTCH's cost reporting period beginning
on or after October 1, 2004 through September 30, 2005 (Federal FY 2005). That is, for a LTCH's cost reporting
period that begins during Federal FY 2004 and located in Chicago, Illinois (MSA 1600), the proposed 3/5ths
wage index value is computed as ((3*1.0892) + 2))/5 = 1.0535. For further details on the 5-year phase-in of
the wage index, see section IV.C.1. of this proposed rule.
Table 2.--Long-Term Care Hospital Proposed Wage Index for Rural Areas for Discharges Occurring From July 1, 2004
Through June 30, 2005
----------------------------------------------------------------------------------------------------------------
\1/5\th \2/5\ths \3/5\ths
Nonurban area Full wage wage index wage index wage index
index \1\ \2\ \3\ \4\
----------------------------------------------------------------------------------------------------------------
Alabama..................................................... 0.7492 0.9498 0.8997 0.8495
Alaska...................................................... 1.1886 1.0377 1.0754 1.1132
Arizona..................................................... 0.9270 0.9854 0.9708 0.9562
Arkansas.................................................... 0.7734 0.9547 0.9094 0.8640
California.................................................. 1.0027 1.0005 1.0011 1.0016
Colorado.................................................... 0.9328 0.9866 0.9731 0.9597
Connecticut................................................. 1.2183 1.0437 1.0873 1.1310
Delaware.................................................... 0.9557 0.9911 0.9823 0.9734
[[Page 4808]]
Florida..................................................... 0.8870 0.9774 0.9548 0.9322
Georgia..................................................... 0.8595 0.9719 0.9438 0.9157
Hawaii...................................................... 0.9958 0.9992 0.9983 0.9975
Idaho....................................................... 0.8974 0.9795 0.9590 0.9384
Illinois.................................................... 0.8254 0.9651 0.9302 0.8952
Indiana..................................................... 0.8824 0.9765 0.9530 0.9294
Iowa........................................................ 0.8416 0.9683 0.9366 0.9050
Kansas...................................................... 0.8034 0.9607 0.9214 0.8820
Kentucky.................................................... 0.7973 0.9595 0.9189 0.8784
Louisiana................................................... 0.7458 0.9492 0.8983 0.8475
Maine....................................................... 0.8812 0.9762 0.9525 0.9287
Maryland.................................................... 0.9125 0.9825 0.9650 0.9475
Massachusetts............................................... 1.0432 1.0086 1.0173 1.0259
Michigan.................................................... 0.8884 0.9777 0.9554 0.9330
Minnesota................................................... 0.9330 0.9866 0.9732 0.9598
Mississippi................................................. 0.7778 0.9556 0.9111 0.8667
Missouri.................................................... 0.7892 0.9578 0.9157 0.8735
Montana..................................................... 0.8800 0.9760 0.9520 0.9280
Nebraska.................................................... 0.8822 0.9764 0.9529 0.9293
Nevada...................................................... 0.9806 0.9961 0.9922 0.9884
New Hampshire............................................... 1.0030 1.0006 1.0012 1.0018
New Jersey \5\.............................................. ........... ........... ........... ...........
New Mexico.................................................. 0.8270 0.9654 0.9308 0.8962
New York.................................................... 0.8526 0.9705 0.9410 0.9116
North Carolina.............................................. 0.8458 0.9692 0.9383 0.9075
North Dakota................................................ 0.7778 0.9556 0.9111 0.8667
Ohio........................................................ 0.8820 0.9764 0.9528 0.9292
Oklahoma.................................................... 0.7537 0.9507 0.9015 0.8522
Oregon...................................................... 0.9994 0.9999 0.9998 0.9996
Pennsylvania................................................ 0.8378 0.9676 0.9351 0.9027
Puerto Rico................................................. 0.4018 0.8804 0.7607 0.6411
Rhode Island \5\............................................ ........... ........... ........... ...........
South Carolina.............................................. 0.8498 0.9700 0.9399 0.9099
South Dakota................................................ 0.8195 0.9639 0.9278 0.8917
Tennessee................................................... 0.7886 0.9577 0.9154 0.8732
Texas....................................................... 0.7780 0.9556 0.9112 0.8668
Utah........................................................ 0.8974 0.9795 0.9590 0.9384
Vermont..................................................... 0.9307 0.9861 0.9723 0.9584
Virginia.................................................... 0.8498 0.9700 0.9399 0.9099
Washington.................................................. 1.0388 1.0078 1.0155 1.0233
West Virginia............................................... 0.8018 0.9604 0.9207 0.8811
Wisconsin................................................... 0.9304 0.9861 0.9722 0.9582
Wyoming..................................................... 0.9110 0.9822 0.9644 0.9466
----------------------------------------------------------------------------------------------------------------
\1\ Wage index calculated using the same wage data used to compute the wage index used by acute care hospitals
under the IPPS for Federal FY 2004 (that is, fiscal year 2000 audited acute care hospital inpatient wage data)
without regard to reclassification under section 1886(d)(8) or section 1886(d)(10) of the Act.
\2\ One-fifth of the proposed full wage index value, applicable for a LTCH's cost reporting period beginning on
or after October 1, 2002 through September 30, 2003 (Federal FY 2203). That is, for a LTCH's cost reporting
period that began during Federal FY 2003 and located in rural Illinois, the proposed \1/5\th wage index value
is computed as (0.8254 + 4)/5 = 0.9651. For further details on the 5-year phase-in of the wage index, see
section IV.C.1. of this proposed rule.
\3\ Two-fifths of the proposed full wage index value, applicable for a LTCH's cost reporting period beginning on
or after October 1, 2003 through September 30, 2004 (Federal FY 2004). That is, for a LTCH's cost reporting
period that begins during Federal FY 2004 and located in rural Illinois, the proposed \2/5\th wage index value
is computed as ((2*0.8254) + 3))/5 = 0.9302. For further details on the 5-year phase-in of the wage index, see
section IV.C.1. of this proposed rule.
\4\ Three-fifths of the proposed full wage index value, applicable for a LTCH's cost reporting period beginning
on or after October 1, 2004 through September 30, 2005 (Federal FY 2005). That is, for a LTCH's cost reporting
period that begins during Federal FY 2004 and located in rural Illinois, the proposed \3/5\ths wage index
value is computed as ((3*0.8254) + 2))/5 = 0.8952. For further details on the 5-year phase-in of the wage
index, see section IV.C.1. of this proposed rule.
\5\ All counties within the State are classified as urban.
Table 3.--Proposed Federal FY 2004 LTC-DRG Relative Weights, Geometric Mean Length of Stay, and Short-Stays of
Five-Sixths Average Length of Stay for Discharges Occurring From October 1, 2003 Through September 30, 2004
----------------------------------------------------------------------------------------------------------------
Geometric 5/6th of
Relative average the average
LTC-DRG Description weight length of length of
stay stay
----------------------------------------------------------------------------------------------------------------
1....................................... CRANIOTOMY AGE 17 W 2.0841 40.0 33.3
CC \5\.
[[Page 4809]]
2....................................... CRANIOTOMY AGE 17 W/ 2.0841 40.0 33.3
O CC \8\.
3....................................... CRANIOTOMY AGE 0-17 \8\........ 2.0841 40.0 33.3
6....................................... CARPAL TUNNEL RELEASE \8\...... 0.4964 18.5 15.4
7....................................... PERIPH & CRANIAL NERVE & OTHER 1.5754 41.0 34.1
NERV SYST PROC W CC \7\.
8....................................... PERIPH & CRANIAL NERVE & OTHER 1.5754 41.0 34.1
NERV SYST PROC W/O CC \7\.
9....................................... SPINAL DISORDERS & INJURIES.... 1.5025 32.9 27.4
10...................................... NERVOUS SYSTEM NEOPLASMS W CC.. 0.7549 23.4 19.5
11...................................... NERVOUS SYSTEM NEOPLASMS W/O CC 0.7281 22.0 18.3
12...................................... DEGENERATIVE NERVOUS SYSTEM 0.7485 25.8 21.5
DISORDERS.
13...................................... MULTIPLE SCLEROSIS & CEREBELLAR 0.7530 25.9 21.5
ATAXIA.
14...................................... INTERCRANIAL HEMORRHAGE & 0.9196 27.4 22.8
STROKE W INFARCT.
15...................................... NONSPECIFIC CVA & PRECEREBRAL 0.8714 28.8 24.0
OCCULUSION W/O INFARCT.
16...................................... NONSPECIFIC CEREBROVASCULAR 0.9125 23.9 19.9
DISORDERS W CC.
17...................................... NONSPECIFIC CEREBROVASCULAR 0.5262 20.4 17.0
DISORDERS W/O CC.
18...................................... CRANIAL & PERIPHERAL NERVE 0.8225 23.9 19.9
DISORDERS W CC.
19...................................... CRANIAL & PERIPHERAL NERVE 0.6236 22.7 18.9
DISORDERS W/O CC.
20...................................... NERVOUS SYSTEM INFECTION EXCEPT 1.0097 24.8 20.6
VIRAL MENINGITIS.
