Att E6_Inpatient Psychiatric Facility--FLU

Vol. 79

Wednesday,

No. 151

August 6, 2014

Part III

Department of Health and Human Services

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Center for Medicare & Medicaid Services
42 CFR Part 412
Medicare Program; Inpatient Psychiatric Facilities Prospective Payment
System—Update for Fiscal Year Beginning October 1, 2014 (FY 2015);
Final Rule

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Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Part 412
[CMS–1606–F]
RIN 0938–AS08

Medicare Program; Inpatient
Psychiatric Facilities Prospective
Payment System—Update for Fiscal
Year Beginning October 1, 2014 (FY
2015)
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Final rule.
AGENCY:

This final rule will update the
prospective payment rates for Medicare
inpatient hospital services provided by
inpatient psychiatric facilities (IPFs).
These changes will be applicable to IPF
discharges occurring during the fiscal
year (FY) beginning October 1, 2014
through September 30, 2015. This final
rule will also address implementation of
ICD–10–CM and ICD–10–PCS codes;
finalize a new methodology for updating
the cost of living adjustment (COLA),
and finalize new quality measures and
reporting requirements under the IPF
quality reporting program.
DATES: These regulations are effective
on October 1, 2014.
FOR FURTHER INFORMATION CONTACT:
Dorothy Myrick or Jana Lindquist, (410)
786–4533, for general information.
Hudson Osgood, (410) 786–7897 or
Bridget Dickensheets, (410) 786–8670,
for information regarding the market
basket and labor-related share.
Theresa Bean, (410) 786–2287, for
information regarding the regulatory
impact analysis. Rebecca Kliman,
(410) 786–9723 or Jeffrey Buck, (410)
786–0407, for information regarding
the inpatient psychiatric facility
quality reporting program.
SUPPLEMENTARY INFORMATION:
SUMMARY:

Table of Contents

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To assist readers in referencing
sections contained in this document, we
are providing the following table of
contents.
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Transfers
II. Background
A. Annual Requirements for Updating the
IPF PPS
B. Overview of the Legislative
Requirements of the IPF PPS
C. General Overview of the IPF PPS

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III. Provisions of the Proposed Regulations
and Responses to Public Comments
IV. Changing the IPF PPS Payment Rate
Update Period From a Rate Year to a
Fiscal Year
V. Market Basket for the IPF PPS
A. Background
B. Development of an IPF-Specific Market
Basket
C. FY 2015 Market Basket Update
D. Labor-Related Share
VI. Updates to the IPF PPS for FY Beginning
October 1, 2014
A. Determining the Standardized BudgetNeutral Federal Per Diem Base Rate
B. Update of the Federal Per Diem Base
Rate and Electroconvulsive Therapy Rate
VII. Update of the IPF PPS Adjustment
Factors
A. Overview of the IPF PPS Adjustment
Factors
B. Patient-Level Adjustments
1. Adjustment for MS–DRG Assignment
2. Payment for Comorbid Conditions
3. Patient Age Adjustments
4. Variable Per Diem Adjustments
C. Facility-Level Adjustments
1. Wage Index Adjustment
a. Background
b. Wage Index for FY 2015
c. OMB Bulletins
2. Adjustment for Rural Location
3. Teaching Adjustment
a. FTE Intern and Resident Cap Adjustment
b. Temporary Adjustment to the FTE Cap
To Reflect Residents Added Due to
Hospital Closure
c. Temporary Adjustment to FTE Cap To
Reflect Residents Affected by Residency
Program Closure
i. Receiving IPF
ii. IPF That Closed Its Program
4. Cost of Living Adjustment for IPFs
Located in Alaska and Hawaii
5. Adjustment for IPFs With a Qualifying
Emergency Department (ED)
D. Other Payment Adjustments and
Policies
1. Outlier Payments
a. Update to the Outlier Fixed Dollar Loss
Threshold Amount
b. Update to IPF Cost-to-Charge Ratio
Ceilings
2. Future Refinements
VIII. Inpatient Psychiatric Facilities Quality
Reporting Program
IX. Provisions of the Final Regulations
X. Collection of Information Requirements
XI. Comments Beyond the Scope of the Final
Rule
XII. Regulatory Impact Analysis
Addenda

Acronyms
Because of the many terms to which
we refer by acronym in this final rule,
we are listing the acronyms used and
their corresponding meanings in
alphabetical order below:
BBRA Medicare, Medicaid and SCHIP
[State Children’s Health Insurance
Program] Balanced Budget Refinement Act
of 1999 (Pub. L. 106–113)
CBSA Core-Based Statistical Area
CCR Cost-to-Charge Ratio

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CAH Critical Access Hospital
DSM–IV–TR Diagnostic and Statistical
Manual of Mental Disorders Fourth
Edition—Text Revision
DRGs Diagnosis-Related Groups
FY Federal Fiscal Year (October 1 through
September 30)
ICD–9–CM International Classification of
Diseases, 9th Revision, Clinical
Modification
ICD–10–CM International Classification of
Diseases, 10th Revision, Clinical
Modification
ICD–10–PCS International Classification of
Diseases, 10th Revision, Procedure Coding
System
IPFs Inpatient Psychiatric Facilities
IPFQR Inpatient Psychiatric Facilities
Quality Reporting
IRFs Inpatient Rehabilitation Facilities
LTCHs Long-Term Care Hospitals
MAC Medicare Administrative Contractor
MedPAR Medicare Provider Analysis and
Review File
RPL Rehabilitation, Psychiatric, and LongTerm Care
RY Rate Year (July 1 through June 30)
TEFRA Tax Equity and Fiscal
Responsibility Act of 1982 (Pub. L. 97–248)

I. Executive Summary
A. Purpose
This final rule updates the
prospective payment rates for Medicare
inpatient hospital services provided by
inpatient psychiatric facilities for
discharges occurring during the fiscal
year (FY) beginning October 1, 2014
through September 30, 2015.
B. Summary of the Major Provisions
In this final rule, we update the IPF
PPS, as specified in 42 CFR 412.428.
The updates include the following:
• The FY 2008-based Rehabilitation,
Psychiatric, and Long Term Care (RPL)
market basket update (currently
estimated to be 2.9 percent) will be
adjusted by a 0.3 percentage point
reduction as required by section
1886(s)(2)(A)(ii) of the Social Security
Act (the Act) and a reduction for
economy-wide productivity (currently
estimated to be 0.5 percentage point) as
required by section 1886(s)(2)(A)(i) of
the Act.
• The FY 2015 per diem rate is
updated from $713.19 to $728. 31.
• The electroconvulsive therapy
payment is updated from $307.04 to
$313.55.
• The fixed dollar loss threshold
amount is updated from $10,245 to
$8,755 in order to maintain outlier
payments that are 2 percent of total IPF
PPS payments.
• The national urban and rural costto-charge ratio (CCR) ceilings for FY
2015 is 1.6582 and 1.8590, respectively,
and the national median CCR will be
0.6220 for rural IPFs and 0.4710 for

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Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations
urban IPFs. These amounts are used in
the outlier calculation to determine if an
IPF’s CCR is statistically accurate and
for new providers without an
established CCR.
• The cost of living adjustment
factors for IPFs located in Alaska and
Hawaii is updated using the approach
finalized in the FY 2014 inpatient
hospital prospective payment system
(IPPS) final rule (78 FR 50985 through
50987).
In addition:

• We identify the ICD–10–CM/PCS
codes that will be eligible for the MS–
DRG and comorbidity payment
adjustments under the IPF PPS. The
effective date of those changes is
October 1, 2015.
• We identify the ICD–9–CM/PCS
codes that will be eligible for the MS–
DRG and comorbidity payment
adjustments under the IPF PPS.
• We use the best available hospital
wage index and establish the wage

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index budget-neutrality adjustment of
1.0002.
• We retain the 17 percent payment
adjustment for IPFs located in rural
areas, the 1.31 payment adjustment
factor for IPFs with a qualifying
emergency department, the coefficient
value of 0.5150 for the teaching
adjustment, and the MS–DRG
adjustment factors and comorbidity
adjustment factors currently being paid
to IPFs in FY 2014.
C. Summary of Impacts

Provision description
Total transfers
FY 2015 IPF PPS payment rate update ..................................................

The overall economic impact of this final rule is an estimated $120 million in increased payments to IPFs during FY 2015.

Costs
.
New quality reporting program requirements ...........................................

II. Background

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A. Annual Requirements for Updating
the IPF PPS
In November 2004, we implemented
the inpatient psychiatric facilities (IPF)
prospective payment system (PPS) in a
final rule that appeared in the
November 15, 2004 Federal Register (69
FR 66922). In developing the IPF PPS,
to ensure that the IPF PPS is able to
account adequately for each IPF’s casemix, we performed an extensive
regression analysis of the relationship
between the per diem costs and certain
patient and facility characteristics to
determine those characteristics
associated with statistically significant
cost differences on a per diem basis. For
characteristics with statistically
significant cost differences, we used the
regression coefficients of those variables
to determine the size of the
corresponding payment adjustments.
In that final rule, we explained that
we believe it is important to delay
updating the adjustment factors derived
from the regression analysis until we
have IPF PPS data that include as much
information as possible regarding the
patient-level characteristics of the
population that each IPF serves.
Therefore, we indicated that we did not
intend to update the regression analysis
and the patient- and facility-level
adjustments until we complete that
analysis. Until that analysis is complete,
we stated our intention to publish a
notice in the Federal Register each

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The total costs in FY 2015 for IPFs as a result of the final new quality
reporting requirements is estimated to be $33,372,508.

spring to update the IPF PPS (71 FR
27041). We have begun the necessary
analysis to make refinements to the IPF
PPS using more current data to set the
adjustment factors; however, we did not
propose those refinements in the
proposed rule and are not finalizing
them in this final rule. Rather, as
explained in section V.D.3 of this final
rule, we expect that in future
rulemaking, possibly for Fiscal Year
(FY) 2017, we will be ready to propose
potential refinements.
In the May 6, 2011 IPF PPS final rule
(76 FR 26432), we changed the payment
rate update period to a rate year (RY)
that coincides with a FY update.
Therefore, update notices are now
published in the Federal Register in the
summer to be effective on October 1.
When proposing changes in IPF
payment policy, a proposed rule would
be issued in the spring and the final rule
in the summer in order to be effective
on October 1. For further discussion on
changing the IPF PPS payment rate
update period to a RY that coincides
with a FY, see the IPF PPS final rule
published in the Federal Register on
May 6, 2011 (76 FR 26434 through
26435). For a detailed list of updates to
the IPF PPS, see 42 CFR 412.428.
Our most recent IPF PPS annual
update occurred in an August 1, 2013,
Federal Register notice (78 FR 46734)
(hereinafter referred to as the August
2013 IPF PPS notice) that set forth
updates to the IPF PPS payment rates
for FY 2014. That notice updated the

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IPF PPS per diem payment rates that
were published in the August 2012 IPF
PPS notice (77 FR 47224) in accordance
with our established policies.
B. Overview of the Legislative
Requirements for the IPF PPS
Section 124 of the Medicare,
Medicaid, and SCHIP (State Children’s
Health Insurance Program) Balanced
Budget Refinement Act of 1999 (BBRA)
(Pub. L. 106–113) required the
establishment and implementation of an
IPF PPS. Specifically, section 124 of the
BBRA mandated that the Secretary
develop a per diem PPS for inpatient
hospital services furnished in
psychiatric hospitals and psychiatric
units including an adequate patient
classification system that reflects the
differences in patient resource use and
costs among psychiatric hospitals and
psychiatric units.
Section 405(g)(2) of the Medicare
Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) (Pub.
L. 108–173) extended the IPF PPS to
distinct part psychiatric units of critical
access hospitals (CAHs).
Section 3401(f) of the Patient
Protection and Affordable Care Act
(Pub. L. 111–148) as amended by
section 10319(e) of that Act and by
section 1105(d) of the Health Care and
Education Reconciliation Act of 2010
(Pub. L. 111–152) (hereafter referred to
as ‘‘the Affordable Care Act’’) added
subsections to section 1886 of the Act.

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Section 1886(s)(1) of the Act titled
‘‘Reference to Establishment and
Implementation of System’’ refers to
section 124 of the BBRA, which relates
to the establishment of the IPF PPS.
Section 1886(s)(2)(A)(i) of the Act
requires the application of the
productivity adjustment described in
section 1886(b)(3)(B)(xi)(II) of the Act to
the IPF PPS for the RY beginning in
2012 (that is, a RY that coincides with
a FY) and each subsequent RY. For the
RY beginning in 2014 (that is, FY 2015),
the current estimate of the productivity
adjustment will be equal to 0.5
percentage point, which we are
finalizing in this FY 2015 final rule.
Section 1886(s)(2)(A)(ii) of the Act
requires the application of an ‘‘other
adjustment’’ that reduces any update to
an IPF PPS base rate by percentages
specified in section 1886(s)(3) of the Act
for the RY beginning in 2010 through
the RY beginning in 2019. For the RY
beginning in 2014 (that is, FY 2015),
section 1886(s)(3)(C) of the Act requires
the reduction to be 0.3 percentage point.
We are finalizing that reduction in this
FY 2015 IPF PPS final rule.
Section 1886(s)(4) of the Act requires
the establishment of a quality data
reporting program for the IPF PPS
beginning in RY 2014. We proposed and
finalized new requirements for quality
reporting for IPFs in the ‘‘Hospital
Inpatient Prospective Payment System
for Acute Care Hospitals and the Long
Term Care Hospital Prospective
Payment System and Fiscal Year 2014
Rates’’ proposed rule published on May
10, 2013 (78 FR 27486, 27734 through
27744) and final rule published on
August 19, 2013 (78 FR 50496, 50887
through 50903).
To implement and periodically
update these provisions, we have
published various proposed and final
rules in the Federal Register. For more
information regarding these rules, see
the CMS Web site at http://
www.cms.hhs.gov/InpatientPsych
FacilPPS/.
C. General Overview of the IPF PPS
The November 2004 IPF PPS final
rule (69 FR 66922) established the IPF
PPS, as required by section 124 of the
BBRA and codified at subpart N of part
412 of the Medicare regulations. The
November 2004 IPF PPS final rule set
forth the per diem Federal rates for the
implementation year (the 18-month
period from January 1, 2005 through
June 30, 2006), and provided payment
for the inpatient operating and capital
costs to IPFs for covered psychiatric
services they furnish (that is, routine,
ancillary, and capital costs, but not costs
of approved educational activities, bad

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debts, and other services or items that
are outside the scope of the IPF PPS).
Covered psychiatric services include
services for which benefits are provided
under the fee-for-service Part A
(Hospital Insurance Program) of the
Medicare program.
The IPF PPS established the Federal
per diem base rate for each patient day
in an IPF derived from the national
average daily routine operating,
ancillary, and capital costs in IPFs in FY
2002. The average per diem cost was
updated to the midpoint of the first year
under the IPF PPS, standardized to
account for the overall positive effects of
the IPF PPS payment adjustments, and
adjusted for budget-neutrality.
The Federal per diem payment under
the IPF PPS is comprised of the Federal
per diem base rate described above and
certain patient- and facility-level
payment adjustments that were found in
the regression analysis to be associated
with statistically significant per diem
cost differences.
The patient-level adjustments include
age, DRG assignment, comorbidities,
and variable per diem adjustments to
reflect higher per diem costs in the early
days of an IPF stay. Facility-level
adjustments include adjustments for the
IPF’s wage index, rural location,
teaching status, a cost-of-living
adjustment for IPFs located in Alaska
and Hawaii, and the presence of a
qualifying emergency department (ED).
The IPF PPS provides additional
payment policies for: outlier cases;
interrupted stays; and a per treatment
adjustment for patients who undergo
electroconvulsive therapy (ECT). During
the IPF PPS mandatory 3-year transition
period, stop-loss payments were also
provided; however, since the transition
ended in 2008, these payments are no
longer available.
A complete discussion of the
regression analysis that established the
IPF PPS adjustment factors appears in
the November 2004 IPF PPS final rule
(69 FR 66933 through 66936).
Section 124 of the BBRA did not
specify an annual rate update strategy
for the IPF PPS and was broadly written
to give the Secretary discretion in
establishing an update methodology.
Therefore, in the November 2004 IPF
PPS final rule, we implemented the IPF
PPS using the following update strategy:
• Calculate the final Federal per diem
base rate to be budget-neutral for the 18month period of January 1, 2005
through June 30, 2006.
• Use a July 1 through June 30 annual
update cycle.
• Allow the IPF PPS first update to be
effective for discharges on or after July
1, 2006 through June 30, 2007.

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III. Provisions of the Proposed
Regulations and Responses to
Comments
On May 6, 2014, we published a
proposed rule in the Federal Register
(79 FR 26040) entitled Medicare
Program; Inpatient Psychiatric Facilities
Prospective Payment System—Update
for Fiscal Year Beginning October 1,
2014 (FY 2015). The May 6, 2014
proposed rule (herein referred to as the
FY 2015 IPF PPS proposed rule) set
forth the proposed update to the
prospective payment rates for Medicare
inpatient hospital services provided by
inpatient psychiatric facilities. In
addition to the update, we proposed to:
• Adjust the FY 2008-based
Rehabilitation, Psychiatric, and Long
Term Care (RPL) market basket update
by 0.3 percentage point reduction.
• Update the FY 2015 per diem rate
from $713.19 to $727.67.
• Update the electroconvulsive
therapy payment from $307.04 to
$313.27.
• Update the fixed dollar loss
threshold amount from $10,245 to
$10,125.
• Update the cost of living adjustment
factors for IPFs located in Alaska and
Hawaii.
In addition, we proposed:
• Effective when ICD–10–CM/PCS
becomes the required medical data code
set for use on Medicare claims (which
we now know will be October 1, 2015),
the ICD–10–CM codes that would be
eligible for the MS–DRG and
comorbidity payment adjustments
under the IPF PPS.
• ICD–9–CM/PCS codes that would
be eligible for the MS–DRG and
comorbidity payment adjustments.
• To use the best available hospital
wage index and establish the wage
index budget-neutrality adjustment.
• New Quality Measures for the FY
2016 Payment Determination and
Subsequent Years (Patient Assessment
of Experience of Care, Use of an
Electronic Health Record).
• New Quality Measures for the FY
2017 Payment Determination and
Subsequent Years (Influenza
Immunization, Influenza Vaccination
Coverage Among Healthcare Personnel,
Tobacco Use Screening, and Tobacco
Use Treatment Provided or Offered and
Tobacco Use Treatment).
• Effective with FY 2017 payment
determination, a requirement that
facilities submit to CMS aggregate
population counts for Medicare and
non-Medicare discharges by age group,
diagnostic group, and quarter, and
sample size counts for measures, for
which sampling is performed.

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• To solicit recommendations from
the public on additions and changes to
the IPF quality reporting program in
future years.
We provided for a 60-day comment
period on the FY 2015 IPF PPS
proposed rule. We received 28 public
comments from hospital and hospitalbased associations. In general, many
commenters supported CMS’ efforts to
continue researching the possibility of
an IPF-specific market basket and
agreed that more work is necessary
before any conclusions can be drawn
regarding a proposal to develop an IPFspecific market basket. The majority of
the comments were regarding the IPF
quality reporting program (IPFQR
Program). In general, the commenters
varied as to their support for the newly
proposed measures for the FY 2016 and
FY 2017 payment determinations.
Furthermore, many commenters offered
recommendations on the IPFQR
Program additions and changes for
future IPFQR Program years. Summaries
of the public comments received and
our responses to those comments are
provided in the appropriate sections in
the preamble of this final rule.
IV. Changing the IPF PPS Payment Rate
Update Period From a Rate Year to a
Fiscal Year
Prior to RY 2012, the IPF PPS was
updated on a July 1 through June 30
annual update cycle. Effective with RY
2012, we switched the IPF PPS payment
rate update from a rate year that begins
on July 1 and ends on June 30 to a
period that coincides with a fiscal year.
In order to transition from a RY to a FY,
the IPF PPS RY 2012 covered a 15month period from July 1 through
September 30. As proposed and
finalized, after RY 2012, the rate year
update period for the IPF PPS payment
rates and other policy changes begin on
October 1 through September 30.
Therefore, the update cycle for FY 2015
will be October 1, 2014 through
September 30, 2015.
For further discussion of the 15month market basket update for RY
2012 and changing the payment rate
update period from a RY to a FY, we
refer readers to the RY 2012 IPF PPS
proposed rule (76 FR 4998) and the RY
2012 IPF PPS final rule (76 FR 26432).

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V. Market Basket for the IPF PPS
A. Background
The input price index (that is, the
market basket) that was used to develop
the IPF PPS was the Excluded Hospital
with Capital market basket. This market
basket was based on 1997 Medicare cost
report data and included data for

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Medicare participating IPFs, inpatient
rehabilitation facilities (IRFs), long-term
care hospitals (LTCHs), cancer
hospitals, and children’s hospitals.
Although ‘‘market basket’’ technically
describes the mix of goods and services
used in providing hospital care, this
term is also commonly used to denote
the input price index (that is, cost
category weights and price proxies
combined) derived from that market
basket. Accordingly, the term ‘‘market
basket’’ as used in this document refers
to a hospital input price index.
Beginning with the May 2006 IPF PPS
final rule (71 FR 27046 through 27054),
IPF PPS payments were updated using
a FY 2002-based market basket
reflecting the operating and capital cost
structures for IRFs, IPFs, and LTCHs
(hereafter referred to as the
Rehabilitation, Psychiatric, and LongTerm Care (RPL) market basket).
We excluded cancer and children’s
hospitals from the RPL market basket
because these hospitals are not
reimbursed through a PPS; rather, their
payments are based entirely on
reasonable costs subject to rate-ofincrease limits established under the
authority of section 1886(b) of the Act,
which are implemented in regulations at
§ 413.40. Moreover, the FY 2002 cost
structures for cancer and children’s
hospitals are noticeably different than
the cost structures of the IRFs, IPFs, and
LTCHs. A complete discussion of the FY
2002-based RPL market basket appears
in the May 2006 IPF PPS final rule (71
FR 27046 through 27054).
In the RY 2012 IPF PPS proposed rule
(76 FR 4998) and final rule (76 FR
26432), we proposed and finalized the
use of a rebased and revised FY 2008based RPL market basket to update IPF
payments.
B. Development of an IPF-Specific
Market Basket
In the May 1, 2009 IPF PPS notice (74
FR 20362), we expressed our interest in
exploring the possibility of creating a
stand-alone, or IPF-specific market
basket that reflects the cost structures of
only IPF providers. We noted that, of
the available options, one would be to
join the Medicare cost report data from
freestanding IPF providers with data
from hospital-based IPF providers. We
indicated that an examination of the
Medicare cost report data comparing
freestanding and hospital-based IPFs
revealed considerable differences
between the two with respect to cost
levels and cost structures. At that time,
we stated that we were unable to fully
explain the differences in costs between
freestanding and hospital-based IPF
providers. As a result, we felt that

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further research was required and we
solicited public comments for
additional information that might help
explain the reasons for the variations in
costs and cost structures, as indicated
by the cost report data (74 FR 20376).
We summarized the public comments
we received and our responses in the
April 2010 IPF PPS notice (75 FR 23111
through 23113).
Since the April 2010 IPF PPS notice
was published, we have made
significant progress on the development
of a stand-alone, or IPF-specific, market
basket. Our research has focused on
addressing several concerns regarding
the use of the hospital-based IPF
Medicare cost report data in the
calculation of the major market basket
cost weights. As discussed above, one
concern is the cost level differences for
hospital-based IPFs relative to
freestanding IPFs that were not readily
explained by the specific characteristics
of the individual providers and the
patients that they serve (for example,
case mix, urban/rural status, teaching
status). Furthermore, we are concerned
about the variability in the cost report
data among these hospital-based IPF
providers and the potential impact on
the market basket cost weights. These
concerns led us to consider whether it
is appropriate to use the universe of IPF
providers to derive an IPF-specific
market basket.
Recently, we have investigated the
use of regression analysis to evaluate the
effect of including hospital-based IPF
Medicare cost report data in the
calculation of cost distributions. We
created preliminary regression models
to try to explain variations in costs per
day across both freestanding and
hospital-based IPFs. These models were
intended to capture the effects of
facility-level and patient-level
characteristics (for example, wage
index, urban/rural status, ownership
status, length-of-stay, occupancy rate,
case mix, and Medicare utilization) on
IPF costs per day. Using the results from
the preliminary regression analyses, we
identified smaller subsets of hospitalbased and freestanding IPF providers
where the predicted costs per day using
the regression model closely matched
the actual costs per day for each IPF. We
then derived different sets of cost
distributions using (1) these subsets of
IPF providers and (2) the entire universe
of freestanding and hospital-based IPF
providers (including those IPFs for
which the variability in cost levels
remains unexplained). After comparing
these sets of cost distributions, the
differences were not substantial enough
for us to conclude that the inclusion of
those IPF providers with unexplained

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variability in costs in the calculation of
the cost distributions is a major cause
for concern.
Another concern with incorporating
the hospital-based IPF data in the
derivation of an IPF-specific market
basket is the complexity of the Medicare
cost report data for these providers. The
freestanding IPFs independently submit
a Medicare cost report for their
facilities, making it relatively
straightforward to obtain the cost
categories necessary to determine the
major market basket cost weights.
However, cost report data submitted for
a hospital-based IPF are embedded in
the Medicare cost report submitted for
the entire hospital facility in which the
IPF is located. Therefore, adjustments
would have to be made to obtain cost
weights that represent just the hospitalbased IPF (as opposed to the hospital as
a whole). For example, ancillary costs
for services such as clinic services,
drugs charged to patients, and
emergency services for the entire
hospital would need to be appropriately
converted to a value that only represents
the hospital-based IPF unit’s cost. The
preliminary method we have developed
to allocate these costs is complex and
still needs to be fully evaluated before
we are ready to propose an IPF-specific
market basket that would reflect both
hospital-based and freestanding IPF
data.
We would also note that our current
preliminary data show higher labor
costs for IPFs than observed for the
2008-based RPL market basket. This
increase is driven primarily by higher
compensation cost as a percent of total
costs for IPFs. In our ongoing research,
we are also evaluating the differences in
salary costs as a percent of total costs for
both hospital-based and freestanding
IPFs. Salary costs are historically the
largest component of the market baskets.
Based on our review of the data reported
on the applicable Medicare cost reports,
our initial findings (using the
preliminary allocation method as
discussed above) have shown that the
hospital-based IPF salary costs as a
percent of total costs tend to be lower
than those of freestanding IPFs. We are
still evaluating the methods for deriving
salary costs as a percent of total costs
and need to further investigate the
percentage of ancillary costs that should
be appropriately allocated to the IPF
salary costs for the hospital-based IPF,
as discussed above.
Also, effective for cost reports
beginning on or after May 1, 2010, we
finalized a revised Hospital and
Hospital Health Care Complex Cost
Report, Form CMS 2552–10, (74 FR
31738). The report is available for

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download from the CMS Web site at
http://www.cms.gov/Research-StatisticsData-and-Systems/Files-for-Order/
CostReports/Hospital-2010-form.html.
The revised Hospital and Hospital
Health Care Complex Cost Report
includes a new worksheet (Worksheet
S–3, part V) that identifies the contract
labor costs and benefit costs for the
hospital/hospital care complex and is
applicable to sub-providers and units.
Our analysis of Worksheet S–3, part V
shows significant underreporting of this
data with fewer than 20 freestanding IPF
providers reporting it. We encourage
providers to submit this data so we can
use it to calculate benefits and contract
labor cost weights for the market basket.
In the absence of this data, we will
likely use the 2008-based RPL market
basket methodology (76 FR 5003) to
calculate the IPF benefit cost weight.
This methodology calculates the ratio of
the IPPS benefit cost weight to the IPPS
salary cost weight and applies this ratio
to the IPF salary cost weight in order to
estimate the IPF benefit cost weight. For
contract labor, in the absence of IPFspecific data, we will use a similar
methodology.
For the reasons discussed above,
while we believe we have made
significant progress on the development
of an IPF-specific market basket, we
believe that further research is required
at this time. As a result, we are not
finalizing an IPF-specific market basket
for FY 2015. We plan to complete our
research during the remainder of this
year and, provided that we are prepared
to draw conclusions from our research,
may propose an IPF-specific market
basket for the FY 2016 rulemaking
cycle. Public comments and responses
on the IPF-specific market basket are
summarized below.
Comment: Several commenters
supported the development of a standalone IPF market basket. In addition, the
commenters acknowledged that further
analysis is required and asked that CMS
make available the methodologies and
data sources that are under
consideration for the development of
the stand-alone IPF market basket.
Response: As the commenters
suggested, we will continue to research
and analyze the development of an IPFspecific market basket that uses the
most appropriate and reliable data
sources and methods. We anticipate
proposing to use an IPF-specific market
basket in the FY 2016 IPF proposed rule
and the public will have the
opportunity to comment on our market
basket methodology and data sources
during the 60-day comment period
following the publication of the
proposed rule.

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C. FY 2015 Market Basket Update
In the FY 2015 IPF PPS proposed rule
(76 FR 26044), we proposed a FY 2015
IPF update of 2.0 percent, reflecting a
2.7 percent market basket update, less
0.4 percentage point MFP adjustment
(as mandated in section 1886(s)(2)(A)(i)
of the Act and further described in
section 1886(b)(3)(B)(xi)(II) of the Act)),
less 0.3 percentage point adjustment (as
mandated in Section 1886(s)(2)(A)(ii) of
the Act). Furthermore, we also proposed
that if more recent data are subsequently
available (for example, a more recent
estimate of the market basket and MFP
adjustment), we would use such data, if
appropriate, to determine the FY 2015
market basket update and MFP
adjustment in the final rule.
Based on a more recent update for this
FY 2015 IPF PPS final rule, that is, the
IHS Global Insight, Inc. (IGI) second
quarter 2014 forecast of the FY 2008based RPL market basket, we are
finalizing a market basket rate-ofincrease of 2.9 percent (prior to the
application of statutory adjustments).
IGI is a nationally recognized economic
and financial forecasting firm that
contracts with CMS to forecast the
components of the market baskets.
As previously described in section
I.B, section 1886(s)(2)(A)(i) of the Act
requires the application of the
productivity adjustment described in
section 1886(b)(3)(B)(xi)(II) of the Act to
the IPF PPS for the RY beginning in
2012 and each subsequent RY. The
statute defines the productivity
adjustment to be equal to the 10-year
moving average of changes in annual
economy-wide private nonfarm business
multifactor productivity (MFP) (as
projected by the Secretary for the 10year period ending with the applicable
FY, year, cost reporting period, or other
annual period) (the ‘‘MFP adjustment’’).
The Bureau of Labor Statistics (BLS)
publishes the official measure of private
non-farm business MFP. We refer
readers to the BLS Web site at http://
www.bls.gov/mfp to obtain the BLS
historical published MFP data. The MFP
adjustment for FY 2015 applicable to
the IPF PPS is derived using a
projection of MFP that is currently
produced by IGI. For a detailed
description of the model currently used
by IGI to project MFP, as well as a
description of how the MFP adjustment
is calculated, we refer readers to the FY
2012 IPPS/LTCH final rule (76 FR 51690
through 51692). Based on the most
recent estimate, that is, IGI’s second
quarter 2014 forecast, the productivity
adjustment for FY 2015 is 0.5
percentage point. Section
1886(s)(2)(A)(ii) of the Act also requires

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the application of an ‘‘other adjustment’’
that reduces any update to an IPF PPS
base rate by percentages specified in
section 1886(s)(3) of the Act for rate
years beginning in 2010 through the RY
beginning in 2019. For the RY beginning
in 2014 (that is, FY 2015), the reduction
is 0.3 percentage point. We are
implementing the productivity
adjustment and ‘‘other adjustment’’ in
this FY 2015 IPF PPS final rule.
In summary, we are basing the FY
2015 market basket update, which is
used to determine the applicable
percentage increase for the IPF
payments, on the most recent estimate
of the FY 2008-based RPL market basket
(2.9 percent based on IGI’s second
quarter 2014 forecast). We are then
reducing this percentage increase by the
current estimate of the MFP adjustment
for FY 2015 of 0.5 percentage point (the
10-year moving average of MFP for the
period ending FY 2015 based on IGI’s
second quarter 2014 forecast). Following
application of the MFP, we are further

reducing the applicable percentage
increase by 0.3 percentage point, as
required by section 1886(s)(3) of the
Act. The final FY 2015 IPF update is 2.1
percent (2.9 percent market basket
update, less 0.5 percentage point MFP
adjustment, less 0.3 percentage point
‘‘other’’ adjustment).
D. Labor-Related Share
Due to variations in geographic wage
levels and other labor-related costs, we
believe that payment rates under the IPF
PPS should continue to be adjusted by
a geographic wage index, which would
apply to the labor-related portion of the
Federal per diem base rate (hereafter
referred to as the labor-related share).
The labor-related share is determined
by identifying the national average
proportion of total costs that are related
to, influenced by, or vary with the local
labor market. We classify a cost category
as labor-related if the costs are laborintensive and vary with the local labor
market. Based on our definition of the

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labor-related share, we include in the
labor-related share the sum of the
relative importance of Wages and
Salaries, Employee Benefits,
Professional Fees: Labor-related,
Administrative and Business Support
Services, All Other: Labor-related
Services, and a portion of the CapitalRelated cost weight.
Therefore, to determine the laborrelated share for the IPF PPS for FY
2015, we used the FY 2008-based RPL
market basket cost weights relative
importance to determine the laborrelated share for the IPF PPS. This
estimate of the FY 2015 labor-related
share is based on IGI’s second quarter
2014 forecast, which is the same
forecast used to derive the FY 2015
market basket update.
Table 1 below shows the FY 2015
relative importance labor-related share
using the FY 2008-based RPL market
basket along with the FY 2014 relative
importance labor-related share.

TABLE 1—FY 2015 RELATIVE IMPORTANCE LABOR-RELATED SHARE AND THE FY 2014 RELATIVE IMPORTANCE LABORRELATED SHARE BASED ON THE FY 2008-BASED RPL MARKET BASKET
FY 2014 relative
importance
labor-related
share 1

FY 2015 relative
importance
labor-related
share 2

Wages and Salaries ................................................................................................................................
Employee Benefits ...................................................................................................................................
Professional Fees: Labor-Related ...........................................................................................................
Administrative and Business Support Services .......................................................................................
All Other: Labor-Related Services ...........................................................................................................
Subtotal ....................................................................................................................................................
Labor-Related Portion of Capital Costs (46%) ........................................................................................

48.394
12.963
2.065
0.415
2.080
65.917
3.577

48.271
12.936
2.058
0.415
2.061
65.741
3.553

Total Labor-Related Share ...............................................................................................................

69.494

69.294

1 Published

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in the FY 2014 IPF PPS notice (78 FR 46738) and based on IHS Global Insight, Inc.’s second quarter 2013 forecast of the FY
2008-based RPL market basket.
2 Based on IHS Global Insight, Inc.’s second quarter 2014 forecast of the FY 2008-based RPL market basket.

The final labor-related share for FY
2015 is the sum of the FY 2015 relative
importance of each labor-related cost
category, and reflects the different rates
of price change for these cost categories
between the base year (FY 2008) and FY
2015. The sum of the relative
importance for FY 2015 for operating
costs (Wages and Salaries, Employee
Benefits, Professional Fees: LaborRelated, Administrative and Business
Support Services, and All Other: Laborrelated Services) is 65.741 percent, as
shown in Table 1 above. The portion of
Capital-related cost that is influenced by
the local labor market is estimated to be
46 percent. Since the relative
importance for Capital-Related Costs is
7.723 percent of the FY 2008-based RPL
market basket in FY 2015, we take 46
percent of 7.723 percent to determine

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the labor-related share of Capital-related
cost for FY 2015. The result is 3.553
percent, which we add to 65.741
percent for the operating cost amount to
determine the total labor-related share
for FY 2015. Therefore, the labor-related
share for the IPF PPS in FY 2015 is
69.294 percent. This labor-related share
is determined using the same general
methodology as employed in calculating
all previous IPF labor-related shares
(see, for example, 69 FR 66952 through
66953). The wage index and the laborrelated share are reflected in budgetneutrality adjustments.