21...................................... VIRAL MENINGITIS \2\........... 0.7372 23.5 19.5
22...................................... HYPERTENSIVE ENCEPHALOPATHY \2\ 0.7372 23.5 19.5
23...................................... NONTRAUMATIC STUPOR & COMA..... 0.9033 28.8 24.0
24...................................... SEIZURE & HEADACHE AGE 17 W CC.
25...................................... SEIZURE & HEADACHE AGE 17 W/O CC.
26...................................... SEIZURE & HEADACHE AGE 0-17 \8\ 0.7372 23.5 19.5
27...................................... TRAUMATIC STUPOR & COMA, COMA 1.1929 30.4 25.3
1 HR.
28...................................... TRAUMATIC STUPOR & COMA, COMA 1.0211 29.0 24.1
<1 HR AGE 17 W CC.
29...................................... TRAUMATIC STUPOR & COMA, COMA 0.9056 26.6 22.1
<1 HR AGE 17 W/O CC.
30...................................... TRAUMATIC STUPOR & COMA, COMA 0.9562 26.1 21.7
<1 HR AGE 0-17 \8\.
31...................................... CONCUSSION AGE 17 W 0.9562 26.1 21.7
CC \7\.
32...................................... CONCUSSION AGE 17 W/ 0.9562 26.1 21.7
O CC \7\.
33...................................... CONCUSSION AGE 0-17 \8\........ 0.7372 23.5 19.5
34...................................... OTHER DISORDERS OF NERVOUS 0.9140 27.8 23.1
SYSTEM W CC.
35...................................... OTHER DISORDERS OF NERVOUS 0.6651 24.5 20.4
SYSTEM W/O CC.
36...................................... RETINAL PROCEDURES \8\......... 0.4964 18.5 15.4
37...................................... ORBITAL PROCEDURES \8\......... 0.4964 18.5 15.4
38...................................... PRIMARY IRIS PROCEDURES \8\.... 0.4964 18.5 15.4
39...................................... LENS PROCEDURES WITH OR WITHOUT 0.4964 18.5 15.4
VITRECTOMY \8\.
40...................................... EXTRAOCULAR PROCEDURES EXCEPT 2.0841 40.0 33.3
ORBIT AGE 17 \5\.
41...................................... EXTRAOCULAR PROCEDURES EXCEPT 0.4964 18.5 15.4
ORBIT AGE 0-17 \8\.
42...................................... INTRAOCULAR PROCEDURES EXCEPT 0.4964 18.5 15.4
RETINA, IRIS & LENS \8\.
43...................................... HYPHEMA \8\.................... 0.4964 18.5 15.4
44...................................... ACUTE MAJOR EYE INFECTIONS \1\. 0.4964 18.5 15.4
45...................................... NEUROLOGICAL EYE DISORDERS \8\. 0.4964 18.5 15.4
46...................................... OTHER DISORDERS OF THE EYE AGE 0.4964 18.5 15.4
17 W CC \1\.
47...................................... OTHER DISORDERS OF THE EYE AGE 0.4964 18.5 15.4
17 W/O CC \1\.
48...................................... OTHER DISORDERS OF THE EYE AGE 0.4964 18.5 15.4
0-17 \8\.
49...................................... MAJOR HEAD & NECK PROCEDURES 1.3569 32.5 27.0
\8\.
50...................................... SIALOADENECTOMY \8\............ 0.9562 26.1 21.7
51...................................... SALIVARY GLAND PROCEDURES 0.9562 26.1 21.7
EXCEPT SIALOADENECTOMY \8\.
52...................................... CLEFT LIP & PALATE REPAIR \8\.. 0.9562 26.1 21.7
53...................................... SINUS & MASTOID PROCEDURES AGE 0.7372 23.5 19.5
17 \2\.
54...................................... SINUS & MASTOID PROCEDURES AGE 0.9562 26.1 21.7
0-17 \8\.
55...................................... MISCELLANEOUS EAR, NOSE, MOUTH 0.9562 26.1 21.7
& THROAT PROCEDURES \8\.
56...................................... RHINOPLASTY \8\................ 0.7372 23.5 19.5
57...................................... T&A PROC, EXCEPT TONSILLECTOMY 0.9562 26.1 21.7
&/OR ADENOIDECTOMY ONLY, AGE
17 \8\.
58...................................... T&A PROC, EXCEPT TONSILLECTOMY 0.9562 26.1 21.7
&/OR ADENOIDECTOMY ONLY, AGE 0-
17 \8\.
59...................................... TONSILLECTOMY &/OR 0.9562 26.1 21.7
ADENOIDECTOMY ONLY, AGE 17 \8\.
60...................................... TONSILLECTOMY &/OR 0.9562 26.1 21.7
ADENOIDECTOMY ONLY, AGE 0-17
\8\.
61...................................... MYRINGOTOMY W TUBE INSERTION 0.7372 23.5 19.5
AGE 17 \2\.
62...................................... MYRINGOTOMY W TUBE INSERTION 0.9562 26.1 21.7
AGE 0-17 \8\.
63...................................... OTHER EAR, NOSE, MOUTH & THROAT 0.9562 26.1 21.7
O.R. PROCEDURES \3\.
64...................................... EAR, NOSE, MOUTH & THROAT 1.2540 27.5 22.9
MALIGNANCY.
65...................................... DYSEQUILIBRIUM \1\............. 0.4964 18.5 15.4
66...................................... EPISTAXIS \1\.................. 0.4964 18.5 15.4
67...................................... EPIGLOTTITIS \8\............... 0.9562 26.1 21.7
68...................................... OTITIS MEDIA & URI AGE 17 W CC.
[[Page 4810]]
69...................................... OTITIS MEDIA & URI AGE 17 W/O CC \1\.
70...................................... OTITIS MEDIA & URI AGE 0-17 \8\ 0.4964 18.5 15.4
71...................................... LARYNGOTRACHEITIS \8\.......... 0.4964 18.5 15.4
72...................................... NASAL TRAUMA & DEFORMITY \2\... 0.7372 23.5 19.5
73...................................... OTHER EAR, NOSE, MOUTH & THROAT 0.7215 20.3 16.9
DIAGNOSES AGE 17.
74...................................... OTHER EAR, NOSE, MOUTH & THROAT 0.4964 18.5 15.4
DIAGNOSES AGE 0-17 \8\.
75...................................... MAJOR CHEST PROCEDURES \5\..... 2.0841 40.0 33.3
76...................................... OTHER RESP SYSTEM O.R. 2.4382 43.9 36.5
PROCEDURES W CC.
77...................................... OTHER RESP SYSTEM O.R. 2.0841 40.0 33.3
PROCEDURES W/O CC \5\.
78...................................... PULMONARY EMBOLISM............. 0.8896 24.2 20.1
79...................................... RESPIRATORY INFECTIONS & 0.8985 22.6 18.8
INFLAMMATIONS AGE 17 W CC.
80...................................... RESPIRATORY INFECTIONS & 0.7645 22.3 18.5
INFLAMMATIONS AGE 17 W/O CC.
81...................................... RESPIRATORY INFECTIONS & 0.4964 18.5 15.4
INFLAMMATIONS AGE 0-17 \8\.
82...................................... RESPIRATORY NEOPLASMS.......... 0.7480 20.3 16.9
83...................................... MAJOR CHEST TRAUMA W CC \3\.... 0.9562 26.1 21.7
84...................................... MAJOR CHEST TRAUMA W/O CC \2\.. 0.7372 23.5 19.5
85...................................... PLEURAL EFFUSION W CC.......... 0.8514 23.5 19.5
86...................................... PLEURAL EFFUSION W/O CC........ 0.6540 22.4 18.6
87...................................... PULMONARY EDEMA & RESPIRATORY 1.6513 31.9 26.5
FAILURE.
88...................................... CHRONIC OBSTRUCTIVE PULMONARY 0.7653 20.7 17.2
DISEASE.
89...................................... SIMPLE PNEUMONIA & PLEURISY AGE 0.8428 23.1 19.2
17 W CC.
90...................................... SIMPLE PNEUMONIA & PLEURISY AGE 0.7318 21.7 18.0
17 W/O CC.
91...................................... SIMPLE PNEUMONIA & PLEURISY AGE 0.7372 23.5 19.5
0-17 \8\.
92...................................... INTERSTITIAL LUNG DISEASE W CC. 0.7702 20.4 17.0
93...................................... INTERSTITIAL LUNG DISEASE W/O 0.4964 18.5 15.4
CC \1\.
94...................................... PNEUMOTHORAX W CC.............. 0.6571 18.9 15.7
95...................................... PNEUMOTHORAX W/O CC \1\........ 0.4964 18.5 15.4
96...................................... BRONCHITIS & ASTHMA AGE 17 W CC.
97...................................... BRONCHITIS & ASTHMA AGE 17 W/O CC.
98...................................... BRONCHITIS & ASTHMA AGE 0-17 0.4964 18.5 15.4
\8\.
99...................................... RESPIRATORY SIGNS & SYMPTOMS W 1.0622 26.6 22.1
CC.
100..................................... RESPIRATORY SIGNS & SYMPTOMS W/ 1.0579 26.1 21.7
O CC.
101..................................... OTHER RESPIRATORY SYSTEM 0.9009 22.6 18.8
DIAGNOSES W CC.
102..................................... OTHER RESPIRATORY SYSTEM 0.7011 21.0 17.5
DIAGNOSES W/O CC.
103..................................... HEART TRANSPLANT \6\........... 0.0000 0.0 0.0
104..................................... CARDIAC VALVE & OTHER MAJOR 2.0841 40.0 33.3
CARDIOTHORACIC PROC W CARDIAC
CATH \8\.
105..................................... CARDIAC VALVE & OTHER MAJOR 2.0841 40.0 33.3
CARDIOTHORACIC PROC W/O
CARDIAC CATH \8\.
106..................................... CORONARY BYPASS W PTCA \8\..... 2.0841 40.0 33.3
107..................................... CORONARY BYPASS W CARDIAC CATH 2.0841 40.0 33.3
\8\.
108..................................... OTHER CARDIOTHORACIC PROCEDURES 2.0841 40.0 33.3
\5\.
109..................................... CORONARY BYPASS W/O PTCA OR 2.0841 40.0 33.3
CARDIAC CATH \8\.
110..................................... MAJOR CARDIOVASCULAR PROCEDURES 2.0841 40.0 33.3
W CC \5\.
111..................................... MAJOR CARDIOVASCULAR PROCEDURES 2.0841 40.0 33.3
W/O CC \8\.
113..................................... AMPUTATION FOR CIRC SYSTEM 1.5629 38.7 32.2
DISORDERS EXCEPT UPPER LIMB &
TOE.
114..................................... UPPER LIMB & TOE AMPUTATION FOR 1.3604 38.3 31.9
CIRC SYSTEM DISORDERS.
115..................................... PRM CARD PACEM IMPL W AMI,HRT 2.0841 40.0 33.3
FAIL OR SHK,OR AICD LEAD OR
GNRTR P \5\.
116..................................... OTH PERM CARD PACEMAK IMPL OR 2.0841 40.0 33.3
PTCA W CORONARY ARTERY STENT
IMPLNT \5\.
117..................................... CARDIAC PACEMAKER REVISION 0.9562 26.1 21.7
EXCEPT DEVICE REPLACEMENT \3\.
118..................................... CARDIAC PACEMAKER DEVICE 2.0841 40.0 33.3
REPLACEMENT \5\.
119..................................... VEIN LIGATION & STRIPPING \4\.. 1.3569 32.5 27.0
120..................................... OTHER CIRCULATORY SYSTEM O.R. 1.2435 34.4 28.6
PROCEDURES.
121..................................... CIRCULATORY DISORDERS W AMI & 0.7467 22.1 18.4
MAJOR COMP, DISCHARGED ALIVE.
122..................................... CIRCULATORY DISORDERS W AMI W/O 0.6440 18.8 15.6
MAJOR COMP, DISCHARGED ALIVE.
123..................................... CIRCULATORY DISORDERS W AMI, 0.8527 18.8 15.6
EXPIRED.
124..................................... CIRCULATORY DISORDERS EXCEPT 1.3569 32.5 27.0
AMI, W CARD CATH & COMPLEX
DIAG \4\.
125..................................... CIRCULATORY DISORDERS EXCEPT 1.3569 32.5 27.0
AMI, W CARD CATH W/O COMPLEX
DIAG \4\.
126..................................... ACUTE & SUBACUTE ENDOCARDITIS.. 0.8706 25.6 21.3
127..................................... HEART FAILURE & SHOCK.......... 0.7719 22.1 18.4
128..................................... DEEP VEIN THROMBOPHLEBITIS \2\. 0.7372 23.5 19.5
129..................................... CARDIAC ARREST, UNEXPLAINED \3\ 0.9562 26.1 21.7
130..................................... PERIPHERAL VASCULAR DISORDERS W 0.7712 24.4 20.3
CC.
131..................................... PERIPHERAL VASCULAR DISORDERS W/ 0.6398 23.1 19.2
O CC.
132..................................... ATHEROSCLEROSIS W CC........... 0.8092 22.4 18.6
[[Page 4811]]
133..................................... ATHEROSCLEROSIS W/O CC......... 0.7044 21.9 18.2
134..................................... HYPERTENSION................... 0.9154 27.9 23.2
135..................................... CARDIAC CONGENITAL & VALVULAR 0.9039 23.1 19.2
DISORDERS AGE 17 W
CC.
136..................................... CARDIAC CONGENITAL & VALVULAR 0.7186 22.4 18.6
DISORDERS AGE 17 W/
O CC.
137..................................... CARDIAC CONGENITAL & VALVULAR 0.7372 23.5 19.5
DISORDERS AGE 0-17 \8\.
138..................................... CARDIAC ARRHYTHMIA & CONDUCTION 0.7430 22.7 18.9
DISORDERS W CC.
139..................................... CARDIAC ARRHYTHMIA & CONDUCTION 0.6032 20.3 16.9
DISORDERS W/O CC.
140..................................... ANGINA PECTORIS................ 0.6094 19.3 16.0
141..................................... SYNCOPE & COLLAPSE W CC........ 0.6453 22.9 19.0
142..................................... SYNCOPE & COLLAPSE W/O CC...... 0.5041 20.3 16.9
143..................................... CHEST PAIN..................... 0.7314 21.8 18.1
144..................................... OTHER CIRCULATORY SYSTEM 0.7921 22.2 18.5
DIAGNOSES W CC.
145..................................... OTHER CIRCULATORY SYSTEM 0.6983 20.7 17.2
DIAGNOSES W/O CC.
146..................................... RECTAL RESECTION W CC \8\...... 2.0841 40.0 33.3
147..................................... RECTAL RESECTION W/O CC \8\.... 2.0841 40.0 33.3
148..................................... MAJOR SMALL & LARGE BOWEL 2.0841 40.0 33.3
PROCEDURES W CC \5\.
149..................................... MAJOR SMALL & LARGE BOWEL 0.4964 18.5 15.4
PROCEDURES W/O CC \1\.
150..................................... PERITONEAL ADHESIOLYSIS W CC 1.3569 32.5 27.0
\4\.
151..................................... PERITONEAL ADHESIOLYSIS W/O CC 1.3569 32.5 27.0
\8\.
152..................................... MINOR SMALL & LARGE BOWEL 1.3569 32.5 27.0
PROCEDURES W CC \4\.
153..................................... MINOR SMALL & LARGE BOWEL 1.3569 32.5 27.0
PROCEDURES W/O CC \8\.
154..................................... STOMACH, ESOPHAGEAL & DUODENAL 2.0841 40.0 33.3
PROCEDURES AGE 17 W
CC \5\.
155..................................... STOMACH, ESOPHAGEAL & DUODENAL 1.3569 32.5 27.0
PROCEDURES AGE 17 W/
O CC \8\.
156..................................... STOMACH, ESOPHAGEAL & DUODENAL 1.3569 32.5 27.0
PROCEDURES AGE 0-17 \8\.
157..................................... ANAL & STOMAL PROCEDURES W CC 1.3569 32.5 27.0
\4\.
158..................................... ANAL & STOMAL PROCEDURES W/O CC 0.9562 26.1 21.7
\3\.
159..................................... HERNIA PROCEDURES EXCEPT 1.3569 32.5 27.0
INGUINAL & FEMORAL AGE 17 W CC \8\.
160..................................... HERNIA PROCEDURES EXCEPT 1.3569 32.5 27.0
INGUINAL & FEMORAL AGE 17 W/O CC \8\.
161..................................... INGUINAL & FEMORAL HERNIA 1.3569 32.5 27.0
PROCEDURES AGE 17 W
CC \4\.
162..................................... INGUINAL & FEMORAL HERNIA 0.4964 18.5 15.4
PROCEDURES AGE 17 W/
O CC \8\.
163..................................... HERNIA PROCEDURES AGE 0-17 \8\. 0.4964 18.5 15.4
164..................................... APPENDECTOMY W COMPLICATED 2.0841 40.0 33.3
PRINCIPAL DIAG WCC \8\.
165..................................... APPENDECTOMY W COMPLICATED 0.4964 18.5 15.4
PRINCIPAL DIAG W/O CC \8\.
166..................................... APPENDECTOMY W/O COMPLICATED 2.0841 40.0 33.3
PRINCIPAL DIAG W CC \8\.
167..................................... APPENDECTOMY W/O COMPLICATED 0.4964 18.5 15.4
PRINCIPAL DIAG W/O CC \8\.
168..................................... MOUTH PROCEDURES W CC \5\...... 2.0841 40.0 33.3
169..................................... MOUTH PROCEDURES W/O CC \8\.... 0.7372 23.5 19.5
170..................................... OTHER DIGESTIVE SYSTEM O.R. 1.7006 40.3 33.5
PROCEDURES W CC.
171..................................... OTHER DIGESTIVE SYSTEM O.R. 1.3569 32.5 27.0
PROCEDURES W/O CC \4\.
172..................................... DIGESTIVE MALIGNANCY W CC...... 0.8702 22.5 18.7
173..................................... DIGESTIVE MALIGNANCY W/O CC.... 0.7092 20.2 16.8
174..................................... G.I. HEMORRHAGE W CC........... 0.7874 23.7 19.7
175..................................... G.I. HEMORRHAGE W/O CC......... 0.6345 21.1 17.5
176..................................... COMPLICATED PEPTIC ULCER....... 0.7728 21.2 17.6
177..................................... UNCOMPLICATED PEPTIC ULCER W CC 0.7372 23.5 19.5
\2\.