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

VI. Updates to the IPF PPS for FY 2015
(Beginning October 1, 2014)

Section 124(a)(1) of the BBRA
required that we implement the IPF PPS
in a budget-neutral manner. In other
words, the amount of total payments
under the IPF PPS, including any
payment adjustments, must be projected

The IPF PPS is based on a
standardized Federal per diem base rate
calculated from the IPF average per

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

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to be equal to the amount of total
payments that would have been made if
the IPF PPS were not implemented.
Therefore, we calculated the budgetneutrality factor by setting the total
estimated IPF PPS payments to be equal
to the total estimated payments that
would have been made under the Tax
Equity and Fiscal Responsibility Act of
1982 (TEFRA) (Pub. L. 97–248)
methodology had the IPF PPS not been
implemented. A step-by-step
description of the methodology used to
estimate payments under the TEFRA
payment system appears in the
November 2004 IPF PPS final rule (69
FR 66926).
Under the IPF PPS methodology, we
calculated the final Federal per diem
base rate to be budget-neutral during the
IPF PPS implementation period (that is,
the 18-month period from January 1,
2005 through June 30, 2006) using a July
1 update cycle. We updated the average
cost per day to the midpoint of the IPF
PPS implementation period (that is,
October 1, 2005), and this amount was
used in the payment model to establish
the budget-neutrality adjustment.
Next, we standardized the IPF PPS
Federal per diem base rate to account
for the overall positive effects of the IPF
PPS payment adjustment factors by
dividing total estimated payments under
the TEFRA payment system by
estimated payments under the IPF PPS.
Additional information concerning this
standardization can be found in the
November 2004 IPF PPS final rule (69
FR 66932) and the RY 2006 IPF PPS
final rule (71 FR 27045). We then
reduced the standardized Federal per
diem base rate to account for the outlier
policy, the stop loss provision, and
anticipated behavioral changes. A
complete discussion of how we
calculated each component of the
budget-neutrality adjustment appears in
the November 2004 IPF PPS final rule
(69 FR 66932 through 66933) and in the
May 2006 IPF PPS final rule (71 FR
27044 through 27046). The final
standardized budget-neutral Federal per
diem base rate established for cost
reporting periods beginning on or after
January 1, 2005 was calculated to be
$575.95.
The Federal per diem base rate has
been updated in accordance with
applicable statutory requirements and
42 CFR 412.428 through publication of
annual notices or proposed and final
rules. These documents are available on
the CMS Web site at http://
www.cms.hhs.gov/InpatientPsych
FacilPPS/. A detailed discussion on the
standardized budget-neutral Federal per
diem base rate and the
electroconvulsive therapy (ECT) rate

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appears in the August 2013 IPF PPS
update notice (78 FR 46738 through
46739).
B. FY 2015 Update of the Federal Per
Diem Base Rate and Electroconvulsive
Therapy (ECT) Rate
In accordance with section
1886(s)(2)(A)(ii) of the Act, which
requires the application of an ‘‘other
adjustment,’’ described in section
1886(s)(3) of the Act (specifically,
section 1886(s)(3)(C)) for FY 2014 that
reduces the update to the IPF PPS base
rate for the FY beginning in Calendar
Year (CY) 2014, we are adjusting the IPF
PPS update by a 0.3 percentage point
reduction for FY 2015. In addition, in
accordance with section 1886(s)(2)(A)(i)
of the Act, which requires the
application of the productivity
adjustment that reduces the update to
the IPF PPS base rate for the FY
beginning in CY 2014, we are adjusting
the IPF PPS update by a 0.5 percentage
point reduction for FY 2015.
The current (that is, FY 2014) Federal
per diem base rate is $713.19 and the
ECT base rate is $307.04. For FY 2015,
we are applying an update of 2.1
percent (that is the FY 2008-based RPL
market basket increase for FY 2015 of
2.9 percent less the productivity
adjustment of 0.5 percentage point less
the 0.3 percentage point required under
section1886(s)(3)(C) of the Act), and the
wage index budget-neutrality factor of
1.0002 (as discussed in section VI.C.1.
of this final rule) to the FY 2014 Federal
per diem base rate of $713.19, yielding
a Federal per diem base rate of $728.31
for FY 2015. Similarly, we are applying
the 2.1 percent payment update, and the
1.0002 wage index budget-neutrality
factor to the FY 2014 ECT base rate,
yielding an ECT base rate of $313.55 for
FY 2015.
As noted above, section 1886(s)(4) of
the Act requires the establishment of a
quality data reporting program for the
IPF PPS beginning in FY 2014. We
finalized new requirements for quality
reporting for IPFs in the ‘‘Hospital
Inpatient Prospective Payment Systems
for Acute Care Hospitals and the Long
Term Care Hospital Prospective
Payment System and Fiscal Year 2014
Rates’’ proposed rule published on May
10, 2013 (78 FR 27486, 27734 through
27744) and final rule published on
August 19, 2013 (78 FR 50496, 50887
through 50903). Section 1886(s)(4)(A)(i)
of the Act requires that, for FY 2014 and
each subsequent rate year, the Secretary
shall reduce any annual update to a
standard Federal rate for discharges
occurring during the rate year by 2.0
percentage points for any IPF that does
not comply with the quality data

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submission requirements with respect to
an applicable year. Therefore, we are
applying a 2.0 percentage point
reduction to the Federal per diem base
rate and the ECT base rate as follows:
For IPFs that fail to submit quality
reporting data under the IPFQR
program, we are applying a 0.1 percent
annual update (that is 2.1 percent
reduced by 2 percentage points in
accordance with section
1886(s)(4)(A)(ii) of the Act) and the
wage index budget-neutrality factor of
1.0002 to the FY 2014 Federal per diem
base rate of $713.19, yielding a Federal
per diem base rate of $714.05 for FY
2015.
Similarly, we are applying the 0.1
percent annual update and the 1.0002
wage index budget-neutrality factor to
the FY 2014 ECT base rate of $307.04,
yielding an ECT base rate of $ 307.41 for
FY 2015.
In the FY 2014 IPPS/LTCH PPS final
rule (78 FR50496), we adopted two new
measures for the FY 2016 payment
determination and subsequent years for
the IPFQR Program. We also finalized a
request for voluntary information
whereby IPFs will be asked to provide
information on the patient experience of
care survey. For the FY 2016 payment
determination and subsequent years, we
are adding two new measures to those
already adopted for the FY 2016
payment determination and subsequent
years. For the FY 2017 payment
determination and subsequent years, we
are adopting four new measures. Public
comments and responses on the FY
2015 updates to the IPF PPS are
summarized below.
Comment: One commenter did not
believe the proposed FY 2015 update
and its associated projected payments to
Michigan IPFs was an adequate increase
as it failed to cover the cost of medical
inflation.
Response: CMS proposed applying an
update of 2.0 percent (79 FR 26044) to
the FY 2014 Federal per diem base rate
of $713.19, as well as a 1.0003 wage
index budget-neutrality factor, yielding
a proposed Federal per diem base rate
of $727.67 for FY 2015 (79 FR 26046).
The proposed 2.0 percent update
reflected the proposed increase in the
FY2008-based RPL market basket for FY
2015, as required by statute, of 2.7
percent less the proposed productivity
adjustment of 0.4 percentage point (as
mandated in section 1886(s)(2)(A)(i) of
the Act and further described in section
1886(b)(3)(B)(xi)(II) of the Act)) and less
the 0.3 percentage point adjustment (as
mandated in Section 1886(s)(2)(A)(ii) of
the Act).
As discussed in section III.C and
section VI.C.1 of this final rule, we are

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finalizing an update of 2.1 percent to the
FY 2014 Federal per diem base rate as
well as a 1.0002 wage index budgetneutrality factor for FY 2015. The final
2.1 percent FY 2015 update reflects the
2.9 percent market basket update less
the productivity adjustment of 0.5
percentage point (as mandated in
section 1886(s)(2)(A)(i) of the Act and
further described in section
1886(b)(3)(B)(xi)(II) of the Act)) and less
the 0.3 percentage point adjustment (as
mandated in Section 1886(s)(2)(A)(ii) of
the Act).

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VII. Update of the IPF PPS Adjustment
Factors
A. Overview of the IPF PPS Adjustment
Factors
The IPF PPS payment adjustments
were derived from a regression analysis
of 100 percent of the FY 2002 MedPAR
data file, which contained 483,038
cases. For a more detailed description of
the data file used for the regression
analysis, see the November 2004 IPF
PPS final rule (69 FR 66935 through
66936). While we have since used more
recent claims data to simulate payments
to set the fixed dollar loss threshold
amount for the outlier policy and to
assess the impact of the IPF PPS
updates, we continue to use the
regression-derived adjustment factors
established in 2005 for FY 2015.
As we stated previously, we have
begun an analysis of more current IPF
claims and cost report data; however, as
we stated in the FY 2015 IPF PPS
proposed rule, we are not making
refinements to the IPF PPS in this final
rule. Once our analysis is complete, we
will propose to update the adjustment
factors in a future notice of proposed
rulemaking. However, we continue to
monitor claims and payment data
independently from cost report data to
assess issues, to determine whether
changes in case-mix or payment shifts
have occurred among freestanding
governmental, non-profit and private
psychiatric hospitals, and psychiatric
units of general hospitals, and CAHs
and other issues of importance to IPFs.
On April 1, 2014, the Protecting
Access to Medicare Act of 2014 (PAMA)
(Pub. L. 113–93) was enacted. Section
212 of PAMA, titled ‘‘Delay in
Transition from ICD–9 to ICD–10 Code
Sets,’’ provides that ‘‘[t]he Secretary of
Health and Human Services may not,
prior to October 1, 2015, adopt ICD–10
code sets as the standard for code sets
under section 1173(c) of the Social
Security Act (42 U.S.C. 1320d–2(c)) and
section 162.1002 of title 45, Code of
Federal Regulations.’’ At the time we
sent the proposed rule to the Federal

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Register for publication, the Secretary
had not yet announced when the new
ICD–10 compliance date would be.
Therefore we indicated that, in light of
PAMA, the effective date of changes
from ICD–9 to ICD–10 for the IPF PPS
would be the date when ICD–10
becomes the required medical data code
set for use on Medicare claims,
whenever that date may be.
On May 1, 2014, the Department
announced that, in light of section 212
of PAMA, ‘‘the U.S. Department of
Health and Human Services expects to
release an interim final rule in the near
future that will include a new
compliance date that would require the
use of ICD–10 beginning October 1,
2015. The rule will also require HIPAA
covered entities to continue to use ICD–
9–CM through September 30, 2015.’’
Therefore, in light of this
announcement, we will continue to
require use of the ICD–9–CM codes for
reporting the MS–DRG and comorbidity
adjustment factors for IPF services
through FY 2015 and we will require
the use of ICD–10 codes beginning
October 1, 2015.
B. Patient-Level Adjustments
The IPF PPS includes payment
adjustments for the following patientlevel characteristics: Medicare Severity
diagnosis related groups (MS–DRGs)
assignment of the patient’s principal
diagnosis, selected comorbidities,
patient age, and the variable per diem
adjustments.
1. Adjustment for MS–DRG Assignment
We believe it is important to maintain
the same diagnostic coding and DRG
classification for IPFs that are used
under the IPPS for providing psychiatric
care. For this reason, when the IPF PPS
was implemented for cost reporting
periods beginning on or after January 1,
2005, we adopted the same diagnostic
code set (ICD–9–CM) and DRG patient
classification system (that is, the CMS
DRGs) that were utilized at the time
under the IPPS. In the May 2008 IPF
PPS notice (73 FR 25709), we discussed
CMS’s effort to better recognize resource
use and the severity of illness among
patients. CMS adopted the new MS–
DRGs for the IPPS in the FY 2008 IPPS
final rule with comment period (72 FR
47130). In the 2008 IPF PPS notice (73
FR 25716) we provided a crosswalk to
reflect changes that were made under
the IPF PPS to adopt the new MS–DRGs.
For a detailed description of the
mapping changes from the original DRG
adjustment categories to the current
MS–DRG adjustment categories, we
refer readers to the May 2008 IPF PPS
notice (73 FR 25714).

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The IPF PPS includes payment
adjustments for designated psychiatric
DRGs assigned to the claim based on the
patient’s principal diagnosis. The DRG
adjustment factors were expressed
relative to the most frequently reported
psychiatric DRG in FY 2002, that is,
DRG 430 (psychoses). The coefficient
values and adjustment factors were
derived from the regression analysis.
Mapping the DRGs to the MS–DRGs
resulted in the current 17 IPF–MS–
DRGs, instead of the original 15 DRGs,
for which the IPF PPS provides an
adjustment. For FY 2015, as we did in
FY 2013 (77 FR 47231) and FY 2014 (78
FR 46741 through 46741), we proposed
to make a payment adjustment for
psychiatric diagnoses that group to one
of the 17 MS–IPF–DRGs listed in Table
2. Psychiatric principal diagnoses that
do not group to one of the 17 designated
DRGs would still receive the Federal per
diem base rate and all other applicable
adjustments, but the payment would not
include a DRG adjustment.
In the Standards for Electronic
Transaction final rule, published in the
Federal Register on August 17, 2000 (65
FR 50312), the Department adopted the
International Classification of Diseases,
9th Revision, Clinical Modification
(ICD–9–CM) as the HIPAA designated
code set for reporting diseases, injuries,
impairments, other health related
problems, their manifestations, and
causes of injury. Therefore, on January
1, 2005 when the IPF PPS began, we
used ICD–9–CM as the designated code
set for the IPF PPS. IPF claims with a
principal diagnosis included in Chapter
Five of the ICD–9–CM are paid the
Federal per diem base rate and all other
applicable adjustments, including any
applicable DRG adjustment. However,
as we indicated in the FY 2014 IPF PPS
notice (78 FR 46741), in accordance
with the requirements of the final rule
that delayed the ICD–10 compliance
date from October 1, 2014, published in
the Federal Register on September 5,
2012 (77 FR 54664), we will be
discontinuing the use of ICD–9–CM
codes. In the FY 2015 IPF PPS proposed
rule we proposed the conversion of
ICD–9–CM to ICD–10–CM/PCS codes. In
light of PAMA, we proposed the
effective date would be when ICD–10
becomes the required medical data code
set for use on Medicare claims. Now
that the Secretary has announced
October 1, 2015 as the new compliance
date for ICD–10, we will continue to
require the use of the ICD–9–CM codes
for reporting the MS–DRGs for IPF
services through FY 2015, and we will
require the use of ICD–10 codes
beginning October 1, 2015.

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The ICD–10–CM/PCS coding
guidelines are available through the
CMS Web site at: www.cms.gov/
Medicare/Coding/ICD10/downloads/
pcs_2012_guidelines.pdf and http://
www.cms.gov/Medicare/Coding/ICD10/
index.html?redirect=/ICD10 or on the
Center for Disease Control and
Prevention (CDC’s) Web site at
www.cdc.gov/nchs/data/icd10/
10cmguidelines2012.pdf.
Every year, changes to the ICD–10–
CM and the ICD–10–PCS coding system
will be addressed in the IPPS proposed
and final rules. The changes to the
codes are effective October 1 of each
year and must be used by acute care
hospitals as well as other providers to
report diagnostic and procedure
information. The IPF PPS has always
incorporated ICD–9–CM coding changes
made in the annual IPPS update and
will continue to do so for the ICD–10–
CM and ICD–10–PCS coding changes.
We will continue to publish coding
changes in a Transmittal/Change
Request, similar to how coding changes
are announced by the IPPS and LTCH
PPS. The coding changes relevant to the
IPF PPS are also published in the IPF
PPS proposed and final rules, or in IPF
PPS update notices. In 42 CFR
412.428(e), we indicate that CMS will
publish information pertaining to the
annual update for the IPF PPS, which
includes describing the ICD–9–CM
coding changes and DRG classification
changes discussed in the annual update
to the hospital IPPS regulations. We
proposed to update § 412.428(e) to
indicate that we will describe the ICD–
10–CM coding changes and DRG
classification changes discussed in the
annual update to the hospital IPPS
regulations when ICD–10–CM/PCS
becomes the required medical data code
set for use on Medicare claims. Now
that we know the ICD–10 compliance
date will be October 1, 2015, we will
include revised § 412.428(e) in the FY
2016 IPF PPS update, which will be
effective on October 1, 2015.

The ICD–9–CM coding changes are
reflected in the FY 2015 GROUPER,
Version 32.0, effective for IPPS
discharges occurring on or after October
1, 2014 through September 30, 2015.
The GROUPER Version 32.0 software
package assigns each case to an MS–
DRG on the basis of the diagnosis and
procedure codes and demographic
information (that is, age, sex, and
discharge status). The Medicare Code
Editor (MCE) version 32.0 has also been
updated for IPPS discharges on or after
October 1, 2014.
The IPF PPS has always used the
same GROUPER and MCE as the IPPS.
We have posted a Definitions Manual of
the ICD–10 MS–DRGs Version 31.0–R
(an updated ICD–10 MS–DRGs version
31.0) on the ICD-10 MS-DRG Conversion
Project Web site at: http://www.cms.hhs.
gov/Medicare/Coding/ICD10/ICD-10MS-DRG-Conversion-Project.html. We
also prepared a document that describes
changes made from Version 31.0 to
Version 31.0–R. We will continue to
share ICD–10–MS–DRG conversion
activities with the public through this
Web site.
The MS–DRGs were converted so that
the MS–DRG assignment logic uses
ICD–10–CM/PCS codes directly. When a
provider submits a claim for discharges,
the ICD–10–CM/PCS diagnosis and
procedure codes will be assigned to the
correct MS–DRG. The MS–DRGs were
converted with a single overarching
goal: That MS–DRG assignment for a
given patient record is the same after
ICD–10–CM implementation as it would
be if the same record had been coded in
ICD–9–CM and submitted prior to ICD–
10–CM/PCS implementation. This goal
is referred to as replication, and every
effort was made to achieve this goal.
The General Equivalence Mappings
(GEMs) were used to assist in converting
the ICD–9–CM-based MS–DRGs to ICD–
10–CM/PCS. The majority of ICD–9–CM
codes (greater than 80 percent) have
straightforward translation alternative(s)
in ICD–10–CM/PCS, where the
diagnoses or procedures classified to a

given ICD–9–CM code are replaced by a
number of (typically more specific)
ICD–10–CM/PCS codes and assigned to
the same MS–DRG as the ICD–9–CM
code they are replacing. Further
information on the assessment of ICD–
10–CM/PCS MS–DRGs and financial
impact can be found on the CMS ICD–
10 Web site at: http://www.cms.hhs.gov/
Medicare/Coding/ICD10/ICD-10-MSDRG-Conversion-Project.html.
Questions concerning the MS–DRGs
should be directed to Patricia E. Brooks,
Co-Chairperson, ICD–10–CM
Coordination and Maintenance
Committee, CMS, Center for Medicare
Management, Hospital and Ambulatory
Policy Group, Division of Acute Care,
[email protected], Mailstop
C4–08–06, 7500 Security Boulevard,
Baltimore, Maryland 21244–1850.
Use of the General Equivalence
Mappings To Assist in Direct
Conversion
For the FY 2015 update, we are not
making changes to the MS–IPF–DRG
adjustment factors. That is, we do not
intend to re-run the regression analysis
to update the 17 IPF MS–DRG
adjustment factors. The General
Equivalence Mappings (GEMs) were
used to assist in converting the ICD–9–
CM-based MS–DRGs to ICD–10–CM/
PCS. For this update, we are using the
ICD–10–CM/PCS codes that will be used
for the MS–DRG payment adjustment.
Further information for the ICD–10–CM/
PCS MS–DRG conversion project can be
found on the CMS ICD–10–CM Web site
at http://www.cms.hhs.gov/Medicare/
Coding/ICD10/ICD-10-MS-DRGConversion-Project.html.
Final Rule Action: The MS–IPF–DRG
adjustment factors (as shown in Table 2)
will continue to be paid for discharges
occurring in FY 2015. The MS–IPF–DRG
adjustment factors will be updated on
October 1, 2014, using the ICD–9–CM/
PCS code set. The conversion of ICD–9–
CM/PCS codes to ICD–10–CM/PCS
codes for the IPF PPS in this final rule
will go into effect on October 1, 2015.

TABLE 2—FY 2015 CURRENT MS–IPF–DRGS APPLICABLE FOR THE PRINCIPAL DIAGNOSIS ADJUSTMENT

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MS–DRG
056
057
080
081
876
880
881
882
883
884

..........
..........
..........
..........
..........
..........
..........
..........
..........
..........

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factor

MS–DRG descriptions
Degenerative nervous system disorders w MCC ...........................................................................................................
Degenerative nervous system disorders w/o MCC ........................................................................................................
Nontraumatic stupor & coma w MCC ............................................................................................................................
Nontraumatic stupor & coma w/o MCC .........................................................................................................................
O.R. Procedure w principal diagnoses of mental illness ...............................................................................................
Acute adjustment reaction & psychosocial dysfunction .................................................................................................
Depressive neuroses ......................................................................................................................................................
Neuroses except depressive ..........................................................................................................................................
Disorders of personality & impulse control ....................................................................................................................
Organic disturbances & mental retardation ....................................................................................................................

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1.05
1.07
1.07
1.22
1.05
0.99
1.02
1.02
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45947

TABLE 2—FY 2015 CURRENT MS–IPF–DRGS APPLICABLE FOR THE PRINCIPAL DIAGNOSIS ADJUSTMENT—Continued
MS–DRG

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885
886
887
894
895
896
897

..........
..........
..........
..........
..........
..........
..........

Psychoses ......................................................................................................................................................................
Behavioral & developmental disorders ...........................................................................................................................
Other mental disorder diagnoses ...................................................................................................................................
Alcohol/drug abuse or dependence, left AMA ...............................................................................................................
Alcohol/drug abuse or dependence w rehabilitation therapy .........................................................................................
Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC .........................................................................
Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC ......................................................................

2. Payment for Comorbid Conditions
The intent of the comorbidity
adjustments is to recognize the
increased costs associated with
comorbid conditions by providing
additional payments for certain
concurrent medical or psychiatric
conditions that are expensive to treat. In
the May 2011 IPF PPS final rule (76 FR
26451 through 26452), we explained
that the IPF PPS includes 17
comorbidity categories and identified
the new, revised, and deleted ICD–9–
CM diagnosis codes that generate a
comorbid condition payment
adjustment under the IPF PPS for RY
2012 (76 FR 26451).
Comorbidities are specific patient
conditions that are secondary to the
patient’s principal diagnosis and that
require treatment during the stay.
Diagnoses that relate to an earlier
episode of care and have no bearing on
the current hospital stay are excluded
and must not be reported on IPF claims.
Comorbid conditions must exist at the
time of admission or develop
subsequently, and affect the treatment
received, length of stay (LOS), or both
treatment and LOS.
For each claim, an IPF may receive
only one comorbidity adjustment within
a comorbidity category, but it may
receive an adjustment for more than one
comorbidity category. Current billing
instructions require IPFs to enter the
full, that is, the complete ICD–9–CM
codes for up to 24 additional diagnoses
if they co-exist at the time of admission
or develop subsequently and impact the
treatment provided. Billing instructions
will require that IPFs enter the full ICD–
10–CM/PCS codes. The effective date of
this change will be October 1, 2015.
The comorbidity adjustments were
determined based on the regression
analysis using the diagnoses reported by
IPFs in FY 2002. The principal
diagnoses were used to establish the
DRG adjustments and were not
accounted for in establishing the
comorbidity category adjustments,
except where ICD–9–CM ‘‘code first’’
instructions apply. As we explained in
the May 2011 IPF PPS final rule (76 FR

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265451), the ‘‘code first’’ rule applies
when a condition has both an
underlying etiology and a manifestation
due to the underlying etiology. For these
conditions, ICD–9–CM has a coding
convention that requires the underlying
conditions to be sequenced first
followed by the manifestation.
Whenever a combination exists, there is
a ‘‘use additional code’’ note at the
etiology code and a ‘‘code first’’ note at
the manifestation code.
The same principle holds for ICD–10–
CM as for ICD–9–CM. Whenever a
combination exists, there is a ‘‘use
additional code’’ note in the ICD–10–
CM codebook pertaining to the etiology
code, and a ‘‘code first’’ code pertaining
to the manifestation code. We provide a
‘‘code first’’ table in Addendum C of
this final rule for reference that
highlights the same or similar
manifestation codes where the ‘‘code
first’’ instructions apply in ICD–10–CM
that were present in ICD–9–CM. In the
‘‘code first’’ table, pertaining to ICD–10–
CM codes F02.80, F02.81 and F05,
where individual examples of possible
etiologies are listed in the codebook, in
the interest of inclusiveness, all ICD–
10–CM examples are included in
addition to the comparable ICD–10–CM
translations of examples listed in the
ICD–9–CM codebook for the same
manifestations. Also, in the interest of
inclusiveness, an ICD–10–CM
manifestation code F45.42 ‘‘Pain
disorder with related psychological
factors,’’ is included in the IPF PPS
‘‘code first’’ table even though it
contains a ‘‘code also’’ instruction rather
than a ‘‘code first’’ instruction, but is
included in this version of the table for
information purposes only. The list of
ICD–10–CM codes that we identified as
‘‘code first’’ can be located in
Addendum C in this final rule.
As discussed in the MS–DRG section,
it is our policy to maintain the same
diagnostic coding set for IPFs that is
used under the IPPS for providing the
same psychiatric care. The 17
comorbidity categories formerly defined
using ICD–9–CM codes have been
converted to ICD–10–CM/PCS. The goal

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1.00
0.99
0.92
0.97
1.02
0.88
0.88

for converting the comorbidity
categories is referred to as replication,
meaning that the payment adjustment
for a given patient encounter is the same
after ICD–10–CM implementation as it
will be if the same record had been
coded in ICD–9–CM and submitted
prior to ICD–10–CM/PCS
implementation. All conversion efforts
were made with the intent of achieving
this goal. The effective date of this
change is October 1 2015.
Direct Conversion of Comorbidity
Categories
We converted the ICD–9–CM codes
for the IPF PPS Comorbidity Payment
Adjustment Categories to ICD–10–CM/
PCS codes. When an IPF submits a
claim for discharges the ICD–10–CM/
PCS codes will be assigned to the
correct comorbidity categories. The
same method of direct conversion to
ICD–10–CM/PCS for replication of ICD–
9–CM based payment applications has
been implemented by policy groups
throughout CMS to convert applications
to ICD–10–CM/PCS, including the MS–
DRGs.
Use of the General Equivalence
Mappings to Assist in Direct Conversion
As with the other policy groups
mentioned above, the General
Equivalence Mappings (GEMs) were
used to assist in converting ICD–9–CMbased applications to ICD–10–CM/PCS.
Further information concerning the
GEMs can be found on the CMS ICD–10
Web site at: http://www.cms.gov/
Medicare/Coding/ICD10/2014-ICD-10CM-and-GEMs.html.
The majority of ICD–9–CM codes
(greater than 80 percent) have
straightforward translation alternative(s)
in ICD–10–CM/PCS, where the
diagnoses or procedures classified to a
given ICD–9–CM code are replaced by a
number of possibly more specific ICD–
10–CM/PCS codes, and those ICD–10–
CM/PCS codes capture the intent of the
payment policy.
In rare instances, ICD–10–CM has
discontinued an area of detail in the
classification. For example, this is the
case with the concept of ‘‘malignant

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hypertension’’ in the Cardiac Conditions
comorbidity category. Malignant
hypertension is no longer classified
separately in codes that specify heart
failure, such as ICD–9–CM code 404.03
Hypertensive heart and chronic kidney
disease, malignant, with heart failure
and with chronic kidney disease stage V
or end-stage renal disease. This code, in
the Cardiac Conditions comorbidity
category, has no corresponding code in
the ICD–10–CM Cardiac Conditions
comorbidity category. Instead, all subtypes of hypertension in the presence of
heart disease or chronic kidney disease
are classified to a single code in ICD–
10–CM that specifies the level of heart
and kidney function, such as I13.2
Hypertensive heart and chronic kidney
disease with heart failure and with stage
5 chronic kidney disease, or end stage
renal disease. Discussed below are the
comorbidity categories where the
crosswalk between ICD–9–CM and ICD–
10–CM diagnosis codes is less than
straightforward. For instance, in some
cases, the use of combination codes in
one code set is represented as two
separate codes in the other code set.

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Conversion of Gangrene and
Uncontrolled Diabetes Mellitus With or
Without Complications Comorbidity
Categories
In the Gangrene comorbidity category,
there are new ICD–10–CM combination
codes not present in ICD–9–CM.
Therefore, we are including many more
ICD–10–CM codes in the comorbidity
definitions than were included using
ICD–9–CM codes so that the
comorbidity category using ICD–10–CM
codes is a complete and accurate
replication of the category using ICD–9–
CM codes.
The ICD–9–CM version of the
comorbidity category Uncontrolled
Diabetes Mellitus With or Without
Complications contains combination
codes with extra information that is not
relevant to the clinical intent of the
category. All patients with uncontrolled
diabetes are eligible for the payment
adjustment, regardless of whether they
have additional diabetic complications.
The diagnosis of uncontrolled diabetes
is coded separately in ICD–10–CM. As
a result, only two ICD–10–CM codes are
needed to achieve complete and
accurate replication of the comorbidity
category definition using ICD–9–CM
codes.
Conversion of the Gangrene
Comorbidity Category
Currently, two ICD–9–CM codes are
used for the Gangrene comorbidity
category: 440.24 Atherosclerosis of

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native arteries of the extremities with
gangrene and 785.4 Gangrene.
The first code, 440.24, is a
combination code and specifies patients
with underlying peripheral vascular
disease and a current acute
manifestation of gangrene. This is the
only ICD–9–CM combination code that
specifies gangrene in addition to the
underlying cause. Also, a number of
ICD–10–CM codes exist for gangrene
and they are all included in the ICD–10–
CM comorbidity category. The ICD–10–
CM codes specify anatomic site in more
detail. An example is given below:
• I70.261 Atherosclerosis of native
arteries of extremities with gangrene,
right leg
• I70.262 Atherosclerosis of native
arteries of extremities with gangrene,
left leg
• I70.263 Atherosclerosis of native
arteries of extremities with gangrene,
bilateral legs
• I70.268 Atherosclerosis of native
arteries of extremities with gangrene,
other extremity
In addition, many ICD–10–CM codes
specify gangrene in combination with
diabetes. We are including these codes
in the comorbidity category to ensure
that a patient with diabetes complicated
by gangrene receives the same payment
adjustment for the condition when it is
coded in ICD–10 as if it had been coded
in ICD–9–CM.
Conversion of the Uncontrolled Diabetes
Mellitus With or Without Complications
Comorbidity Category
Where ICD–9–CM uses combination
codes for uncontrolled diabetes, ICD–
10–CM classifies diabetes that is out of
control in a separate, standalone code.
Unlike ICD–9–CM, ICD–10–CM does not
have additional codes that specify out of
control diabetes in combination with a
complication such as, for example,
diabetic chronic kidney disease. The
result is that the comorbidity category
Uncontrolled Diabetes Mellitus With or
Without Complications is simpler to
define using ICD–10–CM codes than
ICD–9–CM codes.
ICD–10–CM has changed the
classification of a diagnosis of
uncontrolled diabetes in two ways that
affect conversion of the Uncontrolled
Diabetes comorbidity category:
1. ICD–10–CM no longer uses the term
‘‘uncontrolled’’ in reference to diabetes.
2. ICD–10–CM classifies diabetes that
is poorly controlled in a separate,
standalone code.
ICD–10–CM does not use the term
‘‘uncontrolled’’ in codes that classify
diabetes patients. Instead, ICD–10–CM
codes specify diabetes ‘‘with

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hyperglycemia’’ as the new terminology
for classifying patients whose diabetes
is ‘‘poorly controlled’’ or ‘‘inadequately
controlled’’ or ‘‘out of control.’’ We
believe these are appropriate codes to
capture the intent of the Uncontrolled
Diabetes comorbidity category.
Therefore, to ensure that all patients
who qualified for the Uncontrolled
Diabetes comorbidity payment
adjustment using ICD–9–CM codes will
also qualify for the payment adjustment
using ICD–10–CM codes, we propose
that two ICD–10–CM codes specifying
diabetes with hyperglycemia will be
used for the payment adjustment for
Uncontrolled Diabetes Mellitus With or
Without Complications: E10.65 Type 1
diabetes mellitus with hyperglycemia,
and E11.65 Type 2 diabetes mellitus
with hyperglycemia.
Other Differences between ICD–9–CM
and ICD–10–CM Affecting Conversion of
Comorbidity Categories
Two other comorbidity categories in
the IPF PPS required careful review and
additional formatting of the
corresponding ICD–10–CM codes in
order to replicate the clinical intent of
the comorbidity category. In the Drug
and/or Alcohol Induced Mental
Disorders comorbidity category and the
Poisoning comorbidity category,
significant structural changes in the way
that comparable codes are classified in
ICD–10–CM made it more difficult to
list the diagnoses in ICD–10–CM code
ranges, as was possible in ICD–9–CM.
Because comparable codes are not
classified contiguously in the ICD–10–
CM classification scheme, the resulting
list of codes for this comorbidity
category is much longer than the
comorbidity category using ICD–9–CM
codes.
Conversion of the Drug and/or Alcohol
Induced Mental Disorders Comorbidity
Category
ICD–10–CM has changed the
classification of applicable conditions in
two ways that affect conversion of the
Drug and/or Alcohol Induced Mental
Disorders comorbidity category:
1. ICD–10–CM does not use the term
‘‘pathological’’ in reference to drug or
alcohol intoxication, rather it only uses
the phrase ‘‘with intoxication.’’
2. ICD–10–CM contains separate,
detailed codes for specific drug-induced
manifestations of mental disorder. ICD–
10–CM codes specify the particular drug
and whether the pattern of use is
documented as use, abuse, or
dependence.
First, this comorbidity category
currently contains ICD–9–CM code
292.2 Pathological drug intoxication. To

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ensure that all patients who qualified
for the comorbidity payment adjustment
under ICD–9–CM code 292.2 will also
qualify under the ICD–10–CM version of
the same comorbidity category, the 89
ICD–10–CM codes specifying ‘‘with
intoxication’’ will qualify for the
payment adjustment. An example of the
ICD–10–CM codes for a diagnosis of
cocaine abuse with current intoxication
is provided below. All of these codes are
eligible for the payment adjustment.
• F14.120 Cocaine abuse with
intoxication, uncomplicated
• F14.121 Cocaine abuse with
intoxication with delirium
• F14.122 Cocaine abuse with
intoxication with perceptual
disturbance
• F14.129 Cocaine abuse with
intoxication, unspecified
Next, ICD–10–CM contains separate,
detailed codes by drug for specific druginduced manifestations of mental
disorder, such as drug-induced
psychotic disorder with hallucinations.
What was a single code in ICD–9–CM,
292.12 Drug-induced psychotic disorder
with hallucinations, maps to 24
comparable codes in ICD–10–CM. We
will include all of these more specific
ICD–10–CM codes in the comorbidity
category. We believe they are necessary
for replication of the clinical intent of
the comorbidity category so that all
patients with a drug-induced psychotic
disorder with hallucinations coded on
the claim are eligible for the payment
adjustment. Because the ICD–10–CM
codes are not listed contiguously in the
classification, they cannot be formatted
as a range of codes and therefore must
be listed as single codes in the
comorbidity category definition.
The situation described above is
similar for ICD–9–CM code 292.0 Drug
withdrawal. ICD–10–CM contains
separate, detailed codes by drug
specifying that the patient is in
withdrawal. We include all of these
more specific ICD–10–CM codes in the
comorbidity category. We believe they
are necessary for replication of the
clinical intent of the comorbidity
category, so that all patients with a drug
withdrawal code on the claim are
eligible for the payment adjustment.
Likewise, because the ICD–10–CM drug
withdrawal codes are not listed
contiguously in the classification, they
cannot be formatted as a range of codes
and so must be listed as single codes in
the comorbidity category definition.
Conversion of the Poisoning
Comorbidity Category
In ICD–10–CM, the Injury and
Poisoning chapter has added an axis of

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classification for every injury or
poisoning diagnosis code, which
specifies additional information about
the current encounter. This creates three
unique codes for each injury or
poisoning diagnosis, marked by a
different letter in the seventh character
of the code:
1. The seventh character ‘‘A’’ in the
code indicates that the poisoning is a
current diagnosis in its ‘‘acute phase.’’
2. The seventh character ‘‘D’’ in the
code indicates that the poisoning is no
longer in its ‘‘acute phase,’’ but that the
patient is receiving aftercare for the
earlier poisoning.
3. The seventh character ‘‘S’’ in the
code indicates that the patient no longer
requires care for any aspect of the
poisoning itself, but that the patient is
receiving care for a late effect of the
poisoning.
The intent of the Poisoning
comorbidity category is to include only
those patients with a current diagnosis
of poisoning. If the intent had been to
include patients requiring only aftercare
for an earlier, resolved case of
poisoning, or for care associated with
late effects of poisoning that occurred
sometime in the past, the comorbidity
category would have included ICD–9–
CM aftercare codes or late effect codes,
but it does not. Only acute poisoning
codes from the ICD–9–CM classification
are included. Therefore, the Poisoning
comorbidity category will only include
ICD–10–CM poisoning codes with a
seventh character extension ‘‘A,’’ to
indicate that the poisoning is
documented as a current diagnosis.
In addition, ICD–10–CM poisoning
codes specify the circumstances of the
poisoning, whether documented as
accidental, self-harm, assault, or
undetermined, as shown in the heroin
poisoning example below. We include
all of these more specific ICD–10–CM
codes in the comorbidity category for
replication of the clinical intent of the
comorbidity category so that all patients
with a current diagnosis of poisoning
coded on the claim would be eligible for
the payment adjustment, as shown in
the heroin poisoning example below:
• T40.1X1A Poisoning by heroin,
accidental (unintentional), initial
encounter
• T40.1X2A Poisoning by heroin,
intentional self-harm, initial
encounter
• T40.1X3A Poisoning by heroin,
assault, initial encounter
• T40.1X4A Poisoning by heroin,
undetermined, initial encounter
ICD–10–CM classifies poisoning by
substance, alongside separate codes for
adverse effect or underdosing of the

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45949

same substance. Because the poisoning
codes are not listed contiguously in the
classification, they cannot be formatted
as a range of codes and therefore must
be listed as single codes in the
comorbidity category definition.
Proposed Elimination of Codes for
Nonspecific Conditions Based on Side
of the Body (Laterality)
We believe that highly descriptive
coding provides the best and clearest
way to document a patient’s condition
and the appropriateness of the
admission and treatment in an IPF.
Therefore, whenever possible, we
believe that the most specific code that
describes a medical disease, condition,
or injury should be used to document
the patient’s diagnoses. Generally,
‘‘unspecified’’ codes are used when they
most accurately reflect what is known
about the patient’s condition at the time
of that particular encounter (for
example, there is a lack of information
about a specific type of organism
causing an illness). However, site of
illness at the time of the medical
encounter is an important determinant
in assessing a patient’s principal or
secondary diagnosis. For this reason, we
believe that specific diagnosis codes
that narrowly identify anatomical sites
where disease, injury, or condition exist
should be used when coding patients’
diagnoses whenever these codes are
available. Furthermore, on the same
note, we believe that one should also
code to the highest specificity (use the
full ICD–10–CM/PCS code).
In accordance with these principles,
we remove site unspecified codes from
the IPF PPS ICD–10–CM/PCS codes in
instances in which more specific codes
are available as the clinician should be
able to identify a more specific
diagnosis based on clinical assessment
at the medical encounter. For example,
the initial GEMS translation included
non-specific codes such as ICD–10–CM
code C44.111 ‘‘Basal Cell carcinoma of
skin of unspecified eyelid, including
canthus.’’ Under our rule:
• C44.111 Basal Cell Carcinoma of skin
of unspecified eyelid will not be
accepted.
• C44.112 Basal Cell Carcinoma of skin
right eyelid will be accepted.
• C44.119 Basal Cell Carcinoma of skin
left eyelid will be accepted.
We are removing these non-specific
codes whenever a more specific
diagnosis could be identified by the
clinician performing the assessment. For
example code C44.111, we are deleting
this code because the clinician should
be able to identify which eye had the
basal cell carcinoma, and therefore will

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report the condition using the code that
specifies the right or left eye.
We are removing a total of 156 ICD–
10–CM site unspecified codes involving

the following comorbidity categories:
Oncology-93 ICD–10–CM codes,
Gangrene-6 ICD–10–CM codes and
Severe Musculoskeletal and Connective

Tissue—57 ICD–10–CM codes. The site
unspecified IPF PPS ICD–10–CM codes
being removed are listed below in
Tables 3 through 5.

TABLE 3—SITE UNSPECIFIED ICD–10–CM CODES TO BE REMOVED FROM THE ONCOLOGY TREATMENT COMORBIDITY
CATEGORY

tkelley on DSK3SPTVN1PROD with RULES3

ICD–10–CM
diagnosis
C40.00 ..........
C40.10 ..........
C40.20 ..........
C40.30 ..........
C40.80 ..........
C40.90 ..........
C43.10 ..........
C43.20 ..........
C43.60 ..........
C43.70 ..........
C44.101 ........
C44.111 ........
C44.121 ........
C44.191 ........
C44.201 ........
C44.211 ........
C44.221 ........
C44.601 ........
C44.611 ........
C44.621 ........
C44.691 ........
C44.701 ........
C44.711 ........
C44.721 ........
C44.791 ........
C47.10 ..........
C47.20 ..........
C49.10 ..........
C49.20 ..........
C4A.10 ..........
C4A.20 ..........
C4A.60 ..........
C4A.70 ..........
C50.019 ........
C50.029 ........
C50.119 ........
C50.129 ........
C50.219 ........
C50.229 ........
C50.319 ........
C50.329 ........
C50.419 ........
C50.429 ........
C50.519 ........
C50.529 ........
C50.619 ........
C50.629 ........
C50.819 ........
C50.829 ........
C50.919 ........
C50.929 ........
C69.00 ..........
C69.10 ..........
C69.50 ..........
C69.60 ..........
C69.80 ..........
C69.90 ..........
C76.40 ..........
C76.50 ..........
D03.10 ..........
D03.20 ..........
D03.60 ..........
D03.70 ..........
D04.10 ..........
D04.20 ..........