178..................................... UNCOMPLICATED PEPTIC ULCER W/O 0.4964 18.5 15.4
CC \1\.
179..................................... INFLAMMATORY BOWEL DISEASE..... 1.0023 25.2 21.0
180..................................... G.I. OBSTRUCTION W CC \7\...... 0.8222 22.9 19.0
181..................................... G.I. OBSTRUCTION W/O CC \7\.... 0.8222 22.9 19.0
182..................................... ESOPHAGITIS, GASTROENT & MISC 0.8449 23.5 19.5
DIGEST DISORDERS AGE 17 W CC.
183..................................... ESOPHAGITIS, GASTROENT & MISC 0.6362 20.3 16.9
DIGEST DISORDERS AGE 17 W/O CC.
184..................................... ESOPHAGITIS, GASTROENT & MISC 0.7372 23.5 19.5
DIGEST DISORDERS AGE 0-17 \8\.
185..................................... DENTAL & ORAL DIS EXCEPT 0.7372 23.5 19.5
EXTRACTIONS & RESTORATIONS,
AGE 17 \2\.
186..................................... DENTAL & ORAL DIS EXCEPT 0.7372 23.5 19.5
EXTRACTIONS & RESTORATIONS,
AGE 0-17 \8\.
187..................................... DENTAL EXTRACTIONS & 0.7372 23.5 19.5
RESTORATIONS \8\.
188..................................... OTHER DIGESTIVE SYSTEM 1.0308 25.3 21.0
DIAGNOSES AGE 17 W
CC.
189..................................... OTHER DIGESTIVE SYSTEM 0.7826 21.8 18.1
DIAGNOSES AGE 17 W/
O CC.
190..................................... OTHER DIGESTIVE SYSTEM 0.7372 23.5 19.5
DIAGNOSES AGE 0-17 \8\.
191..................................... PANCREAS, LIVER & SHUNT 1.3569 32.5 27.0
PROCEDURES W CC \4\.
192..................................... PANCREAS, LIVER & SHUNT 0.4964 18.5 15.4
PROCEDURES W/O CC \1\.
193..................................... BILIARY TRACT PROC EXCEPT ONLY 0.7372 23.5 19.5
CHOLECYST W OR W/O C.D.E. W CC
\2\.
194..................................... BILIARY TRACT PROC EXCEPT ONLY 0.7372 23.5 19.5
CHOLECYST W OR W/O C.D.E. W/O
CC \3\.
195..................................... CHOLECYSTECTOMY W C.D.E. W CC 1.3569 32.5 27.0
\4\.
196..................................... CHOLECYSTECTOMY W C.D.E. W/O CC 0.9562 26.1 21.7
\8\.
197..................................... CHOLECYSTECTOMY EXCEPT BY 0.9562 26.1 21.7
LAPAROSCOPE W/O C.D.E. W CC
\3\.
198..................................... CHOLECYSTECTOMY EXCEPT BY 0.9562 26.1 21.7
LAPAROSCOPE W/O C.D.E. W/O CC
\8\.
199..................................... HEPATOBILIARY DIAGNOSTIC 0.7372 23.5 19.5
PROCEDURE FOR MALIGNANCY \8\.
[[Page 4812]]
200..................................... HEPATOBILIARY DIAGNOSTIC 0.7372 23.5 19.5
PROCEDURE FOR NON-MALIGNANCY
\2\.
201..................................... OTHER HEPATOBILIARY OR PANCREAS 2.0841 40.0 33.3
O.R. PROCEDURES \5\.
202..................................... CIRRHOSIS & ALCOHOLIC HEPATITIS 0.7254 22.3 18.5
203..................................... MALIGNANCY OF HEPATOBILIARY 0.6758 18.9 15.7
SYSTEM OR PANCREAS.
204..................................... DISORDERS OF PANCREAS EXCEPT 0.9986 23.4 19.5
MALIGNANCY.
205..................................... DISORDERS OF LIVER EXCEPT 0.7029 22.1 18.4
MALIG,CIRR,ALC HEPA W CC \7\.
206..................................... DISORDERS OF LIVER EXCEPT 0.7029 22.1 18.4
MALIG,CIRR,ALC HEPA W/O CC \7\.
207..................................... DISORDERS OF THE BILIARY TRACT 0.6671 20.5 17.0
W CC \7\.
208..................................... DISORDERS OF THE BILIARY TRACT 0.6671 20.5 17.0
W/O CC \7\.
209..................................... MAJOR JOINT & LIMB REATTACHMENT 1.3569 32.5 27.0
PROCEDURES OF LOWER EXTREMITY
\4\.
210..................................... HIP & FEMUR PROCEDURES EXCEPT 1.3569 32.5 27.0
MAJOR JOINT AGE 17
W CC \4\.
211..................................... HIP & FEMUR PROCEDURES EXCEPT 0.7372 23.5 19.5
MAJOR JOINT AGE 17
W/O CC \2\.
212..................................... HIP & FEMUR PROCEDURES EXCEPT 0.7372 23.5 19.5
MAJOR JOINT AGE 0-17 \8\.
213..................................... AMPUTATION FOR MUSCULOSKELETAL 1.3851 33.8 28.1
SYSTEM & CONN TISSUE DISORDERS.
216..................................... BIOPSIES OF MUSCULOSKELETAL 1.3569 32.5 27.0
SYSTEM & CONNECTIVE TISSUE \4\.
217..................................... WND DEBRID & SKN GRFT EXCEPT 1.4038 39.3 32.7
HAND,FOR MUSCSKELET & CONN
TISS DIS.
218..................................... LOWER EXTREM & HUMER PROC 0.9562 26.1 21.7
EXCEPT HIP,FOOT,FEMUR AGE 17 W CC \3\.
219..................................... LOWER EXTREM & HUMER PROC 0.9562 26.1 21.7
EXCEPT HIP,FOOT,FEMUR AGE 17 W/O CC \8\.
220..................................... LOWER EXTREM & HUMER PROC 0.9562 26.1 21.7
EXCEPT HIP,FOOT,FEMUR AGE 0-17
\8\.
223..................................... MAJOR SHOULDER/ELBOW PROC, OR 0.9562 26.1 21.7
OTHER UPPER EXTREMITY PROC W
CC \3\.
224..................................... SHOULDER,ELBOW OR FOREARM 0.9562 26.1 21.7
PROC,EXC MAJOR JOINT PROC, W/O
CC \8\.
225..................................... FOOT PROCEDURES \3\............ 0.9562 26.1 21.7
226..................................... SOFT TISSUE PROCEDURES W CC \7\ 1.3569 32.5 27.0
227..................................... SOFT TISSUE PROCEDURES W/O CC 1.3569 32.5 27.0
\7\.
228..................................... MAJOR THUMB OR JOINT PROC,OR 1.3569 32.5 27.0
OTH HAND OR WRIST PROC W CC
\4\.
229..................................... HAND OR WRIST PROC, EXCEPT 0.9562 26.1 21.7
MAJOR JOINT PROC, W/O CC \8\.
230..................................... LOCAL EXCISION & REMOVAL OF INT 1.3569 32.5 27.0
FIX DEVICES OF HIP & FEMUR \4\.
232..................................... ARTHROSCOPY \2\................ 0.7372 23.5 19.5
233..................................... OTHER MUSCULOSKELET SYS & CONN 0.9562 26.1 21.7
TISS O.R. PROC W CC \3\.
234..................................... OTHER MUSCULOSKELET SYS & CONN 0.9562 26.1 21.7
TISS O.R. PROC W/O CC \3\.
235..................................... FRACTURES OF FEMUR............. 0.8396 29.6 24.6
236..................................... FRACTURES OF HIP & PELVIS...... 0.7368 27.1 22.5
237..................................... SPRAINS, STRAINS, & 0.7372 23.5 19.5
DISLOCATIONS OF HIP, PELVIS &
THIGH \2\.
238..................................... OSTEOMYELITIS.................. 0.8432 27.9 23.2
239..................................... PATHOLOGICAL FRACTURES & 0.6610 22.0 18.3
MUSCULOSKELETAL & CONN TISS
MALIGNANCY.
240..................................... CONNECTIVE TISSUE DISORDERS W 0.6685 21.2 17.6
CC.
241..................................... CONNECTIVE TISSUE DISORDERS W/O 0.4538 18.7 15.5
CC.
242..................................... SEPTIC ARTHRITIS............... 0.7721 26.4 22.0
243..................................... MEDICAL BACK PROBLEMS.......... 0.6616 23.2 19.3
244..................................... BONE DISEASES & SPECIFIC 0.5563 20.0 16.6
ARTHROPATHIES W CC.
245..................................... BONE DISEASES & SPECIFIC 0.4721 18.5 15.4
ARTHROPATHIES W/O CC.
246..................................... NON-SPECIFIC ARTHROPATHIES..... 0.5128 22.2 18.5
247..................................... SIGNS & SYMPTOMS OF 0.5536 20.2 16.8
MUSCULOSKELETAL SYSTEM & CONN
TISSUE.
248..................................... TENDONITIS, MYOSITIS & BURSITIS 0.7274 24.5 20.4
249..................................... AFTERCARE, MUSCULOSKELETAL 0.7829 27.0 22.5
SYSTEM & CONNECTIVE TISSUE.
250..................................... FX, SPRN, STRN & DISL OF 0.8206 29.9 24.9
FOREARM, HAND, FOOT AGE 17 W CC.
251..................................... FX, SPRN, STRN & DISL OF 0.6009 27.3 22.7
FOREARM, HAND, FOOT AGE 17 W/O CC.
252..................................... FX, SPRN, STRN & DISL OF 0.9562 26.1 21.7
FOREARM, HAND, FOOT AGE 0-17
\8\.
253..................................... FX, SPRN, STRN & DISL OF UPARM, 0.8176 27.6 23.0
LOWLEG EX FOOT AGE 17 W CC.
254..................................... FX, SPRN, STRN & DISL OF UPARM, 0.6691 25.1 20.9
LOWLEG EX FOOT AGE 17 W/O CC.
255..................................... FX, SPRN, STRN & DISL OF UPARM, 0.9562 26.1 21.7
LOWLEG EX FOOT AGE 0-17 \8\.
256..................................... OTHER MUSCULOSKELETAL SYSTEM & 0.8294 25.9 21.5
CONNECTIVE TISSUE DIAGNOSES.
257..................................... TOTAL MASTECTOMY FOR MALIGNANCY 0.9562 26.1 21.7
W CC \3\.
258..................................... TOTAL MASTECTOMY FOR MALIGNANCY 0.9562 26.1 21.7
W/O CC \8\.
259..................................... SUBTOTAL MASTECTOMY FOR 0.9562 26.1 21.7
MALIGNANCY W CC \8\.
260..................................... SUBTOTAL MASTECTOMY FOR 0.9562 26.1 21.7
MALIGNANCY W/O CC \8\.
261..................................... BREAST PROC FOR NON-MALIGNANCY 2.0841 40.0 33.3
EXCEPT BIOPSY & LOCAL EXCISION
\5\.
262..................................... BREAST BIOPSY & LOCAL EXCISION 0.9562 26.1 21.7
FOR NON-MALIGNANCY \3\.
263..................................... SKIN GRAFT &/OR DEBRID FOR SKN 1.4522 42.4 35.3
ULCER OR CELLULITIS W CC.
264..................................... SKIN GRAFT &/OR DEBRID FOR SKN 1.2892 44.1 36.7
ULCER OR CELLULITIS W/O CC.
265..................................... SKIN GRAFT &/OR DEBRID EXCEPT 1.2215 34.8 29.0
FOR SKIN ULCER OR CELLULITIS W
CC \7\.
266..................................... SKIN GRAFT &/OR DEBRID EXCEPT 1.2215 34.8 29.0
FOR SKIN ULCER OR CELLULITIS W/
O CC \7\.
267..................................... PERIANAL & PILONIDAL PROCEDURES 0.9562 26.1 21.7
\8\.
268..................................... SKIN, SUBCUTANEOUS TISSUE & 2.0841 40.0 33.3
BREAST PLASTIC PROCEDURES \5\.
269..................................... OTHER SKIN, SUBCUT TISS & 1.4466 43.0 35.8
BREAST PROC W CC.
[[Page 4813]]
270..................................... OTHER SKIN, SUBCUT TISS & 0.9916 33.9 28.2
BREAST PROC W/O CC.
271..................................... SKIN ULCERS.................... 0.9620 30.4 25.3
272..................................... MAJOR SKIN DISORDERS W CC...... 0.7121 22.8 19.0
273..................................... MAJOR SKIN DISORDERS W/O CC \1\ 0.4964 18.5 15.4
274..................................... MALIGNANT BREAST DISORDERS W CC 0.9072 24.9 20.7
275..................................... MALIGNANT BREAST DISORDERS W/O 0.7372 23.5 19.5
CC \2\.
276..................................... NON-MALIGNANT BREAST DISORDERS 0.4964 18.5 15.4
\1\.
277..................................... CELLULITIS AGE 17 W 0.7409 23.6 19.6
CC.
278..................................... CELLULITIS AGE 17 W/ 0.5982 20.7 17.2
O CC.
279..................................... CELLULITIS AGE 0-17 \8\........ 0.9562 26.1 21.7
280..................................... TRAUMA TO THE SKIN, SUBCUT TISS 0.9724 29.5 24.5
& BREAST AGE 17 W
CC.
281..................................... TRAUMA TO THE SKIN, SUBCUT TISS 0.7386 26.4 22.0
& BREAST AGE 17 W/O
CC.
282..................................... TRAUMA TO THE SKIN, SUBCUT TISS 0.7372 23.5 19.5
& BREAST AGE 0-17.
283..................................... MINOR SKIN DISORDERS W CC \8\.. 0.6508 19.3 16.0
284..................................... MINOR SKIN DISORDERS W/O CC \1\ 0.4964 18.5 15.4
285..................................... AMPUTAT OF LOWER LIMB FOR 1.5176 37.4 31.1
ENDOCRINE, NUTRIT,& METABOL
DISORDERS.
286..................................... ADRENAL & PITUITARY PROCEDURES 0.7372 23.5 19.5
\8\.
287..................................... SKIN GRAFTS & WOUND DEBRID FOR 1.3982 39.7 33.0
ENDOC, NUTRIT & METAB
DISORDERS.
288..................................... O.R. PROCEDURES FOR OBESITY \5\ 2.0841 40.0 33.3
289..................................... PARATHYROID PROCEDURES \8\..... 0.7372 23.5 19.5
290..................................... THYROID PROCEDURES \8\......... 0.7372 23.5 19.5
291..................................... THYROGLOSSAL PROCEDURES \8\.... 0.7372 23.5 19.5
292..................................... OTHER ENDOCRINE, NUTRIT & METAB 1.3569 32.5 27.0
O.R. PROC W CC \4\.
293..................................... OTHER ENDOCRINE, NUTRIT & METAB 0.9562 26.1 21.7
O.R. PROC W/O CC \8\.
294..................................... DIABETES AGE 35..... 0.8061 25.9 21.5
295..................................... DIABETES AGE 0-35 \3\.......... 0.9562 26.1 21.7
296..................................... NUTRITIONAL & MISC METABOLIC 0.8207 24.1 20.0
DISORDERS AGE 17 W
CC.
297..................................... NUTRITIONAL & MISC METABOLIC 0.6524 24.5 20.4
DISORDERS AGE 17 W/
O CC.
298..................................... NUTRITIONAL & MISC METABOLIC 0.7372 23.5 19.5
DISORDERS AGE 0-17 \8\.
299..................................... INBORN ERRORS OF METABOLISM \3\ 0.9562 26.1 21.7
300..................................... ENDOCRINE DISORDERS W CC....... 0.7704 22.3 18.5
301..................................... ENDOCRINE DISORDERS W/O CC \2\. 0.7372 23.5 19.5
302..................................... KIDNEY TRANSPLANT \6\.......... 0.0000 0.0 0.0
303..................................... KIDNEY,URETER & MAJOR BLADDER 2.0841 40.0 33.3
PROCEDURES FOR NEOPLASM \8\.
304..................................... KIDNEY,URETER & MAJOR BLADDER 2.0841 40.0 33.3
PROC FOR NON-NEOPL W CC \5\.
305..................................... KIDNEY,URETER & MAJOR BLADDER 0.4964 18.5 15.4
PROC FOR NON-NEOPL W/O CC \1\.
306..................................... PROSTATECTOMY W CC \8\......... 1.3569 32.5 27.0
307..................................... PROSTATECTOMY W/O CC \8\....... 1.3569 32.5 27.0
308..................................... MINOR BLADDER PROCEDURES W CC 1.3569 32.5 27.0
\4\.
309..................................... MINOR BLADDER PROCEDURES W/O CC 0.7372 23.5 19.5
\2\.
310..................................... TRANSURETHRAL PROCEDURES W CC 1.3569 32.5 27.0
\4\.
311..................................... TRANSURETHRAL PROCEDURES W/O CC 0.4964 18.5 15.4
\1\.
312..................................... URETHRAL PROCEDURES, AGE 17 W CC \4\.
313..................................... URETHRAL PROCEDURES, AGE 17 W/O CC \8\.
314..................................... URETHRAL PROCEDURES, AGE 0-17 0.4964 18.5 15.4
\8\.
315..................................... OTHER KIDNEY & URINARY TRACT 1.5070 36.8 30.6
O.R. PROCEDURES.
316..................................... RENAL FAILURE.................. 0.9214 23.8 19.8
317..................................... ADMIT FOR RENAL DIALYSIS \3\... 0.9562 26.1 21.7
318..................................... KIDNEY & URINARY TRACT 0.7048 21.1 17.5
NEOPLASMS W CC.
319..................................... KIDNEY & URINARY TRACT 0.4964 18.5 15.4
NEOPLASMS W/O CC \1\.
320..................................... KIDNEY & URINARY TRACT 0.7223 23.0 19.1
INFECTIONS AGE 17 W
CC.
321..................................... KIDNEY & URINARY TRACT 0.6260 23.2 19.3
INFECTIONS AGE 17 W/
O CC.