VerDate Mar<15>2010

Code title
Malignant neoplasm of scapula and long bones of unspecified upper limb.
Malignant neoplasm of short bones of unspecified upper limb.
Malignant neoplasm of long bones of unspecified lower limb.
Malignant neoplasm of short bones of unspecified lower limb.
Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb.
Malignant neoplasm of unspecified bones and articular cartilage of unspecified limb.
Malignant melanoma of unspecified eyelid, including canthus.
Malignant melanoma of unspecified ear and external auricular canal.
Malignant melanoma of unspecified upper limb, including shoulder.
Malignant melanoma of unspecified lower limb, including hip.
Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus.
Basal cell carcinoma of skin of unspecified eyelid, including canthus.
Squamous cell carcinoma of skin of unspecified eyelid, including canthus.
Other specified malignant neoplasm of skin of unspecified eyelid, including canthus.
Unspecified malignant neoplasm of skin of unspecified ear and external auricular canal.
Basal cell carcinoma of skin of unspecified ear and external auricular canal.
Squamous cell carcinoma of skin of unspecified ear and external auricular canal.
Unspecified malignant neoplasm of skin of unspecified upper limb, including shoulder.
Basal cell carcinoma of skin of unspecified upper limb, including shoulder.
Squamous cell carcinoma of skin of unspecified upper limb, including shoulder.
Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder.
Unspecified malignant neoplasm of skin of unspecified lower limb, including hip.
Basal cell carcinoma of skin of unspecified lower limb, including hip.
Squamous cell carcinoma of skin of unspecified lower limb, including hip.
Other specified malignant neoplasm of skin of unspecified lower limb, including hip.
Malignant neoplasm of peripheral nerves of unspecified upper limb, including shoulder.
Malignant neoplasm of peripheral nerves of unspecified lower limb, including hip.
Malignant neoplasm of connective and soft tissue of unspecified upper limb, including shoulder.
Malignant neoplasm of connective and soft tissue of unspecified lower limb, including hip.
Merkel cell carcinoma of unspecified eyelid, including canthus.
Merkel cell carcinoma of unspecified ear and external auricular canal.
Merkel cell carcinoma of unspecified upper limb, including shoulder.
Merkel cell carcinoma of unspecified lower limb, including hip.
Malignant neoplasm of nipple and areola, unspecified female breast.
Malignant neoplasm of nipple and areola, unspecified male breast.
Malignant neoplasm of central portion of unspecified female breast.
Malignant neoplasm of central portion of unspecified male breast.
Malignant neoplasm of upper-inner quadrant of unspecified female breast.
Malignant neoplasm of upper-inner quadrant of unspecified male breast.
Malignant neoplasm of lower-inner quadrant of unspecified female breast.
Malignant neoplasm of lower-inner quadrant of unspecified male breast.
Malignant neoplasm of upper-outer quadrant of unspecified female breast.
Malignant neoplasm of upper-outer quadrant of unspecified male breast.
Malignant neoplasm of lower-outer quadrant of unspecified female breast.
Malignant neoplasm of lower-outer quadrant of unspecified male breast.
Malignant neoplasm of axillary tail of unspecified female breast.
Malignant neoplasm of axillary tail of unspecified male breast.
Malignant neoplasm of overlapping sites of unspecified female breast.
Malignant neoplasm of overlapping sites of unspecified male breast.
Malignant neoplasm of unspecified site of unspecified female breast.
Malignant neoplasm of unspecified site of unspecified male breast.
Malignant neoplasm of unspecified conjunctiva.
Malignant neoplasm of unspecified cornea.
Malignant neoplasm of unspecified lacrimal gland and duct.
Malignant neoplasm of unspecified orbit.
Malignant neoplasm of overlapping sites of unspecified eye and adnexa.
Malignant neoplasm of unspecified site of unspecified eye.
Malignant neoplasm of unspecified upper limb.
Malignant neoplasm of unspecified lower limb.
Melanoma in situ of unspecified eyelid, including canthus.
Melanoma in situ of unspecified ear and external auricular canal.
Melanoma in situ of unspecified upper limb, including shoulder.
Melanoma in situ of unspecified lower limb, including hip.
Carcinoma in situ of skin of unspecified eyelid, including canthus.
Carcinoma in situ of skin of unspecified ear and external auricular canal.

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45951

TABLE 3—SITE UNSPECIFIED ICD–10–CM CODES TO BE REMOVED FROM THE ONCOLOGY TREATMENT COMORBIDITY
CATEGORY—Continued
ICD–10–CM
diagnosis
D04.60 ..........
D04.70 ..........
D05.00 ..........
D05.10 ..........
D05.80 ..........
D05.90 ..........
D09.20 ..........
D16.00 ..........
D16.10 ..........
D16.20 ..........
D16.30 ..........
D17.20 ..........
D21.10 ..........
D21.20 ..........
D22.10 ..........
D22.20 ..........
D22.60 ..........
D22.70 ..........
D23.10 ..........
D23.20 ..........
D23.60 ..........
D23.70 ..........
D24.9 ............
D31.00 ..........
D31.50 ..........
D31.60 ..........
D31.90 ..........
D48.60 ..........

Code title
Carcinoma in situ of skin of unspecified upper limb, including shoulder.
Carcinoma in situ of skin of unspecified lower limb, including hip.
Lobular carcinoma in situ of unspecified breast.
Intraductal carcinoma in situ of unspecified breast.
Other specified type of carcinoma in situ of unspecified breast.
Unspecified type of carcinoma in situ of unspecified breast.
Carcinoma in situ of unspecified eye.
Benign neoplasm of scapula and long bones of unspecified upper limb.
Benign neoplasm of short bones of unspecified upper limb.
Benign neoplasm of long bones of unspecified lower limb.
Benign neoplasm of short bones of unspecified lower limb.
Benign lipomatous neoplasm of skin and subcutaneous tissue of unspecified limb.
Benign neoplasm of connective and other soft tissue of unspecified upper limb, including shoulder.
Benign neoplasm of connective and other soft tissue of unspecified lower limb, including hip.
Melanocytic nevi of unspecified eyelid, including canthus.
Melanocytic nevi of unspecified ear and external auricular canal.
Melanocytic nevi of unspecified upper limb, including shoulder.
Melanocytic nevi of unspecified lower limb, including hip.
Other benign neoplasm of skin of unspecified eyelid, including canthus.
Other benign neoplasm of skin of unspecified ear and external auricular canal.
Other benign neoplasm of skin of unspecified upper limb, including shoulder.
Other benign neoplasm of skin of unspecified lower limb, including hip.
Benign neoplasm of unspecified breast.
Benign neoplasm of unspecified conjunctiva.
Benign neoplasm of unspecified lacrimal gland and duct.
Benign neoplasm of unspecified site of unspecified orbit.
Benign neoplasm of unspecified part of unspecified eye.
Neoplasm of uncertain behavior of unspecified breast.

TABLE 4—SITE UNSPECIFIED ICD–10–CM CODES TO BE REMOVED FROM THE GANGRENE COMORBIDITY CATEGORY
ICD10
I70269
I70369
I70469
I70569
I70669
I70769

...........
...........
...........
...........
...........
...........

ICD10 description
Atherosclerosis
Atherosclerosis
Atherosclerosis
Atherosclerosis
Atherosclerosis
Atherosclerosis

of
of
of
of
of
of

native arteries of extremities with gangrene, unspecified extremity.
unspecified type of bypass graft(s) of the extremities with gangrene, unspecified extremity.
autologous vein bypass graft(s) of the extremities with gangrene, unspecified extremity.
nonautologous biological bypass graft(s) of the extremities with gangrene, unspecified extremity.
nonbiological bypass graft(s) of the extremities with gangrene, unspecified extremity.
other type of bypass graft(s) of the extremities with gangrene, unspecified extremity.

TABLE 5—SITE UNSPECIFIED ICD–10–CM CODES TO BE REMOVED FROM THE SEVERE MUSCULOSKELETAL AND
CONNECTIVE TISSUE DISEASES CATEGORY

tkelley on DSK3SPTVN1PROD with RULES3

ICD10
M8600 ...........
M86019 .........
M86029 .........
M86039 .........
M86049 .........
M86059 .........
M86069 .........
M86079 .........
M8610 ...........
M86119 .........
M86129 .........
M86139 .........
M86149 .........
M86159 .........
M86169 .........
M86179 .........
M8620 ...........
M86219 .........
M86229 .........
M86239 .........
M86249 .........
M86259 .........
M86269 .........

VerDate Mar<15>2010

ICD10 description
Acute hematogenous osteomyelitis, unspecified site.
Acute hematogenous osteomyelitis, unspecified shoulder.
Acute hematogenous osteomyelitis, unspecified humerus.
Acute hematogenous osteomyelitis, unspecified radius and ulna.
Acute hematogenous osteomyelitis, unspecified hand.
Acute hematogenous osteomyelitis, unspecified femur.
Acute hematogenous osteomyelitis, unspecified tibia and fibula.
Acute hematogenous osteomyelitis, unspecified ankle and foot.
Other acute osteomyelitis, unspecified site.
Other acute osteomyelitis, unspecified shoulder.
Other acute osteomyelitis, unspecified humerus.
Other acute osteomyelitis, unspecified radius and ulna.
Other acute osteomyelitis, unspecified hand.
Other acute osteomyelitis, unspecified femur.
Other acute osteomyelitis, unspecified tibia and fibula.
Other acute osteomyelitis, unspecified ankle and foot.
Subacute osteomyelitis, unspecified site.
Subacute osteomyelitis, unspecified shoulder.
Subacute osteomyelitis, unspecified humerus.
Subacute osteomyelitis, unspecified radius and ulna.
Subacute osteomyelitis, unspecified hand.
Subacute osteomyelitis, unspecified femur.
Subacute osteomyelitis, unspecified tibia and fibula.

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TABLE 5—SITE UNSPECIFIED ICD–10–CM CODES TO BE REMOVED FROM THE SEVERE MUSCULOSKELETAL AND
CONNECTIVE TISSUE DISEASES CATEGORY—Continued
ICD10

ICD10 description

M86279 .........
M8630 ...........
M86319 .........
M86329 .........
M86339 .........
M86349 .........
M86359 .........
M86369 .........
M86379 .........
M8640 ...........
M86419 .........
M86429 .........
M86439 .........
M86449 .........
M86459 .........
M86469 .........
M86479 .........
M8650 ...........
M86519 .........
M86529 .........
M86539 .........
M86549 .........
M86559 .........
M86569 .........
M86579 .........
M8660 ...........
M86619 .........
M86629 .........
M86639 .........
M86649 .........
M86659 .........
M86669 .........
M86679 .........
M868x9 .........

Subacute osteomyelitis, unspecified ankle and foot.
Chronic multifocal osteomyelitis, unspecified site.
Chronic multifocal osteomyelitis, unspecified shoulder.
Chronic multifocal osteomyelitis, unspecified humerus.
Chronic multifocal osteomyelitis, unspecified radius and ulna.
Chronic multifocal osteomyelitis, unspecified hand.
Chronic multifocal osteomyelitis, unspecified femur.
Chronic multifocal osteomyelitis, unspecified tibia and fibula.
Chronic multifocal osteomyelitis, unspecified ankle and foot.
Chronic osteomyelitis with draining sinus, unspecified site.
Chronic osteomyelitis with draining sinus, unspecified shoulder.
Chronic osteomyelitis with draining sinus, unspecified humerus.
Chronic osteomyelitis with draining sinus, unspecified forearm.
Chronic osteomyelitis with draining sinus, unspecified hand.
Chronic osteomyelitis with draining sinus, unspecified femur.
Chronic osteomyelitis with draining sinus, unspecified lower leg.
Chronic osteomyelitis with draining sinus, unspecified ankle and foot.
Other chronic hematogenous osteomyelitis, unspecified site.
Other chronic hematogenous osteomyelitis, unspecified shoulder.
Other chronic hematogenous osteomyelitis, unspecified humerus.
Other chronic hematogenous osteomyelitis, unspecified forearm.
Other chronic hematogenous osteomyelitis, unspecified hand.
Other chronic hematogenous osteomyelitis, unspecified femur.
Other chronic hematogenous osteomyelitis, unspecified lower leg.
Other chronic hematogenous osteomyelitis, unspecified ankle and foot.
Other chronic osteomyelitis, unspecified site.
Other chronic osteomyelitis, unspecified shoulder.
Other chronic osteomyelitis, unspecified upper arm.
Other chronic osteomyelitis, unspecified forearm.
Other chronic osteomyelitis, unspecified hand.
Other chronic osteomyelitis, unspecified thigh.
Other chronic osteomyelitis, unspecified tibia and fibula.
Other chronic osteomyelitis, unspecified ankle and foot.
Other osteomyelitis, unspecified sites.

There are some site unspecified ICD–
10–CM codes that we are not removing.
In the case where the site unspecified
code is the only available ICD–10–CM
code, that is when a laterality code (site

specific code) is not available, the site
unspecified code will not be removed
and it would be appropriate to submit
that code.

Currently, IPFs are receiving the
comorbidity adjustment using the ICD–
9–CM diagnosis codes for the
comorbidity categories shown in Table
6 below.

TABLE 6—FY 2014 CURRENT DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES
ICD–9–CM diagnoses codes

Developmental Disabilities ..................................
Coagulation Factor Deficits .................................
Tracheostomy ......................................................
Renal Failure, Acute ............................................

317, 3180, 3181, 3182, and 319 .......................................................................
2860 through 2864 ............................................................................................
51900 through 51909 and V440 .......................................................................
5845 through 5849, 63630, 63631, 63632, 63730, 63731, 63732, 6383,
6393, 66932, 66934, 9585.
40301, 40311, 40391, 40402, 40412, 40413, 40492, 40493, 5853, 5854,
5855, 5856, 5859, 586, V4511, V4512, V560, V561, and V562.
1400 through 2399 with a radiation therapy code 92.21–92.29 or chemotherapy code 99.25.
25002, 25003, 25012, 25013, 25022, 25023, 25032, 25033, 25042, 25043,
25052, 25053, 25062, 25063, 25072, 25073, 25082, 25083, 25092, and
25093.
260 through 262 ................................................................................................
3071, 30750, 31203, 31233, and 31234 ...........................................................
01000 through 04110, 042, 04500 through 05319, 05440 through 05449,
0550 through 0770, 0782 through 07889, and 07950 through 07959.
2910, 2920, 29212, 2922, 30300, and 30400 ..................................................
3910, 3911, 3912, 40201, 40403, 4160, 4210, 4211, and 4219 ......................
44024 and 7854 ................................................................................................
49121, 4941, 5100, 51883, 51884, V4611, V4612, V4613 and V4614 ...........
56960 through 56969, 9975, and V441 through V446 .....................................

Renal Failure, Chronic .........................................
Oncology Treatment ............................................
Uncontrolled Diabetes-Mellitus with or without
complications.

tkelley on DSK3SPTVN1PROD with RULES3

Adjustment
factor

Description of comorbidity

Severe Protein Calorie Malnutrition ....................
Eating and Conduct Disorders ............................
Infectious Disease ...............................................
Drug and/or Alcohol Induced Mental Disorders ..
Cardiac Conditions ..............................................
Gangrene .............................................................
Chronic Obstructive Pulmonary Disease .............
Artificial Openings—Digestive and Urinary .........

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1.13
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1.13
1.12
1.07
1.03
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45953

TABLE 6—FY 2014 CURRENT DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES—
Continued
Adjustment
factor

Description of comorbidity

ICD–9–CM diagnoses codes

Severe Musculoskeletal and Connective Tissue
Disease.
Poisoning .............................................................

6960, 7100, 73000 through 73009, 73010 through 73019, and 73020
through 73029.
96500 through 96509, 9654, 9670 through 9699, 9770, 9800 through 9809,
9830 through 9839, 986, 9890 through 9897.

Final Rule Action: For FY 2015, we
are applying the 17 comorbidity
categories for which we provide an
adjustment as shown in Table 6 above.

Also, the ICD–10–CM/PCS codes and
adjustment factors shown in Table 7
below, as well as, the removal of 153
site unspecified ICD–10–CM codes in

1.09
1.11

Tables 3 through 5 above will go into
effect October 1, 2015.

TABLE 7—FY 2015 DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES
ICD–10–CM diagnoses codes

Developmental Disabilities .....................................
Coagulation Factor Deficits ....................................
Tracheostomy .........................................................
Renal Failure, Acute ...............................................
Renal Failure, Chronic ...........................................

F70 through F79 .............................................................................................
D66 through D682 ..........................................................................................
J9500 through J9509, and Z930 ....................................................................
N170 through N179, O0482, O0732, O084 O904, and T795XXA ................
I120, I1311 through I132, N183 through N19, Z4901 through Z4931,
Z9115, and Z992.
C000 through C4002, C4011, C4012 C4021, C4022, C4031, C4032,
C4081, C4082, C4091 through C430, C4311, C4312 , C4321, C4322,
C4361, C4362, C4371, C4372 though C4409, C44102, C44109,
C44112, C44119, C44122, C44129, C44191, C44192, C44202, C44209,
C44212, C44219, C44222, C44229 through C44599, C44602, C44609,
C44612, C44619, C44622, C44629, C44692, C44699, C44702, C44709,
C44712, C44719, C44722, C44729, C44792, C44799 through C470,
C4711, C4712, C4721, C4722 through C490, C4911, C4912, C4921,
C4922 through C4A0, C4A11, C4A12, C4A21, C4A22 through C4A59,
C4A61, C4A62, C4A71, C4A72 through C50012, C50021, C50022,
C50111, C50112, C50121, C50122, C50211, C50212, C50221, C50222,
C50311, C50312, C50321, C50322, C50411, C50412, C50421, C50422,
C50511, C50512, C50521, C50522, C50611, C50612, C50621, C50622,
C50811, C50812, C50821, C50822, C50911, C50912, C50921, C50922,
C510 through C689, C6901, C6902, C6911, C6912 through C6942,
C6951, C6952, C6961, C6962, C6981, C6982, C6991, C6992 through
C763, C7641, C7642, C7651, C7652 through C866, C882 through C964,
C96A, C96Z, C969 through D030, D0311, D0312, D0321, D0322
through D0359, D0361, D0362, D0371, D0372 through D040, D0411,
D0412, D0421, D0422 through D045, D0461, D0462, D0471, D0472
through D049, D0501, D0502, D0511, D0512, D0581, D0582, D0591,
D0592 through D0919, D0921 through D159, D1601, D1602, D1611,
D1612, D1621, D1622, D1631, D1632 through D171, D1721 through
D210, D2111, D2112, D2121, D2122 through D220, D2211, D2212,
D2221, D2222, D225 through D2261, D2262, D2271, D2272 through
D230, D2311, D2312, D2321, D2322 through D235, D2361, D2362,
D2371, D2372 through D242, D250 through D309, D3101 through
D3142, D3151, D3152, D3161, D3162, D3191, D3192 through D485,
D4861 through D471, D473, D47Z1 through D47Z9, D479 through D499,
K317, K635, Q8500, and Q8501 through Q8509 with a radiation therapy
code from ICD–10–PCS tables 08H through 0YH with a sixth character
device value 1 Radioactive Element, ICD–10–PCS table CW7, ICD–10–
PCS tables D00 through DW0, ICD–10–PCS tables D01 through DW1,
tables D0Y through DWY, or a chemotherapy code from ICD–10–PCS
table 3E0 with a sixth character substance value 0 Antineoplastic and a
seventh character qualifier 5 Other Antineoplastic.
E1065 and E1165 ...........................................................................................

1.05

E40 through E43 .............................................................................................
F5000 through F5002, F509, F631, F6381, and F911 ..................................

1.13
1.12

Oncology Treatment ...............................................

tkelley on DSK3SPTVN1PROD with RULES3

Adjustment
factor

Description of comorbidity

Uncontrolled Diabetes-Mellitus with or without
complications.
Severe Protein Calorie Malnutrition .......................
Eating and Conduct Disorders ...............................

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1.11
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TABLE 7—FY 2015 DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES—Continued
ICD–10–CM diagnoses codes

Infectious Disease ..................................................

A150 through A269, A280 through A329, A35 through A439, A46 through
A480, A482 through A488, A491, A70 through A740, A7489, A800
through A99, B0050 through B0059, B010 through B0229, B03 through
B069, B08010 through B0809, B0820 through B2799, B330 through
B333, B338, B341, B471 through B479, B950 through B955, B958,
B9730 through B9739, G032, I673, J020, J0300, J0301, J202, K9081,
L081, L444, M60009, and R1111.
Alcohol dependence with intoxication and/or withdrawal ...............................
F10121, F10220 through F10229, F10231, and F10921 ...............................
Drug withdrawal ..............................................................................................
F1193, F1123, F13230 through F13239, F13930 through F13939, F1423,
F1523, F1593, F17203, F17213, F17223, F17293, F19230 through
F19239, and F19930 through F19939.
Drug-induced psychotic disorder with hallucinations .....................................
F11251, F11151, F11951, F12151, F12251, F13151, F12951, F13251,
F13951, F14151, F14251, F14951, F15151, F15251, F15951, F16151,
F16251, F16951, F18151, F18251, F18951, F19151, F19251, and
F19951.
Drug intoxication .............................................................................................
F11220 through F11229, F11920 through F11929, F12120 through
F12129, F12220 through F12229, F12920 through F12929, F13120
through F13129, F13220 through F13229, F13920 through F13929,
F14120 through F14129, F14220 through F14229, F14920 through
F14929, F15120 through F15129, F15220 through F15229, F15920
through F15929, F16120 through F16129, F16220 through F16229,
F16920 through F16929, F18120 through F18129, F18220 through
F18229, F18920 through F18929, F19120 through F19129, F19220
through F19229, F19230 through F19239, and F19920 through F19929.
Opioid dependence not listed above ..............................................................
F1120, F1124, F11250, F11259, F11281 through F11288, F1129 ...............
I010 through I012, I110, I270, I330 through I339, and I39 ............................
E0852, E0952, E1052, E1152, E1352, I70261 through I70268, I70361
through I70368, I70461 through I70468, I70561 through I70568, I70661
through I70668, I70761 through I70768, I7301, and I96.
J441, J470 through J471, J860, J95850, J9610 through J9622, and Z9911
through Z9912.
K9400 through K9419, N990, N99520 through N99538, N9981, N9989,
and Z931 through Z936.
L4050 through L4059, M320 through M329, M4620 through M4628,
M86011, M86012, M86021, M86022, M86031, M86032, M86041,
M86042, M86051, M86052, M86061, M86062, M86071, M86072,
M8608, M8609, M86111, M86112, M86121, M86122, M86131, M86132,
M86141, M86142, M86151, M86152, M86161, M86162, M86171,
M86172, M8618, M8619, M86211, M86212, M86221, M86222, M86231,
M86232, M86241, M86242, M86251, M86252, M86261, M86262,
M86271, M86272, M8628, M8629, M86311, M86312, M86321, M86322,
M86331, M86332, M86341, M86342, M86351, M86352, M86361,
M86362, M86371, M86372, M8638, M8639, M86411, M86412, M86421,
M86422, M86431, M86432, M86441, M86442, M86451, M86452,
M86461, M86462, M86471, M86472, M8648, M8649, M86511, M86512,
M86521, M86522, M86531, M86532, M86541, M86542, M86551,
M86552, M86561, M86562, M86571, M86572, M8658, M8659, M86611,
M86612, M86621, M86622, M86631, M86632, M86641, M86642,
M86651, M86652, M86661, M86662, M86671, M86672, M8668, M8669,
M868X0, M868X1, M868X2, M868X3, M868X4, M868X5, M868X6,
M868X7, M868X8, and M869.
Note: Only includes the codes below with seventh character A specifying
initial encounter.

Drug and/or Alcohol Induced Mental Disorders .....

Cardiac Conditions .................................................
Gangrene ................................................................

Chronic Obstructive Pulmonary Disease ...............
Artificial Openings—Digestive and Urinary ............
Severe Musculoskeletal and Connective Tissue
Diseases.

Poisoning ................................................................

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Adjustment
factor

Description of comorbidity

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1.07

1.03
........................
........................
........................

........................
........................

........................
........................

........................
........................
1.11
1.10

1.12
1.08
1.09

1.11

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45955

TABLE 7—FY 2015 DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES—Continued
ICD–10–CM diagnoses codes

Adjustment
factor

T391X1 through T391X4, T400X1 through T400X4, T401X1 through
T401X4, T402X1 through T402X4, T403X1 through T403X4, T404X1
through T404X4, T40601 through T40604, T40691 through T40694,
T407X1 through T407X4, T408X1 through T408X4, T40901 through
T40904, T40991 through T40994, T410X1 through T410X4, T411X1
through T411X4, T41201 through T41204, T41291 through T41294,
T413X1 through T413X4, T4141X through T4144X, T423X1 through
T423X4, T424X1 through T424X4, T426X1 through T426X4, T4271X
through T4274X, T428X1 through T428X4, T43011 through T43014,
T43021 through T43024, T431X1 through T431X4, T43201 through
T43204, T43211 through T43214, T43221 through T43224, T43291
through T43294, T433X1 through T433X4, T434X1 through T434X4,
T43501 through T43504, T43591 through T43594, T43601 through
T43604, T43611 through T43614, T43621 through T43624, T43631
through T43634, T43691 through T43694, T438X1 through T438X4,
T4391X through T4394X, T505X1 through T505X4, T510X1 through
T5194X, T510X1 through T510X4, T5391X through T5394X, T540X1
through T5494X, T550X1 through T551X4, T560X1 through T560X4,
T571X1 through T571X4, T5801X through T5804X, T5811X through
T5814X, T582X1 through T582X4, T588X1 through T588X4, T5891X
through T5894X, T600X1 through T600X4, T601X1 through T601X4,
T602X1 through T602X4, T6041X through T6094X, T63001 through
T6394X, T6401X through T6484X, T650X1 through T650X4, T651X1
through T651X4.

........................

Description of comorbidity

3. Patient Age Adjustments
As explained in the November 2004
IPF PPS final rule (69 FR 66922), we
analyzed the impact of age on per diem
cost by examining the age variable (that
is, the range of ages) for payment
adjustments.
In general, we found that the cost per
day increases with age. The older age
groups are more costly than the under
45 age group, the differences in per
diem cost increase for each successive
age group, and the differences are
statistically significant.
For FY 2015, we will to continue to
use the patient age adjustments
currently in effect as shown in Table 8
below.

TABLE 8—AGE GROUPINGS AND
ADJUSTMENT FACTORS
Age

Adjustment
factor

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Under 45 ...............................
45 and under 50 ...................
50 and under 55 ...................
55 and under 60 ...................
60 and under 65 ...................
65 and under 70 ...................
70 and under 75 ...................
75 and under 80 ...................
80 and over ..........................

1.00
1.01
1.02
1.04
1.07
1.10
1.13
1.15
1.17

Final Rule Action: We received no
comments on the FY 2015 IPF PPS
proposed rule concerning the age
adjustment. We are adopting the age
adjustments currently in effect and as
shown in Table 8 above for FY 2015.

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4. Variable Per Diem Adjustments
We explained in the November 2004
IPF PPS final rule (69 FR 66946) that the
regression analysis indicated that per
diem cost declines as the LOS increases.
The variable per diem adjustments to
the Federal per diem base rate account
for ancillary and administrative costs
that occur disproportionately in the first
days after admission to an IPF.
We used a regression analysis to
estimate the average differences in per
diem cost among stays of different
lengths. As a result of this analysis, we
established variable per diem
adjustments that begin on day 1 and
decline gradually until day 21 of a
patient’s stay. For day 22 and thereafter,
the variable per diem adjustment
remains the same each day for the
remainder of the stay. However, the
adjustment applied to day 1 depends
upon whether the IPF has a qualifying
emergency department (ED). If an IPF
has a qualifying ED, it receives a 1.31
adjustment factor for day 1 of each stay.
If an IPF does not have a qualifying ED,
it receives a 1.19 adjustment factor for
day 1 of the stay. The ED adjustment is
explained in more detail in section
VII.C.5 of this final rule.
For FY 2015, we will continue to use
the variable per diem adjustment factors
currently in effect as shown in Table 9
below. A complete discussion of the
variable per diem adjustments appears
in the November 2004 IPF PPS final rule
(69 FR 66946).

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TABLE 9—VARIABLE PER DIEM
ADJUSTMENTS
Day-of-stay
Day 1- IPF Without a Qualifying ED ............................
Day 1- IPF With a Qualifying
ED .....................................
Day 2 ....................................
Day 3 ....................................
Day 4 ....................................
Day 5 ....................................
Day 6 ....................................
Day 7 ....................................
Day 8 ....................................
Day 9 ....................................
Day 10 ..................................
Day 11 ..................................
Day 12 ..................................
Day 13 ..................................
Day 14 ..................................
Day 15 ..................................
Day 16 ..................................
Day 17 ..................................
Day 18 ..................................
Day 19 ..................................
Day 20 ..................................
Day 21 ..................................
After Day 21 .........................

Adjustment
factor
1.19
1.31
1.12
1.08
1.05
1.04
1.02
1.01
1.01
1.00
1.00
0.99
0.99
0.99
0.99
0.98
0.97
0.97
0.96
0.95
0.95
0.95
0.92

Final Rule Action: In response to the
FY 2015 IPF PPS proposed rule, we
received no public comments
concerning the variable per diem
adjustment. We are adopting the
variable per diem adjustments currently
in effect and as shown in Table 9 above
for FY 2015.

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C. Facility-Level Adjustments
The IPF PPS includes facility-level
adjustments for the wage index, IPFs
located in rural areas, teaching IPFs,
cost of living adjustments for IPFs
located in Alaska and Hawaii, and IPFs
with a qualifying ED.
1. Wage Index Adjustment

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a. Background
As discussed in the May 2006 IPF PPS
final rule (71 FR 27061) and in the May
2008 (73 FR 25719) and May 2009 IPF
PPS notices (74 FR 20373), in order to
provide an adjustment for geographic
wage levels, the labor-related portion of
an IPF’s payment is adjusted using an
appropriate wage index. Currently, an
IPF’s geographic wage index value is
determined based on the actual location
of the IPF in an urban or rural area as
defined in § 412.64(b)(1)(ii)(A) and (C).
b. Wage Index for FY 2015
Since the inception of the IPF PPS, we
have used the pre-reclassified, pre-floor
hospital wage index in developing a
wage index to be applied to IPFs
because there is not an IPF-specific
wage index available and we believe
that IPFs generally compete in the same
labor market as acute care hospitals so
the pre-reclassified, pre-floor inpatient
acute care hospital wage index should
be reflective of labor costs of IPFs. As
discussed in the May 2006 IPF PPS final
rule for FY 2007 (71 FR 27061 through
27067), under the IPF PPS, the wage
index is calculated using the IPPS wage
index for the labor market area in which
the IPF is located, without taking into
account geographic reclassifications,
floors, and other adjustments made to
the wage index under the IPPS. For a
complete description of these IPPS wage
index adjustments, please see the CY
2013 IPPS/LTCH PPS final rule (77 FR
53365 through 53374). We will continue
that practice for FY 2015.
We apply the wage index adjustment
to the labor-related portion of the
Federal rate, which is currently
estimated to be 69.294 percent. This
percentage reflects the labor-related
relative importance of the FY 2008based RPL market basket for FY 2015
(see section V.C. of this final rule).
Changes to the wage index are made
in a budget-neutral manner so that
updates do not increase expenditures.
For FY 2015, we are applying the most
recent hospital wage index (that is, the
FY 2014 pre-floor, pre-reclassified
hospital wage index which is the most
appropriate index as it best reflects the
variation in local labor costs of IPFs in
the various geographic areas) using the
most recent hospital wage data (that is,

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data from hospital cost reports for the
cost reporting period beginning during
FY 2010), and applying an adjustment
in accordance with our budgetneutrality policy. This policy requires
us to estimate the total amount of IPF
PPS payments for FY 2014 using the
labor-related share and the wage indices
from FY 2014 divided by the total
estimated IPF PPS payments for FY
2015 using the labor-related share and
wage indices from FY 2015. The
estimated payments are based on FY
2013 IPF claims, inflated to the
appropriate FY. This quotient is the
wage index budget-neutrality factor, and
it is applied in the update of the Federal
per diem base rate for FY 2015 in
addition to the market basket described
in section VI.B. of this final rule. The
wage index budget-neutrality factor for
FY 2015 is 1.0002. The wage index
applicable for FY 2015 appears in Table
1 and Table 2 in Addendum B of this
final rule.
In the May 2006 IPF PPS final rule for
RY 2007 (71 FR 27061–27067), we
adopted the changes discussed in the
Office of Management and Budget
(OMB) Bulletin No. 03–04 (June 6,
2003), which announced revised
definitions for Metropolitan Statistical
Areas (MSAs), and the creation of
Micropolitan Statistical Areas and
Combined Statistical Areas. In adopting
the OMB Core-Based Statistical Area
(CBSA) geographic designations, we did
not provide a separate transition for the
CBSA-based wage index since the IPF
PPS was already in a transition period
from TEFRA payments to PPS
payments.
As was the case in FY 2014, for FY
2015, we will continue to use the CBSA
geographic designations. The updated
FY 2015 CBSA-based wage index values
are presented in Tables 1 and 2 in
Addendum B of this final rule. A
complete discussion of the CBSA labor
market definitions appears in the May
2006 IPF PPS final rule (71 FR 27061
through 27067).
In keeping with established IPF PPS
wage index policy, we are using the FY
2014 pre-floor, pre-reclassified hospital
wage index (which is based on data
collected from hospital cost reports
submitted by hospitals for cost reporting
periods beginning during FY 2010) to
adjust IPF PPS payments beginning
October 1, 2014.
c. OMB Bulletins
OMB publishes bulletins regarding
CBSA changes, including changes to
CBSA numbers and titles. In the May
2008 IPF PPS notice, we incorporated
the CBSA nomenclature changes
published in the most recent OMB

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bulletin that applies to the hospital
wage index used to determine the
current IPF PPS wage index and stated
that we expect to continue to do the
same for all the OMB CBSA
nomenclature changes in future IPF PPS
rules and notices, as necessary (73 FR
25721). The OMB bulletins may be
accessed online at http://www.
whitehouse.gov/omb/bullentins/
index.html.
In accordance with our established
methodology, we have historically
adopted any CBSA changes that are
published in the OMB bulletin that
corresponds with the hospital wage
index used to determine the IPF PPS
wage index. For FY 2015, we use the FY
2014 pre-floor, pre-reclassified hospital
wage index to adjust the IPF PPS
payments. On February 28, 2013, OMB
issued OMB Bulletin No. 13–01, which
establishes revised delineations of
statistical areas based on OMB
standards published in the Federal
Register on June 28, 2010 and 2010
Census Bureau data. Because the FY
2014 pre-floor, pre-reclassified hospital
wage index was finalized prior to the
issuance of this Bulletin, the FY 2014
pre-floor, pre-reclassified hospital wage
index does not reflect OMB’s new area
delineations based on the 2010 Census
and, thus, the FY 2015 IPF PPS wage
index will not reflect the OMB changes.
CMS will use the hospital wage index
based on the OMB Bulletin in the FY
2015 IPPS/LTCH PPS final rule.
Therefore, the OMB Bulletin changes
are reflected in the FY 2015 hospital
wage index. Because we base the IPF
PPS wage index on the hospital wage
index from the prior year, we anticipate
that the OMB Bulletin changes will be
reflected in the FY 2016 IPPS wage
index.
Final Rule Action: In response to the
FY 2015 IPF PPS proposed rule, we
received no comments concerning the
wage adjustment. We are adopting the
FY 2014 pre-floor, pre-reclassified
hospital wage index for FY 2015.
2. Adjustment for Rural Location
In the November 2004 IPF PPS final
rule, we provided a 17 percent payment
adjustment for IPFs located in a rural
area. This adjustment was based on the
regression analysis, which indicated
that the per diem cost of rural facilities
was 17 percent higher than that of urban
facilities after accounting for the
influence of the other variables included
in the regression. For FY 2015, we are
applying a 17 percent payment
adjustment for IPFs located in a rural
area as defined at § 412.64(b)(1)(ii)(C). A
complete discussion of the adjustment
for rural locations appears in the

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tkelley on DSK3SPTVN1PROD with RULES3

November 2004 IPF PPS final rule (69
FR 66954).
Final Rule Action: In response to the
FY 2015 IPF PPS proposed rule, we
received no comments concerning the
rural adjustment. We are adopting the
rural adjustments currently in effect for
FY 2015.
3. Teaching Adjustment
In the November 2004 IPF PPS final
rule, we implemented regulations at
§ 412.424(d)(1)(iii) to establish a facilitylevel adjustment for IPFs that are, or are
part of, teaching hospitals. The teaching
adjustment accounts for the higher
indirect operating costs experienced by
hospitals that participate in graduate
medical education (GME) programs. The
payment adjustments are made based on
the ratio of the number of full-time
equivalent (FTE) interns and residents
training in the IPF and the IPF’s average
daily census.
Medicare makes direct GME payments
(for direct costs such as resident and
teaching physician salaries, and other
direct teaching costs) to all teaching
hospitals including those paid under a
PPS, and those paid under the TEFRA
rate-of-increase limits. These direct
GME payments are made separately
from payments for hospital operating
costs and are not part of the IPF PPS.
The direct GME payments do not
address the estimated higher indirect
operating costs teaching hospitals may
face.
The results of the regression analysis
of FY 2002 IPF data established the
basis for the payment adjustments
included in the November 2004 IPF PPS
final rule. The results showed that the
indirect teaching cost variable is
significant in explaining the higher
costs of IPFs that have teaching
programs. We calculated the teaching
adjustment based on the IPF’s ‘‘teaching
variable,’’ which is one plus the ratio of
the number of FTE residents training in
the IPF (subject to limitations described
below) to the IPF’s average daily census
(ADC).
We established the teaching
adjustment in a manner that limited the
incentives for IPFs to add FTE residents
for the purpose of increasing their
teaching adjustment. We imposed a cap
on the number of FTE residents that
may be counted for purposes of
calculating the teaching adjustment. The
cap limits the number of FTE residents
that teaching IPFs may count for the
purpose of calculating the IPF PPS
teaching adjustment, not the number of
residents teaching institutions can hire
or train. We calculated the number of
FTE residents that trained in the IPF
during a ‘‘base year’’ and used that FTE

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resident number as the cap. An IPF’s
FTE resident cap is ultimately
determined based on the final
settlement of the IPF’s most recent cost
report filed before November 15, 2004
(that is, the publication date of the IPF
PPS final rule).
In the regression analysis, the
logarithm of the teaching variable had a
coefficient value of 0.5150. We
converted this cost effect to a teaching
payment adjustment by treating the
regression coefficient as an exponent
and raising the teaching variable to a
power equal to the coefficient value. We
note that the coefficient value of 0.5150
was based on the regression analysis
holding all other components of the
payment system constant. A complete
discussion of how the teaching
adjustment was calculated appears in
the November 2004 IPF PPS final rule
(69 FR 66954 through 66957) and the
May 2008 IPF PPS notice (73 FR 25721).
Final Rule Action: As with other
adjustment factors derived through the
regression analysis, we do not plan to
rerun the regression analysis until we
analyze IPF PPS data. Therefore, in this
final rule, for FY 2015, we are retaining
the coefficient value of 0.5150 for the
teaching adjustment to the Federal per
diem base rate.
a. FTE Intern and Resident Cap
Adjustment
CMS had been asked by the IPF
industry to reconsider the original IPF
teaching policy and permit a temporary
increase in the FTE resident cap when
an IPF increases the number of FTE
residents it trains due to the acceptance
of displaced residents (residents that are
training in an IPF or a program before
the IPF or program closed) when
another IPF closes or closes its medical
residency training program.
To help us assess how many IPFs had
been, or were expected to be adversely
affected by their inability to adjust their
caps under § 412.424(d)(1)(iii) and
under these situations, we specifically
requested public comment from IPFs in
the May 1, 2009 IPF PPS notice (74 FR
20376 through 20377). A summary of
the comments and our responses can be
reviewed in the April 30, 2010 IPF PPS
notice (75 FR 23106 through 23117). All
of the commenters recommended that
CMS modify the IPF PPS teaching
adjustment policy, supporting a policy
change that would permit the IPF PPS
residency cap to be temporarily adjusted
when that IPF trains displaced residents
due to closure of an IPF or closure of an
IPF’s medical residency training
program(s). The commenters
recommended a temporary resident cap
adjustment policy similar to the policies