322..................................... KIDNEY & URINARY TRACT 0.4964 18.5 15.4
INFECTIONS AGE 0-17 \8\.
323..................................... URINARY STONES W CC, &/OR ESW 0.7372 23.5 19.5
LITHOTRIPSY \2\.
324..................................... URINARY STONES W/O CC \2\...... 0.7372 23.5 19.5
325..................................... KIDNEY & URINARY TRACT SIGNS & 0.9562 26.1 21.7
SYMPTOMS AGE 17 W
CC \3\.
326..................................... KIDNEY & URINARY TRACT SIGNS & 0.4964 18.5 15.4
SYMPTOMS AGE 17 W/O
CC \1\.
327..................................... KIDNEY & URINARY TRACT SIGNS & 0.4964 18.5 15.4
SYMPTOMS AGE 0-17 \8\.
328..................................... URETHRAL STRICTURE AGE 17 W CC \8\.
329..................................... URETHRAL STRICTURE AGE 17 W/O CC \8\.
330..................................... URETHRAL STRICTURE AGE 0-17 \8\ 0.4964 18.5 15.4
331..................................... OTHER KIDNEY & URINARY TRACT 0.8473 23.2 19.3
DIAGNOSES AGE 17 W/
O CC.
332..................................... OTHER KIDNEY & URINARY TRACT 0.5722 21.1 17.5
DIAGNOSES AGE 17 W/
O CC.
333..................................... OTHER KIDNEY & URINARY TRACT 0.4964 18.5 15.4
DIAGNOSES AGE 0-17 \8\.
334..................................... MAJOR MALE PELVIC PROCEDURES W 2.0841 40.0 33.3
CC \8\.
335..................................... MAJOR MALE PELVIC PROCEDURES W/ 2.0841 40.0 33.3
O CC \8\.
336..................................... TRANSURETHRAL PROSTATECTOMY W 0.7372 23.5 19.5
CC \8\.
[[Page 4814]]
337..................................... TRANSURETHRAL PROSTATECTOMY W/O 0.7372 23.5 19.5
CC \8\.
338..................................... TESTES PROCEDURES, FOR 0.7372 23.5 19.5
MALIGNANCY \8\.
339..................................... TESTES PROCEDURES, NON- 0.7372 23.5 19.5
MALIGNANCY AGE 17
\2\.
340..................................... TESTES PROCEDURES, NON- 0.7372 23.5 19.5
MALIGNANCY AGE 0-17 \8\.
341..................................... PENIS PROCEDURES \2\........... 0.7372 23.5 19.5
342..................................... CIRCUMCISION AGE 17 0.4964 18.5 15.4
\1\.
343..................................... CIRCUMCISION AGE 0-17 \8\...... 0.7372 23.5 19.5
344..................................... OTHER MALE REPRODUCTIVE SYSTEM 0.4964 18.5 15.4
O.R. PROCEDURES FOR MALIGNANCY
\1\.
345..................................... OTHER MALE REPRODUCTIVE SYSTEM 2.0841 40.0 33.3
O.R. PROC EXCEPT FOR
MALIGNANCY \5\.
346..................................... MALIGNANCY, MALE REPRODUCTIVE 0.7150 22.3 18.5
SYSTEM, W CC \7\.
347..................................... MALIGNANCY, MALE REPRODUCTIVE 0.7150 22.3 18.5
SYSTEM, W/O CC \7\.
348..................................... BENIGN PROSTATIC HYPERTROPHY W 0.4964 18.5 15.4
CC \1\.
349..................................... BENIGN PROSTATIC HYPERTROPHY W/ 0.4964 18.5 15.4
O CC \1\.
350..................................... INFLAMMATION OF THE MALE 1.1820 26.6 22.1
REPRODUCTIVE SYSTEM.
351..................................... STERILIZATION, MALE \8\........ 0.7372 23.5 19.5
352..................................... OTHER MALE REPRODUCTIVE SYSTEM 0.9562 26.1 21.7
DIAGNOSES \3\.
353..................................... PELVIC EVISCERATION, RADICAL 2.0841 40.0 33.3
HYSTERECTOMY RADICAL
VULVECTOMY \8\.
354..................................... UTERINE,ADNEXA PROC FOR NON- 2.0841 40.0 33.3
OVARIAN/ADNEXAL MALIG W CC \8\.
355..................................... UTERINE,ADNEXA PROC FOR NON- 2.0841 40.0 33.3
OVARIAN/ADNEXAL MALIG W/O CC
\8\.
356..................................... FEMALE REPRODUCTIVE SYSTEM 1.3569 32.5 27.0
RECONSTRUCTIVE PROCEDURES \8\.
357..................................... UTERINE & ADNEXA PROC FOR 1.3569 32.5 27.0
OVARIAN OR ADNEXAL MALIGNANCY
\8\.
358..................................... UTERINE & ADNEXA PROC FOR NON- 1.3569 32.5 27.0
MALIGNANCY W CC \8\.
359..................................... UTERINE & ADNEXA PROC FOR NON- 1.3569 32.5 27.0
MALIGNANCY W/O CC \8\.
360..................................... VAGINA, CERVIX & VULVA 1.3569 32.5 27.0
PROCEDURES \4\.
361..................................... LAPAROSCOPY & INCISIONAL TUBAL 0.4964 18.5 15.4
INTERRUPTION \8\.
362..................................... ENDOSCOPIC TUBAL INTERRUPTION 0.4964 18.5 15.4
\8\.
363..................................... DC, CONIZATION & RADIO-IMPLANT, 0.4964 18.5 15.4
FOR MALIGNANCY \8\.
364..................................... DC, CONIZATION EXCEPT FOR 0.4964 18.5 15.4
MALIGNANCY \8\.
365..................................... OTHER FEMALE REPRODUCTIVE 2.0841 40.0 33.3
SYSTEM O.R. PROCEDURES \5\.
366..................................... MALIGNANCY, FEMALE REPRODUCTIVE 0.8139 23.1 19.2
SYSTEM W CC.
367..................................... MALIGNANCY, FEMALE REPRODUCTIVE 0.4964 18.5 15.4
SYSTEM W/O CC \1\.
368..................................... INFECTIONS, FEMALE REPRODUCTIVE 0.6963 19.3 16.0
SYSTEM.
369..................................... MENSTRUAL & OTHER FEMALE 0.9562 26.1 21.7
REPRODUCTIVE SYSTEM DISORDERS
\3\.
370..................................... CESAREAN SECTION W CC \8\...... 0.9562 26.1 21.7
371..................................... CESAREAN SECTION W/O CC \8\.... 0.4964 18.5 15.4
372..................................... VAGINAL DELIVERY W COMPLICATING 0.4964 18.5 15.4
DIAGNOSES \8\.
373..................................... VAGINAL DELIVERY W/O 0.4964 18.5 15.4
COMPLICATING DIAGNOSES \8\.
374..................................... VAGINAL DELIVERY W 0.4964 18.5 15.4
STERILIZATION /OR DaC \8\.
375..................................... VAGINAL DELIVERY W O.R. PROC 0.4964 18.5 15.4
EXCEPT STERIL /OR DaC \8\.
376..................................... POSTPARTUM & POST ABORTION 0.4964 18.5 15.4
DIAGNOSES W/O O.R. PROCEDURE
\1\.
377..................................... POSTPARTUM & POST ABORTION 0.4964 18.5 15.4
DIAGNOSES W O.R. PROCEDURE \8\.
378..................................... ECTOPIC PREGNANCY \8\.......... 0.9562 26.1 21.7
379..................................... THREATENED ABORTION \8\........ 0.4964 18.5 15.4
380..................................... ABORTION W/O D&C \8\........... 0.4964 18.5 15.4
381..................................... ABORTION W D&C, ASPIRATION 0.4964 18.5 15.4
CURETTAGE OR HYSTEROTOMY \8\.
382..................................... FALSE LABOR \8\................ 0.4964 18.5 15.4
383..................................... OTHER ANTEPARTUM DIAGNOSES W 0.4964 18.5 15.4
MEDICAL COMPLICATIONS \8\.
384..................................... OTHER ANTEPARTUM DIAGNOSES W/O 0.4964 18.5 15.4
MEDICAL COMPLICATIONS \8\.
385..................................... NEONATES, DIED OR TRANSFERRED 0.4964 18.5 15.4
TO ANOTHER ACUTE CARE FACILITY
\8\.
386..................................... EXTREME IMMATURITY \8\......... 0.4964 18.5 15.4
387..................................... PREMATURITY W MAJOR PROBLEMS 0.4964 18.5 15.4
\8\.
388..................................... PREMATURITY W/O MAJOR PROBLEMS 0.4964 18.5 15.4
\8\.
389..................................... FULL TERM NEONATE W MAJOR 0.4964 18.5 15.4
PROBLEMS \8\.
390..................................... NEONATE W OTHER SIGNIFICANT 0.4964 18.5 15.4
PROBLEMS \8\.
391..................................... NORMAL NEWBORN \8\............. 0.4964 18.5 15.4
392..................................... SPLENECTOMY AGE 17 0.7372 23.5 19.5
\8\.
393..................................... SPLENECTOMY AGE 0-17 \8\....... 0.7372 23.5 19.5
394..................................... OTHER O.R. PROCEDURES OF THE 0.9562 26.1 21.7
BLOOD AND BLOOD FORMING ORGANS
\3\.
395..................................... RED BLOOD CELL DISORDERS AGE 0.7782 24.0 20.0
17.
396..................................... RED BLOOD CELL DISORDERS AGE 0- 0.4964 18.5 15.4
17 \8\.
397..................................... COAGULATION DISORDERS.......... 0.9454 23.5 19.5
398..................................... RETICULOENDOTHELIAL & IMMUNITY 0.8372 22.0 18.3
DISORDERS W CC.
399..................................... RETICULOENDOTHELIAL & IMMUNITY 0.4964 18.5 15.4
DISORDERS W/O CC \1\.
401..................................... LYMPHOMA & NON-ACUTE LEUKEMIA W 2.0841 40.0 33.3
OTHER O.R. PROC W CC \5\.
402..................................... LYMPHOMA & NON-ACUTE LEUKEMIA W 0.9562 26.1 21.7
OTHER O.R. PROC W/O CC \3\.
[[Page 4815]]
403..................................... LYMPHOMA & NON-ACUTE LEUKEMIA W 0.8941 22.4 18.6
CC.
404..................................... LYMPHOMA & NON-ACUTE LEUKEMIA W/ 0.7394 18.0 15.0
O CC.
405..................................... ACUTE LEUKEMIA W/O MAJOR O.R. 0.7372 23.5 19.5
PROCEDURE AGE 0-17 \8\.
406..................................... MYELOPROLIF DISORD OR POORLY 2.0841 40.0 33.3
DIFF NEOPL W MAJ O.R.PROC W CC
\5\.
407..................................... MYELOPROLIF DISORD OR POORLY 0.9562 26.1 21.7
DIFF NEOPL W MAJ O.R.PROC W/O
CC \8\.
408..................................... MYELOPROLIF DISORD OR POORLY 0.9562 26.1 21.7
DIFF NEOPL W OTHER O.R.PROC
\3\.
409..................................... RADIOTHERAPY................... 0.8871 25.1 20.9
410..................................... CHEMOTHERAPY W/O ACUTE LEUKEMIA 0.9562 26.1 21.7
AS SECONDARY DIAGNOSIS \3\.
411..................................... HISTORY OF MALIGNANCY W/O 0.4964 18.5 15.4
ENDOSCOPY \8\.
412..................................... HISTORY OF MALIGNANCY W 0.4964 18.5 15.4
ENDOSCOPY \8\.
413..................................... OTHER MYELOPROLIF DIS OR POORLY 0.9541 25.5 21.2
DIFF NEOPL DIAG W CC.
414..................................... OTHER MYELOPROLIF DIS OR POORLY 0.4964 18.5 15.4
DIFF NEOPL DIAG W/O CC \1\.
415..................................... O.R. PROCEDURE FOR INFECTIOUS & 1.6849 40.1 33.4
PARASITIC DISEASES.
416..................................... SEPTICEMIA AGE 17... 0.9191 24.9 20.7
417..................................... SEPTICEMIA AGE 0-17 \8\........ 0.9562 26.1 21.7
418..................................... POSTOPERATIVE & POST-TRAUMATIC 0.8304 25.2 21.0
INFECTIONS.
419..................................... FEVER OF UNKNOWN ORIGIN AGE 17 W CC \3\.
420..................................... FEVER OF UNKNOWN ORIGIN AGE 17 W/O CC \2\.
421..................................... VIRAL ILLNESS AGE 17 0.7372 23.5 19.5
\2\.
422..................................... VIRAL ILLNESS & FEVER OF 0.7372 23.5 19.5
UNKNOWN ORIGIN AGE 0-17 \8\.
423..................................... OTHER INFECTIOUS & PARASITIC 0.9024 23.1 19.2
DISEASES DIAGNOSES.
424..................................... O.R. PROCEDURE W PRINCIPAL 1.3569 32.5 27.0
DIAGNOSES OF MENTAL ILLNESS
\4\.
425..................................... ACUTE ADJUSTMENT REACTION & 0.5981 27.5 22.9
PSYCHOLOGICAL DYSFUNCTION.
426..................................... DEPRESSIVE NEUROSES............ 0.4660 22.3 18.5
427..................................... NEUROSES EXCEPT DEPRESSIVE \4\. 1.3569 32.5 27.0
428..................................... DISORDERS OF PERSONALITY & 0.4964 18.5 15.4
IMPULSE CONTROL \1\.
429..................................... ORGANIC DISTURBANCES & MENTAL 0.6438 27.4 22.8
RETARDATION.
430..................................... PSYCHOSES...................... 0.4689 22.7 18.9
431..................................... CHILDHOOD MENTAL DISORDERS \1\. 0.4964 18.5 15.4
432..................................... OTHER MENTAL DISORDER DIAGNOSES 0.4964 18.5 15.4
\1\.
433..................................... ALCOHOL/DRUG ABUSE OR 0.4964 18.5 15.4
DEPENDENCE, LEFT AMA \1\.
439..................................... SKIN GRAFTS FOR INJURIES....... 1.3663 40.5 33.7
440..................................... WOUND DEBRIDEMENTS FOR INJURIES 1.5854 40.0 33.3
441..................................... HAND PROCEDURES FOR INJURIES 2.0841 40.0 33.3
\5\.
442..................................... OTHER O.R. PROCEDURES FOR 1.4971 44.6 37.1
INJURIES W CC.
443..................................... OTHER O.R. PROCEDURES FOR 1.3569 32.5 27.0
INJURIES W/O CC \4\.
444..................................... TRAUMATIC INJURY AGE 17 W CC.
445..................................... TRAUMATIC INJURY AGE 17 W/O CC.
446..................................... TRAUMATIC INJURY AGE 0-17 \8\.. 0.7372 23.5 19.5
447..................................... ALLERGIC REACTIONS AGE 17 \3\.
448..................................... ALLERGIC REACTIONS AGE 0-17 \8\ 0.7372 23.5 19.5
449..................................... POISONING & TOXIC EFFECTS OF 0.9562 26.1 21.7
DRUGS AGE 17 W CC
\7\.
450..................................... POISONING & TOXIC EFFECTS OF 0.9562 26.1 21.7
DRUGS AGE 17 W/O CC
\7\.
451..................................... POISONING & TOXIC EFFECTS OF 0.7372 23.5 19.5
DRUGS AGE 0-17 \8\.
452..................................... COMPLICATIONS OF TREATMENT W CC 0.9692 24.9 20.7
453..................................... COMPLICATIONS OF TREATMENT W/O 0.8633 24.2 20.1
CC.
454..................................... OTHER INJURY, POISONING & TOXIC 0.7372 23.5 19.5
EFFECT DIAG W CC \2\.
455..................................... OTHER INJURY, POISONING & TOXIC 0.7372 23.5 19.5
EFFECT DIAG W/O CC \2\.
461..................................... O.R. PROC W DIAGNOSES OF OTHER 1.3216 36.5 30.4
CONTACT W HEALTH SERVICES.
462..................................... REHABILITATION................. 0.6471 23.2 19.3
463..................................... SIGNS & SYMPTOMS W CC.......... 0.7541 26.8 22.3
464..................................... SIGNS & SYMPTOMS W/O CC........ 0.6170 25.5 21.2
465..................................... AFTERCARE W HISTORY OF 0.7372 23.5 19.5
MALIGNANCY AS SECONDARY
DIAGNOSIS \2\.
466..................................... AFTERCARE W/O HISTORY OF 0.7365 22.0 18.3
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467..................................... OTHER FACTORS INFLUENCING 0.4964 18.5 15.4
HEALTH STATUS \1\.
468..................................... EXTENSIVE O.R. PROCEDURE 2.0686 42.5 35.4
UNRELATED TO PRINCIPAL
DIAGNOSIS.
469..................................... PRINCIPAL DIAGNOSIS INVALID AS 0.0000 0.0 0.0
DISCHARGE DIAGNOSIS \6\.
470..................................... UNGROUPABLE \6\................ 0.0000 0.0 0.0
471..................................... BILATERAL OR MULTIPLE MAJOR 2.0841 40.0 33.3
JOINT PROCS OF LOWER EXTREMITY
\5\.
473..................................... ACUTE LEUKEMIA W/O MAJOR O.R. 0.9562 26.1 21.7
PROCEDURE AGE 17
\3\.
475..................................... RESPIRATORY SYSTEM DIAGNOSIS 2.1358 35.2 29.3
WITH VENTILATOR SUPPORT.
476..................................... PROSTATIC O.R. PROCEDURE 1.0032 31.9 26.5
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477..................................... NON-EXTENSIVE O.R. PROCEDURE 1.8998 40.0 33.3
UNRELATED TO PRINCIPAL
DIAGNOSIS.
478..................................... OTHER VASCULAR PROCEDURES W CC 1.2567 34.2 28.5
\7\.
479..................................... OTHER VASCULAR PROCEDURES W/O 1.2567 34.2 28.5
CC \7\.
480..................................... LIVER TRANSPLANT \6\........... 0.0000 0.0 0.0
481..................................... BONE MARROW TRANSPLANT \8\..... 0.9562 26.1 21.7
[[Page 4816]]
482..................................... TRACHEOSTOMY FOR FACE, MOUTH & 2.0841 40.0 33.3
NECK DIAGNOSES \5\.