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45957

applied in similar contexts for acute
care hospitals.
We agreed with the commenters
therefore, in the May 6, 2011 IPF PPS
final rule (76 FR 26455), we adopted the
temporary resident cap adjustment
policies described below, similar to the
temporary adjustments to the FTE cap
used for acute care hospitals.
b. Temporary Adjustment to the FTE
Cap To Reflect Residents Added Due to
Hospital Closure
In the May 6, 2011 IPF PPS final rule
(76 FR 26455), we added a new
§ 412.424(d)(1)(iii)(F)(1) to allow a
temporary adjustment to an IPF’s FTE
cap to reflect residents added because of
another IPF’s closure on or after July 1,
2011, to be effective for cost reporting
periods beginning on or after July 1,
2011. For purposes of this policy, we
adopted the IPPS definition of ‘‘closure
of a hospital’’ in 42 CFR 413.79(h) to
mean the IPF terminates its Medicare
provider agreement as specified in 42
CFR 489.52. The regulations permit an
adjustment to an IPF’s FTE cap if the
IPF meets the following criteria: (1) The
IPF is training displaced residents from
another IPF that closed on or after July
1, 2011; and (2) no later than 60 days
after the hospital first begins training
the displaced residents, the IPF that is
training the displaced residents from the
closed IPF submits a request for a
temporary adjustment to its FTE cap to
its Medicare Administrative Contractor
(MAC), and documents that the IPF is
eligible for this temporary adjustment to
its FTE cap by identifying the residents
who have come from the closed IPF and
have caused the requesting IPF to
exceed its cap, (or the IPF may already
be over its cap) and specifies the length
of time that the adjustment is needed.
After the displaced residents leave the
IPF’s training program or complete their
residency program, the IPF’s cap would
revert to its original level. Further, the
total amount of temporary cap
adjustments that can be distributed to
all receiving hospitals cannot exceed the
cap amount of the IPF that closed.
c. Temporary Adjustment to FTE Cap To
Reflect Residents Affected by Residency
Program Closure
In the May 6, 2011 final rule (76 FR
26455), we added a new
§ 412.424(d)(1)(iii)(F)(2) providing that
if an IPF that ceases training residents
in a residency training program(s) agrees
to temporarily reduce its FTE cap, we
would allow another IPF to receive a
temporary adjustment to its FTE cap to
reflect residents added because of the
closure of another IPF’s residency
training program. For purposes of this

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policy on closed residency programs,
we apply the IPPS definition of ‘‘closure
of a hospital residency training
program’’ to mean that the hospital
ceases to offer training for residents in
a particular approved medical residency
training program as specified in
§ 413.79(h). The methodology for
adjusting the caps for the ‘‘receiving
IPF’’ and the ‘‘IPF that closed its
program’’ is described below.
i. Receiving IPF
The regulations at
§ 412.424(d)(1)(iii)(F)(2)(i) allow an IPF
to receive a temporary adjustment to its
FTE cap to reflect residents added
because of the closure of another IPF’s
residency training program for cost
reporting periods beginning on or after
July 1, 2011 if—
• The IPF is training additional
residents from the residency training
program of an IPF that closed its
program on or after July 1, 2011.
• No later than 60 days after the IPF
begins to train the residents, the IPF
submits to its MAC a request for a
temporary adjustment to its FTE cap,
documents that the IPF is eligible for
this temporary adjustment by
identifying the residents who have come
from another IPF’s closed program and
have caused the IPF to exceed its cap (or
the IPF may already be in excess of its
cap), specifies the length of time the
adjustment is needed, and submits to its
MAC a copy of the FTE cap reduction
statement by the IPF closing the
residency training program.
ii. IPF That Closed Its Program
The regulations at
§ 412.424(d)(1)(iii)(F)(2)(ii) provide that
an IPF that agrees to train residents who
have been displaced by the closure of
another IPF’s resident teaching program
may receive a temporary FTE cap
adjustment only if the IPF that closed a
program:
• Temporarily reduces its FTE cap
based on the number of FTE residents
in each program year, training in the
program at the time of the program’s
closure.
• No later than 60 days after the
residents who were in the closed

program begin training at another IPF,
submits to its MAC a statement signed
and dated by its representative that
specifies that it agrees to the temporary
reduction in its FTE cap to allow the IPF
training the displaced residents to
obtain a temporary adjustment to its
cap; identifies the residents who were
training at the time of the program’s
closure; identifies the IPFs to which the
residents are transferring once the
program closes; and specifies the
reduction for the applicable program
years.
A complete discussion on the
temporary adjustment to the FTE cap to
reflect residents added due to hospital
closure and by residency program
appears in the January 27, 2011 IPF PPS
proposed rule (76 FR 5018 through
5020) and the May 6, 2011 IPF PPS final
rule (76 FR 26453 through 26456).
4. Cost of Living Adjustment for IPFs
Located in Alaska and Hawaii
The IPF PPS includes a payment
adjustment for IPFs located in Alaska
and Hawaii based upon the county in
which the IPF is located. As we
explained in the November 2004 IPF
PPS final rule, the FY 2002 data
demonstrated that IPFs in Alaska and
Hawaii had per diem costs that were
disproportionately higher than other
IPFs. Other Medicare PPSs (for example,
the IPPS and LTCH PPS) adopted a cost
of living adjustment (COLA) to account
for the cost differential of care furnished
in Alaska and Hawaii.
We analyzed the effect of applying a
COLA to payments for IPFs located in
Alaska and Hawaii. The results of our
analysis demonstrated that a COLA for
IPFs located in Alaska and Hawaii
would improve payment equity for
these facilities. As a result of this
analysis, we provided a COLA in the
November 2004 IPF PPS final rule.
A COLA for IPFs located in Alaska
and Hawaii is made by multiplying the
nonlabor-related portion of the Federal
per diem base rate by the applicable
COLA factor based on the COLA area in
which the IPF is located.
The COLA factors are published on
the Office of Personnel Management

(OPM) Web site (http://www.opm.gov/
oca/cola/rates.asp).
We note that the COLA areas for
Alaska are not defined by county as are
the COLA areas for Hawaii. In 5 CFR
591.207, the OPM established the
following COLA areas:
• City of Anchorage, and 80-kilometer
(50-mile) radius by road, as measured
from the Federal courthouse;
• City of Fairbanks, and 80-kilometer
(50-mile) radius by road, as measured
from the Federal courthouse;
• City of Juneau, and 80-kilometer
(50-mile) radius by road, as measured
from the Federal courthouse;
• Rest of the State of Alaska.
As stated in the November 2004 IPF
PPS final rule, we update the COLA
factors according to updates established
by the OPM. However, sections 1911
through 1919 of the Nonforeign Area
Retirement Equity Assurance Act, as
contained in subtitle B of title XIX of the
National Defense Authorization Act
(NDAA) for Fiscal Year 2010 (Pub. L.
111–84, October 28, 2009), transitions
the Alaska and Hawaii COLAs to
locality pay. Under section 1914 of Pub.
L. 111–84, locality pay is being phased
in over a 3-year period beginning in
January 2010, with COLA rates frozen as
of the date of enactment, October 28,
2009, and then proportionately reduced
to reflect the phase-in of locality pay.
When we published the proposed
COLA factors in the January 2011 IPF
PPS proposed rule (76 FR 4998), we
inadvertently selected the FY 2010
COLA rates which had been reduced to
account for the phase-in of locality pay.
We did not intend to propose the
reduced COLA rates because that would
have understated the adjustment.
Since the 2009 COLA rates did not
reflect the phase-in of locality pay, we
finalized the FY 2009 COLA rates for RY
2010 through RY 2014 and indicated
our intent to address the COLA in FY
2015. Currently, IPFs located in Alaska
and Hawaii receive the updated COLA
factors based on the COLA area in
which the IPF is located as shown in
Table 10 below.

TABLE 10—COLA FACTORS FOR ALASKA AND HAWAII IPFS
Cost of
living
adjustment
factor

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Area

Alaska:
City of Anchorage and 80-kilometer (50-mile) radius by road .....................................................................................................
City of Fairbanks and 80-kilometer (50-mile) radius by road ......................................................................................................
City of Juneau and 80-kilometer (50-mile) radius by road ..........................................................................................................
Rest of Alaska ..............................................................................................................................................................................
Hawaii:

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45959

TABLE 10—COLA FACTORS FOR ALASKA AND HAWAII IPFS—Continued
Cost of
living
adjustment
factor

Area

City and County of Honolulu ........................................................................................................................................................
County of Hawaii ..........................................................................................................................................................................
County of Kauai ............................................................................................................................................................................
County of Maui and County of Kalawao ......................................................................................................................................

1.25
1.18
1.25
1.25

(The above factors are based on data obtained from the U.S. Office of Personnel Management Web site at: http://www.opm.gov/oca/cola/
rates.asp.)

In the FY 2013 IPPS/LTCH final rule
(77 FR 53700 through 53701), CMS
established a methodology for FY 2014
to update the COLA factors for Alaska
and Hawaii. Under that methodology,
we use a comparison of the growth in
the Consumer Price Indices (CPIs) in
Anchorage, Alaska and Honolulu,
Hawaii relative to the growth in the
overall CPI as published by the Bureau
of Labor Statistics (BLS) to update the
COLA factors for all areas in Alaska and
Hawaii, respectively. As discussed in
the FY 2013 IPPS/LTCH proposed rule
(77 FR 28145), because BLS publishes
CPI data for only Anchorage, Alaska and
Honolulu, Hawaii, our methodology for
updating the COLA factors uses a
comparison of the growth in the CPIs for
those cities relative to the growth in the
overall CPI to update the COLA factors
for all areas in Alaska and Hawaii,
respectively. We believe that the relative
price differences between these cities
and the United States (as measured by
the CPIs mentioned above) are generally
appropriate proxies for the relative price
differences between the ‘‘other areas’’ of
Alaska and Hawaii and the United
States.
The CPIs for ‘‘All Items’’ that BLS
publishes for Anchorage, Alaska,
Honolulu, Hawaii, and for the average
U.S. city are based on a different mix of

commodities and services than is
reflected in the nonlabor-related share
of the IPPS market basket. As such,
under the methodology we established
to update the COLA factors, we
calculated a ‘‘reweighted CPI’’ using the
CPI for commodities and the CPI for
services for each of the geographic areas
to mirror the composition of the IPPS
market basket nonlabor-related share.
The current composition of BLS’ CPI for
‘‘All Items’’ for all of the respective
areas is approximately 40 percent
commodities and 60 percent services.
However, the nonlabor-related share of
the IPPS market basket is comprised of
60 percent commodities and 40 percent
services. Therefore, under the
methodology established for FY 2014 in
the FY 2013 IPPS/LTCH PPS final rule,
we created reweighted indexes for
Anchorage, Alaska, Honolulu, Hawaii,
and the average U.S. city using the
respective CPI commodities index and
CPI services index and applying the
approximate 60/40 weights from the
IPPS market basket. This approach is
appropriate because we continue to
make a COLA for hospitals located in
Alaska and Hawaii by multiplying the
nonlabor-related portion of the
standardized amount by a COLA factor.
Under the COLA factor update
methodology established in the FY 2014

IPPS/LTCH final rule, we adjust
payments made to hospitals located in
Alaska and Hawaii by incorporating a
25-percent cap on the CPI-updated
COLA factors. We note that OPM’s
COLA factors were calculated with a
statutorily mandated cap of 25 percent,
and since at least 1984, we have
exercised our discretionary authority to
adjust Alaska and Hawaii payments by
incorporating this cap. In keeping with
this historical policy, we continue to
use such a cap, as our rule is based on
OPM’s COLA factors. We believe this
approach is appropriate because our
CPI-updated COLA factors use the 2009
OPM COLA factors as a basis.
We believe it is appropriate to adopt
the same methodology for the COLA
factors applied under the IPPS because
IPFs are hospitals with a similar mix of
commodities and services. In addition,
we think it is appropriate to have a
consistent policy approach with that of
other hospitals in Alaska and Hawaii.
Therefore, we are adopting the cost of
living adjustment factors shown in
Table 11 below for IPFs located in
Alaska and Hawaii. We are adopting the
COLA rates, which were published in
the FY 2014 IPPS/LTCH final rule (78
FR 50986) using the new update
methodology.

TABLE 11—COST-OF-LIVING ADJUSTMENT FACTORS—ALASKA AND HAWAII HOSPITALS AREA COLA FACTOR
Cost of
living
adjustment
factor

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Area

Alaska:
City of Anchorage and 80-kilometer (50-mile) radius by road .....................................................................................................
City of Fairbanks and 80-kilometer (50-mile) radius by road ......................................................................................................
City of Juneau and 80-kilometer (50-mile) radius by road ..........................................................................................................
Rest of Alaska ..............................................................................................................................................................................
Hawaii:
City and County of Honolulu ........................................................................................................................................................
County of Hawaii ..........................................................................................................................................................................
County of Kauai ............................................................................................................................................................................
County of Maui and County of Kalawao ......................................................................................................................................

Final Rule Action: We did not receive
any public comments on the proposed

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COLA methodology and adjustment
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We are adopting the update

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methodology and adjustment factors
shown in Table 11 above.
5. Adjustment for IPFs With a
Qualifying Emergency Department (ED)
The IPF PPS includes a facility-level
adjustment for IPFs with qualifying EDs.
We provide an adjustment to the
Federal per diem base rate to account
for the costs associated with
maintaining a full-service ED. The
adjustment is intended to account for
ED costs incurred by a freestanding
psychiatric hospital with a qualifying
ED or a distinct part psychiatric unit of
an acute care hospital or a CAH for
preadmission services otherwise
payable under the Medicare Outpatient
Prospective Payment System (OPPS)
furnished to a beneficiary on the date of
the beneficiary’s admission to the
hospital and during the day
immediately preceding the date of
admission to the IPF (see § 413.40(c)(2))
and the overhead cost of maintaining
the ED. This payment is a facility-level
adjustment that applies to all IPF
admissions (with one exception
described below), regardless of whether
a particular patient receives
preadmission services in the hospital’s
ED.
The ED adjustment is incorporated
into the variable per diem adjustment
for the first day of each stay for IPFs
with a qualifying ED. That is, IPFs with
a qualifying ED receive an adjustment
factor of 1.31 as the variable per diem
adjustment for day 1 of each stay. If an
IPF does not have a qualifying ED, it
receives an adjustment factor of 1.19 as
the variable per diem adjustment for day
1 of each patient stay.
The ED adjustment is made on every
qualifying claim except as described
below. As specified in
§ 412.424(d)(1)(v)(B), the ED adjustment
is not made when a patient is
discharged from an acute care hospital
or CAH and admitted to the same
hospital’s or CAH’s psychiatric unit. We
clarified in the November 2004 IPF PPS
final rule (69 FR 66960) that an ED
adjustment is not made in this case
because the costs associated with ED
services are reflected in the DRG
payment to the acute care hospital or
through the reasonable cost payment
made to the CAH.
Therefore, when patients are
discharged from an acute care hospital
or CAH and admitted to the same
hospital or CAH’s psychiatric unit, the
IPF receives the 1.19 adjustment factor
as the variable per diem adjustment for
the first day of the patient’s stay in the
IPF.
Final Rule Action: For FY 2015, we
are retaining the 1.31 adjustment factor

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for IPFs with qualifying EDs. A
complete discussion of the steps
involved in the calculation of the ED
adjustment factor appears in the
November 2004 IPF PPS final rule (69
FR 66959 through 66960) and the May
2006 IPF PPS final rule (71 FR 27070
through 27072).
D. Other Payment Adjustments and
Policies
1. Outlier Payments
The IPF PPS includes an outlier
adjustment to promote access to IPF
care for those patients who require
expensive care and to limit the financial
risk of IPFs treating unusually costly
patients. In the November 2004 IPF PPS
final rule, we implemented regulations
at § 412.424(d)(3)(i) to provide a percase payment for IPF stays that are
extraordinarily costly. Providing
additional payments to IPFs for
extremely costly cases strongly
improves the accuracy of the IPF PPS in
determining resource costs at the patient
and facility level. These additional
payments reduce the financial losses
that would otherwise be incurred in
treating patients who require more
costly care and, therefore, reduce the
incentives for IPFs to under-serve these
patients.
We make outlier payments for
discharges in which an IPF’s estimated
total cost for a case exceeds a fixed
dollar loss threshold amount
(multiplied by the IPF’s facility-level
adjustments) plus the Federal per diem
payment amount for the case.
In instances when the case qualifies
for an outlier payment, we pay 80
percent of the difference between the
estimated cost for the case and the
adjusted threshold amount for days 1
through 9 of the stay (consistent with
the median LOS for IPFs in FY 2002),
and 60 percent of the difference for day
10 and thereafter. We established the 80
percent and 60 percent loss sharing
ratios because we were concerned that
a single ratio established at 80 percent
(like other Medicare PPSs) might
provide an incentive under the IPF per
diem payment system to increase LOS
in order to receive additional payments.
After establishing the loss sharing
ratios, we determined the current fixed
dollar loss threshold amount of $10,245
through payment simulations designed
to compute a dollar loss beyond which
payments are estimated to meet the 2
percent outlier spending target. Each
year when we update the IPF PPS, we
simulate payments using the latest
available data to compute the fixed
dollar loss threshold so that outlier

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payments represent 2 percent of total
projected IPF PPS payments.
a. Update to the Outlier Fixed Dollar
Loss Threshold Amount
In accordance with the update
methodology described in § 412.428(d),
we will update the fixed dollar loss
threshold amount used under the IPF
PPS outlier policy. Based on the
regression analysis and payment
simulations used to develop the IPF
PPS, we established a 2 percent outlier
policy which strikes an appropriate
balance between protecting IPFs from
extraordinarily costly cases while
ensuring the adequacy of the Federal
per diem base rate for all other cases
that are not outlier cases.
Based on an analysis of the latest
available data (that is, FY 2013 IPF
claims) and rate increases, we believe it
is necessary to update the fixed dollar
loss threshold amount in order to
maintain an outlier percentage that
equals 2 percent of total estimated IPF
PPS payments.
In the May 2006 IPF PPS final rule (71
FR 27072), we describe the process by
which we calculate the outlier fixed
dollar loss threshold amount. We are
not changing this process for FY 2015.
We begin by simulating aggregate
payments with and without an outlier
policy, and applying an iterative process
to determine an outlier fixed dollar loss
threshold amount that will result in
estimated outlier payments being equal
to 2 percent of total estimated payments
under the simulation. Based on this
process, using the FY 2013 claims data,
we estimate that IPF outlier payments as
a percentage of total estimated payments
are approximately 1.6 percent in FY
2014. Thus, we updated the FY 2015
IPF outlier threshold amount to ensure
that estimated FY 2015 outlier payments
are approximately 2 percent of total
estimated IPF payments. The outlier
fixed dollar loss threshold amount of
$10,245 for FY 2014 changed to $8,755
for FY 2015 to increase estimated outlier
payments and thereby maintain
estimated outlier payments at 2 percent
of total estimated aggregate IPF
payments for FY 2015.
Final Rule Action: In this final rule,
we are adopting $8,755 as the fixed
dollar loss threshold amount for FY
2015.
b. Update to IPF Cost-to-Charge Ratio
Ceilings
Under the IPF PPS, an outlier
payment is made if an IPF’s cost for a
stay exceeds a fixed dollar loss
threshold amount plus the IPF PPS
amount. In order to establish an IPF’s
cost for a particular case, we multiply

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Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations
the IPF’s reported charges on the
discharge bill by its overall cost-tocharge ratio (CCR). This approach to
determining an IPF’s cost is consistent
with the approach used under the IPPS
and other PPSs. In the June 2003 IPPS
final rule (68 FR 34494), we
implemented changes to the IPPS policy
used to determine CCRs for acute care
hospitals because we became aware that
payment vulnerabilities resulted in
inappropriate outlier payments. Under
the IPPS, we established a statistical
measure of accuracy for CCRs in order
to ensure that aberrant CCR data did not
result in inappropriate outlier
payments.
As we indicated in the November
2004 IPF PPS final rule (69 FR 66961),
because we believe that the IPF outlier
policy is susceptible to the same
payment vulnerabilities as the IPPS, we
adopted a method to ensure the
statistical accuracy of CCRs under the
IPF PPS. Specifically, we adopted the
following procedure in the November
2004 IPF PPS final rule: We calculated
two national ceilings, one for IPFs
located in rural areas and one for IPFs
located in urban areas. We computed
the ceilings by first calculating the
national average and the standard
deviation of the CCR for both urban and
rural IPFs using the most recent CCRs
entered in the CY 2014 Provider
Specific File.
To determine the rural and urban
ceilings, we multiplied each of the
standard deviations by 3 and added the
result to the appropriate national CCR
average (either rural or urban). The
upper threshold CCR for IPFs in FY
2015 is 1.8590 for rural IPFs, and 1.6582
for urban IPFs, based on CBSA-based
geographic designations. If an IPF’s CCR
is above the applicable ceiling, the ratio
is considered statistically inaccurate
and we assign the appropriate national
(either rural or urban) median CCR to
the IPF.
We apply the national CCRs to the
following situations:
++ New IPFs that have not yet
submitted their first Medicare cost
report. We continue to use these
national CCRs until the facility’s actual
CCR can be computed using the first
tentatively or final settled cost report.
++ IPFs whose overall CCR is in
excess of 3 standard deviations above
the corresponding national geometric
mean (that is, above the ceiling).
++ Other IPFs for which the MAC
obtains inaccurate or incomplete data
with which to calculate a CCR.
We are not making any changes to the
application of the national CCRs or to
the procedures for updating the CCR
ceilings in FY 2015. However, we are

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updating the FY 2015 national median
and ceiling CCRs for urban and rural
IPFs based on the CCRs entered in the
latest available IPF PPS Provider
Specific File. Specifically, for FY 2015,
and to be used in each of the three
situations listed above, using the most
recent CCRs entered in the CY 2014
Provider Specific File, we estimate the
national median CCR of 0.6220 for rural
IPFs and the national median CCR of
0.4710 for urban IPFs. These
calculations are based on the IPF’s
location (either urban or rural) using the
CBSA-based geographic designations.
A complete discussion regarding the
national median CCRs appears in the
November 2004 IPF PPS final rule (69
FR 66961 through 66964).
2. Future Refinements
For RY 2012, we identified several
areas of concern for future refinement
and we invited comments on these
issues in our RY 2012 proposed and
final rules. For further discussion of
these issues and to review the public
comments, we refer readers to the RY
2012 IPF PPS proposed rule (76 FR
4998) and final rule (76 FR 26432).
As we have indicated throughout this
final rule, we have delayed making
refinements to the IPF PPS until we
have completed a thorough analysis of
IPF PPS data on which to base those
refinements. Specifically, we explained
that we will delay updating the
adjustment factors derived from the
regression analysis until we have IPF
PPS data that include as much
information as possible regarding the
patient-level characteristics of the
population that each IPF serves. We
have begun the necessary analysis to
better understand IPF industry practices
so that we may refine the IPF PPS as
appropriate. Using more recent data, we
plan to re-run the regression analyses
and the patient- and facility-level
adjustments. While we are not
implementing refinements in this final
rule, we expect that in the rulemaking
for FY 2017 we will be ready to present
the results of our analysis.
VIII. Inpatient Psychiatric Facilities
Quality Reporting (IPFQR) Program
1. Statutory Authority
Section 1886(s)(4) of the Act, as added
and amended by sections 3401(f) and
10322(a) of the Affordable Care Act,
requires the Secretary to implement a
quality reporting program for inpatient
psychiatric hospitals and psychiatric
units. Section 1886(s)(4)(A)(i) of the Act
requires that, for rate year (RY) 2014 and
each subsequent rate year, the Secretary
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standard Federal rate for discharges
occurring during the rate year by 2.0
percentage points for any inpatient
psychiatric hospital or psychiatric unit
that does not comply with quality data
submission requirements with respect to
an applicable rate year.
As noted above, section
1886(s)(4)(A)(i) of the Act uses the term
‘‘rate year.’’ Beginning with the annual
update of the inpatient psychiatric
facility prospective payment system
(IPF PPS) that took effect on July 1, 2011
(RY 2012), we aligned the IPF PPS
update with the annual update of the
ICD–9–CM codes, which are effective on
October 1 of each year. The change
allows for annual payment updates and
the ICD–9–CM coding update to occur
on the same schedule and appear in the
same Federal Register document, thus
making rule updates more
administratively efficient. To reflect the
change to the annual payment rate
update cycle, we revised the regulations
at § 412.402 to specify that, beginning
October 1, 2012, the rate year update
period would be the 12-month period of
October 1 through September 30, which
we refer to as a fiscal year (FY) (76 FR
26435). For more information regarding
this terminology change, we refer
readers to section III. of the RY 2012 IPF
PPS final rule (76 FR 26434 through
26435).
As provided in section
1886(s)(4)(A)(ii) of the Act, the
application of the reduction for failure
to report under section 1886(s)(4)(A)(i)
of the Act may result in an annual
update of less than 0.0 percent for a
fiscal year, and may result in payment
rates under section 1886(s)(1) of the Act
being less than the payment rates for the
preceding year. In addition, section
1886(s)(4)(B) of the Act requires that the
application of the reduction to a
standard Federal rate update be
noncumulative across fiscal years. Thus,
any reduction applied under section
1886(s)(4)(A) of the Act will apply only
with respect to the fiscal year rate
involved and the Secretary shall not
take into account the reduction in
computing the payment amount under
the system described in section
1886(s)(1) of the Act for subsequent
years.
Section 1886(s)(4)(C) of the Act
requires that, for FY 2014 (October 1,
2013, through September 30, 2014) and
each subsequent year, each psychiatric
hospital and psychiatric unit shall
submit to the Secretary data on quality
measures as specified by the Secretary.
The data shall be submitted in a form
and manner, and at a time, specified by
the Secretary. Under section
1886(s)(4)(D)(i) of the Act, measures

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selected for the quality reporting
program must have been endorsed by
the entity with a contract under section
1890(a) of the Act. The National Quality
Forum (NQF) currently holds this
contract.
Section 1886(s)(4)(D)(ii) of the Act
provides that, in the case of a specified
area or medical topic determined
appropriate by the Secretary for which
a feasible and practical measure has not
been endorsed by the entity with a
contract under section 1890(a) of the
Act, the Secretary may specify a
measure that is not so endorsed as long
as due consideration is given to
measures that have been endorsed or
adopted by a consensus organization
identified by the Secretary. Pursuant to
section 1886(s)(4)(D)(iii) of the Act, the
Secretary shall publish the measures
applicable to the FY 2014 IPFQR
Program no later than October 1, 2012.
Section 1886(s)(4)(E) of the Act
requires the Secretary to establish
procedures for making public the data
submitted by inpatient psychiatric
hospitals and psychiatric units under
the IPFQR Program. These procedures
must ensure that a facility has the
opportunity to review its data prior to
the data being made public. The
Secretary must report quality measures
that relate to services furnished by the
psychiatric hospitals and units on the
CMS Web site.
2. Application of the Payment Update
Reduction for Failure to Report for the
FY 2015 Payment Determination and
Subsequent Years
Beginning in FY 2014, section
1886(s)(4)(A)(i) of the Act requires the
application of a 2.0 percentage point
reduction to the applicable annual
update to a Federal standard rate for
those psychiatric hospitals and
psychiatric units that fail to comply
with the quality reporting requirements
implemented in accordance with
section 1886(s)(4)(C) of the Act, as
detailed below. The application of the
reduction may result in an annual
update for a fiscal year that is less than
0.0 percent and in payment rates for a
fiscal year being less than the payment
rates for the preceding fiscal year.
Pursuant to section 1886(s)(4)(B) of the
Act, any such reduction is not
cumulative and will apply only to the
fiscal year involved. In the FY 2013
IPPS/LTCH PPS final rule (77 FR
53678), we adopted requirements
regarding the application of the
payment reduction to the annual update
of the standard Federal rate for failure
to report data on measures selected for
the FY 2014 payment determination and
subsequent years, and added new

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regulatory text at 42 CFR 412.424 to
codify these requirements.
3. Covered Entities
In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53645), we established that
the IPFQR Program’s quality reporting
requirements cover those psychiatric
hospitals and psychiatric units paid
under Medicare’s IPF PPS (42 CFR
412.404(b)). Generally, psychiatric
hospitals and psychiatric units within
acute care and critical access hospitals
that treat Medicare patients are paid
under the IPF PPS. For more
information on the application of, and
exceptions to, payments under the IPF
PPS, we refer readers to section IV. of
the November 15, 2004 IPF PPS final
rule (69 FR 66926). As we noted in the
FY 2013 IPPS/LTCH PPS final rule (77
FR 53645), we use the term ‘‘inpatient
psychiatric facility’’ (IPF) to refer to
both inpatient psychiatric hospitals and
psychiatric units. This usage follows the
terminology in our IPF PPS regulations
(42 CFR 412.402).
4. Considerations in Selecting Quality
Measures
In implementing the IPFQR Program,
our overarching objective is to support
the HHS National Quality Strategy
(NQS) and CMS Quality Strategy’s goal
for better health care for individuals,
better health for populations, and lower
costs for health care services. More
information on the CMS Quality
Strategy can be found at http://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/QualityInitiativesGenInfo/
CMS-Quality-Strategy.html.
Implementation of the IPFQR Program
works to achieve the goals of the CMS
Quality Strategy by promoting
transparency around the quality of care
provided at IPFs to support patient
decision-making and drive quality
improvement, as well as to further the
alignment of quality measurement and
improvement goals at IPFs with those of
other health care providers.
For purposes of the IPFQR Program,
section 1886(s)(4)(D)(i) of the Act
requires that any measure specified by
the Secretary must have been endorsed
by the entity with a contract under
section 1890(a) of the Act. However, the
statutory requirements under section
1886(s)(4)(D)(ii) of the Act provide an
exception that, in the case of a specified
area or medical topic determined
appropriate by the Secretary for which
a feasible and practical measure has not
been endorsed by the entity with a
contract under section 1890(a) of the
Act, the Secretary may specify a
measure that is not so endorsed,

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provided that due consideration is given
to measures that have been endorsed or
adopted by a consensus organization
identified by the Secretary.
We seek to collect data in a manner
that balances the need for information
related to the full spectrum of quality
performance and the need to minimize
the burden of data collection and
reporting. We have focused on measures
that have high impact and support CMS
and HHS priorities for improved quality
and efficiency of care provided by IPFs.
We refer readers to the FY 2013 IPPS/
LTCH PPS final rule (77 FR 53645
through 53646) for a detailed discussion
of the considerations taken into account
for measure development and selection.
Prior to being proposed in the
proposed rule, we place our measures
on a measure under consideration list,
which is made public by December 1 of
each year. Measures proposed for the
Program were included in a publicly
available document entitled ‘‘List of
Measures under Consideration for
December 1, 2013’’ in compliance with
section 1890A(a)(2) of the Act. The
Measure Application Partnership
(MAP), a multi-stakeholder group
convened by the NQF, then reviews the
measures being proposed for Federal
programs and provides input on those
measures to the Secretary, as captured
in its ‘‘MAP Pre-Rulemaking Report:
2014 Recommendations on Measures for
More than 20 Federal Programs,’’ which
is available on the NQF Web site at
http://www.qualityforum.org/Setting_
Priorities/Partnership/Measure_
Applications_Partnership.aspx. We
considered the input and
recommendations provided by the MAP
in selecting measures for the Program.
4. Considerations in Selecting Quality
Measures
In implementing the IPFQR Program,
our overarching objective is to support
the HHS National Quality Strategy
(NQS) and CMS Quality Strategy’s goal
for better health care for individuals,
better health for populations, and lower
costs for health care services. More
information on the CMS Quality
Strategy can be found at http://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/QualityInitiativesGenInfo/
CMS-Quality-Strategy.html.
Implementation of the IPFQR Program
works to achieve the goals of the CMS
Quality Strategy by promoting
transparency around the quality of care
provided at IPFs to support patient
decision-making and drive quality
improvement, as well as to further the
alignment of quality measurement and

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improvement goals at IPFs with those of
other health care providers.
For purposes of the IPFQR Program,
section 1886(s)(4)(D)(i) of the Act
requires that any measure specified by
the Secretary must have been endorsed
by the entity with a contract under
section 1890(a) of the Act. However, the
statutory requirements under section
1886(s)(4)(D)(ii) of the Act provide an
exception that, in the case of a specified
area or medical topic determined
appropriate by the Secretary for which
a feasible and practical measure has not
been endorsed by the entity with a
contract under section 1890(a) of the
Act, the Secretary may specify a
measure that is not so endorsed,
provided that due consideration is given
to measures that have been endorsed or
adopted by a consensus organization
identified by the Secretary.
We seek to collect data in a manner
that balances the need for information
related to the full spectrum of quality
performance and the need to minimize
the burden of data collection and
reporting. We have focused on measures
that have high impact and support CMS
and HHS priorities for improved quality
and efficiency of care provided by IPFs.
We refer readers to the FY 2013 IPPS/
LTCH PPS final rule (77 FR 53645
through 53646) for a detailed discussion
of the considerations taken into account
for measure development and selection.

Prior to being proposed in the
proposed rule, we place our measures
on a measure under consideration list,
which is made public by December 1 of
each year. Measures proposed for the
Program were included in a publicly
available document entitled ‘‘List of
Measures under Consideration for
December 1, 2013’’ in compliance with
section 1890A(a)(2) of the Act. The
Measure Application Partnership
(MAP), a multi-stakeholder group
convened by the NQF, then reviews the
measures being proposed for Federal
programs and provides input on those
measures to the Secretary, as captured
in its ‘‘MAP Pre-Rulemaking Report:
2014 Recommendations on Measures for
More than 20 Federal Programs,’’ which
is available on the NQF Web site at
http://www.qualityforum.org/Setting_
Priorities/Partnership/Measure_
Applications_Partnership.aspx. We
considered the input and
recommendations provided by the MAP
in selecting measures for the Program.
5. Quality Measures
a. Quality Measures for the FY 2016
Payment Determination and Subsequent
Years
In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53646 through 53652), we
adopted six chart-abstracted IPF quality

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measures for the FY 2014 payment
determination and subsequent years.
We note that, at the time that we
adopted the measures in the FY 2013
IPPS/LTCH PPS final rule (77 FR
53258), providers were using ICD–9–CM
codes. The conversion of ICD–9–CM to
ICD–10–CM/PCS codes for the IPF PPS
will become effective on October 1,
2015. We do not anticipate that this
change will have substantive effects on
any Program measures at this time. CMS
will update the user manual, discussed
further in section V below, to reflect any
necessary measure updates. Generally,
measures adopted for the IPFQR
Program will remain in the Program for
all subsequent years, unless and until
specifically stated otherwise (for
example, through removal or
replacement).
In the FY 2014 IPPS/LTCH PPS final
rule (78 FR 50890 through 50895), we
added one new chart-abstracted
measure for the IPFQR Program:
Alcohol Use Screening (SUB–1) (NQF
#1661). We also added one new claimsbased measure: Follow-Up After
Hospitalization for Mental Illness (FUH)
(NQF #0576). Both measures apply to
the FY 2016 payment determination and
subsequent years, unless and until we
change them through future rulemaking.
The table below sets out the
previously adopted measures.

TABLE 12—PREVIOUSLY ADOPTED QUALITY MEASURES FOR THE IPFQR PROGRAM
National quality strategy priority

NQF #

Patient Safety .............................................................................
Clinical Quality of Care ...............................................................

Care Coordination .......................................................................

Measure ID

Measure description

0640
0641
*** 0552

HBIPS–2 .....
HBIPS–3 .....
HBIPS–4 .....

0560

HBIPS–5 .....

1661
0576

SUB–1 .........
FUH .............

0557

HBIPS–6 .....

0558

HBIPS–7 .....

Hours of Physical Restraint Use.*
Hours of Seclusion Use.*
Patients Discharged on Multiple Antipsychotic
Medications.*
Patients Discharged on Multiple Antipsychotic
Medications with Appropriate Justification.*
Alcohol Use Screening.**
Follow-Up After Hospitalization for Mental Illness.**
Post-Discharge Continuing Care Plan Created.*
Post-Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon
Discharge.*

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* Quality measures adopted in the FY 2013 IPPS/LTCH PPS final rule for the FY 2014 payment determination and subsequent years.
** Quality measures adopted in the FY 2014 IPPS/LTCH PPS final rule for the FY 2016 payment determination and subsequent years.
*** Measure 0552 is no longer endorsed by the NQF.

We note that in the FY 2014 IPPS/
LTCH PPS final rule (78 FR 50896
through 50897 and 50900), we also
adopted for the FY 2016 payment
determination and subsequent years a
voluntary collection of information, IPF
Assessment of Patient Experience of
Care (now renamed Assessment of
Patient Experience of Care), which was
to be collected using a Web-Based

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Measures Tool and would not affect an
IPF’s FY 2016 payment determination.
We also noted that we intended to
propose to make this a mandatory
measure in future rulemaking (78 FR
50897), which we proposed in the FY
2015 IPF PPS proposed rule.
In the FY 2015 proposed rule (79 FR
26063 through 26065), we proposed two
new measures to the IPFQR Program to

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those already adopted for the FY 2016
payment determination and subsequent
years: (1) Assessment of Patient
Experience of Care; and (2) use of an
Electronic Health Record. We are not
removing or replacing any of the
previously adopted measures from the
IPFQR Program for FY 2016. These two
new measures will be captured in the
IPF Web-Based Measures Tool, which

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can be accessed through the QualityNet
home page at: http://
www.qualitynet.org/dcs/
ContentServer?pagename=QnetPublic/
Page/QnetHomepage. The Tool will be
updated, so that when IPFs submit their
data for FY 2016 (between July 1, 2015,
and August 15, 2015) there will be a
place to provide responses for these two
structural measures.
1. Assessment of Patient Experience of
Care
Improvement of experience of care for
patients, families, and caregivers is one
of our objectives within the CMS
Quality Strategy and is not currently
addressed in the IPFQR Program.
Surveys of individuals about their
experience in all health care settings
provide important information as to
whether or not high-quality, personcentered care is actually provided, and
address elements of service delivery that
matter most to recipients of care.
We included the measure ‘‘Inpatient
Consumer Survey (ICS) Consumer
Evaluation of Inpatient Behavioral
Healthcare Services’’ (NQF #0726) in
our ‘‘List of Measures under
Consideration for December 1, 2012.’’
The measure would gather clients’
evaluation of their inpatient care based
on six domains—outcome, dignity,
rights, treatment, environment, and
empowerment. The MAP provided
input on the measure and supported its
inclusion in the IPFQR Program.
However, we did not propose to adopt
the measure in the FY 2014 IPPS/LTCH
PPS proposed rule for several reasons,
including potential reporting and
information collection burdens in a new
program, and compatibility with the
content and format of other similar CMS
beneficiary surveys (78 FR 27740 and 78
FR 50896). We also recognized the
challenges of measuring patient
experience of care, particularly for
involuntary cases and geriatric
psychiatric patients suffering from
dementia. In addition, we recognized
that IPFs may have developed their own
survey instruments, which we wanted
to learn more about prior to requiring
collection of a patient experience of care
survey for the Program (78 FR 50897).
We also indicated our intention to
pursue the adoption of a standardized
measure of patient experience of care for
the IPFQR program in the near future for
public reporting and consumer decision
making purposes.
In the final rule (78 FR 50896), in an
effort to proceed cautiously with the
selection of an assessment instrument
and collection protocol, and as an
intermediate measure, we implemented
a voluntary collection of information on

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whether IPFs administer a detailed
assessment of patient experience of care
using a standardized collection protocol
and a structured instrument. If the IPFs
answered ‘‘Yes,’’ we also asked them to
indicate the name of the survey that
they administer. We indicated our
intention to propose to change this
request for voluntary information into a
mandatory measure in future
rulemaking. We are now requiring this
request to be a structural measure for
the FY 2016 payment determination.
The measure ‘‘Inpatient Psychiatric
Facility Routinely Assesses Patient
Experience of Care’’ (now, ‘‘Assessment
of Patient Experience of Care’’) was
included on our ‘‘List of Measures
under Consideration for December 1,
2013.’’ The measure asks IPFs whether
they routinely assess patient experience
of care using a standardized collection
protocol and a structured instrument.
The MAP supported this measure, but
encouraged its eventual replacement
with a robust survey of patient
experience and a measure based on
consumer-reported information, such as
a Consumer Assessment of Healthcare
Providers and Systems (CAHPS®) tool.
We believe that the reporting of this
measure will begin to provide
information on a priority area of the
HHS National Quality Strategy that is
currently unaddressed in the IPFQR
Program, that of patient and family
engagement and experience of care.
Further, the information gathered
through the collection of this measure
will be helpful in the development of a
standardized survey of patient
assessment of care that we intend to
develop as a successor to this measure.
Because this is a structural measure
that does not depend on systems for
collecting and abstracting individual
patient information, only requires
simple attestation, and does not require
extended time to prepare to report, we
believe that it will not be burdensome
to IPFs. Accordingly, we are proposing
to include it as a mandatory measure for
the FY 2016 payment determination, a
year earlier than for other measures
proposed in this rule that are dependent
on these systems.
The measure is currently not NQFendorsed. Section 1886(s)(4)(D)(ii) of the
Act authorizes the Secretary to specify
a measure that is not endorsed by the
NQF as long as due consideration is
given to measures that have been
endorsed or adopted by a consensus
organization identified by the Secretary.
We attempted to find available measures
that have been endorsed or adopted by
a consensus organization and found no
other feasible and practical measures on
the topic of patient experience of care

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for the IPF setting. Therefore, we believe
that the Assessment of Patient
Experience of Care proposed measure
meets the measure selection exception
requirement under section
1886(s)(4)(D)(ii) of the Act. Public
comments and responses on the Patient
Experience of Care Measure are
summarized below.
Comment: Some commenters stated
that inclusion of this structural measure
was not appropriate because it was not
endorsed by the NQF and not supported
for use in the Program by the MAP.
Response: We believe that inclusion
of this measure without NQF
endorsement meets the statutory
requirements under section
1886(s)(4)(D)(ii) of the Act. Under that
section, the Secretary is authorized to
specify a measure that is not endorsed
by the NQF as long as due consideration
is given to measures that have been
endorsed or adopted by a consensus
organization identified by the Secretary.
We attempted to find available measures
that had been endorsed or adopted by a
consensus organization, and found no
other feasible and practical measures on
the topic of patient experience of care
for the IPF setting. In addition, this
measure was proposed to collect data
that will aid in the development of a
future instrument that is more
compatible with the content and format
of other similar CMS beneficiary
surveys than the Inpatient Consumer
Survey (ICS) Consumer Evaluation of
Inpatient Behavioral Healthcare
Services.
We disagree with the commenters’
assessment that the MAP did not
support inclusion of this measure. The
MAP did support the measure, but
encouraged its eventual replacement
with a robust survey of patient
experience and a measure based on
consumer-reported information. As we
stated in the proposed rule, we intend
to develop a successor to this measure
that will be specified and tested in the
inpatient psychiatric setting, and that
will be informed by the collection of
information associated with the
Assessment of Patient Experience of
Care measure.
Comment: One commenter sought
clarification on whether an IPF will be
penalized if it does not collect patient
experience of care data.
Response: An IPF will not be
penalized for not collecting patient
experience of care data. CMS credits
IPFs for reporting this measure in the
IPFQR Program applicable FY if they
successfully report by the deadline
whether they collect these data.
Comment: Some commenters stated
that, because this measure is an

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Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations
attestation measure only, it is not a
quality of care measure that should be
part of a requirement that affects
payment and that is publicly reported.
Similarly, some commenters stated that
this measure would provide very
limited insight to patients on the actual
experience of care in IPFs.
Response: We disagree with the
commenters. We believe that the
potential value of a quality measure is
primarily in the information that it
provides, and is not necessarily limited
by how it is collected or reported. CMS
credits IPFs for reporting this measure
in the IPFQR Program applicable FY if
they successfully report by the deadline
whether they collect these data. We
believe that the data collected through
reporting of this measure will begin to
provide information on a priority area of
the HHS National Quality Strategy,
patient and family engagement and
experience of care, which is currently
unaddressed in the Program. Collection
of this information will further enable
the development of a successor to this
measure that will provide valuable,
actionable information for patients, and
their families and caregivers, on the
quality of care provided in IPFs.
Comment: Some commenters
suggested that, instead of implementing
this measure, CMS should continue its
efforts to develop a standardized patient
assessment survey for IPFs. In
particular, some commenters suggested
that CMS undertake an in-depth study
of IPFs to identify not only which
survey instruments are currently in use,
but also the potential costs of and
operational barriers to implementing
such a standardized survey.
Response: We thank the commenters
for their support for development of a
standardized patient assessment survey
for IPFs. However, we believe that
implementing this Assessment of
Patient Experience of Care measure at
this time will significantly enhance our
ability to develop such a standardized
survey by providing useful information
to aid in the development process. As
previously stated, we are committed to
developing a standardized patient
assessment survey instrument for IPFs.
Comment: One commenter stated that
the proposed rule does not specify what
constitutes the routine assessment of
patient experience of care using a
standardized collection protocol and a
structured instrument.
Response: By ‘‘routine assessment’’
we mean that administration of an
experience of care instrument occurs as
a regular, commonplace activity of the
facility. By ‘‘standardized collection
protocol’’ we mean that the
administration of the instrument occurs

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under rules or guidelines that ensure or
promote comparability of individual
responses. By ‘‘structured instrument’’
we mean that oral or written questions
constituting the instrument are the same
for all respondents and follow
consistent rules for administration.
Comment: One commenter expressed
support for this measure, but stated that
IPFs should not be required to report the
name of the instrument because there
currently is no nationally utilized,
industry standard tool. Instead, the
commenter stated, it should be
sufficient that an IPF demonstrate that
the instrument utilized is standardized
in delivery, and structured in formatting
and scoring.
Response: We disagree with the
commenter. We believe that reporting
the name of the instrument utilized by
the IPF will provide more accurate
information through collecting specific
survey names, as well as aiding in the
process of developing a future
instrument that is more compatible with
the content and format of other similar
CMS beneficiary surveys.
Final Rule Action: After consideration
of the public comments, we are
finalizing the Assessment of Patient
Experience of Care measure as proposed
for the FY 2016 payment determination
and subsequent years.
2. Use of an Electronic Health Record
In 2009, as part of the Health
Information Technology for Economic
and Clinical Health (HITECH) Act,
incentives were provided to encourage
eligible hospitals and eligible
professionals to adopt electronic health
record (EHR) systems. The widespread
adoption of these systems holds the
potential to support multiple goals of
CMS’ quality strategy, including making
care safer and more affordable, and
promoting coordination of care. One
review of over a hundred studies of the
effects of EHRs showed that nearly all
demonstrated positive overall results.1
These results were most frequently
demonstrated in the areas of efficiency
and effectiveness of care, patient safety
and satisfaction, and process of care.2
Positive results such as these depend
in part on the ways in which an EHR
system is used. EHRs can facilitate the
use of clinical decision support tools,
physician order entry systems, and
health information exchange. The
concept of ‘‘meaningful use’’ of EHRs
captures the goals for which incentive
1 M.B. Buntin, M.F. Burke, M.C. Hoaglin, et al.,
‘‘The Benefits of Health Information Technology: A
Review of the Recent Literature Shows
Predominantly Positive Results,’’ Health Affairs,
March 2011 30(3):464–71.
2 Ibid.

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payments are made. These goals
include, among others: Quality
improvement, safety, and efficiency;
health disparities reduction; patient and
family engagement; care coordination
improvement and population health;
and maintenance of the privacy and
security of patient health information.3
We believe that a measure of the
degree of EHR implementation provides
important information about an element
of health care service delivery shown to
be associated with the delivery of
quality care. Further, we believe that it
provides useful information to
consumers and others in choosing
among different facilities.
A key issue in EHR adoption and
implementation is the use of this
technology to support health
information exchange. HHS has a
number of initiatives designed to
encourage and support the adoption of
health information technology and
promote nationwide health information
exchange to improve health care. The
Office of the National Coordinator for
Health Information Technology (ONC)
and CMS work to promote the adoption
of health information technology.
Through a number of activities, HHS is
promoting the adoption of ONCcertified EHRs developed to support
secure, interoperable health information
exchange. While available ONC-certified
EHRs are not specifically certified for
IPFs and other providers who are not
eligible for the Medicare and Medicaid
EHR Incentive Programs, ONC has
requested that the HIT Policy
Committee (a Federal Advisory
Committee) explore the expansion of
EHR certification under the ONC HIT
Certification Program, focusing on EHR
certification criteria needed for longterm and post-acute care (including
LTCHs), and behavioral health care
providers. ONC has also proposed a
Voluntary 2015 Edition EHR
Certification rule (79 FR 10880) that
would increase the flexibility in ONC’s
regulatory structure to more easily
accommodate health IT certification for
other types of health care settings where
individual or institutional health care
providers are not typically eligible to
qualify for the Medicare and Medicaid
EHR Incentive Programs.
While certified EHRs are not
specifically certified for IPFs, we believe
that many of the core functions of
clinical care that are captured in EHRs
are common across care settings. We
believe that the use of certified EHRs by
3 HealthIT.gov, ‘‘EHR Incentives & Certification:
Meaningful Use Definition & Objectives.’’ [Internet
Cited 2014 February 11]. Available from http://
www.healthit.gov/providers-professionals/
meaningful-use-definition-objectives.

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IPFs (and other providers ineligible for
the Medicare and Medicaid EHR
Incentive Programs) can effectively and
efficiently help providers improve
internal care delivery practices, support
the exchange of important information
across care partners and during
transitions of care, and could enable the
reporting of electronically specified
clinical quality measures (eCQMs) (as
described elsewhere in this rule). More
information on the proposed rule on
voluntary 2015 Edition EHR
Certification, identification of EHR
certification criteria and development of
standards applicable to IPFQRs can be
found at:
• http://www.healthit.gov/policyresearchers-implementers/standardsand-certification-regulations
• http://www.healthit.gov/facas/
FACAS/health-it-policy-committee/
hitpc-workgroups/certification
adoption
• http://wiki.siframework.org/LCC+
LTPAC+Care+Transition+SWG
• http://wiki.siframework.org/
Longitudinal+Coordination+of+Care
We included the measure, ‘‘IPF Use of
an Electronic Health Record Meeting
Stage 1 or Stage 2 Meaningful Use
Criteria’’ (now, ‘‘Use of an Electronic
Health Record’’) in the ‘‘List of
Measures under Consideration for
December 1, 2013.’’ The measure will
assess the degree to which facilities
employ EHR systems in their service
program and use such systems to
support health information exchange at
times of transitions in care. It is a
structural measure that only requires the
facility to attest to which one of the
following statements best describes the
facility’s highest level typical use of an
EHR system (excluding the billing
system) during the reporting period, and
whether this use includes the exchange
of interoperable health information with
a health information service provider:
a. The facility most commonly used
paper documents or other forms of
information exchange (for example,
email) not involving the transfer of
health information using EHR
technology at times of transitions in
care.
b. The facility most commonly
exchanged health information using
non-certified EHR technology (that is,
not certified under the ONC HIT
Certification Program) at times of
transitions in care.
c. The facility most commonly
exchanged health information using
certified EHR technology (certified
under the ONC HIT Certification
Program) at times of transitions in care.
We will also ask IPFs to indicate
whether transfers of health information

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at times of transitions in care included
the exchange of interoperable health
information with a health information
service provider (HISP).
In its 2014 report, available at
https://www.qualityforum.org/
WorkArea/linkit.aspx?LinkIdentifier=
id&ItemID=74634, the MAP concluded
that it does not support this measure
because it does not adequately address
any current needs of the Program. The
MAP noted that psychiatric hospitals
were excluded from the EHR Incentive
Programs and imposing the measure
criteria is not realistic. The MAP also
expressed concerns about using quality
reporting programs to collect data on
systems and infrastructure, and
suggested that the American Hospital
Association’s survey of hospitals may be
a better source for this type of data.
We disagree with the MAP’s
contention that the purpose of this
measure is to collect data on systems
and infrastructure. The purpose of the
measure is to assess the use of processes
for the collection, use, and transmission
of medical information that have been
demonstrated to impact the quality of
care, rather than to collect data on
systems and infrastructure. As we have
described above, many studies
document the benefits of EHR use on
multiple dimensions related to health
care quality, and to multiple goals of
CMS’ quality strategy. Additionally, this
is a structural measure that does not
depend on systems for collecting and
abstracting individual patient
information and, therefore, is not
burdensome on IPFs. Accordingly, we
are adopting it as a measure for FY 2016
payment determination, a year earlier
than for other measures we proposed in
the FY 2015 IPF PPS proposed rule.
The Use of an Electronic Health
Record proposed measure is not NQFendorsed. Section 1886(s)(4)(D)(ii) of the
Act authorizes the Secretary to specify
a measure that is not endorsed by the
NQF as long as due consideration is
given to measures that have been
endorsed or adopted by a consensus
organization identified by the Secretary.
We attempted to find available measures
that have been endorsed or adopted by
a consensus organization and found no
other feasible and practical measures on
the topic of the degree to which
facilities employ an EHR system in their
program. Therefore, we believe that the
Use of an Electronic Health Record
proposed measure meets the measure
selection exception requirement under
section 1886(s)(4)(D)(ii) of the Act.
Public comments and responses to
comments on the Electronic Health
Record measure are summarized below.

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Comment: Some commenters stated
that inclusion of this structural measure
was not appropriate because it was not
endorsed by the NQF and not supported
for use in the Program by the MAP.
Response: As outlined in the
proposed rule, we believe that inclusion
of this measure without NQFendorsement meets the statutory
requirements under section
1886(s)(4)(D)(ii) of the Act. Under that
section, the Secretary is authorized to
specify a measure that is not endorsed
by the NQF insofar as due consideration
is given to measures that have been
endorsed or adopted by a consensus
organization identified by the Secretary.
We attempted to find available measures
that had been endorsed or adopted by a
consensus organization and found no
other feasible and practical measures on
the topic of EHR use in the IPF setting.
While the MAP did not support
inclusion of this measure, we disagreed
with its interpretation of the purpose of
this measure. The purpose of the
measure is to assess the use of processes
for the collection, use, and transmission
of medical information that have been
demonstrated to impact the quality of
care, rather than to collect data on
systems and infrastructure. Many
studies document the benefits of EHR
use on multiple dimensions related to
health care quality, and to multiple
goals of CMS’ quality strategy.
Comment: Some commenters stated
that IPFs are currently excluded from
the Medicare EHR Incentive Program
and, therefore, it is inappropriate to
subject IPFs to the statutory 2.0
percentage point reduction for failure to
report the measure without also
permitting them to avail themselves of
associated incentives. Some
commenters indicated their support of
this measure if CMS and the Office of
the National Coordinator for Health
Information Technology plan to expand
the EHR Incentive Program to include
IPFs.
Response: We believe that the
evidence demonstrating the positive
effects of EHR use on multiple aspects
of medical care supports its adoption as
a quality measure independent of a
facility’s possible eligibility for
incentives promoting such use. Further,
even though current certification
requirements have not explicitly
considered the needs of IPFs, much of
the care process in IPFs is common with
that of eligible hospitals, meaning that
use of existing certified EHRs can
effectively and efficiently improve care.
Comment: Some commenters stated
that, because this measure is an
attestation only measure, it is not a
quality of care measure that should be

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part of a requirement that affects
payment and that is publicly reported.
Response: We disagree with the
commenters. CMS credits IPFs for
reporting any response category
indicating their current EHR use status.
We believe that the potential value of a
quality measure is primarily in the
information that it provides, and is not
necessarily limited by how it is
collected or reported. Further,
information collected through reporting
of this measure will provide valuable
information on EHR use in IPFs, which
is tied to the provision of high quality
care. Therefore, we believe that public
reporting of this measure would provide
significant insight to patients, and their
families and caregivers, on the quality of
care provided in IPFs.
Comment: Some commenters stated
that the proposed rule does not present
sufficient empirical evidence to support
the conclusion that the use of currently
available EHR technology platforms
facilitates the delivery of a high quality
of care.
Response: The use of EHRs in
hospitals has proven over the years to be
effective in reducing medication errors,
supporting timely exchange of patient
information to the next level of provider
(for example, the provider who will care
for the patient after discharge), and
improving communication among the
health care team.4 5 In 2008, the
Substance Abuse and Mental Health
Services Administration (SAMHSA)
conducted a study of state mental health
facilities and found that five states
already have a complete EHR system in
their state psychiatric hospitals and 18
states have incorporated some parts of
EHRs. The study found that these
systems improved the communication
of information and patient safety.6
Final Rule Action: After consideration
of the public comments, we are
finalizing the Use of an Electronic
Health Record measure as proposed for
the FY 2016 payment determination and
subsequent years.
4 Institute of Medicine. Preventing Medication
Errors: Quality Chasm Series. Washington, DC: The
National Academies Press, 2007.
5 Chaudhry B, Wang J, Wu S, Maglione M, Mojica
W, Roth E, et al. Systematic Review: Impact of
Health Information Technology on Quality,
Efficiency, and Costs of Medical Care. Ann Intern
Med. 2006;144:742–752.
6 Lutterman, T., Phelan, B., Berhane, A., Shaw, R.,
Rana, V. (2008). Characteristics of State Mental
Health Agency Data Systems. DHHS Pub. No.
(SMA) 08–4361. Rockville, MD: Center for Mental
Health Services, Substance Abuse and Mental
Health Services Administration. Report can be
accessed at: http://store.samhsa.gov/shin/content/
SMA08-4361/SMA08-4361.pdf.

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b. Quality Measures for the FY 2017
Payment Determination and Subsequent
Years
In the FY 2015 proposed rule (78 FR
26065 through 26068), we proposed four
quality measures to the IPFQR Program
for the FY 2017 payment determination
and subsequent years: (1) Influenza
Immunization (IMM–2); (2) Influenza
Vaccination Coverage Among
Healthcare Personnel; (3) Tobacco Use
Screening (TOB–1); and (4) Tobacco Use
Treatment Provided or Offered (TOB–2)
and Tobacco Use Treatment (TOB–2a).
1. Influenza Immunization (IMM–2)
(NQF #1659)
Increasing influenza (flu) vaccination
can reduce unnecessary hospitalizations
and secondary complications,
particularly among high risk
populations such as the elderly.7 Each
year, approximately 226,000 people in
the U.S. are hospitalized with
complications from influenza, and
between 3,000 and 49,000 die from the
disease and its complications.8
Vaccination is the most effective
method for preventing influenza virus
infection and its potentially severe
complications, and vaccination is
associated with reductions in influenza
among all age groups.9 The Advisory
Committee on Immunization Practices
(ACIP) recommends seasonal influenza
vaccination for all persons 6 months of
age and older, thereby stressing the
importance of influenza prevention.
Evidence from a Veteran’s Affairs
locked behavioral psychiatric unit with
26 patients and 40 staff during an
influenza outbreak demonstrates
significant room for improvement in
vaccination rates among IPFs.10 In this
study, 54 percent of the patients had not
been vaccinated, and 36 percent of nonvaccinated patients manifested
symptoms as compared with 25 percent
of vaccinated patients.11 We believe that
the adoption of a measure that assesses
7 Centers for Disease Control and Prevention.
‘‘People at High Risk of Developing Flu-Related
Complications.’’ [Internet Cited 2014 February 11].
Available from http://www.cdc.gov/flu/about/
disease/high_risk.htm.
8 Thompson WW, Shay DK, Weintraub E,
Brammer L, Cox N, Anderson LJ, Fukuda.
‘‘Mortality associated with influenza and
respiratory syncytial virus in the United States.’’
JAMA. 2003 January 8; 289 (2): 179–186.
9 Centers for Disease Control and Prevention.
Newsroom press release February 24, 2010. ‘‘CDC’s
Advisory Committee on Immunization Practices
(ACIP) Recommends Universal Annual Influenza
Vaccination.’’ [Internet Cited 2010 March 3].
Available from http://www.cdc/media/pressrel/
2010/r100224.htm.
10 Risa KJ, et al. ‘‘InÖuenza outbreak management
on a locked behavioral health unit.’’ Am J Infect
Control 2009;37:76–8.
11 Ibid.

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influenza immunization in the IPF
setting not only works toward reducing
the rate of influenza infection, but also
affords consumers and others useful
information in choosing among different
facilities.
We included the Influenza
Immunization (NQF #1659) measure in
the ‘‘List of Measures under
Consideration for December 1, 2013.’’
The Influenza Immunization (IMM–2)
chart-abstracted measure assesses
inpatients, age 6 months and older,
discharged during October, November,
December, January, February, or March,
who are screened for influenza
vaccination status and vaccinated prior
to discharge, if indicated. The
numerator includes discharges that were
screened for influenza vaccine status
and were vaccinated prior to discharge,
if indicated. The denominator includes
inpatients, age 6 months and older,
discharged during October, November,
December, January, February, or March.
The measure excludes patients who:
expire prior to hospital discharge or
have an organ transplant during the
current hospitalization; have a length of
stay greater than 120 days; are
transferred or discharged to another
acute care hospital; or leave Against
Medical Advice (AMA). We refer
readers to https://
www.qualityforum.org/QPS/1659 for
further technical specifications.
The MAP gave conditional support for
the measure, concluding that it is not
ready for implementation because it
needs more experience or testing. In its
2014 final report, the MAP recognized
that influenza immunization is
important for healthcare personnel and
patients, but cautioned that CDC and
CMS need to collaborate on adjusting
specifications for reporting from
psychiatric units before the measure can
be included in the IPFQR Program. CMS
does not agree with this
recommendation. Given previous
experience with the use of this measure
in inpatient settings and the clarity of
specifications for it, CMS does not
believe that additional experience or
testing is needed before implementing
this measure in IPFs, or that
specifications need to be further
adjusted for these facilities. We also
believe that comments concerning
collaboration with CDC largely apply to
the subsequent measure for influenza
vaccination among healthcare
personnel, which is explained in the
discussion for that measure.
We believe that the IMM–2 measure
meets the measure selection criterion
under section 1886(s)(4)(D)(ii) of the
Act. This section provides that, in the
case of a specified area or medical topic

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determined appropriate by the Secretary
for which a feasible and practical
measure has not been endorsed by the
entity with a contract under section
1890(a) of the Act, the Secretary may
specify a measure that is not so
endorsed as long as due consideration is
given to measures that have been
endorsed or adopted by a consensus
organization identified by the Secretary.
This measure is not NQF-endorsed in
the IPF setting and we could not find
any other comparable measure that is
specifically endorsed for the IPF setting.
However, we believe that this measure
is appropriate for the assessment of the
quality of care furnished by IPFs for the
reasons discussed above. Further, this
measure has been endorsed by NQF for
the ‘‘Hospital/Acute care facility’’
setting. Although not explicitly
endorsed for use in the IPF setting, we
believe that the characteristics of IPFs as
distinct part units of hospitals or
freestanding hospitals are similar
enough to hospitals/acute care facilities
that this measure may be appropriately
used in such facilities. Finally, the
adoption of this measure in the IPFQR
Program aligns with the Hospital
Inpatient Quality Reporting (HIQR)
Program, which also includes this
measure in its measure set. Public
comments and responses to comments
on the IMM–2 measure are summarized
below.
Comment: Multiple commenters
expressed support for inclusion of this
measure. Some commenters stated that
it is ready to be implemented, and that
further testing or experience is not
required. In addition, one commenter
also stated that inclusion of this
measure would further alignment with
similar measures collected across
multiple types of acute and post-acute
care settings.
Response: We thank the commenters
for their support.
Comment: Some commenters stated
that this measure is not relevant to the
quality of care in IPFs. In particular,
some commenters stated that there is no
empirically demonstrated direct, or
indirect, relationship between this
measure and the delivery of high quality
behavioral health care in the IPF setting.
Therefore, according to some
commenters, this measure only provides
public health value and is not an
appropriate addition to the Program.
Response: We disagree with the
commenters. While this measure does
not speak directly to specific behavioral
health care services, it provides
meaningful information on the overall
quality of care provided in IPFs by
addressing an area directly tied to
improving patient health. Accordingly,

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this measure not only provides value
from a public health standpoint, but
speaks directly to the overall quality of
care that IPFs are able to provide.
Comment: Some commenters
recommended that this measure should
first be pilot-tested in the IPF setting
before it is proposed for adoption into
the Program. The commenters stated
that this measure had been adequately
tested in the acute care setting, but
expressed concern as to the potential for
negative unintended consequences in
the IPF setting without further testing.
Response: We disagree with the need
to pilot test this measure in the IPF
setting before adoption. We believe that
the challenges associated with this
measure in the acute care setting are not
sufficiently distinguishable from those
present in the IPF setting such that they
would warrant delaying adoption at this
time.
Comment: One commenter stated that
adopting influenza vaccination
measures for both patients and
personnel may create double-reporting
for facilities that have distinct inpatient
units for patients and staff.
Response: We believe that
simultaneous adoption of the IMM–2
and Influenza Vaccination Coverage
Among HealthCare Personnel measures
is appropriate because only through
both can potential influenza exposure
for the patient population be fully
assessed. We do not perceive a potential
for double-reporting in the use of the
measures.
Final Rule Action: After consideration
of the public comments, we are
finalizing the IMM–2 measure as
proposed for the FY 2017 payment
determination and subsequent years.

Healthcare personnel (HCP) can serve
as vectors for influenza transmission
because they are at risk for both
acquiring influenza from patients and
transmitting it to patients, and HCP
often come to work when ill.12 An early
report of HCP influenza infections
during the 2009 H1N1 influenza
pandemic estimated that 50 percent of
infected HCP had contracted the
influenza virus from patients or
coworkers in the health care setting.13

Influenza virus infection is common
among HCP, with evidence suggesting
that nearly one-quarter of HCP were
infected during influenza season, but
few recalled having influenza.14 While
it is difficult to precisely assess HCP
influenza vaccination rates among IPFs
because of varying state policies
requiring hospitals to collect and report
HCP vaccination coverage rates,
evidence from a Veterans Affairs locked
behavioral psychiatric unit with 26
patients and 40 staff during an influenza
outbreak demonstrates significant room
for improvement.15 In this study, only
55 percent of all staff had been
vaccinated, and 22 percent of nonvaccinated staff manifested symptoms
as compared with 18 percent of
vaccinated staff.16 We believe that the
adoption of a measure that assesses
influenza vaccination among HCP in the
IPF setting not only works toward
improving the rate at which nonvaccinated HCP manifest symptoms as
compared with vaccinated HCP, but also
affords consumers and others useful
information in choosing among different
facilities.
We included the Influenza
Vaccination Coverage Among
Healthcare Personnel (NQF #0431)
measure in the ‘‘List of Measures under
Consideration for December 1, 2013.’’
The measure assesses the percentage of
HCP who receive the influenza
vaccination. The measure is designed to
ensure that reported HCP influenza
vaccination percentages are consistent
over time within a single healthcare
facility, as well as comparable across
facilities. The numerator includes HCP
in the denominator population who,
during the time from October 1 (or when
the vaccine became available) through
March 31 of the following year:
a. Received an influenza vaccination
administered at the healthcare facility,
or reported in writing (paper or
electronic) or provided documentation
that influenza vaccination was received
elsewhere;
b. Were determined to have a medical
contraindication/condition of severe
allergic reaction to eggs or to other
component(s) of the vaccine, or history
of Guillain-Barre Syndrome within 6
weeks after a previous influenza
vaccination;
c. Declined influenza vaccination; or

12 Wilde JA, McMillan JA, Serwint J, et al.
‘‘Effectiveness of influenza vaccine in healthcare
professionals: a randomized trial.’’ JAMA 1999; 281:
908–913.
13 Harriman K, Rosenberg J, Robinson S, et al.
‘‘Novel influenza A (H1N1) virus infections among
health-care personnel—United States, April-May
2009.’’ Morb Mortal Wkly Rep. 2009; 58(23): 641–
645.

14 Elder AG, O’Donnell B, McCruden EA, et al.
‘‘Incidence and recall of influenza in a cohort of
Glasgow health-care workers during the 1993–4
epidemic: results of serum testing and
questionnaire.’’ BMJ. 1996; 313:1241–1242.
15 Risa KJ, et al. ‘‘Influenza outbreak management
on a locked behavioral health unit.’’ Am J Infect
Control 2009;37:76–8.
16 Ibid.

2. Influenza Vaccination Coverage
Among HealthCare Personnel (NQF
#0431)

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d. Had an unknown vaccination status
or did not otherwise fall under any of
the abovementioned numerator
categories.
The denominator includes the
number of HCP working in the
healthcare facility for at least one
working day between October 1 and
March 31 of the following year,
regardless of clinical responsibility or
patient contact, and is calculated
separately for employees, licensed
independent practitioners, and adult
students/trainees and volunteers. The
measure has no exclusions. We refer
readers to https://
www.qualityforum.org/QPS/0431 and
the CDC Web site (
http://www.cdc.gov/nhsn/PDFs/HPSmanual/vaccination/HPS-flu-vaccineprotocol.pdf) for further technical
specifications.
The MAP gave conditional support for
the measure, concluding that it is not
ready for implementation because it
needs more experience or testing. In its
2014 report, the MAP recognized that
influenza immunization is important for
healthcare personnel and patients, but
cautioned that CDC and CMS need to
collaborate on adjusting specifications
for reporting from psychiatric units
before the measure can be included in
the IPFQR Program. CMS does not agree
with this recommendation. As
explained for the IMM–2 measure, given
previous experience with the use of this
measure and the clarity of its
specifications, CMS does not believe
that additional experience or testing is
needed before implementing this
measure in IPFs, or that specifications
need to be further adjusted for these
facilities. In response to comments
concerning collaboration with CDC,
CDC and CMS have conferred on this
issue and language has been added to
the description of this measure below
that clarifies that IPFs will use the CDC
National Healthcare Safety Network
(NHSN) infrastructure and protocol to
report the measure for IPFQR Program
purposes. Neither CMS nor CDC
believes that there are any coordination
issues remaining for the implementation
of this measure.
We believe that the Influenza
Vaccination Coverage Among Health
Care Personnel proposed measure meets
the measure selection criterion under
section 1886(s)(4)(D)(ii) of the Act. This
section provides that, in the case of a
specified area or medical topic
determined appropriate by the Secretary
for which a feasible and practical
measure has not been endorsed by the
entity with a contract under section
1890(a) of the Act, the Secretary may
specify a measure that is not so

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endorsed as long as due consideration is
given to measures that have been
endorsed or adopted by a consensus
organization identified by the Secretary.
This measure is not NQF-endorsed in
the IPF setting and we could not find
any other comparable measure that is
specifically endorsed for the IPF setting.
However, we believe that this measure
is appropriate for the assessment of the
quality of care furnished by IPFs for the
reasons discussed above. Further, this
measure has been endorsed by NQF for
the ‘‘Hospital/Acute care facility’’
setting. Although not explicitly
endorsed for use in IPF settings, we
believe that the characteristics of IPFs as
distinct part units of hospitals or
freestanding hospitals mean that this
measure may be appropriately used in
such facilities.
IPFs will use the CDC National
Healthcare Safety Network (NHSN)
infrastructure and protocol to report the
measure for IPFQR Program purposes.
The IPF reporting of HCP influenza
vaccination summary data to NHSN will
begin for the 2015–2016 influenza
season, from October 1, 2015, to March
31, 2016, with a reporting deadline of
May 15, 2016. Although the collection
period for this measure extends into the
first quarter of the following calendar
year, this measure data will be included
with other measures that will be
required for FY 2017 payment
determination. Similarly, reporting for
subsequent years will include results for
the influenza season that begins in the
last quarter of the applicable calendar
year’s reporting.
The adoption of this measure in the
IPFQR Program will align with the
HIQR, the Hospital Outpatient Quality
Reporting (HOQR), and the Ambulatory
Surgical Center Quality Reporting
(ASCQR) Programs. The Influenza
Vaccination Coverage Among
Healthcare Personnel (HCP) (NQF
#0431) measure was finalized for the
HIQR Program in the FY 2012 IPPS/
LTCH PPS final rule (76 FR 51636), and
the HOQR Program in the CY 2014
OPPS/ASC final rule (78 FR 75099), and
the ASCQR Program in the CY 2013
Hospital Outpatient Prospective
Payment final rule (77 FR 68495).
We are aware of public concerns
about the burden of separately
collecting healthcare personnel (HCP)
influenza vaccination status across
inpatient and outpatient settings, in
particular, distinguishing between the
inpatient and outpatient setting
personnel for reporting purposes. We
also understand that some are unclear
about how the measure will be reported
to CDC’s NHSN.

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We believe reporting a single
vaccination count for each healthcare
facility by each individual facility’s
CMS Certification Number (CCN) will
be less burdensome to IPFs than
requiring them to distinguish between
their inpatient and outpatient
personnel. Therefore, beginning with
the 2015–2016 influenza season, IPFs
will collect and report all HCP under
each individual IPF’s CCN and submit
this single number to CDC’s NHSN. For
each CMS CCN, a percentage of the HCP
who received an influenza vaccination
will be calculated and publically
reported, so that the public will know
what percentage of the HCP have been
vaccinated in each IPF. We believe this
will provide meaningful data that would
help inform the public and healthcare
facilities, while improving the quality of
care. Specific details on data submission
for this measure can be found in an
Operational Guidance available at:
http://www.cdc.gov/nhsn/acute-carehospital/hcp-vaccination/ and at http://
www.cdc.gov/nhsn/acute-care-hospital/
index.html.
Public comments and responses to
comments on the Influenza Vaccination
Coverage Among Healthcare Personnel
measure are summarized below.
Comment: Multiple commenters
supported the adoption of this measure.
Some commenters stated that its
proposed timeline promotes alignment
across quality reporting programs and
that the public reporting of an overall
vaccination rate for a facility will
provide meaningful data to inform the
public on the quality of care provided
by the IPF. Some commenters also
expressed support for CMS’ intention to
allow reporting as a single vaccination
count for each healthcare facility by
each individual facility CCN because it
will simplify data collection for
facilities with multiple care settings. In
addition, some commenters stressed
that inclusion of this measure would
further alignment with similar measures
collected across multiple types of acute
and post-acute care settings.
Response: We thank the commenters
for their support.
Comment: Some commenters
expressed concern over the burden on
facilities to require documentation of
vaccination status for volunteers at their
facilities. One commenter stated that the
measure should either exclude
volunteers from its requirements or be
limited only to volunteers who spend a
substantial portion of time at a facility
over the course of a year.
Response: We understand the
commenters’ concern and are cognizant
of the burden associated with reporting
on this measure. However, because of

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the known benefits of vaccination and
the fact that adoption of this measure
furthers alignment across quality
reporting programs, we believe that its
inclusion in the Program is appropriate.
Furthermore, we believe that limiting
the scope of this measure with regard to
volunteers would undercut the purpose
of the measure. By being present in
facilities, and interacting with patients
and other personnel, the vaccination
status of volunteers is effectively as
important as that of other healthcare
personnel, regardless of the amount of
time spent in the facility.
Comment: Some commenters stated
that this measure is not pertinent to the
quality of care in IPFs. In particular,
some commenters stated that there is no
empirically demonstrated direct, or
indirect, relationship between this
measure and the delivery of high quality
behavioral health care in the IPF setting.
Therefore, according to some
commenters, this measure only provides
public health value and is not an
appropriate addition to the Program.
Response: We disagree with the
commenters. While this measure does
not speak directly to specific behavioral
health care services, it provides
meaningful information on the overall
quality of care provided at IPFs by
addressing an area tied directly to
improving patient health. Accordingly,
this measure not only provides value
from a public health standpoint, but
speaks directly to the overall quality of
care that any given IPF is able to
provide.
Comment: Some commenters sought
clarification on which individuals were
considered ‘healthcare personnel’ for
purposes of reporting on this measure.
Response: Clarification as to which
individuals are considered healthcare
personnel for purposes of this measure
can be found at: http://www.cdc.gov/
nhsn/PDFs/HPS-manual/vaccination/
HPS-flu-vaccine-protocol.pdf.
Comment: Some commenters
recommended that this measure should
first be pilot-tested in the IPF setting
before adoption into the Program.
Response: We disagree with the need
to first pilot-test this measure in the IPF
setting before adoption. We believe that
the challenges associated with this
measure in the acute care setting are not
sufficiently distinguishable from those
present in the IPF setting such that they
would warrant delaying adoption at this
time.
Comment: Some commenters stated
that, while reporting this measure under
IPFs’ CCN to the CDC’s NHSN may
simplify reporting, reporting will
depend on how the facility chooses to
bill for the services. For instance, an

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acute care hospital with an IPF unit may
choose to bill under one CCN, or have
one CCN for the acute care hospital and
another CCN for the IPF. Therefore,
commenters suggested, CMS should
make both values available through
QualityNet prior to public reporting, so
that facilities can reconcile any
differences.
Response: We understand the
commenters’ concerns. However, we
believe that reporting this measure
under IPFs’ CCN to the CDC’s NHSN
best promotes efficiency and accuracy of
data collection.
Final Rule Action: After consideration
of the public comments, we are
finalizing the Influenza Vaccination
Coverage Among HealthCare Personnel
measure as proposed for the FY 2017
payment determination and subsequent
years.
3. Tobacco Use Screening (TOB–1)
(NQF #1651)
Tobacco use is currently the single
greatest cause of disease in the U.S.,
accounting for more than 435,000
deaths annually.17 Smoking is a known
cause of multiple cancers, heart disease,
stroke, complications of pregnancy,
chronic obstructive pulmonary disease,
other respiratory problems, poorer
wound healing, and many other
diseases.18 This health issue is
especially important for persons with
mental illness and substance use
disorders. One study has estimated that
these individuals are twice as likely to
smoke as the rest of the population.19
Tobacco use also creates a heavy cost to
both individuals and society. Smokingattributable health care expenditures are
estimated at $96 billion per year in
direct medical expenses and $97 billion
in lost productivity.20
Strong and consistent evidence
demonstrates that timely tobacco
17 Centers for Disease Control and Prevention.
‘‘Annual Smoking-Attributable Mortality, Years of
Potential Life Lost, and Productivity Losses—
United States, 2000–2004.’’ Morb Mortal Wkly Rep.
2008. 57(45): 1226–1228. Available at: http://
www.cdc.gov/mmwr/preview/mmwrhtml/
mm5745a3.htm.
18 U.S. Department of Health and Human
Services. ‘‘The health consequences of smoking: a
report of the Surgeon General.’’ Atlanta, GA, U.S.
Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center
for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2004.
19 Lasser K, Boyd JW, Woolhandler S,
Himmelstein, DU, McCormick D, Bor DH. Smoking
and mental illness: A population-based prevalence
study. JAMA. 2000;284(20):2606–2610.
20 Centers for Disease Control and Prevention.
‘‘Best Practices for Comprehensive Tobacco Control
Programs—2007.’’ Atlanta, GA, Department of
Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on
Smoking and Health, 2007.