483..................................... TRACH W MECH VENT 96+ HRS OR 3.2131 55.7 46.4
PDX EXCEPT FACE,MOUTH & NECK
DIAG.
484..................................... CRANIOTOMY FOR MULTIPLE 2.0841 40.0 33.3
SIGNIFICANT TRAUMA \8\.
485..................................... LIMB REATTACHMENT, HIP AND 1.3569 32.5 27.0
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TR \8\.
486..................................... OTHER O.R. PROCEDURES FOR 1.3569 32.5 27.0
MULTIPLE SIGNIFICANT TRAUMA
\4\.
487..................................... OTHER MULTIPLE SIGNIFICANT 1.2484 32.7 27.2
TRAUMA.
488..................................... HIV W EXTENSIVE O.R. PROCEDURE 2.0841 40.0 33.3
\5\.
489..................................... HIV W MAJOR RELATED CONDITION.. 0.9254 21.3 17.7
490..................................... HIV W OR W/O OTHER RELATED 0.7361 19.6 16.3
CONDITION.
491..................................... MAJOR JOINT & LIMB REATTACHMENT 1.3569 32.5 27.0
PROCEDURES OF UPPER EXTREMITY
\8\.
492..................................... CHEMOTHERAPY W ACUTE LEUKEMIA 0.9562 26.1 21.7
AS SECONDARY DIAGNOSIS OR W
USE HIGH DOSE CHEMOTHERAPY
AGENT \8\.
493..................................... LAPAROSCOPIC CHOLECYSTECTOMY W/ 1.3569 32.5 27.0
O C.D.E. W CC \7\.
494..................................... LAPAROSCOPIC CHOLECYSTECTOMY W/ 2.0841 40.0 33.3
O C.D.E. W/O CC \7\.
495..................................... LUNG TRANSPLANT \6\............ 0.0000 0.0 0.0
496..................................... COMBINED ANTERIOR/POSTERIOR 1.3569 32.5 27.0
SPINAL FUSION \8\.
497..................................... SPINAL FUSION W CC \7\......... 0.9562 26.1 21.7
498..................................... SPINAL FUSION W/O CC \7\....... 0.9562 26.1 21.7
499..................................... BACK & NECK PROCEDURES EXCEPT 2.0841 40.0 33.3
SPINAL FUSION W CC \5\.
500..................................... BACK & NECK PROCEDURES EXCEPT 1.3569 32.5 27.0
SPINAL FUSION W/O CC \4\.
501..................................... KNEE PROCEDURES W PDX OF 2.0841 40.0 33.3
INFECTION W CC \5\.
502..................................... KNEE PROCEDURES W PDX OF 0.7372 23.5 19.5
INFECTION W/O CC \2\.
503..................................... KNEE PROCEDURES W/O PDX OF 0.9562 26.1 21.7
INFECTION \3\.
504..................................... EXTENSIVE 3RD DEGREE BURNS W 2.0841 40.0 33.3
SKIN GRAFT \8\.
505..................................... EXTENSIVE 3RD DEGREE BURNS W/O 1.3569 32.5 27.0
SKIN GRAFT \4\.
506..................................... FULL THICKNESS BURN W SKIN 0.7372 23.5 19.5
GRAFT OR INHAL INJ W CC OR SIG
TRAUMA \7\.
507..................................... FULL THICKNESS BURN W SKIN GRFT 0.7372 23.5 19.5
OR INHAL INJ W/O CC OR SIG
TRAUMA \7\.
508..................................... FULL THICKNESS BURN W/O SKIN 0.7372 23.5 19.5
GRFT OR INHAL INJ W CC OR SIG
TRAUMA \2\.
509..................................... FULL THICKNESS BURN W/O SKIN 0.7372 23.5 19.5
GRFT OR INH INJ W/O CC OR SIG
TRAUMA \2\.
510..................................... NON-EXTENSIVE BURNS W CC OR 0.7372 23.5 19.5
SIGNIFICANT TRAUMA \2\.
511..................................... NON-EXTENSIVE BURNS W/O CC OR 0.4964 18.5 15.4
SIGNIFICANT TRAUMA \1\.
512..................................... SIMULTANEOUS PANCREAS/KIDNEY 0.0000 0.0 0.0
TRANSPLANT \6\.
513..................................... PANCREAS TRANSPLANT \6\........ 0.0000 0.0 0.0
515..................................... CARDIAC DEFIBRILATOR IMPLANT W/ 2.0841 40.0 33.3
O CARDIAC CATH \5\.
516..................................... PERCUTANEOUS CARDIVASCULAR 0.9562 26.1 21.7
PROCEDURE W AMI \8\.
517..................................... PERCUTANEOUS CARDIVASCULAR PROC 1.3569 32.5 27.0
W NON-DRUG ELUTING STENT W/O
AMI \4\.
518..................................... PERCUTANEOUS CARDIVASCULAR PROC 0.9562 26.1 21.7
W/O CORONARY ARTERY STENT OR
AMI \3\.
519..................................... CERVICAL SPINAL FUSION W CC \4\ 1.3569 32.5 27.0
520..................................... CERVICAL SPINAL FUSION W/O CC 0.9562 26.1 21.7
\8\.
521..................................... ALCOHOL/DRUG ABUSE OR 0.4753 20.5 17.0
DEPENDENCE W CC.
522..................................... ALCOHOL/DRUG ABUSE OR 0.4061 20.4 17.0
DEPENDENCE W REHABILITATION
THERAPY W/O CC.
523..................................... ALCOHOL/DRUG ABUSE OR 0.4214 19.8 16.5
DEPENDENCE W/O REHABILITATION
THERAPY W/O CC.
524..................................... TRANSIENT ISCHEMIA............. 0.5885 22.9 19.0
525..................................... HEART ASSIST SYSTEM, OTHER THAN 2.0841 40.0 33.3
IMPLANT \8\.
526..................................... PERCUTANEOUS CARVIOVASCULAR 1.3569 32.5 27.0
PROC W DRUG-ELUTING STENT W
AMI \8\.
527..................................... PERCUTANEOUS CARVIOVASCULAR 1.3569 32.5 27.0
PROC W DRUG-ELUTING STENT W/O
AMI \8\.
528..................................... INTRACRANIAL VASCLUAR 2.0841 40.0 33.3
PROCEDURES WITH PDX HEMORRHAGE
\8\.
529..................................... VENTRICULAR SHUNT PROCEDURES 0.7372 23.5 19.5
WITH CC \2\.
530..................................... VENTRICULAR SHUNT PROCEDURES 0.7372 23.5 19.5
WITHOUT CC \8\.
531..................................... SPINAL PROCEDURES WITH CC \4\.. 1.3569 32.5 27.0
532..................................... SPINAL PROCEDURES WITHOUT CC 0.9562 26.1 21.7
\3\.
533..................................... EXTRACRANIAL VASCULAR 2.0841 40.0 33.3
PROCEDURES WITH CC \5\.
534..................................... EXTRACRANIAL VASCULAR 1.3569 32.5 27.0
PROCEDURES WITHOUT CC \8\.
535..................................... CARDIAC DEFIB IMPLANT WITH 2.0841 40.0 33.3
CARDIAC CATH WITH AMI/HF/SHOCK
\8\.
536..................................... CARDIAC DEFIB IMPLANT WITH 2.0841 40.0 33.3
CARDIAC CATH WITHOUT AMI/HF/
SHOCK \5\.
537..................................... LOCAL EXCISION AND REMOVAL OF 1.3569 32.5 27.0
INTERNAL FIXATION DEVICES
EXCEPT HIP AND FEMUR WITH CC
\4\.
538..................................... LOCAL EXCISION AND REMOVAL OF 0.4964 18.5 15.4
INTERNAL FIXATION DEVICES
EXCEPT HIP AND FEMUR WITHOUT
CC \1\.
539..................................... LYMPHOMA AND LEUKEMIA WITH 2.0841 40.0 33.3
MAJOR O.R. PROCEDURE WITH CC
\8\.
540..................................... LYMPHOMA AND LEUKEMIA WITH 0.4964 18.5 15.4
MAJOR O.R. PROCEDURE WITHOUT
CC \1\.
[[Page 4817]]
541..................................... IMPLANT, PULSATILE HEART ASSIST 0.0000 0.0 0.0
SYSTEM \6\.
----------------------------------------------------------------------------------------------------------------
\1\ Proposed Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile
1.
\2\ Proposed Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile
2.
\3\ Proposed Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile
3.
\4\ Proposed Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile
4.
\5\ Proposed Relative weights for these LTC-DRGs were determined by assigning these cases to low volume quintile
5.
\6\ Proposed Relative weights for these LTC-DRGs were assigned a value of 0.000.
\7\ Proposed Relative weights for these LTC-DRGs were determined after adjusting to account for nonmonotonicity.
\8\ Proposed Relative weights for these LTC-DRGs were determined by assigning these cases to the appropriate low
volume quintile because they had no LTCH cases in the FY 2002 MedPAR.
[FR Doc. 04-1886 Filed 1-23-04; 5:03 pm]
BILLING CODE 4120-01-P