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dependence interventions for patients
using tobacco can significantly reduce
the risk of suffering from tobacco-related
disease, as well as provide improved
health outcomes for those already
suffering from a tobacco-related
disease.21 Research demonstrates that
tobacco users hospitalized with
psychiatric illnesses who enter into
treatment can successfully overcome
their tobacco dependence.22 Evidence
also suggests that tobacco cessation
treatment does not increase, and may
even decrease, the risk of
rehospitalization for tobacco users
hospitalized with psychiatric
illnesses.23 Research further
demonstrates that effective tobacco
cessation support across the care
continuum can be provided with only a
minimal additional effort and without
harm to the mental health recovery
process.24 We believe that the adoption
of a measure that assesses tobacco use
screening among patients of IPFs
encourages the uptake of tobacco
cessation treatment and its attendant
benefits. We further believe that the
reporting of this measure will afford
consumers and others useful
information in choosing among different
facilities.
The Tobacco Use Screening (TOB–1)
chart-abstracted measure assesses
hospitalized patients who are screened
within the first three days of admission
for tobacco use (cigarettes, smokeless
tobacco, pipe, and cigar) within the
previous 30 days. The numerator
includes the number of patients who
were screened for tobacco use status
within the first 3 days of admission. The
denominator includes the number of
hospitalized inpatients 18 years of age
and older. The measure excludes
patients who: Are less than 18 years of
age; are cognitively impaired; have a
duration of stay less than or equal to 3
days, or greater than 120 days; or have
Comfort Measures Only documented.
We refer readers to http://
www.jointcommission.org/
specifications_manual_for_national_
hospital_inpatient_quality_
measures.aspx for further details on
measure specifications.
21 U.S. Department of Health and Human
Services. ‘‘The health consequences of smoking: a
report of the Surgeon General.’’ Atlanta, GA, U.S.
Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center
for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2004.
22 Prochaska, JJ, et al. ‘‘Efficacy of Initiating
Tobacco Dependence Treatment in Inpatient
Psychiatry: A Randomized Controlled Trial.’’ Am.
J. Pub. Health. 2013 August 15; e1-e9.
23 Ibid.
24 Ibid.

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Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations
In the ‘‘List of Measure under
Consideration for December 1, 2013,’’
we originally proposed a similar
measure to that finalized here, which
was ‘‘Preventive Care & Screening:
Tobacco Use: Screening & Cessation
Intervention (NQF 0028).’’ However, the
MAP determined that this measure did
not meet the needs of the program and
instead recommended that we adopt an
alternate measure from the Joint
Commission’s suite of measures for
inpatient settings, which we are now
finalizing. This measure, and the
following one (TOB–2 and 2a), best
reflect the activities encompassed by the
original NQF 0028 measure.
The measure was NQF-endorsed on
March 7, 2014, and meets the measure
selection criterion under section
1886(s)(4)(D)(i) of the Act. Public
comments and responses to comments
on the TOB–1 measure are summarized
below.
Comment: One commenter stated that
this measure requires labor-intensive
manual chart abstraction, does not
permit sampling, and does not benefit
from data validation of aggregately
submitted data. Without sampling, the
commenter further stated that facilities
will have to invest valuable resources
abstracting data that has not been
validated for accuracy for public
reporting and possible future payment
penalty.
Response: We understand the
commenter’s concern with regard to the
burden associated with reporting on this
measure. We believe, however, that this
measure strikes an appropriate balance
between encouraging the uptake of
tobacco cessation treatment and its
documented benefits without
unnecessarily burdening facilities. We
also understand the commenter’s
concern with regard to the
unavailability of validation. We are
aware of this issue and currently are
working toward developing a validation
methodology for future use in the
Program.
Comment: Some commenters stated
that this measure does not provide
meaningful information on the quality
of care provided in IPFs. Similarly,
some commenters stated that screening
for tobacco use is important for the IPF
patient population, but asserted that this
should be an individualized part of a
patient’s care. One commenter also
stated that this measure has limitations,
such as not being developed and tested
in the IPF setting and only applying to
patients 18 years old and older, that
affect its utility.
Response: We disagree with the
commenters. We believe that reporting
of this measure will yield information

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that provides meaningful distinctions in
the quality of care provided across IPFs
and address an important health
behavior for persons with mental
illness. Precisely because tobacco use
screening is considered an essential step
in the care process for IPF patients, we
believe that it is critical for patients, and
their families and caregivers, to have
accurate available information on
whether IPFs integrate this into their
care processes. Moreover, we do not
believe that the limitations that the
commenter noted substantially discount
the value of this measure for the
Program.
Comment: Some commenters stated
that, while screening for tobacco use in
the IPF setting is important, the HBIPS–
1 measure is a better alternative because
it is already collected by most IPFs,
captures much of the information on
tobacco use that CMS seeks to collect,
and facilitates a more holistic approach
to addressing tobacco use.
Response: We disagree with the
commenters. The HBIPS–1 measure
does not explicitly provide for tobacco
screening and intervention. Please refer
to the following link http://
www.jointcommission.org/
specifications_manual_for_national_
hospital_inpatient_quality_
measures.aspx for further details on
HBIPS–1 measure specifications.
Comment: One commenter stated that
the burden for reporting this measure is
too great because documenting a generic
assessment of whether a patient uses
smokeless tobacco or cigarettes should
be enough of an assessment to
determine if counseling or treatment for
cessation should be provided.
Response: We disagree with the
commenter. We believe that the
requirements associated with reporting
on this measure strike a reasonable
balance between provider burden and
providing useful information to the
public on the quality of care provided
in IPFs.
Final Rule Action: After consideration
of the public comments, we are
finalizing the TOB–1 measure as
proposed for the FY 2017 payment
determination and subsequent years.
4. Tobacco Use Treatment Provided or
Offered (TOB–2) and Tobacco Use
Treatment (TOB–2a) (NQF #1654)
As stated in our discussion of the
proposed TOB–1 measure, tobacco use
is currently the single greatest cause of
disease in the U.S. We also indicated
that research demonstrates that timely
tobacco cessation treatment for
hospitalized tobacco users with
psychiatric illnesses may decrease the
risk of rehospitalization, have only a

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minimal additional effort, and not harm
the mental health recovery process. We
believe that the adoption of a measure
that assesses tobacco use screening
treatment among IPFs encourages the
uptake of tobacco cessation treatment
and its attendant benefits. We further
believe that the reporting of this
measure will afford consumers and
others useful information in choosing
among different facilities.
The Tobacco Use Treatment Provided
or Offered (TOB–2) and Tobacco Use
Treatment (TOB–2a) chart-abstracted
measure is reported as an overall rate
that includes all patients to whom
tobacco use treatment was provided, or
offered and refused, and a second rate,
a subset of the first, which includes only
those patients who received tobacco use
treatment. The overall rate, TOB–2,
assesses patients identified as tobacco
product users within the past 30 days
who receive or refuse practical
counseling to quit, and receive or refuse
Food and Drug Administration (FDA)approved cessation medications during
the first 3 days following admission.
The numerator includes the number of
patients who received or refused
practical counseling to quit, and
received or refused FDA-approved
cessation medications during the first 3
days after admission.
The second rate, TOB–2a, assesses
patients who received counseling and
medication, as well as those who
received counseling and had reason for
not receiving the medication during the
first 3 days following admission. The
numerator includes the number of
patients who received practical
counseling to quit and received FDAapproved cessation medications during
the first 3 days after admission.
The denominator for both TOB–2 and
TOB–2a includes the number of
hospitalized inpatients 18 years of age
and older identified as current tobacco
users. The measure excludes patients
who: Are less than 18 years of age; are
cognitively impaired; are not current
tobacco users; refused or were not
screened for tobacco use during the
hospital stay; have a duration of stay
less than or equal to 3 days, or greater
than 120 days; or have Comfort
Measures Only documented.
We refer readers to http://
www.jointcommission.org/
specifications_manual_for_national_
hospital_inpatient_quality_
measures.aspx for further details on
measure specifications.
The measure was NQF-endorsed on
March 7, 2014, and meets the measure
selection criteria under section
1886(s)(4)(D)(i) of the Act. We also note
that at this time we are not adopting two

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other tobacco treatment measures that
are part of the set from which TOB–1,
TOB–2 and TOB2a are taken. We
believe that the two measures we are
finalizing best encompass the activities
that we originally proposed to measure
through the use of the NQF 0028
measure, and best assess activities
demonstrated to produce positive
results in tobacco use reduction.
Additionally, we believe that the other
measure represents a significantly
greater collection and reporting burden.
Public comments and responses to
comments on the TOB–2 and TOB–2a
measures are summarized below.
Comment: One commenter stated that
this measure requires labor-intensive
manual chart abstraction, does not
permit sampling, and does not benefit
from data validation of aggregately
submitted data. Without sampling, the
commenter further argued, facilities will
have to invest valuable resources
abstracting data that has not been
validated for accuracy for public
reporting and possible future payment
penalty.
Response: We understand the
commenter’s concern with regard to the
burden associated with reporting on this
measure. However, we believe that this
measure strikes an appropriate balance
between encouraging the uptake of
tobacco cessation treatment, providing
consumers with relevant and actionable
information about this aspect of quality,
and its documented benefits without
unnecessarily burdening facilities.
Comment: Some commenters stated
that this measure does not provide
meaningful information on the quality
of care provided in IPFs. Similarly,
some commenters stated that tobacco

use treatment is important for the IPF
patient population, but asserted that this
should be an individualized part of a
patient’s care. One commenter also
stated that this measure has limitations,
such as not being developed and tested
in the IPF setting and applying only to
patients 18 years old and older, that
affect its utility.
Response: We disagree with the
commenters. We believe that reporting
of this measure will yield information
that provides meaningful distinctions in
the quality of care provided across IPFs
and does not conflict with the inclusion
of cessation treatment within an
individualized plan of care. Precisely
because tobacco use cessation treatment
is considered an essential step in the
care process for IPF patients, we believe
that it is critical for patients, and their
families and caregivers, to have accurate
available information on whether IPFs
integrate this into their care processes.
Moreover, we do not believe that the
limitations that the commenter noted
substantially discount the value of this
measure for the Program.
Comment: Some commenters stated
that, while tobacco use treatment in the
IPF setting is important, the HBIPS–1
measure is a better alternative because
it is already collected by most IPFs,
captures much of the information on
tobacco use that CMS seeks to collect,
and facilitates a more holistic approach
to addressing tobacco use.
Response: We disagree with the
commenters. Importantly, the HBIPS–1
measure does not explicitly provide for
tobacco screening and intervention.
Therefore, we believe that the TOB–2
and TOB–2a measures more adequately
align with the Program’s reporting goals.

Please refer to the following link:
http://www.jointcommission.org/
specifications_manual_for_national_
hospital_inpatient_quality_
measures.aspx for further details on
HBIPS–1 measure specifications.
Comment: One commenter stated that
the abstraction burden for reporting this
measure is too great because
documenting a generic assessment of
whether a patient uses smokeless
tobacco or cigarettes should be enough
of an assessment to determine if
counseling or treatment for cessation
should be provided.
Response: We disagree with the
commenter. We believe that the
requirements associated with reporting
on this measure strike a reasonable
balance between provider burden and
providing useful information to the
public on the quality of care provided
in IPFs.
Final Rule Action: After consideration
of the public comments, we are
finalizing the TOB–2 and TOB–2a
measure as proposed for the FY 2017
payment determination and subsequent
years.
c. Summary of Measures
In addition to the eight measures that
we previously finalized for the IPFQR
Program, we are adding two new
measures for reporting for the FY 2016
payment determination and subsequent
years. We are also adding four new
measures for the FY 2017 payment
determination and subsequent years.
The tables below list the new measures
for the FY 2016 and FY 2017 payment
determinations and subsequent years.

TABLE 13—NEW QUALITY MEASURES FOR THE IPFQR PROGRAM FOR FY 2016 PAYMENT DETERMINATION AND
SUBSEQUENT YEARS
National quality strategy priority

NQF #

Patient- and Caregiver-Centered Experience of Care ...............
Effective Communication and Coordination of Care ..................

Measure ID
N/A
N/A

N/A ..............
N/A ..............

Measure description
Assessment of Patient Experience of Care.
Use of an Electronic Health Record.

TABLE 14—NEW QUALITY MEASURES FOR THE IPFQR PROGRAM FOR FY 2017 PAYMENT DETERMINATION AND
SUBSEQUENT YEARS

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National quality strategy priority

NQF #

Measure ID

Measure description
Influenza Immunization.
Influenza Vaccination Coverage Among
Healthcare Personnel.
Tobacco Use Screening.
Tobacco Use Treatment Provided or Offered
and Tobacco Use Treatment.

Population/Community Health ....................................................
Population/Community Health ....................................................

1659
0431

IMM–2 .........
N/A ..............

Clinical Quality of Care ...............................................................
Clinical Quality of Care ...............................................................

1651
1654

TOB–1 .........
TOB–2
TOB–2a .......

Public comments and responses to
comments on the new measures for FY
2016 and FY 2017 payment

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determinations and subsequent years
are summarized below.

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Comment: Some commenters
expressed concern that CMS has
proposed too many process measures at

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the expense of outcome measures. One
commenter recommended that CMS
should evaluate critically the extent to
which potential measures will
contribute to meaningful differences in
the health outcomes achieved by IPF
patients. This commenter further noted
that CMS should be mindful of the
burden associated with proposing new
measures for the Program.
Response: We agree with the
commenter that concern for measuring
health outcomes should play an
important role in measure development.
To this end, as we stated in the
proposed rule, we intend to propose the
addition of a readmissions measure to
the Program through future rulemaking.
Further, we continue to welcome
recommendations for the adoption of
other outcome measures for inpatient
psychiatric care.
We also understand the commenter’s
concern regarding the reporting burden
associated with complying with the
Program’s requirements. We are mindful
that the reporting burden can be
particularly acute for the many small
IPFs that participate in the Program.
Accordingly, we have endeavored to
keep the number of measures in the
Program at a manageable number that is
far fewer than is required for many other
quality reporting programs. In
considering how to expand the
Program’s measure set in future years,
we intend to strike a balance between
developing a measure set that
adequately assesses the quality of care
provided in IPFs, while not requiring
IPFs to report on unnecessary or
duplicative measures.
Comment: Some commenters
requested that more time be afforded to
IPFs before data collection on new
measures is required.
Response: The Program’s data
collection requirements for new
measures are consistent with policies
adopted in other quality reporting
programs. The period from the adoption
of final measures to the beginning of the
applicable reporting period typically
exceeds four months. Depending on the
individual facility’s practices, actual
data collection may take place
significantly after this period.
d. Additional Procedural Requirements
for the FY 2017 Payment Determination
and Subsequent Years
In addition to the quality measures
that we have described above, IPFs
must, when they begin reporting for the
FY 2017 payment determination, submit
to CMS aggregate population counts for
Medicare and non-Medicare discharges
by age group, diagnostic group, and
quarter, and sample size counts for

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measures, for which sampling is
performed (as is allowed for in HBIPS–
4–7, and SUB–1). These requirements
are separate from those described under
subsection (c) of the section entitled
‘‘Form, Manner, and Timing of Quality
Data Submission.’’ That subsection
describes the population, sample size,
and minimum reporting case threshold
requirements for individual measures,
while this section describes the
collection of general population and
sampling data that will assist in
determining compliance with those
requirements. We believe that it is vital
for IPFs to accurately determine and
submit to CMS their population and
sampling size data in order for CMS to
assess IPFs’ data reporting completeness
for their total population, both Medicare
and non-Medicare. In addition to
helping to better assess the quality and
completeness of measure data, we
expect that this information will
improve our ability to assess the
relevance and impact of potential future
measures. For example, understanding
that the size of subgroups of patients
addressed by a particular measure varies
greatly over time could be helpful in
assessing the stability of reported
measure values, and subsequent
decisions concerning measure retention.
Similarly, better understanding of the
size of particular subgroups in the
overall population will assist us in
making choices among potential future
measures specific to a particular
subgroup (e.g., those with depression).
Furthermore, the form, manner, and
timing of this submission will follow
the policies discussed at section VIII of
this preamble, and that failure to
provide this information will be subject
to the 2.0 percentage point reduction in
the annual update for any IPF that does
not comply with quality data
submission requirements, pursuant to
section 1886(s)(4)(A)(i) of the Act.
Public comments and responses to
comments on the additional procedural
requirements for the FY 2017 payment
determination and subsequent years are
summarized below.
Comment: Some commenters
expressed support for the adoption of
the requirement that IPFs must submit
to CMS aggregate population counts for
Medicare and non-Medicare discharges
by age group, diagnostic group, and
quarter, and sample size counts for
measures for which sampling is
performed.
Response: We thank the commenters
for their support.
Comment: Some commenters stated
that the requirement for IPFs to submit
to CMS aggregate population counts for
Medicare and non-Medicare discharges

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45973

by age group, diagnostic group, and
quarter, and sample size counts for
measures for which sampling is
performed is an inefficient use of a
quality reporting program and, instead,
this information would be more
properly gathered through other means
not tied to public reporting and under
the Program’s statutory penalty for
failure to report IPFQR quality measure
data and meet other program
requirements. Similarly, some
commenters further stated that this
requirement would be unique among
quality reporting programs.
Response: We disagree with the
commenters. We believe that collection
of this information will not only work
to better assess the quality and
completeness of measure data, but also
improve our ability to assess the
relevance and impact of potential future
measures. Moreover, collection of this
type of information is not
unprecedented among quality reporting
programs. For instance, the PPS-Exempt
Cancer Hospital Quality Reporting
(PCHQR) made a similar proposal in the
FY 2015 IPPS proposed rule (79 FR
28259).
Comment: Some commenters
recommended that the specifications for
this data submission should mirror the
same elements collected by The Joint
Commission (TJC).
Response: We do not have plans at
this time to align our data submission
with that of TJC, but will consider their
requirements in providing direction
concerning these submissions.
Comment: Due to the Program’s
statutory penalty for failure to report
IPFQR quality measure data and meet
other program requirements, some
commenters stated that CMS should
specify its data validation approach
before requiring submission of this
information. The commenters further
stated that the results of a validation
methodology should be a factor in
determining whether a statutory penalty
should be assessed.
Response: We disagree with the
commenters. While we are working
toward developing a validation
methodology for use in future Program
years, we do not believe that submission
of these data warrants being delayed
until implementation of such a
methodology.
Final Rule Action: After consideration
of the public comments, we are
finalizing the requirement for IPFs to
submit to CMS aggregate population
counts for Medicare and non-Medicare
discharges by age group, diagnostic
group, and quarter, and sample size
counts for measures for which sampling
is performed as proposed for the FY

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2017 payment determination and
subsequent years.
e. Maintenance of Technical
Specifications for Quality Measures
We will provide a user manual that
will contain links to measure
specifications, data abstraction
information, data submission
information, a data submission
mechanism known as the Web-based
Measures Tool, and other information
necessary for IPFs to participate in the
IPFQR Program. This manual will be
posted on the QualityNet Web site at:
https://www.qualitynet.org/dcs/Content
Server?c=Page&pagename=Qnet
Public%2FPage%2FQnetTier2&cid=
1228772250192. We will maintain the
technical specifications for the quality
measures by updating this manual
periodically and including detailed
instructions for IPFs to use when
collecting and submitting data on the
required measures. These updates will
be accompanied by notifications to
IPFQR Program participants, providing
sufficient time between the change and
effective dates in order to allow users to
incorporate changes and updates to the
measure specifications into data
collection systems.
Many of the quality measures used in
different Medicare and Medicaid
reporting programs are endorsed by the
National Quality Forum (NQF). As part
of its regular maintenance process for
endorsed performance measures, the
NQF requires measure stewards to
submit annual measure maintenance
updates and undergo maintenance of
endorsement review every 3 years. In
the measure maintenance process, the
measure steward (owner/developer) is
responsible for updating and
maintaining the currency and relevance
of the measure and will confirm existing
or minor specification changes with
NQF on an annual basis. NQF solicits
information from measure stewards for
annual reviews, and it reviews measures
for continued endorsement in a specific
3-year cycle.
We note that NQF’s annual or
triennial maintenance processes for
endorsed measures may result in the
NQF requiring updates to the measures
in order to maintain endorsement status.
We believe that it is important to have
in place a subregulatory process to
incorporate non-substantive updates
required by the NQF into the measure
specifications we have adopted for the
IPFQR Program, so that these measures
remain up-to-date.
We also recognize that some changes
the NQF might require to its endorsed
measures are substantive in nature and
might not be appropriate for adoption

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using a subregulatory process.
Therefore, in the FY 2013 IPPS/LTCH
PPS final rule (77 FR 53503 through
53505), we finalized a policy under
which we will use a subregulatory
process to make only non-substantive
updates to measures used for the IPFQR
Program (77 FR 53653). With respect to
what constitutes substantive versus nonsubstantive changes, we expect to make
this determination on a case-by-case
basis. Examples of non-substantive
changes to measures might include
updates to diagnosis or procedure
codes, medication updates for categories
of medications, broadening of age
ranges, and exclusions for a measure.
We believe that non-substantive changes
may include updates to NQF-endorsed
measures based upon changes to
guidelines upon which the measures are
based. As stated in the FY 2013 IPPS/
LTCH PPS final rule, we will revise the
manual, so that it clearly identifies the
updates and provides links to where
additional information on the updates
can be found. We will also post the
updates on the QualityNet Web site at
https://www.QualityNet.org. We will
provide 6 months for facilities to
implement changes where changes to
the data collection systems are
necessary.
We will continue to use rulemaking to
adopt substantive updates required by
the NQF to the endorsed measures that
we have adopted for the IPFQR
Program. Examples of changes that we
might consider to be substantive are
those in which the changes are so
significant that the measure is no longer
the same measure, or when a standard
of performance assessed by a measure
becomes more stringent (for example,
changes in acceptable timing of
medication, procedure/process, or test
administration). Another example of a
substantive change would be where the
NQF has extended its endorsement of a
previously endorsed measure to a new
setting, such as extending a measure
from the inpatient setting to hospice.
These policies regarding what is
considered substantive versus nonsubstantive would apply to all measures
in the IPFQR Program. We also note that
the NQF process incorporates an
opportunity for public comment and
engagement in the measure maintenance
process.
We believe that this policy adequately
balances our need to incorporate
technical updates to all Program
measures in the most expeditious
manner possible, while preserving the
public’s ability to comment on updates
that so fundamentally change an
endorsed measure that it is no longer
the same measure that we originally

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adopted. Public comments and our
responses are summarized below.
Comment: One commenter expressed
support for use of the Specifications
Manual in the Program.
Response: We thank the commenter
for its support.
Comment: One commenter
recommended that CMS provide a more
detailed Specifications Manual that
would, for instance, include more
robust definitions, and explanations of
measures and data requirements.
Response: We thank the commenter
for its recommendation. Once finalized,
CMS will review the Specifications
Manual on a regular basis and make
updates as necessary.
6. New Quality Measures for Future
Years
As we have previously indicated, we
seek to develop a comprehensive set of
quality measures to be available for
widespread use for informed decisionmaking and quality improvement in the
IPF setting. Therefore, through future
rulemaking, we intend to propose new
measures that will help further our goal
of achieving better health care and
improved health for Medicare
beneficiaries who obtain inpatient
psychiatric services through the
widespread dissemination and use of
quality information.
As part of the 2013 Measures under
Consideration (http://
www.qualityforum.org/Setting_
Priorities/Partnership/Measures_Under_
Consideration_List.aspx), we identified
10 possible measures for the IPFQR
Program. We are finalizing four of these
measures for adoption in this final rule.
Five of the measures are currently
undergoing testing, and we anticipate
that one or more would be adopted in
the near future. These measures are:
• Suicide Risk Screening completed
within one day of admission
• Violence Risk Screening completed
within one day of admission
• Drug Use Screening completed within
one day of admission
• Alcohol Use Screening completed
within one day of admission
• Metabolic Screening
We also are currently planning to
develop a 30-day psychiatric
readmission measure. Similar to
readmission measures currently in use
for other CMS quality reporting
programs, such as the HIQR Program,
we envision that this measure will
encompass all 30-day readmissions for
discharges from IPFs, including
readmissions for non-psychiatric
diagnoses. Additionally, we intend to
develop a standardized survey of patient

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Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations
experience of care tailored for use in
inpatient psychiatric settings, but also
sharing elements with similar surveys in
use in other CMS reporting programs.
We further anticipate that we will
recommend additional measures for
development or adoption in the future.
We intend to develop a measure set that
effectively assesses IPF quality across
the range of services and diagnoses,
encompasses all of the goals of the CMS
quality strategy, addresses measure gaps
identified by the MAP and others, and
minimizes collection and reporting
burden. Finally, we may propose the
removal of some measures in the future,
should one or more no longer reflect
significant variation in quality among
IPFs, or prove to be less effective than
alternative measures in measuring the
intended focus area. Public comments
and responses to comments on new
quality measures for future years are
summarized below.
Comment: CMS received several
comments in response to our proposal
for new quality measures for future
years. Some commenters stated that a
number of the measures noted as
currently undergoing testing address
areas included in the HBIPS–1 measure
and; therefore, would be unnecessarily
duplicative. One commenter asserted
that HBIPS–1 also contains additional
areas of screening that are important for
all patients and, as an integrated,
comprehensive set of screens, would
provide a clinical picture of the patient
that any individual screen by itself
could not provide. Disaggregating this
measure into separate measures,
according to the commenter, would
introduce the potential for weakening
the screening process. In addition, the
commenter noted that HBIPS–1
provides very similar screenings to the
measures currently undergoing testing,
but within 3 days of admission, which
is more appropriate for the IPF setting.
In addition, the commenter stated that
the metabolic screening measure that is
currently undergoing testing should be
limited to anthropomorphic screening.
Some commenters recommended that
CMS should not include the five
measures currently undergoing testing
in the Program until they have been
approved by the MAP and endorsed by
the NQF. Another commenter stated
that adopting the measures that are
currently undergoing testing may result
in unnecessary laboratory work for IPFs
and; therefore, would increase the cost
of health care services. One commenter
recommended that, with regard to the
measures that are currently undergoing
testing, CMS consider a three-day
timeframe for assessment, as opposed to

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a one-day timeframe, as part of the
measure specifications.
We also received a comment
supporting the inclusion of a
readmissions measure that focuses on
those readmissions that are clinically
related to the index admission and are
potentially preventable by the IPF. The
commenter also suggested that
readmissions measures should be riskadjusted to account for differences
across patients in the likelihood of
readmission, and stated that appropriate
risk adjustment should include patient
assessment data. Other commenters
stated that a readmissions measure for
the IPF setting may not be a true
assessment of the quality of inpatient
psychiatric care because IPF patients
tend to exhibit characteristics that the
available literature associates as risk
factors for hospital readmissions. One
commenter further stated that, while
quality measures and care pathways
aimed at improving medical care for
heart attacks, heart failure, and
pneumonia have been in place for more
than a decade, psychiatric measures and
care pathways for treating chronic
psychiatric diseases are in their early
stages of development, suggesting that a
readmission to IPF care may not
indicate anything meaningful about the
quality and extent of care provided
during an initial stay. In addition, we
received a comment recommending that
CMS consider a number of issues as it
develops a readmissions measure for the
Program. First, the commenter asked
whether such a measure would include
only Medicare patients or all IPF
admissions because providers do not
have access to the databases required to
report or track readmissions across all
payers. Second, the commenter
expressed concern that there may be no
relationship between a psychiatric
hospital admission and a subsequent
medical or surgical admission within 30
days, but that consumers will not have
access to this level of information.
Third, the commenter expressed
concern that there are presently no
published studies on the current
readmission rate for IPFs. Fourth, the
commenter expressed concern that there
is no risk-adjustment proposed. Fifth,
the commenter argued that there is
currently no NQF endorsement of the
measure being developed. Other
commenters stated that a future
readmissions measure should be limited
to psychiatric readmission to the same
facility. One commenter expressed
support for a readmissions measure in
future Program years, but recommended
that CMS remove the unrelated acute
medical admissions from the definition

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45975

of an unplanned 30-day IPF readmission
because such a readmission is not a
reflection on the quality of care
provided at the index IPF admission.
Another commenter recommended that,
with regard to a potential readmissions
measure, an exception should be made
for dementia-related behavior disorders
because these are by nature frequently
repeating and heavily dependent on
factors beyond the control of acute
psychiatry.
In addition, we received several
comments recommending that CMS
engage the IPF technical expert panel
for its guidance and advice on the
challenges associated with
implementing many of the measures
under consideration for proposal for
inclusion in future Program years. We
also received comments recommending
the following areas for further
development and testing of potential
measures: Readmission to the same IPF
within 30 days of discharge; improved
functioning or stabilization of
functioning as measured through
clinical assessment, patient selfassessment, or discharge to a lower level
of care; receiving best-practices specific
to the conditions noted in the treatment
plan (for example, depression, bipolar,
and schizophrenia), as well as acuity of
illness; and scheduled appointment for
aftercare within 7 days of discharge,
controlling for urban/rural area and type
of provider, at a minimum.
Lastly, one commenter recommended
that CMS propose the adoption of
Tobacco Use Treatment Management at
Discharge measure (TOB–3; NQF #
1656) in future program years.
Response: We thank the commenters
for their recommendations on potential
measures and related issues for the
IPFQR Program. We will take these
recommendations into consideration as
we continue to develop and propose
measures for future program years.
7. Public Display and Review
Requirements
Section 1886(s)(4)(E) of the Act
requires the Secretary to establish
procedures for making the data
submitted under the IPFQR Program
available to the public. The statute also
requires that these procedures shall
ensure that an IPF has the opportunity
to review the data that is to be made
public with respect to the IPF prior to
the data being made public.
In the FY 2014 IPPS/LTCH PPS final
rule (78 FR 50897 through 50898), we
adopted our proposal to change our
policies to better align the IPFQR
Program preview and display periods
with those under the HIQR Program. For
the FY 2014 payment determination and

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subsequent years, we adopted our
proposed policy to publicly display the
submitted data on a CMS Web site in
April of each calendar year following
the start of the respective payment
determination year. In other words, the
public display period for the FY 2014

payment determination would be April
2014; the public display periods for the
FY 2015 and FY 2016 payment
determinations would be April 2015
and April 2016, respectively; and so
forth. We also adopted our proposed
policy that the preview period for the

FY 2014 payment determination and
subsequent years be modified from
September 20 through October 19 (78
FR 50898) to 30 days, approximately
twelve weeks prior to the public display
of the data. The table below sets out the
public display timeline.

TABLE 15—PUBLIC DISPLAY TIMELINE
Payment determination
(fiscal year)
2015 ...........................................

Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4

2016 ...........................................

2017 ...........................................

2013
2013
2013
2014
2014
2014
2014
2015
2015
2015
2015

(April 1, 2013–June 30, 2013) ......................................................................................
(July 1, 2013–September 30, 2013).
(October 1, 2013–December 31, 2013).
(January 1, 2014–March 31, 2014) ..............................................................................
(April 1, 2014–June 30, 2014).
(July 1, 2014–September 30, 2014).
(October 1, 2014–December 31, 2014).
(January 1, 2015–March 31, 2015) ..............................................................................
(April 1, 2015–June 30, 2015).
(July 1, 2015–September 30, 2015).
(October 1, 2015–December 31, 2015).

Although we have listed the public
display timeline only for the FY 2015
through FY 2017 payment
determinations, we wish to clarify that
this policy applies to the FY 2015
payment determination and subsequent
years.
We did not propose any changes to
these policies in the FY 2015 proposed
rule. Therefore, we are finalizing these
policies in this final rule.
8. Form, Manner, and Timing of Quality
Data Submission

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a. Procedural and Submission
Requirements
Section 1886(s)(4)(C) of the Act
requires that, for the FY 2014 payment
determination and subsequent years,
each IPF shall submit to the Secretary
data on quality measures as specified by
the Secretary. Such data shall be
submitted in a form and manner, and at
a time, specified by the Secretary. As
required by section 1886(s)(4)(A) of the
Act, for any IPF that fails to submit
quality data in accordance with section
1886(s)(4)(C) of the Act, the Secretary
will reduce the annual update to a
standard Federal rate for discharges
occurring in such fiscal year by 2.0
percentage points. In the FY 2013 IPPS/
LTCH PPS final rule (77 FR 53655
through 53656), we finalized a policy
requiring that IPFs submit aggregate
data on measures on an annual basis via

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Public display
(calendar
year)

Reporting period
(calendar year)

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the Web-Based Measures Tool found in
the IPF section on the QualityNet Web
site. The complete data submission
requirements, submission deadlines,
and data submission mechanism,
known as the Web-Based Measures
Tool, are posted on the QualityNet Web
site at: http://www.qualitynet.org/. The
data input forms on the QualityNet Web
site for submission require aggregate
data for each separate quarter.
Therefore, IPFs need to track and
maintain quarterly records for their
data. In that final rule, we also clarified
that this policy applies to all subsequent
years, unless and until we change our
policy through future rulemaking.
To participate in the IPFQR Program,
in the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53654 through 53655) and
in the FY 2014 IPPS/LTCH PPS final
rule (77 FR 50898 through 50899), we
required IPFs to comply with certain
procedural requirements. We refer
readers to the FY 2014 IPPS/LTCH PPS
final rule (77 FR 50898 through 50899)
for further details on specific procedural
requirements.
We did not propose any changes to
these policies in the FY 2015 proposed
rule. Therefore, we are finalizing these
policies in this final rule.
b. Reporting Periods and Submission
Timeframes
In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53655 through 53657), we

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April 2015.
April 2016.

April 2017.

established reporting periods and
submission timeframes for the FY 2014,
FY 2015, and FY 2016 payment
determinations, but we did not require
any data validation approach. However,
as we stated in that final rule, we
encourage IPFs to use a validation
method and conduct their own analysis.
In that final rule, we also explained that
the reporting periods for the FY 2014
and FY 2015 payment determinations
were 6 and 9 months, respectively, to
allow us to achieve a 12-month
(calendar year) reporting period for the
FY 2016 payment determination. In the
FY 2014 IPPS/LTCH PPS final rule (78
FR 50901), we clarified that the policy
we adopted for the FY 2016 payment
determination also applies to the FY
2017 payment determination and
subsequent years, unless we change it
through rulemaking. We also indicated
that the submission timeframe is
between July 1 and August 15 of the
calendar year in which the applicable
payment determination year begins.
We did not propose any changes to
this submission timeframe in 79 FR
26040, which we finalized in the FY
2014 IPPS/LTCH PPS final rule for all
future payment determinations. IPFs
will have the opportunity to review and
correct data that they have submitted
during the entirety of July 1 through
August 15. We have summarized this
information in the table below.

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TABLE 16—QUALITY REPORTING PERIODS AND SUBMISSION TIMEFRAMES FOR THE FY 2015 PAYMENT DETERMINATION
AND SUBSEQUENT YEARS
Payment
determination
(fiscal year)

Reporting period for services provided
(calendar year)

Data submission
timeframe

Quality Reporting Periods and Submission Timeframes for the FY 2015 Payment Determination and Subsequent Years
FY 2015 .........................................
FY 2016 .........................................

FY 2017 .........................................

Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4

2013 (April 1, 2013–June 30, 2013) ...................................................
2013 (July 1, 2013–September 30, 2013).
2013 (October 1, 2013–December 31, 2013).
2014 (January 1, 2014–March 31, 2014) ...........................................
2014 (April 1, 2014–June 30, 2014).
2014 July 1, 2014–September 30, 2014).
2014 (October 1, 2014–December 31, 2014).
2015 (January 1, 2015–March 31, 2015) ...........................................
2015 (April 1, 2015–June 30, 2015).
2015 (July 1, 2015–September 30, 2015).
2015(October 1, 2015–December 31, 2015).

We have adopted the timeframes
discussed above for all future payment
years of the program, and these
timeframes will remain in place, unless
and until we change them through
future rulemaking. Therefore, our policy
with respect to reporting timeframes is
that the reporting period is the calendar
year preceding the calendar year in
which the payment determination year
begins. The data submission timeframe
is between July 1 and August 15 of the
calendar year in which the applicable
payment determination year begins. We
will continue to provide charts with the
specific reporting and data submission
timeframes for future years as we
approach those years.
We did not propose any changes to
these policies in the FY 2015 proposed
rule.

c. Population, Sampling, and Minimum
Case Threshold
In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53657 through 53658), for
the FY 2014 payment determination and
subsequent years, we finalized our
proposed policy that participating IPFs
must meet specific population, sample
size, and minimum reporting case
threshold requirements as specified in
TJC’s Specifications Manual. We refer
readers to the FY 2014 IPPS/LTCH PPS
final rule (78 FR 58901 through 58902).
We are not proposing any changes to
this policy. We refer participating IPFs
to TJC’s Specifications Manual (https://
manual.jointcommission.org/bin/view/
Manual/WebHome) for measure-specific
population, sampling, and minimum
case threshold requirements.
We did not propose any changes to
these policies in the FY 2015 proposed

July 1, 2014–August 15, 2014.
July 1, 2015–August 15, 2015.

July 1, 2016–August 15, 2016.

rule. Therefore, we are finalizing these
policies in this final rule.
d. Data Accuracy and Completeness
Acknowledgement (DACA)
Requirements
In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53658), we finalized our
proposed DACA policy for the FY 2014
payment determination and subsequent
years. We refer readers to that final rule
for further details on DACA policies.
We are not changing the quarterly
reporting periods or DACA deadline.
Therefore, we will continue our adopted
policy that the deadline for submission
of the DACA form is no later than
August 15 prior to the applicable IPFQR
Program payment determination year.
The table below summarizes these
policies and timeframes.

TABLE 17—DACA SUBMISSION DEADLINE
Payment
determination
(fiscal year)

Reporting period for services provided
(calendar year)

2015 .......................

Q2 2013 (April 1, 2013–June 30, 2013) ............
Q3 2013 (July 1, 2013–September 30, 2013).
Q4 2013 (October 1, 2013–December 31,
2013).
Q1 2014 (January 1, 2014–March 31, 2014) ....
Q2 2014 (April 1, 2014–June 30, 2014).
Q3 2014 (July 1, 2014–September 30, 2014).
Q4 2014 (October 1, 2014–December 31,
2014).
Q1 2015 (January 1, 2015–March 31, 2015) ....
Q2 2015 (April 1, 2015–June 30, 2015).
Q3 2015 (July 1, 2015–September 30, 2015).
Q4 2015 (October 1, 2015–December 31,
2015).

2016 .......................

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2017 .......................

We once again clarify that the DACA
policies adopted in the FY 2013 IPPS/
LTCH PPS final rule will continue to
apply for the FY 2014 payment

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Submission
timeframe

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Public
display

July 1, 2014–August 15, 2014

August 15, 2014 ........

April 2015.

July 1, 2015–August 15, 2015

August 15, 2015 ........

April 2016.

July 1, 2016–August 15, 2016

August 15, 2016 ........

April 2017.

determination and subsequent years,
unless and until we change these
policies through our rulemaking
process.

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deadline

Sfmt 4700

We did not propose any changes to
these policies in the FY 2015 proposed
rule. Therefore, we are finalizing these
policies in this final rule.

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9. Reconsideration and Appeals
Procedures
In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53658 through 53659), we
adopted a reconsideration process, later
codified at 42 CFR 412.434, whereby
IPFs can request a reconsideration of
their payment update reduction in the
event that an IPF believes that its annual
payment update has been incorrectly
reduced for failure to report quality data
under the IPFQR Program. We refer
readers to that final rule, as well as the
FY 2014 IPPS/LTCH PPS final rule (78
FR 50903), for further details on the
reconsideration process.
We did not propose any changes to
these policies in the FY 2015 proposed
rule. Therefore, we are finalizing these
policies in this final rule.

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10. Exceptions to Quality Reporting
Requirements
In our experience with other quality
reporting and performance programs,
we have noted occasions where
participants have been unable to submit
required quality data due to
extraordinary circumstances that are not
within their control (for example,
natural disasters). It is our goal to avoid
penalizing IPFs in these circumstances
or unduly increasing their burden
during these times. Therefore, in the FY
2013 IPPS/LTCH PPS final rule (77 FR
53659 through 53660), we adopted a
policy where, for the FY 2014 payment
determination and subsequent years,
IPFs may request, and we may grant, an
exception with respect to the reporting
of required quality data where
extraordinary circumstances beyond the
control of the IPF may warrant. We wish
to clarify that use of the term
‘‘exception’’ in this final rule is
synonymous with the term ‘‘waiver’’ as
used in previous rules. We are in the
process of revising the Extraordinary
Circumstances/Disaster Extension or
Waiver Request form (CMS–10432),
approved under OMB control number
0938–1171. Revisions to the form are
being addressed in the FY 2015
Inpatient Prospective Payment System
(IPPS) rule (RIN 0938–AS11; CMS–
1607–P) in the section entitled
‘‘Hospital IQR Program Extraordinary
Circumstances Extensions or
Exemptions’’. These efforts will work to
facilitate alignment across CMS quality
reporting programs.
When an exception is granted, IPFs
will not incur payment reductions for
failure to comply with IPFQR Program
requirements. This process does not
preclude us from granting exceptions,
including extensions, to IPFs that have
not requested them, should we

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determine that an extraordinary
circumstance affects an entire region or
locale. We refer readers to the FY 2013
IPPS/LTCH PPS final rule (77 FR 53659
through 53660), as well as the FY 2014
IPPS/LTCH PPS final rule (78 FR
50903), for further details on this
process. We are not changing this
process.
In the FY 2015 proposed rule (78 FR
26072 through 26073), we proposed to
add an Extraordinary Circumstances
Exception to the IPFQR Program,
effective for the FY 2016 payment
determination and subsequent years, to
align with similar exceptions provided
for in other CMS quality reporting
programs. Under this exception, we may
grant a waiver or extension to IPFs if we
determine that a systemic problem with
one of our data collection systems
directly affects the ability of the IPFs to
submit data. Because we do not
anticipate that these types of systemic
errors will occur often, we do not
anticipate granting a waiver or
extension on this basis frequently. If we
make the determination to grant a
waiver or extension, we will
communicate this decision through
routine communication channels to
IPFs, vendors, and quality improvement
organizations (QIOs) by means of, for
example, memoranda, emails, and
notices on the QualityNet Web site.
Public comments and responses to
comments on the exceptions to quality
reporting requirements are summarized
below.
Comment: Some commenters
expressed support for inclusion of an
Extraordinary Circumstances Exception
in the Program.
Response: We thank the commenters
for their support.
Final Rule Action: After consideration
of the public comments, we are
finalizing the Extraordinary
Circumstances Exception as proposed
for the FY 2016 payment determination
and subsequent years.
IX. Provisions of the Final Regulations
This final rule essentially
incorporates the provisions of the
proposed rule set forth in the FY 2015
IPF PPS proposed rule (79 FR 26040), in
which we proposed to update the IPF
PPS for FY 2015 applicable to IPF
discharges occurring during the FY
beginning October 1, 2014 through
September 30, 2015. In addition, we
proposed to update the COLA
adjustment factors for IPFs located in
Alaska and Hawaii using the approach
finalized in the FY 2014 IPPS final rule
(FR 50985 through 50987). This final
rule will also address implementation of
ICD–10–CM and ICD–9–PCS codes and

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finalize new quality measures and
quality reporting requirements under
the quality reporting program.
X. Collection of Information
Requirements
Under the Paperwork Reduction Act
of 1995, we are required to provide 60day notice in the Federal Register and
solicit public comment before a
collection of information requirement is
submitted to the Office of Management
and Budget (OMB) for review and
approval. In order to fairly evaluate
whether an information collection
should be approved by OMB, section
3506(c)(2)(A) of the Paperwork
Reduction Act of 1995 requires that we
solicit comment on the following issues:
• The need for the information
collection and its usefulness in carrying
out the proper functions of our agency
• The accuracy of our estimate of the
information collection burden
• The quality, utility, and clarity of
the information to be collected
• Recommendations to minimize the
information collection burden on the
affected public, including automated
collection techniques.
In the May 6, 2014 (79 FR 26040)
proposed rule, we solicited public
comment on each of the section
3506(c)(2)(A)-required issues for the
following information collection
requirements (ICRs). However, we did
not receive any public comments on
these ICRs and are adopting the policies
as proposed.
A. ICRs Regarding the Inpatient
Psychiatric Facilities Quality Reporting
(IPFQR) Program
The following sets out the estimated
burden (hours and cost) for inpatient
psychiatric facilities (IPFs) to comply
with the reporting requirements under
section VIII of this rule.
In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53644), we finalized policies
implementing the IPFQR Program. The
Program implements the statutory
requirements of section 1886(s)(4) of the
Social Security Act, as added by
sections 3401(f) and 10322(a) of the
Affordable Care Act. One program
priority is to help achieve better health
and better health care for individuals
through the collection of valid, reliable,
and relevant measures of quality health
care data. The data are publicly
available for use in improving health
care quality which, in turn, works to
further Program goals. IPFs can use this
quality data for many purposes,
including in their risk management
programs, patient safety and quality
improvement initiatives, and research

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and development of mental health
programs, among others.
As clarified throughout the FY 2014
IPPS/LTCH PPS final rule (78 FR
50887), policies finalized in prior rules
will apply to FY 2015, unless and until
we change them through future
rulemaking. The burden on IPFs
includes the time used for chart
abstraction and for personnel training
on the collection of chart-abstracted
data, the aggregation of data, and
training for the submission of aggregatelevel data through QualityNet. We note
that, beginning in the FY 2016 payment
determination, we have adopted the
Assessment of Patient Experience of
Care measure, thereby removing the
request for voluntary information
adopted in the FY 2014 IPPS/LTCH PPS
final rule.
Based on current participation rates,
we estimate that there will be
approximately 574 fewer IPF facilities,
or 1,626 facilities nationwide eligible to
participate in the IPFQR Program. Based
on previous measure data submission,
we further estimate that the average

facility submits measure data on 556
cases per year. In total, this calculates to
904,056 cases (aggregate) per year.
In section V of this preamble, we are
finalizing our proposals that, for the FY
2016 payment determination and
subsequent years, IPFs must submit data
on the following new measures:
Assessment of Patient Experience of
Care, and Use of an Electronic Health
Record. Because both of these measures
require only an annual
acknowledgement, we anticipate a
negligible additional burden on IPFs.
In the same section of this preamble,
we are finalizing our proposals that, for
the FY 2017 payment determination and
subsequent years, IPFs must submit
aggregate data on the following new
measures: Influenza Immunization
(IMM–2), Influenza Vaccination
Coverage Among Healthcare Personnel,
Tobacco Use Screening (TOB–1), and
Tobacco Use Treatment Provided or
Offered (TOB–2) and Tobacco Use
Treatment (TOB–2a).
We estimate that the average time
spent for chart abstraction per patient
for each of these measures is

45979

approximately 15 minutes. Assuming an
approximately uniform sampling
methodology, we estimate (based on
prior Program data) that the annual
burden for reporting the IMM–2
measure is 139 hours per year of annual
effort per facility (556 × 0.25). This same
calculation also applies to the TOB–1,
and TOB–2 and TOB–2a measures. The
Influenza Vaccination Coverage Among
Healthcare Personnel measure does not
allow sampling; therefore, we anticipate
that the average facility would be
required to abstract approximately 40
healthcare personnel, totaling an annual
effort per facility of 10 hours (40 × 0.25).
We anticipate no measurable burden for
the Inpatient Psychiatric Facility
Routinely Assesses Patient Experience
of Care measure and the Use of an
Electronic Health Record measure
because both require only attestation.
In total, we estimate an additional 427
hours of annual effort per facility for the
FY 2017 payment determination and
subsequent years. The following table
summarizes the estimated hours (per
facility) for each measure.

TABLE 18—ESTIMATED ANNUAL EFFORT PER FACILITY
Estimated cases
(per facility)

Measure

Effort
(per case)

Annual effort
(per facility)

Assessment of Patient Experience of Care .......................................................
Use of an Electronic Health Record ..................................................................
IMM–2 .................................................................................................................
Influenza Vaccination Coverage Among Healthcare Personnel ........................
TOB–1 ................................................................................................................
TOB–2, TOB–2a .................................................................................................

*0
*0;
556
40
556
556

n/a * .................................
a * ....................................
1⁄4 hour ............................
1⁄4 hour ............................
1⁄4 hour ............................
1⁄4 hour ............................

*0
*0
139
10
139
139

Total ............................................................................................................

............................

.........................................

427

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* New non-measurable attestation burden.

The Bureau of Labor Statistics wage
estimate for health care workers that are
known to engage in chart abstraction is
$31.71/hour. To account for overhead
and fringe benefits we have doubled this
estimate to $63.42/hour. Considering
the 427 hours of annual effort (per
facility) for the FY 2017 payment
determination and subsequent years, the
annual cost is approximately $27,080.34
(63.42 × 427). Across all 1,626 IPFs, the
aggregate total is $44,032,632.84 (1,626
× 27,080.34).
The estimated burden for training
personnel for data collection and
submission for current and future
measures is 2 hours per facility. The
cost for this training, based on an hourly
rate of $63.42, is $126.84 training costs

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for each IPF (63.42 × 2), which totals
$206,241.84 for all facilities (1,626 ×
126.84).
Using an estimated 1,626 IPFs
nationwide eligible for participation in
the IPFQR Program, we estimate that the
annual hourly burden for the collection,
submission, and training of personnel
for submitting all quality measures is
approximately 429 hours (per IPF) or
697,554 (aggregate) per year. The allinclusive measure cost for each facility
is approximately $27,207.18 (27,080.34
+ 126.84) and for all facilities we
estimate a cost of $44,238,874.68
(44,032,632.84 + 206,241.84).
In section V of this preamble, for the
FY 2017 payment determination, we
finalized our proposal that IPFs must
submit to CMS aggregate population

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counts for Medicare and non-Medicare
discharges by age group, diagnostic
group, and quarter, and sample size
counts for measures for which sampling
is performed (as is allowed for in
HBIPS–4 through –7, and SUB–1). We
estimate that it will take each facility
approximately 2.5 hours to comply with
this requirement. The burden across all
1,626 IPFs calculates to 4,065 hours
annually (2.5 × 1,626) at a total of
$257,802.30 (4,065 × 63.42) or $158.55
per IPF (2.5 × 63.42).
The following tables set out the total
estimated burden that IPFs will incur to
comply with the reporting requirements
for both measure and non-measure data
for the FY 2016 and FY 2017 payment
determinations.

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TABLE 19—SUMMARY OF BURDEN ESTIMATES (OCN 0938–1171, CMS–10432) FOR THE FY 2016 PAYMENT
DETERMINATION
Facility
burden
(hours)

Respondents

Total
annual burden
(hours)

Labor
cost of
reporting
($/hr)

Total cost
($)

Fiscal year 2016

Number of measures

From this FY 2015 rule .......

2 (attestation only) .............
training ................................

1,626
1,626

0
0

0
0

0
0

0
0

Total .............................

.............................................

1,626

0

0

0

0

TABLE 20—SUMMARY OF BURDEN ESTIMATES (OCN 0938–1171, CMS–10432) FOR THE FY 2017 PAYMENT
DETERMINATION
Fiscal year 2017

Number of measures

From this FY 2015 rule .....

4 ........................................

1,626

2 (attestation only) ............
training ..............................
Subtotal ......................
From this FY 2015 rule .....
Total ....................

Total annual
burden
(hours)

Labor
cost of
reporting
($/hr)

Total cost
($)

694,302

63.42

44,032,632.84

........................
........................

0
3,252

........................
........................

........................
206,241.84

...........................................
Non-measure data ............

1,626
1,626

429
2.50

697,554
4,065

63.42
63.42

44,238,874.68
257,802.30

...........................................

1,626

431.50

701,619

63.42

44,496,676.98

B. FY 2014 and FY 2015 Burden
Adjustments (OCN 0938–1171, CMS–
10432)

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Facility burden
(hours)
427
(139 × 3 + 10)
............................
2

We are not changing any of the
administrative, reporting, or submission
requirements for the measures
previously finalized in the FY 2013
IPPS/LTCH PPS final rule (77 FR 53654
through 53657) and the FY 2014 IPPS/
LTCH PPS final rule (78 FR 50898
through 50903), except that we are
removing the Request for Voluntary
Information—IPF Assessment of Patient
Experience of Care section because of
the Assessment of Patient Experience of
Care measure.

In the FY 2014 final rule (78 FR
50964), we estimated that the annual
hourly burden per IPF for the collection,
submission, and training of personnel
for submitting all quality measures was
approximately 761 hours. This figure
represented an estimate for all
measures, both previously and newly
finalized, in the Program. We further
stated that because we were unable to
estimate how many IPFs will
participate, we could not estimate the
aggregate impact.
Because the estimates we present
herein, including the estimated annual
burden of 431.5 hours per IPF, represent
estimates only for measure and nonmeasure data collection and submission
requirements, an accurate comparison
with estimates presented in the FY 2014
final rule is not possible.

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C. ICRs Regarding the Hospital and
Health Care Complex Cost Report
(CMS–2552–10)
This final rule would not impose any
new or revised collection of information
requirements associated with CMS–
2552–10 (as discussed under preamble
section IV.B.). Consequently, the cost
report does not require additional OMB
review under the authority of the
Paperwork Reduction Act of 1995 (44
U.S.C. 3501 et seq.). The report’s
information collection requirements and
burden estimates have been approved
by OMB under OCN 0938–0052.
D. ICRs Regarding Exceptions to Quality
Reporting Requirements
As discussed in section VII.10, we are
in the process of revising the
Extraordinary Circumstances/Disaster
Extension or Waiver Request form,
currently approved under OMB control
number 0938–1171. Revisions to the
form are being addressed in the FY 2015
Inpatient Prospective Payment System
rule (RIN 0938–AS11, CMS–1607–F). In
that rule we update the form’s
instructions and simplify the form so
that a hospital or facility may apply for
an extension for all applicable quality
reporting programs at the same time.
E. Submission of PRA-Related
Comments
We have submitted a copy of this rule
to OMB for its review of the rule’s
information collection and

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recordkeeping requirements. These
requirements are not effective until they
have been approved by the OMB.
When commenting on the stated
information collections, please reference
the document identifier or OMB control
number. To be assured consideration,
comments and recommendations must
be received by the OMB desk officer via
one of the following transmissions:
Mail: OMB, Office of Information and
Regulatory Affairs Attention: CMS
Desk Officer
Fax: (202) 395–5806 OR
Email: [email protected].
PRA-related comments must be
received on/by September 2, 2014.
XI. Comments Beyond the Scope of the
Final Rule
In response to the proposed rule, a
few commenters chose to raise issues
that are beyond the scope of our
proposals. In this final rule, we are not
summarizing or responding to those
comments in this document.
XII. Regulatory Impact Analysis
A. Statement of Need
This final rule updates the
prospective payment rates for Medicare
inpatient hospital services provided by
IPFs for discharges occurring during the
FY beginning October 1, 2014, through
September 30, 2015. We are applying
the FY 2008-based RPL market basket
increase of 2.9 percent, less the
productivity adjustment of 0.5

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percentage point as required by section
1886(s)(2)(A)(i) of the Act, and less the
0.3 percentage point required by
sections 1886(s)(2)(A)(ii) and
1886(s)(3)(C) of the Act. In this final
rule, we also address the
implementation of the International
Classification of Diseases, 10th
Revision, Clinical Modification (ICD–
10–CM/PCS) for the IPF prospective
payment system, and describe new
quality reporting requirements for the
IPFQR Program.
B. Overall Impact
We have examined the impact of this
final rule as required by Executive
Order 12866 on Regulatory Planning
and Review (September 30, 1993),
Executive Order 13563 on Improving
Regulation and Regulatory Review
(January 18, 2011), the Regulatory
Flexibility Act (RFA) (September 19,
1980, Pub.L. 96–354), section 1102(b) of
the Social Security Act, section 202 of
the Unfunded Mandates Reform Act of
1995 (March 22, 1995; Pub. L. 104–4),
Executive Order 13132 on Federalism
(August 4, 1999) and the Congressional
Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563
direct agencies to assess all costs and
benefits of available regulatory
alternatives and, if regulation is
necessary, to select regulatory
approaches that maximize net benefits
(including potential economic,
environmental, public health and safety
effects, distributive impacts, and
equity). A regulatory impact analysis
(RIA) must be prepared for major rules
with economically significant effects
($100 million or more in any 1 year).
This final rule is designated as
economically ‘‘significant’’ under
section 3(f)(1) of Executive Order 12866.
We estimate that the total impact of
these changes for FY 2015 payments
compared to FY 2014 payments will be
a net increase of approximately $120
million. This reflects a $100 million
increase from the update to the payment
rates, as well as a $20 million increase
as a result of the update to the outlier
threshold amount. Outlier payments are
estimated to increase from 1.6 percent
in FY 2014 to 2.0 percent in FY 2015.
The RFA requires agencies to analyze
options for regulatory relief of small
entities if a rule has a significant impact
on a substantial number of small
entities. For purposes of the RFA, small
entities include small businesses,
nonprofit organizations, and small
governmental jurisdictions. Most IPFs
and most other providers and suppliers
are small entities, either by nonprofit
status or having revenues of $7 million
to $35.5 million or less in any 1 year,

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depending on industry classification
(for details, refer to the SBA Small
Business Size Standards found at http://
www.sba.gov/sites/default/files/files/
Size_Standards_Table.pdf), or being
nonprofit organizations that are not
dominant in their markets.
Because we lack data on individual
hospital receipts, we cannot determine
the number of small proprietary IPFs or
the proportion of IPFs’ revenue derived
from Medicare payments. Therefore, we
assume that all IPFs are considered
small entities. The Department of Health
and Human Services generally uses a
revenue impact of 3 to 5 percent as a
significance threshold under the RFA.
As shown in Table 21, we estimate
that the overall revenue impact of this
proposed rule on all IPFs is to increase
Medicare payments by approximately
2.5 percent. As a result, since the
estimated impact of this final rule is a
net increase in revenue across all
categories of IPFs, the Secretary has
determined that this final rule will have
a positive revenue impact on a
substantial number of small entities.
MACs are not considered to be small
entities. Individuals and States are not
included in the definition of a small
entity.
In addition, section 1102(b) of the
Social Security Act requires us to
prepare a regulatory impact analysis if
a 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 final
rule will not have an adverse impact on
the rural hospitals based on the data of
the 309 rural units and 75 rural
hospitals in our database of 1,626 IPFs
for which data were available.
Therefore, the Secretary has determined
that this final rule will not have a
significant impact on the operations of
a substantial number of small rural
hospitals.
Section 202 of the Unfunded
Mandates Reform Act of 1995 (UMRA)
also requires that agencies assess
anticipated costs and benefits before
issuing any rule whose mandates
require spending in any 1 year of $100
million in 1995 dollars, updated
annually for inflation. In 2014, that
threshold is approximately $141
million. This final rule will not impose
spending costs on state, local, or tribal
governments in the aggregate, or by the
private sector, of $141 million.

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45981

Executive Order 13132 establishes
certain requirements that an agency
must meet when it promulgates a
proposed rule (and subsequent final
rule) that imposes substantial direct
requirement costs on state and local
governments, preempts state law, or
otherwise has Federalism implications.
As stated above, this final rule will not
have a substantial effect on state and
local governments.
C. Anticipated Effects
We discuss the historical background
of the IPF PPS and the impact of this
final rule on the Federal Medicare
budget and on IPFs.
1. Budgetary Impact
As discussed in the November 2004
and May 2006 IPF PPS final rules, we
applied a budget neutrality factor to the
Federal per diem and ECT base rates to
ensure that total estimated payments
under the IPF PPS in the
implementation period would equal the
amount that would have been paid if the
IPF PPS had not been implemented. The
budget neutrality factor includes the
following components: Outlier
adjustment, stop-loss adjustment, and
the behavioral offset. As discussed in
the May 2008 IPF PPS notice (73 FR
25711), the stop-loss adjustment is no
longer applicable under the IPF PPS.
In accordance with § 412.424(c)(3)(ii),
we indicated that we will evaluate the
accuracy of the budget neutrality
adjustment within the first 5 years after
implementation of the payment system.
We may make a one-time prospective
adjustment to the Federal per diem and
ECT base rates to account for differences
between the historical data on costbased TEFRA payments (the basis of the
budget neutrality adjustment) and
estimates of TEFRA payments based on
actual data from the first year of the IPF
PPS. As part of that process, we will
reassess the accuracy of all of the factors
impacting budget neutrality. In
addition, as discussed in section VII.C.1
of this final rule, we are using the wage
index and labor-related share in a
budget neutral manner by applying a
wage index budget neutrality factor to
the Federal per diem and ECT base
rates. Therefore, the budgetary impact to
the Medicare program of this final rule
will be due to the market basket update
for FY 2015 of 2.9 percent (see section
V.B. of this final rule) less the
productivity adjustment of 0.5
percentage point required by section
1886 (s)(2)(A)(i) of the Act, less the
‘‘other adjustment’’ of 0.3 percentage
point under sections 1886(s)(2)(A)(ii)
and 1886 (s)(3)(C) of the Act, and the

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update to the outlier fixed dollar loss
threshold amount.
We estimate that the FY 2015 impact
will be a net increase of $120 million in
payments to IPF providers. This reflects
an estimated $100 million increase from
the update to the payment rates and a
$20 million increase due to the update
to the outlier threshold amount to
increase outlier payments from
approximately 1.6 percent in FY 2014 to
2.0 percent in FY 2015. This estimate
does not include the implementation of
the required 2 percentage point
reduction of the market basket increase
factor for any IPF that fails to meet the
IPF quality reporting requirements (as
discussed in section 4 below).
2. Impact on Providers
To understand the impact of the
changes to the IPF PPS on providers,
discussed in this final rule, it is
necessary to compare estimated
payments under the IPF PPS rates and
factors for FY 2015 versus those under
FY 2014. The estimated payments for
FY 2014 and FY 2015 will be 100
percent of the IPF PPS payment, since
the transition period has ended and
stop-loss payments are no longer paid.

We determined the percent change of
estimated FY 2015 IPF PPS payments to
FY 2014 IPF PPS payments for each
category of IPFs. In addition, for each
category of IPFs, we have included the
estimated percent change in payments
resulting from the update to the outlier
fixed dollar loss threshold amount, the
labor-related share and wage index
changes for the FY 2015 IPF PPS, and
the market basket update for FY 2015,
as adjusted by the productivity
adjustment according to section
1886(s)(2)(A)(i), and the ‘‘other
adjustment’’ according to sections
1886(s)(2)(A)(ii) and 1886(s)(3)(C) of the
Act.
To illustrate the impacts of the FY
2015 changes in this final rule, our
analysis begins with a FY 2014 baseline
simulation model based on FY 2013 IPF
payments inflated to the midpoint of FY
2014 using IHS Global Insight Inc.’s
most recent forecast of the market basket
update (see section IV.C. of this final
rule); the estimated outlier payments in
FY 2014; the CBSA designations for
IPFs based on OMB’s MSA definitions
after June 2003; the FY 2013 pre-floor,
pre-reclassified hospital wage index; the
FY 2014 labor-related share; and the FY

2014 percentage amount of the rural
adjustment. During the simulation, the
total estimated outlier payments are
maintained at 2 percent of total IPF PPS
payments.
Each of the following changes is
added incrementally to this baseline
model in order for us to isolate the
effects of each change:
• The update to the outlier fixed
dollar loss threshold amount.
• The FY 2014 pre-floor, prereclassified hospital wage index and FY
2015 labor-related share.
• The market basket update for FY
2015 of 2.9 percent less the productivity
adjustment of 0.5 percentage point
reduction in accordance with section
1886(s)(2)(A)(i) of the Act and less the
‘‘other adjustment’’ of 0.3 percentage
point in accordance with sections
1886(s)(2)(A)(ii) and 1886(s)(3)(C) of the
Act.
Our final comparison illustrates the
percent change in payments from FY
2014 (that is, October 1, 2013, to
September 30, 2014) to FY 2015 (that is,
October 1, 2014, to September 30, 2015)
including all the changes in this final
rule.

TABLE 21—IPF IMPACT TABLE FOR FY 2015

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[Projected impacts (% change in columns 3–6)]
Facility by type

Number of
facilities

Outlier

CBSA wage
index &
labor share

Adjusted
market basket
update 1

Total
percent
change 2

(1)

(2)

(3)

(4)

(5)

(6)

All Facilities: .........................................................................
Total Urban ...................................................................
Total Rural ....................................................................
Urban unit ............................................................................
Urban hospital ......................................................................
Rural unit ..............................................................................
Rural hospital .......................................................................
By Type of Ownership:
Freestanding IPFs:
Urban Psychiatric Hospitals:
Government ...........................................................
Non-Profit ...............................................................
For-Profit ................................................................
Rural Psychiatric Hospitals:
Government ...........................................................
Non-Profit ...............................................................
For-Profit ................................................................
IPF Units:
Urban:
Government ...........................................................
Non-Profit ...............................................................
For-Profit ................................................................
Rural:
Government ...........................................................
Non-Profit ...............................................................
For-Profit ................................................................
By Teaching Status:
Non-teaching .................................................................
Less than 10% interns and residents to beds ..............
10% to 30% interns and residents to beds ..................
More than 30% interns and residents to beds .............
By Region:

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1,626
1,242
384
827
415
309
75

0.4
0.4
0.3
0.6
0.2
0.4
0.2

0.0
0.0
¥0.1
0.1
0.0
¥0.1
¥0.3

2.1
2.1
2.1
2.1
2.1
2.1
2.1

2.5
2.5
2.3
2.7
2.2
2.4
2.0

129
99
187

0.4
0.3
0.0

¥0.1
0.2
¥0.2

2.1
2.1
2.1

2.4
2.6
2.0

37
13
25

0.3
0.2
0.0

0.2
¥0.1
¥0.7

2.1
2.1
2.1

2.7
2.2
1.4

125
546
156

0.8
0.6
0.3

0.1
0.1
¥0.1

2.1
2.1
2.1

3.0
2.8
2.3

76
168
65

0.3
0.4
0.4

¥0.1
¥0.1
0.0

2.1
2.1
2.1

2.3
2.4
2.6

1,426
109
65
26

0.3
0.5
0.8
1.0

0.0
0.2
¥0.1
0.5

2.1
2.1
2.1
2.1

2.4
2.8
2.9
3.7

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45983

TABLE 21—IPF IMPACT TABLE FOR FY 2015—Continued
[Projected impacts (% change in columns 3–6)]
Facility by type

Number of
facilities

Outlier

CBSA wage
index &
labor share

Adjusted
market basket
update 1

Total
percent
change 2

(1)

(2)

(3)

(4)

(5)

(6)

New England ................................................................
Mid-Atlantic ...................................................................
South Atlantic ................................................................
East North Central ........................................................
East South Central .......................................................
West North Central .......................................................
West South Central ......................................................
Mountain .......................................................................
Pacific ...........................................................................
By Bed Size:
Psychiatric Hospitals:
Beds: 0–24 ............................................................
Beds: 25–49 ..........................................................
Beds: 50–75 ..........................................................
Beds: 76 + .............................................................
Psychiatric Units:
Beds: 0–24 ............................................................
Beds: 25–49 ..........................................................
Beds: 50–75 ..........................................................
Beds: 76 + .............................................................

109
250
235
260
165
144
238
103
122

0.6
0.4
0.3
0.4
0.3
0.4
0.2
0.3
0.6

0.1
0.6
¥0.3
¥0.2
¥0.3
¥0.3
¥0.4
¥0.3
0.9

2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1

2.8
3.1
2.1
2.3
2.2
2.3
1.9
2.1
3.7

88
67
87
248

0.1
0.1
0.2
0.2

¥0.3
¥0.1
¥0.1
0.0

2.1
2.1
2.1
2.1

2.0
2.1
2.2
2.2

677
298
102
59

0.6
0.5
0.4
0.6

0.0
¥0.1
0.0
0.4

2.1
2.1
2.1
2.1

2.7
2.6
2.6
3.1

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1 This column reflects the payment update impact of the RPL market basket update for FY 2015 of 2.9 percent, a 0.5 percentage point reduction for the productivity adjustment as required by section 1886(s)(2)(A)(i) of the Act, and a 0.3 percentage point reduction in accordance with
sections 1886(s)(2)(A)(ii) and 1886(s)(3)(C) of the Act.
2 Percent changes in estimated payments from FY 2014 to FY 2015 include all of the changes presented in this proposed rule. Note, the products of these impacts may be different from the percentage changes shown here due to rounding effects.

3. Results
Table 21 above displays the results of
our analysis. The table groups IPFs into
the categories listed below based on
characteristics provided in the Provider
of Services (POS) file, the IPF provider
specific file, and cost report data from
HCRIS:
• Facility Type
• Location
• Teaching Status Adjustment
• Census Region
• Size
The top row of the table shows the
overall impact on the 1,626 IPFs
included in this analysis.
In column 3, we present the effects of
the update to the outlier fixed dollar
loss threshold amount. We estimate that
IPF outlier payments as a percentage of
total IPF payments are 1.6 percent in FY
2014. Thus, we are adjusting the outlier
threshold amount in this final rule to set
total estimated outlier payments equal
to 2 percent of total payments in FY
2015. The estimated change in total IPF
payments for FY 2015, therefore,
includes an approximate 0.4 percent
increase in payments because the outlier
portion of total payments is expected to
increase from approximately 1.6 percent
to 2 percent.
The overall impact of this outlier
adjustment update (as shown in column
3 of table 21), across all hospital groups,

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is to increase total estimated payments
to IPFs by 0.4 percent. We do not
estimate that any group of IPFs will
experience a decrease in payments from
this update. The largest increase in
payments is estimated to reflect a 1
percent increase in payments for IPFs
located in teaching hospitals with an
intern and resident ADC ratio greater
than 30 percent.
In column 4, we present the effects of
the budget-neutral update to the laborrelated share and the wage index
adjustment under the CBSA geographic
area definitions announced by OMB in
June 2003. This is a comparison of the
simulated FY 2015 payments under the
FY 2014 hospital wage index under
CBSA classification and associated
labor-related share to the simulated FY
2014 payments under the FY 2013
hospital wage index under CBSA
classifications and associated laborrelated share. We note that there is no
projected change in aggregate payments
to IPFs, as indicated in the first row of
column 4. However, there will be small
distributional effects among different
categories of IPFs. For example, we
estimate the largest increase in
payments to be a 0.9 percent increase
for IPFs in the Pacific region and the
largest decrease in payments to be a 0.7
percent decrease for rural for-profit
IPFs.

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Column 5 shows the estimated effect
of the update to the IPF PPS payment
rates, which includes a 2.9 percent
market basket update less the
productivity adjustment of 0.5
percentage point in accordance with
section 1886(s)(2)(A)(i), and less the 0.3
percentage point in accordance with
section 1886(s)(2)(A)(ii) and
1886(s)(3)(C).
Column 6 compares our estimates of
the total changes reflected in this final
rule for FY 2015, to our payments for FY
2014 (without these changes). This
column reflects all FY 2015 changes
relative to FY 2014. The average
estimated increase for all IPFs is
approximately 2.5 percent. This
estimated net increase includes the
effects of the 2.9 percent market basket
update adjusted by the productivity
adjustment of minus 0.5 percentage
point, as required by section
1886(s)(2)(A)(i) of the Act and the
‘‘other adjustment’’ of minus 0.3
percentage point, as required by
sections 1886(s)(2)(A)(ii) and
1886(s)(3)(C) of the Act. It also includes
the overall estimated 0.4 percent
increase in payments from the update to
the outlier fixed dollar loss threshold
amount. Since we are making the
updates to the IPF labor-related share
and wage index in a budget-neutral
manner, they will not affect total

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estimated IPF payments in the
aggregate. However, they will affect the
estimated distribution of payments
among providers.
Overall, no IPFs are estimated to
experience a net decrease in payments
as a result of the updates in this final
rule. IPFs in urban areas will experience
a 2.5 percent increase and IPFs in rural
areas will experience a 2.3 percent
increase. The largest payment increase
is estimated at 3.7 percent for IPFs
located in teaching hospitals with an
intern and resident ADC ratio greater
than 30 percent and IPFs in the Pacific
region. This is due to the larger than
average positive effect of the CBSA wage
index and labor-related share updates
and the higher volume of outlier
payments for IPFs in these categories.
4. Effects of Updates to the IPF QRP
As discussed in section V.B. of this
final rule and in accordance with
section 1886(s)(4)(A)(ii) of the Act, we
will implement a 2 percentage point
reduction in the FY 2015 increase factor
for IPFs that have failed to report the
required quality reporting data to us
during the most recent IPF quality
reporting period. In section V.B. of this
final rule, we discuss how the 2
percentage point reduction will be
applied. Only a few IPFs received the 2
percentage point reduction in the FY
2014 increase factor for failure to meet
program requirements, and we will
anticipate that even fewer IPFs would
receive the reduction for FY 2015 as
IPFs become more familiar with the
requirements. Thus, we estimate that
this policy will have a negligible impact
on overall IPF payments for FY 2015.
For the FY 2016 payment
determination, we estimate no
additional burden on IPFs as a result of
changes in reporting requirements. For

the FY 2017 payment determination, we
estimate an additional annual burden
across all 1,626 IPFs of 701,619 hours,
with a total Program cost of
$44,496,677. This estimate includes an
estimated 3,252 hours annually for
training, at an estimated annual cost of
$206,241. It also includes an estimated
4,065 hours annually, at an estimated
annual cost of $257,802, for IPFs to
submit to CMS aggregate population
counts for Medicare and non-Medicare
discharges by age group, diagnostic
group, and quarter, and sample size
counts for measures for which sampling
is performed. Further discussion of
these figures can be found in section IX.
For the FY 2017 payment
determination, the applicable reporting
period is calendar year (CY) 2015.
Assuming that reporting costs are
uniformly distributed across the year,
three-quarters of those costs would have
been incurred in FY 2015, which ends
on September 30, 2015. Therefore, the
estimated FY 2015 burden for IPFs will
be three-quarters of $44,496,677, or
approximately $33,372,508.
We intend to closely monitor the
effects of this new quality reporting
program on IPF providers and help
facilitate successful reporting outcomes
through ongoing stakeholder education,
national trainings, and a technical help
desk.
5. Effect on Beneficiaries
Under the IPF PPS, IPFs will receive
payment based on the average resources
consumed by patients for each day. We
do not expect changes in the quality of
care or access to services for Medicare
beneficiaries under the FY 2015 IPF PPS
but we continue to expect that paying
prospectively for IPF services would
enhance the efficiency of the Medicare
program.

D. Alternatives Considered
The statute does not specify an update
strategy for the IPF PPS and is broadly
written to give the Secretary discretion
in establishing an update methodology.
Therefore, we are updating the IPF PPS
using the methodology published in the
November 2004 IPF PPS final rule. No
alternative policy options were
considered in this final rule since this
final rule simply provides an update to
the rates for FY 2015 and transition
ICD–9–CM codes to ICD–10–CM codes.
Additionally, for the IPFQR Program,
alternatives were not considered
because the Program, as designed, best
achieves quality reporting goals for the
inpatient psychiatric care setting, while
minimizing associated reporting
burdens on IPFs. Lastly, sections VIII.1.
and VIII.4. discuss other benefits and
objectives of the Program.
E. Accounting Statement
As required by OMB Circular A–4
(available at http://
www.whitehouse.gov/omb/circulars_
a004_a-4), in Table 22 below, we have
prepared an accounting statement
showing the classification of the
expenditures associated with the
provisions of this final rule. The costs
for data submission presented in Table
22 are calculated in section IX, which
also discusses the benefits of data
collection. This table provides our best
estimate of the increase in Medicare
payments under the IPF PPS as a result
of the changes presented in this final
rule and based on the data for 1,626
IPFs in our database. Furthermore, we
present the estimated costs associated
with updating the IPFQR program. The
increases in Medicare payments are
classified as Federal transfers to IPF
Medicare providers.

TABLE 22—ACCOUNTING STATEMENT—CLASSIFICATION OF ESTIMATED EXPENDITURES
Category

Transfers

Change in Estimated Transfers from FY 2014 IPF PPS to FY 2015 IPF PPS
Annualized Monetized Transfers ..............................................................................
From Whom to Whom? ............................................................................................

$120 million.
Federal Government to IPF Medicare providers.

FY 2015 Costs to updating the Quality Reporting Program for IPFs
Category

Costs

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Annualized Monetized Costs for IPFs to Submit Data (Quality Reporting Program).

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33,372,508.

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In accordance with the provisions of
Executive Order 12866, this final rule
was reviewed by the Office of
Management and Budget.
Dated: July 24, 2014
Marilyn Tavenner,
Administrator, Centers for Medicare &
Medicaid Services.
Approved: July 30, 2014.
Sylvia M. Burwell,
Secretary.

Addendum A—Rate and Adjustment
Factors

PER DIEM RATE
Federal Per Diem Base Rate .......
Labor Share (0.69294) .................
Non-Labor Share (0.30706) .........

$728.31
504.68
223.63

PER DIEM RATE APPLYING THE 2
PERCENTAGE POINT REDUCTION

Note: The following Addenda will not
appear in the Code of Federal Regulations.

Federal Per Diem Base Rate .......

PER DIEM RATE APPLYING THE 2 PERCENTAGE POINT REDUCTION—Continued
Labor Share (0.69294) .................
Non-Labor Share (0.30706) .........

494.79
219.26

Fixed Dollar Loss Threshold Amount:
$8,755
Wage Index Budget-Neutrality Factor:
1.0002

$714.05

FACILITY ADJUSTMENTS
Rural Adjustment Factor ......................................................................................................................
Teaching Adjustment Factor ................................................................................................................
Wage Index ..........................................................................................................................................

COST OF LIVING ADJUSTMENTS
(COLAS)
Area

PATIENT ADJUSTMENTS—Continued

Cost of
living
adjustment
factor

Alaska:
City of Anchorage and 80-kilometer (50-mile) radius by
road ...................................
City of Fairbanks and 80-kilometer (50-mile) radius by
road ...................................
City of Juneau and 80-kilometer (50-mile) radius by
road ...................................
Rest of Alaska .......................
Hawaii:
City and County of Honolulu .................................
County of Hawaii ...............
County of Kauai .................
County of Maui and County of Kalawao .................

1.23
1.23
1.23
1.25
1.25
1.19
1.25
1.25

$313.55

VARIABLE PER DIEM ADJUSTMENTS—
Continued
Adjustment
factor

307.41

VARIABLE PER DIEM ADJUSTMENTS
Adjustment
factor

PATIENT ADJUSTMENTS
ECT—Per Treatment ................

ECT—Per Treatment Applying
the 2 Percentage Point Reduction ...................................

1.17.
0.5150.
Pre-reclass Hospital Wage Index (FY2014).

Day 1—Facility Without a
Qualifying Emergency Department ..............................
Day 1—Facility With a Qualifying Emergency Department ....................................
Day 2 ......................................
Day 3 ......................................
Day 4 ......................................
Day 5 ......................................
Day 6 ......................................
Day 7 ......................................
Day 8 ......................................
Day 9 ......................................
Day 10 ....................................
Day 11 ....................................
Day 12 ....................................
Day 13 ....................................
Day 14 ....................................

1.19
1.31
1.12
1.08
1.05
1.04
1.02
1.01
1.01
1.00
1.00
0.99
0.99
0.99
0.99

Day 15 ....................................
Day 16 ....................................
Day 17 ....................................
Day 18 ....................................
Day 19 ....................................
Day 20 ....................................
Day 21 ....................................
After Day 21 ...........................

0.98
0.97
0.97
0.96
0.95
0.95
0.95
0.92

AGE ADJUSTMENTS
Age
(in years)
Under 45 .................................
45 and under 50 .....................
50 and under 55 .....................
55 and under 60 .....................
60 and under 65 .....................
65 and under 70 .....................
70 and under 75 .....................
75 and under 80 .....................
80 and over ............................

Adjustment
factor
1.00
1.01
1.02
1.04
1.07
1.10
1.13
1.15
1.17

DRG ADJUSTMENTS
MS–DRG descriptions

Adjustment
factor

Degenerative nervous system disorders w MCC .........................................................................................................
Degenerative nervous system disorders w/o MCC ......................................................................................................
Nontraumatic stupor & coma w MCC ...........................................................................................................................
Nontraumatic stupor & coma w/o MCC ........................................................................................................................
O.R. procedure w principal diagnoses of mental illness ..............................................................................................
Acute adjustment reaction & psychosocial dysfunction ...............................................................................................
Depressive neuroses ....................................................................................................................................................
Neuroses except depressive ........................................................................................................................................
Disorders of personality & impulse control ...................................................................................................................
Organic disturbances & mental retardation ..................................................................................................................
Psychoses .....................................................................................................................................................................
Behavioral & developmental disorders .........................................................................................................................
Other mental disorder diagnoses .................................................................................................................................
Alcohol/drug abuse or dependence, left AMA ..............................................................................................................
Alcohol/drug abuse or dependence w rehabilitation therapy .......................................................................................
Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC .......................................................................

1.05
........................
1.07
........................
1.22
1.05
0.99
1.02
1.02
1.03
1.00
0.99
0.92
0.97
1.02
0.88

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MS–DRG
056
057
080
081
876
880
881
882
883
884
885
886
887
894
895
896

............
............
............
............
............
............
............
............
............
............
............
............
............
............
............
............

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DRG ADJUSTMENTS—Continued

MS–DRG

MS–DRG descriptions

Adjustment
factor

897 ............

Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC ....................................................................

........................

COMORBIDITY ADJUSTMENTS
Adjustment
factor

Comorbidity
Developmental Disabilities ...................................................................................................................................................................
Coagulation Factor Deficit ...................................................................................................................................................................
Tracheostomy ......................................................................................................................................................................................
Eating and Conduct Disorders ............................................................................................................................................................
Infectious Diseases ..............................................................................................................................................................................
Renal Failure, Acute ............................................................................................................................................................................
Renal Failure, Chronic .........................................................................................................................................................................
Oncology Treatment ............................................................................................................................................................................
Uncontrolled Diabetes Mellitus ............................................................................................................................................................
Severe Protein Malnutrition .................................................................................................................................................................
Drug/Alcohol Induced Mental Disorders ..............................................................................................................................................
Cardiac Conditions ..............................................................................................................................................................................
Gangrene .............................................................................................................................................................................................
Chronic Obstructive Pulmonary Disease .............................................................................................................................................
Artificial Openings—Digestive & Urinary .............................................................................................................................................
Severe Musculoskeletal & Connective Tissue Diseases ....................................................................................................................
Poisoning .............................................................................................................................................................................................

Addendum B—FY 2015 CBSA Wage
Index Tables
In this addendum, we provide the wage
index tables referred to in the preamble to

this final rule. The tables presented below are
as follows:
Table 1–FY 2015 Wage Index For Urban
Areas Based on CBSA Labor Market Areas.

1.04
1.13
1.06
1.12
1.07
1.11
1.11
1.07
1.05
1.13
1.03
1.11
1.10
1.12
1.08
1.09
1.11

Table 2–FY 2015 Wage Index Based On
CBSA Labor Market Areas For Rural Areas.

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS
CBSA Code

Urban area
(constituent counties)

10180 ........................

Abilene, TX ...........................................................................................................................................................
Callahan County, TX.
Jones County, TX.
Taylor County, TX.
Aguadilla-Isabela-San Sebastia´n, PR ..................................................................................................................
Aguada Municipio, PR.
Aguadilla Municipio, PR.
An˜asco Municipio, PR.
Isabela Municipio, PR.
Lares Municipio, PR.
Moca Municipio, PR.
Rinco´n Municipio, PR.
San Sebastia´n Municipio, PR.
Akron, OH .............................................................................................................................................................
Portage County, OH.
Summit County, OH.
Albany, GA ...........................................................................................................................................................
Baker County, GA.
Dougherty County, GA.
Lee County, GA.
Terrell County, GA.
Worth County, GA.
Albany-Schenectady-Troy, NY .............................................................................................................................
Albany County, NY.
Rensselaer County, NY.
Saratoga County, NY.
Schenectady County, NY.
Schoharie County, NY.
Albuquerque, NM ..................................................................................................................................................
Bernalillo County, NM.
Sandoval County, NM.
Torrance County, NM.
Valencia County, NM.

10380 ........................

10420 ........................
10500 ........................

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10580 ........................

10740 ........................

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06AUR3

0.8225

0.3647

0.8521
0.8713

0.8600

0.9663

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

45987

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA Code

Urban area
(constituent counties)

10780 ........................

Alexandria, LA ......................................................................................................................................................
Grant Parish, LA.
Rapides Parish, LA.
Allentown-Bethlehem-Easton, PA-NJ ...................................................................................................................
Warren County, NJ.
Carbon County, PA.
Lehigh County, PA.
Northampton County, PA.
Altoona, PA ...........................................................................................................................................................
Blair County, PA.
Amarillo, TX ..........................................................................................................................................................
Armstrong County, TX.
Carson County, TX.
Potter County, TX.
Randall County, TX.
Ames, IA ...............................................................................................................................................................
Story County, IA.
Anchorage, AK .....................................................................................................................................................
Anchorage Municipality, AK.
Matanuska-Susitna Borough, AK.
Anderson, IN .........................................................................................................................................................
Madison County, IN.
Anderson, SC .......................................................................................................................................................
Anderson County, SC.
Arbor, MI ...............................................................................................................................................................
Washtenaw County, MI.
Anniston-Oxford, AL .............................................................................................................................................
Calhoun County, AL.
Appleton, WI .........................................................................................................................................................
Calumet County, WI.
Outagamie County, WI.
Asheville, NC ........................................................................................................................................................
Buncombe County, NC.
Haywood County, NC.
Henderson County, NC.
Madison County, NC.
Athens-Clarke County, GA ...................................................................................................................................
Clarke County, GA.
Madison County, GA.
Oconee County, GA.
Oglethorpe County, GA.
Atlanta-Sandy Springs-Marietta, GA ....................................................................................................................
Barrow County, GA.
Bartow County, GA.
Butts County, GA.
Carroll County, GA.
Cherokee County, GA.
Clayton County, GA.
Cobb County, GA.
Coweta County, GA.
Dawson County, GA.
DeKalb County, GA.
Douglas County, GA.
Fayette County, GA.
Forsyth County, GA.
Fulton County, GA.
Gwinnett County, GA.
Haralson County, GA.
Heard County, GA.
Henry County, GA.
Jasper County, GA.
Lamar County, GA.
Meriwether County, GA.
Newton County, GA.
Paulding County, GA.
Pickens County, GA.
Pike County, GA.
Rockdale County, GA.
Spalding County, GA.
Walton County, GA.
Atlantic City-Hammonton, NJ ...............................................................................................................................

10900 ........................

11020 ........................
11100 ........................

11180 ........................
11260 ........................
11300 ........................
11340 ........................
11460 ........................
11500 ........................
11540 ........................
11700 ........................

12020 ........................

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12060 ........................

12100 ........................

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0.7788
0.9215

0.9101
0.8302

0.9425
1.2221
0.9654
0.8766
1.0086
0.7402
0.9445
0.8511

0.9244

0.9452

1.2258

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TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

12220 ........................
12260 ........................

12420 ........................

12540 ........................
12580 ........................

12620 ........................
12700 ........................
12940 ........................

12980 ........................
13020 ........................
13140 ........................

13380 ........................
13460 ........................
13644 ........................
13740 ........................
13780 ........................

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13820 ........................

13900 ........................

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Wage
index

Atlantic County, NJ.
Auburn-Opelika, AL ..............................................................................................................................................
Lee County, AL.
Augusta-Richmond County, GA-SC .....................................................................................................................
Burke County, GA.
Columbia County, GA.
McDuffie County, GA.
Richmond County, GA.
Aiken County, SC.
Edgefield County, SC.
Austin-Round Rock-San Marcos, TX ...................................................................................................................
Bastrop County, TX.
Caldwell County, TX.
Hays County, TX.
Travis County, TX.
Williamson County, TX.
Bakersfield-Delano, CA ........................................................................................................................................
Kern County, CA.
Baltimore-Towson, MD .........................................................................................................................................
Anne Arundel County, MD.
Baltimore County, MD.
Carroll County, MD.
Harford County, MD.
Howard County, MD.
Queen Anne’s County, MD.
Baltimore City, MD.
Bangor, ME ...........................................................................................................................................................
Penobscot County, ME.
Barnstable Town, MA ...........................................................................................................................................
Barnstable County, MA.
Baton Rouge, LA ..................................................................................................................................................
Ascension Parish, LA.
East Baton Rouge Parish, LA.
East Feliciana Parish, LA.
Iberville Parish, LA.
Livingston Parish, LA.
Pointe Coupee Parish, LA.
St. Helena Parish, LA.
West Baton Rouge Parish, LA.
West Feliciana Parish, LA.
Battle Creek, MI ....................................................................................................................................................
Calhoun County, MI.
Bay City, MI ..........................................................................................................................................................
Bay County, MI.
Beaumont-Port Arthur, TX ....................................................................................................................................
Hardin County, TX.
Jefferson County, TX.
Orange County, TX.
Bellingham, WA ....................................................................................................................................................
Whatcom County, WA.
Bend, OR ..............................................................................................................................................................
Deschutes County, OR.
Bethesda-Rockville-Frederick, MD .......................................................................................................................
Frederick County, MD.
Montgomery County, MD.
Billings, MT ...........................................................................................................................................................
Carbon County, MT.
Yellowstone County, MT.
Binghamton, NY ...................................................................................................................................................
Broome County, NY.
Tioga County, NY.
Birmingham-Hoover, AL .......................................................................................................................................
Bibb County, AL.
Blount County, AL.
Chilton County, AL.
Jefferson County, AL.
St. Clair County, AL.
Shelby County, AL.
Walker County, AL.
Bismarck, ND ........................................................................................................................................................
Burleigh County, ND.

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0.7771
0.9150

0.9576

1.1579
0.9873

0.9710
1.3007
0.8078

0.9915
0.9486
0.8598

1.1890
1.1807
1.0319
0.8691
0.8602
0.8367

0.7282

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TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

13980 ........................

14020 ........................

14060 ........................
14260 ........................

14484 ........................

14500 ........................
14540 ........................
14740 ........................
14860 ........................
15180 ........................
15260 ........................

15380 ........................
15500 ........................
15540 ........................

15764 ........................
15804 ........................

15940 ........................
15980 ........................
16020 ........................

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16180 ........................
16220 ........................
16300 ........................

16580 ........................

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Wage
index

Morton County, ND.
Blacksburg-Christiansburg-Radford, VA ...............................................................................................................
Giles County, VA.
Montgomery County, VA.
Pulaski County, VA.
Radford City, VA.
Bloomington, IN ....................................................................................................................................................
Greene County, IN.
Monroe County, IN.
Owen County, IN.
Bloomington-Normal, IL ........................................................................................................................................
McLean County, IL.
Boise City-Nampa, ID ...........................................................................................................................................
Ada County, ID.
Boise County, ID.
Canyon County, ID.
Gem County, ID.
Owyhee County, ID.
Boston-Quincy, MA ...............................................................................................................................................
Norfolk County, MA.
Plymouth County, MA.
Suffolk County, MA.
Boulder, CO ..........................................................................................................................................................
Boulder County, CO.
Bowling Green, KY ...............................................................................................................................................
Edmonson County, KY.
Warren County, KY.
Bremerton-Silverdale, WA ....................................................................................................................................
Kitsap County, WA.
Bridgeport-Stamford-Norwalk, CT ........................................................................................................................
Fairfield County, CT.
Brownsville-Harlingen, TX ....................................................................................................................................
Cameron County, TX.
Brunswick, GA ......................................................................................................................................................
Brantley County, GA.
Glynn County, GA.
McIntosh County, GA.
Buffalo-Niagara Falls, NY .....................................................................................................................................
Erie County, NY.
Niagara County, NY.
Burlington, NC ......................................................................................................................................................
Alamance County, NC.
Burlington-South Burlington, VT ...........................................................................................................................
Chittenden County, VT.
Franklin County, VT.
Grand Isle County, VT.
Cambridge-Newton-Framingham, MA ..................................................................................................................
Middlesex County, MA.
Camden, NJ ..........................................................................................................................................................
Burlington County, NJ.
Camden County, NJ.
Gloucester County, NJ.
Canton-Massillon, OH ..........................................................................................................................................
Carroll County, OH.
Stark County, OH.
Cape Coral-Fort Myers, FL ...................................................................................................................................
Lee County, FL.
Cape Girardeau-Jackson, MO-IL ..........................................................................................................................
Alexander County, IL.
Bollinger County, MO.
Cape Girardeau County, MO.
Carson City, NV ....................................................................................................................................................
Carson City, NV.
Casper, WY ..........................................................................................................................................................
Natrona County, WY.
Cedar Rapids, IA ..................................................................................................................................................
Benton County, IA.
Jones County, IA.
Linn County, IA.
Champaign-Urbana, IL .........................................................................................................................................
Champaign County, IL.

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1.2453

0.9850
0.8573
1.0268
1.3252
0.8179
0.8457

1.0045
0.8529
1.0130

1.1146
1.0254

0.8730
0.8683
0.9174

1.0721
1.0111
0.8964

0.9416

45990

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

16620 ........................

16700 ........................

16740 ........................

16820 ........................

16860 ........................

16940 ........................
16974 ........................

17020 ........................
17140 ........................

tkelley on DSK3SPTVN1PROD with RULES3

17300 ........................

17420 ........................
17460 ........................

VerDate Mar<15>2010

Wage
index

Ford County, IL.
Piatt County, IL.
Charleston, WV ....................................................................................................................................................
Boone County, WV.
Clay County, WV.
Kanawha County, WV.
Lincoln County, WV.
Putnam County, WV.
Charleston-North Charleston-Summerville, SC ....................................................................................................
Berkeley County, SC.
Charleston County, SC.
Dorchester County, SC.
Charlotte-Gastonia-Rock Hill, NC-SC ...................................................................................................................
Anson County, NC.
Cabarrus County, NC.
Gaston County, NC.
Mecklenburg County, NC.
Union County, NC.
York County, SC.
Charlottesville, VA ................................................................................................................................................
Albemarle County, VA.
Fluvanna County, VA.
Greene County, VA.
Nelson County, VA.
Charlottesville City, VA.
Chattanooga, TN-GA ............................................................................................................................................
Catoosa County, GA.
Dade County, GA.
Walker County, GA.
Hamilton County, TN.
Marion County, TN.
Sequatchie County, TN.
Cheyenne, WY .....................................................................................................................................................
Laramie County, WY.
Chicago-Naperville-Joliet, IL .................................................................................................................................
Cook County, IL.
DeKalb County, IL.
DuPage County, IL.
Grundy County, IL.
Kane County, IL.
Kendall County, IL.
McHenry County, IL.
Will County, IL.
Chico, CA .............................................................................................................................................................
Butte County, CA.
Cincinnati-Middletown, OH-KY-IN ........................................................................................................................
Dearborn County, IN.
Franklin County, IN.
Ohio County, IN.
Boone County, KY.
Bracken County, KY.
Campbell County, KY.
Gallatin County, KY.
Grant County, KY.
Kenton County, KY.
Pendleton County, KY.
Brown County, OH.
Butler County, OH.
Clermont County, OH.
Hamilton County, OH.
Warren County, OH.
Clarksville, TN-KY ................................................................................................................................................
Christian County, KY.
Trigg County, KY.
Montgomery County, TN.
Stewart County, TN.
Cleveland, TN .......................................................................................................................................................
Bradley County, TN.
Polk County, TN.
Cleveland-Elyria-Mentor, OH ................................................................................................................................
Cuyahoga County, OH.

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1.1616
0.9470

0.7802

0.7496
0.9303

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

45991

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

17660 ........................
17780 ........................

17820 ........................
17860 ........................
17900 ........................

17980 ........................

18020 ........................
18140 ........................

18580 ........................

18700 ........................
18880 ........................
19060 ........................
19124 ........................

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19140 ........................
19180 ........................
19260 ........................
19340 ........................

VerDate Mar<15>2010

Wage
index

Geauga County, OH.
Lake County, OH.
Lorain County, OH.
Medina County, OH.
Coeur d’Alene, ID .................................................................................................................................................
Kootenai County, ID.
College Station-Bryan, TX ....................................................................................................................................
Brazos County, TX.
Burleson County, TX.
Robertson County, TX.
Colorado Springs, CO ..........................................................................................................................................
El Paso County, CO.
Teller County, CO.
Columbia, MO .......................................................................................................................................................
Boone County, MO.
Howard County, MO.
Columbia, SC .......................................................................................................................................................
Calhoun County, SC.
Fairfield County, SC.
Kershaw County, SC.
Lexington County, SC.
Richland County, SC.
Saluda County, SC.
Columbus, GA-AL .................................................................................................................................................
Russell County, AL.
Chattahoochee County, GA.
Harris County, GA.
Marion County, GA.
Muscogee County, GA.
Columbus, IN ........................................................................................................................................................
Bartholomew County, IN.
Columbus, OH ......................................................................................................................................................
Delaware County, OH.
Fairfield County, OH.
Franklin County, OH.
Licking County, OH.
Madison County, OH.
Morrow County, OH.
Pickaway County, OH.
Union County, OH.
Corpus Christi, TX ................................................................................................................................................
Aransas County, TX.
Nueces County, TX.
San Patricio County, TX.
Corvallis, OR ........................................................................................................................................................
Benton County, OR.
Crestview-Fort Walton Beach-Destin, FL .............................................................................................................
Okaloosa County, FL.
Cumberland, MD-WV ............................................................................................................................................
Allegany County, MD.
Mineral County, WV.
Dallas-Plano-Irving, TX .........................................................................................................................................
Collin County, TX.
Dallas County, TX.
Delta County, TX.
Denton County, TX.
Ellis County, TX.
Hunt County, TX.
Kaufman County, TX.
Rockwall County, TX.
Dalton, GA ............................................................................................................................................................
Murray County, GA.
Whitfield County, GA.
Danville, IL ............................................................................................................................................................
Vermilion County, IL.
Danville, VA ..........................................................................................................................................................
Pittsylvania County, VA.
Danville City, VA.
Davenport-Moline-Rock Island, IA-IL ....................................................................................................................
Henry County, IL.
Mercer County, IL.

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0.9282
0.8196
0.8601

0.8170

0.9818
0.9803

0.8433

1.0596
0.8911
0.8054
0.9831

0.8625
0.9460
0.7888
0.9306

45992

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

19380 ........................

19460 ........................
19500 ........................
19660 ........................
19740 ........................

19780 ........................

19804 ........................
20020 ........................

20100 ........................
20220 ........................
20260 ........................

20500 ........................

20740 ........................
20764 ........................

20940 ........................

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21060 ........................
21140 ........................
21300 ........................
21340 ........................
21500 ........................

VerDate Mar<15>2010

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index

Rock Island County, IL.
Scott County, IA.
Dayton, OH ...........................................................................................................................................................
Greene County, OH.
Miami County, OH.
Montgomery County, OH.
Preble County, OH.
Decatur, AL ...........................................................................................................................................................
Lawrence County, AL.
Morgan County, AL.
Decatur, IL ............................................................................................................................................................
Macon County, IL.
Deltona-Daytona Beach-Ormond Beach, FL ........................................................................................................
Volusia County, FL.
Denver-Aurora-Broomfield, CO ............................................................................................................................
Adams County, CO.
Arapahoe County, CO.
Broomfield County, CO.
Clear Creek County, CO.
Denver County, CO.
Douglas County, CO.
Elbert County, CO.
Gilpin County, CO.
Jefferson County, CO.
Park County, CO.
Des Moines-West Des Moines, IA .......................................................................................................................
Dallas County, IA.
Guthrie County, IA.
Madison County, IA.
Polk County, IA.
Warren County, IA.
Detroit-Livonia-Dearborn, MI ................................................................................................................................
Wayne County, MI.
Dothan, AL ............................................................................................................................................................
Geneva County, AL.
Henry County, AL.
Houston County, AL.
Dover, DE .............................................................................................................................................................
Kent County, DE.
Dubuque, IA ..........................................................................................................................................................
Dubuque County, IA.
Duluth, MN-WI ......................................................................................................................................................
Carlton County, MN.
St. Louis County, MN.
Douglas County, WI.
Durham-Chapel Hill, NC .......................................................................................................................................
Chatham County, NC.
Durham County, NC.
Orange County, NC.
Person County, NC.
Eau Claire, WI ......................................................................................................................................................
Chippewa County, WI.
Eau Claire County, WI.
Edison-New Brunswick, NJ ..................................................................................................................................
Middlesex County, NJ.
Monmouth County, NJ.
Ocean County, NJ.
Somerset County, NJ.
El Centro, CA .......................................................................................................................................................
Imperial County, CA.
Elizabethtown, KY ................................................................................................................................................
Hardin County, KY.
Larue County, KY.
Elkhart-Goshen, IN ...............................................................................................................................................
Elkhart County, IN.
Elmira, NY ............................................................................................................................................................
Chemung County, NY.
El Paso, TX ..........................................................................................................................................................
El Paso County, TX.
Erie, PA ................................................................................................................................................................
Erie County, PA.

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0.9034

0.7165
0.8151
0.8560
1.0395

0.9393

0.9237
0.7108

0.9939
0.8790
1.0123

0.9669

1.0103
1.0985

0.8848
0.7894
0.9337
0.8725
0.8404
0.7940

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

45993

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA Code

Urban area
(constituent counties)

21660 ........................

Eugene-Springfield, OR ........................................................................................................................................
Lane County, OR.
Evansville, IN-KY ..................................................................................................................................................
Gibson County, IN.
Posey County, IN.
Vanderburgh County, IN.
Warrick County, IN.
Henderson County, KY.
Webster County, KY.
Fairbanks, AK .......................................................................................................................................................
Fairbanks North Star Borough, AK.
Fajardo, PR ..........................................................................................................................................................
Ceiba Municipio, PR.
Fajardo Municipio, PR.
Luquillo Municipio, PR.
Fargo, ND-MN ......................................................................................................................................................
Cass County, ND.
Clay County, MN.
Farmington, NM ....................................................................................................................................................
San Juan County, NM.
Fayetteville, NC ....................................................................................................................................................
Cumberland County, NC.
Hoke County, NC.
Fayetteville-Springdale-Rogers, AR-MO ..............................................................................................................
Benton County, AR.
Madison County, AR.
Washington County, AR.
McDonald County, MO.
Flagstaff, AZ .........................................................................................................................................................
Coconino County, AZ.
Flint, MI .................................................................................................................................................................
Genesee County, MI.
Florence, SC .........................................................................................................................................................
Darlington County, SC.
Florence County, SC.
Florence-Muscle Shoals, AL .................................................................................................................................
Colbert County, AL.
Lauderdale County, AL.
Fond du Lac, WI ...................................................................................................................................................
Fond du Lac County, WI.
Fort Collins-Loveland, CO ....................................................................................................................................
Larimer County, CO.
Fort Lauderdale-Pompano Beach-Deerfield, FL ..................................................................................................
Broward County, FL.
Fort Smith, AR-OK ...............................................................................................................................................
Crawford County, AR.
Franklin County, AR.
Sebastian County, AR.
Le Flore County, OK.
Sequoyah County, OK.
Fort Wayne, IN .....................................................................................................................................................
Allen County, IN.
Wells County, IN.
Whitley County, IN.
Fort Worth-Arlington, TX .......................................................................................................................................
Johnson County, TX.
Parker County, TX.
Tarrant County, TX.
Wise County, TX.
Fresno, CA ...........................................................................................................................................................
Fresno County, CA.
Gadsden, AL .........................................................................................................................................................
Etowah County, AL.
Gainesville, FL ......................................................................................................................................................
Alachua County, FL.
Gilchrist County, FL.
Gainesville, GA .....................................................................................................................................................
Hall County, GA.
Gary, IN ................................................................................................................................................................
Jasper County, IN.
Lake County, IN.

21780 ........................

21820 ........................
21940 ........................

22020 ........................
22140 ........................
22180 ........................
22220 ........................

22380 ........................
22420 ........................
22500 ........................
22520 ........................
22540 ........................
22660 ........................
22744 ........................
22900 ........................

23060 ........................

23104 ........................

23420 ........................

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23460 ........................
23540 ........................
23580 ........................
23844 ........................

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06AUR3

1.1723
0.8381

1.0997
0.3728

0.7802
0.9735
0.8601
0.8955

1.2786
1.1238
0.7999
0.7684
0.9477
0.9704
1.0378
0.7561

0.9010

0.9535

1.1768
0.7983
0.9710
0.9253
0.9418

45994

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

24020 ........................
24140 ........................
24220 ........................
24300 ........................
24340 ........................

24500 ........................
24540 ........................
24580 ........................

24660 ........................

24780 ........................
24860 ........................

25020 ........................

25060 ........................

25180 ........................

25260 ........................
25420 ........................

25500 ........................
25540 ........................

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25620 ........................

25860 ........................

25980 ........................

VerDate Mar<15>2010

Wage
index

Newton County, IN.
Porter County, IN.
Glens Falls, NY ....................................................................................................................................................
Warren County, NY.
Washington County, NY.
Goldsboro, NC ......................................................................................................................................................
Wayne County, NC.
Grand Forks, ND-MN ............................................................................................................................................
Polk County, MN.
Grand Forks County, ND.
Grand Junction, CO ..............................................................................................................................................
Mesa County, CO.
Grand Rapids-Wyoming, MI .................................................................................................................................
Barry County, MI.
Ionia County, MI.
Kent County, MI.
Newaygo County, MI.
Great Falls, MT .....................................................................................................................................................
Cascade County, MT.
Greeley, CO ..........................................................................................................................................................
Weld County, CO.
Green Bay, WI ......................................................................................................................................................
Brown County, WI.
Kewaunee County, WI.
Oconto County, WI.
Greensboro-High Point, NC ..................................................................................................................................
Guilford County, NC.
Randolph County, NC.
Rockingham County, NC.
Greenville, NC ......................................................................................................................................................
Greene County, NC.
Pitt County, NC.
Greenville-Mauldin-Easley, SC .............................................................................................................................
Greenville County, SC.
Laurens County, SC.
Pickens County, SC.
Guayama, PR .......................................................................................................................................................
Arroyo Municipio, PR.
Guayama Municipio, PR.
Patillas Municipio, PR.
Gulfport-Biloxi, MS ................................................................................................................................................
Hancock County, MS.
Harrison County, MS.
Stone County, MS.
Hagerstown-Martinsburg, MD-WV ........................................................................................................................
Washington County, MD.
Berkeley County, WV.
Morgan County, WV.
Hanford-Corcoran, CA ..........................................................................................................................................
Kings County, CA.
Harrisburg-Carlisle, PA .........................................................................................................................................
Cumberland County, PA.
Dauphin County, PA.
Perry County, PA.
Harrisonburg, VA ..................................................................................................................................................
Rockingham County, VA.
Harrisonburg City, VA.
Hartford-West Hartford-East Hartford, CT ............................................................................................................
Hartford County, CT.
Middlesex County, CT.
Tolland County, CT.
Hattiesburg, MS ....................................................................................................................................................
Forrest County, MS.
Lamar County, MS.
Perry County, MS.
Hickory-Lenoir-Morganton, NC .............................................................................................................................
Alexander County, NC.
Burke County, NC.
Caldwell County, NC.
Catawba County, NC.
Hinesville-Fort Stewart, GA 1 ................................................................................................................................

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0.8550
0.7290
0.9270
0.9091

0.9235
0.9653
0.9587

0.8320

0.9343
0.9604

0.3707

0.8575

0.9234

1.1124
0.9533

0.9090
1.1050

0.7938

0.8492

0.8700

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

45995

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

26100 ........................
26180 ........................
26300 ........................
26380 ........................
26420 ........................

26580 ........................

26620 ........................
26820 ........................
26900 ........................

26980 ........................
27060 ........................
27100 ........................
27140 ........................

27180 ........................

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27260 ........................

27340 ........................
27500 ........................

VerDate Mar<15>2010

Wage
index

Liberty County, GA.
Long County, GA.
Holland-Grand Haven, MI .....................................................................................................................................
Ottawa County, MI.
Honolulu, HI ..........................................................................................................................................................
Honolulu County, HI.
Hot Springs, AR ....................................................................................................................................................
Garland County, AR.
Houma-Bayou Cane-Thibodaux, LA ....................................................................................................................
Lafourche Parish, LA.
Terrebonne Parish, LA.
Houston-Sugar Land-Baytown, TX .......................................................................................................................
Austin County, TX.
Brazoria County, TX.
Chambers County, TX.
Fort Bend County, TX.
Galveston County, TX.
Harris County, TX.
Liberty County, TX.
Montgomery County, TX.
San Jacinto County, TX.
Waller County, TX.
Huntington-Ashland, WV-KY-OH ..........................................................................................................................
Boyd County, KY.
Greenup County, KY.
Lawrence County, OH.
Cabell County, WV.
Wayne County, WV.
Huntsville, AL ........................................................................................................................................................
Limestone County, AL.
Madison County, AL.
Idaho Falls, ID ......................................................................................................................................................
Bonneville County, ID.
Jefferson County, ID.
Indianapolis-Carmel, IN ........................................................................................................................................
Boone County, IN.
Brown County, IN.
Hamilton County, IN.
Hancock County, IN.
Hendricks County, IN.
Johnson County, IN.
Marion County, IN.
Morgan County, IN.
Putnam County, IN.
Shelby County, IN.
Iowa City, IA .........................................................................................................................................................
Johnson County, IA.
Washington County, IA.
Ithaca, NY .............................................................................................................................................................
Tompkins County, NY.
Jackson, MI ..........................................................................................................................................................
Jackson County, MI.
Jackson, MS .........................................................................................................................................................
Copiah County, MS.
Hinds County, MS.
Madison County, MS.
Rankin County, MS.
Simpson County, MS.
Jackson, TN ..........................................................................................................................................................
Chester County, TN.
Madison County, TN.
Jacksonville, FL ....................................................................................................................................................
Baker County, FL.
Clay County, FL.
Duval County, FL.
Nassau County, FL.
St. Johns County, FL.
Jacksonville, NC ...................................................................................................................................................
Onslow County, NC.
Janesville, WI .......................................................................................................................................................
Rock County, WI.

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0.9915

0.8944

0.8455
0.9312
1.0108

0.9854
0.9326
0.8944
0.8162

0.7729
0.8956

0.7861
0.9071

45996

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA Code

Urban area
(constituent counties)

27620 ........................

Jefferson City, MO ................................................................................................................................................
Callaway County, MO.
Cole County, MO.
Moniteau County, MO.
Osage County, MO.
Johnson City, TN ..................................................................................................................................................
Carter County, TN.
Unicoi County, TN.
Washington County, TN.
Johnstown, PA ......................................................................................................................................................
Cambria County, PA.
Jonesboro, AR ......................................................................................................................................................
Craighead County, AR.
Poinsett County, AR.
Joplin, MO ............................................................................................................................................................
Jasper County, MO.
Newton County, MO.
Kalamazoo-Portage, MI ........................................................................................................................................
Kalamazoo County, MI.
Van Buren County, MI.
Kankakee-Bradley, IL ...........................................................................................................................................
Kankakee County, IL.
Kansas City, MO-KS .............................................................................................................................................
Franklin County, KS.
Johnson County, KS.
Leavenworth County, KS.
Linn County, KS.
Miami County, KS.
Wyandotte County, KS.
Bates County, MO.
Caldwell County, MO.
Cass County, MO.
Clay County, MO.
Clinton County, MO.
Jackson County, MO.
Lafayette County, MO.
Platte County, MO.
Ray County, MO.
Kennewick-Pasco-Richland, WA ..........................................................................................................................
Benton County, WA.
Franklin County, WA.
Killeen-Temple-Fort Hood, TX ..............................................................................................................................
Bell County, TX.
Coryell County, TX.
Lampasas County, TX.
Kingsport-Bristol-Bristol, TN-VA ...........................................................................................................................
Hawkins County, TN.
Sullivan County, TN.
Bristol City, VA.
Scott County, VA.
Washington County, VA.
Kingston, NY .........................................................................................................................................................
Ulster County, NY.
Knoxville, TN ........................................................................................................................................................
Anderson County, TN.
Blount County, TN.
Knox County, TN.
Loudon County, TN.
Union County, TN.
Kokomo, IN ...........................................................................................................................................................
Howard County, IN.
Tipton County, IN.
La Crosse, WI-MN ................................................................................................................................................
Houston County, MN.
La Crosse County, WI.
Lafayette, IN .........................................................................................................................................................
Benton County, IN.
Carroll County, IN.
Tippecanoe County, IN.
Lafayette, LA ........................................................................................................................................................
Lafayette Parish, LA.

27740 ........................

27780 ........................
27860 ........................
27900 ........................
28020 ........................
28100 ........................
28140 ........................

28420 ........................
28660 ........................

28700 ........................

28740 ........................
28940 ........................

29020 ........................

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29100 ........................
29140 ........................

29180 ........................

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06AUR3

0.8465

0.7226

0.8450
0.7983
0.7983
0.9959
0.9657
0.9447

0.9459
0.8925

0.7192

0.9066
0.7432

0.9061
1.0205
0.9954

0.8231

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

45997

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

29340 ........................
29404 ........................
29420 ........................
29460 ........................
29540 ........................
29620 ........................

29700 ........................
29740 ........................
29820 ........................
29940 ........................
30020 ........................
30140 ........................
30300 ........................
30340 ........................
30460 ........................

30620 ........................
30700 ........................
30780 ........................

30860 ........................
30980 ........................

31020 ........................

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31084 ........................
31140 ........................

VerDate Mar<15>2010

Wage
index

St. Martin Parish, LA.
Lake Charles, LA ..................................................................................................................................................
Calcasieu Parish, LA.
Cameron Parish, LA.
Lake County-Kenosha County, IL-WI ...................................................................................................................
Lake County, IL.
Kenosha County, WI.
Lake Havasu City-Kingman, AZ ...........................................................................................................................
Mohave County, AZ.
Lakeland-Winter Haven, FL ..................................................................................................................................
Polk County, FL.
Lancaster, PA .......................................................................................................................................................
Lancaster County, PA.
Lansing-East Lansing, MI .....................................................................................................................................
Clinton County, MI.
Eaton County, MI.
Ingham County, MI.
Laredo, TX ............................................................................................................................................................
Webb County, TX.
Las Cruces, NM ....................................................................................................................................................
Dona Ana County, NM.
Las Vegas-Paradise, NV ......................................................................................................................................
Clark County, NV.
Lawrence, KS .......................................................................................................................................................
Douglas County, KS.
Lawton, OK ...........................................................................................................................................................
Comanche County, OK.
Lebanon, PA .........................................................................................................................................................
Lebanon County, PA.
Lewiston, ID-WA ...................................................................................................................................................
Nez Perce County, ID.
Asotin County, WA.
Lewiston-Auburn, ME ...........................................................................................................................................
Androscoggin County, ME.
Lexington-Fayette, KY ..........................................................................................................................................
Bourbon County, KY.
Clark County, KY.
Fayette County, KY.
Jessamine County, KY.
Scott County, KY.
Woodford County, KY.
Lima, OH ..............................................................................................................................................................
Allen County, OH.
Lincoln, NE ...........................................................................................................................................................
Lancaster County, NE.
Seward County, NE.
Little Rock-North Little Rock-Conway, AR ...........................................................................................................
Faulkner County, AR.
Grant County, AR.
Lonoke County, AR.
Perry County, AR.
Pulaski County, AR.
Saline County, AR.
Logan, UT-ID ........................................................................................................................................................
Franklin County, ID.
Cache County, UT.
Longview, TX ........................................................................................................................................................
Gregg County, TX.
Rusk County, TX.
Upshur County, TX.
Longview, WA .......................................................................................................................................................
Cowlitz County, WA.
Los Angeles-Long Beach-Glendale, CA ...............................................................................................................
Los Angeles County, CA.
Louisville-Jefferson County, KY-IN .......................................................................................................................
Clark County, IN.
Floyd County, IN.
Harrison County, IN.
Washington County, IN.
Bullitt County, KY.
Henry County, KY.

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1.0658
0.9912
0.8283
0.9695
1.0618

0.7586
0.9265
1.1627
0.8664
0.7893
0.8157
0.9215
0.9048
0.8902

0.9158
0.9465
0.8632

0.8754
0.8933

1.0460
1.2417
0.8852

45998

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

31180 ........................
31340 ........................

31420 ........................

31460 ........................
31540 ........................

31700 ........................
31740 ........................

31860 ........................
31900 ........................
32420 ........................
32580 ........................
32780 ........................
32820 ........................

32900 ........................
33124 ........................
33140 ........................

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33260 ........................
33340 ........................

33460 ........................

VerDate Mar<15>2010

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Meade County, KY.
Nelson County, KY.
Oldham County, KY.
Shelby County, KY.
Spencer County, KY.
Trimble County, KY.
Lubbock, TX .........................................................................................................................................................
Crosby County, TX.
Lubbock County, TX.
Lynchburg, VA ......................................................................................................................................................
Amherst County, VA.
Appomattox County, VA.
Bedford County, VA.
Campbell County, VA.
Bedford City, VA.
Lynchburg City, VA.
Macon, GA ............................................................................................................................................................
Bibb County, GA.
Crawford County, GA.
Jones County, GA.
Monroe County, GA.
Twiggs County, GA.
Madera-Chowchilla, CA ........................................................................................................................................
Madera County, CA.
Madison, WI ..........................................................................................................................................................
Columbia County, WI.
Dane County, WI.
Iowa County, WI.
Manchester-Nashua, NH ......................................................................................................................................
Hillsborough County, NH.
Manhattan, KS ......................................................................................................................................................
Geary County, KS.
Pottawatomie County, KS.
Riley County, KS.
Mankato-North Mankato, MN ...............................................................................................................................
Blue Earth County, MN.
Nicollet County, MN.
Mansfield, OH .......................................................................................................................................................
Richland County, OH.
Mayagu¨ez, PR ......................................................................................................................................................
Hormigueros Municipio, PR.
Mayagu¨ez Municipio, PR.
McAllen-Edinburg-Mission, TX .............................................................................................................................
Hidalgo County, TX.
Medford, OR .........................................................................................................................................................
Jackson County, OR.
Memphis, TN-MS-AR ............................................................................................................................................
Crittenden County, AR.
DeSoto County, MS.
Marshall County, MS.
Tate County, MS.
Tunica County, MS.
Fayette County, TN.
Shelby County, TN.
Tipton County, TN.
Merced, CA ...........................................................................................................................................................
Merced County, CA.
Miami-Miami Beach-Kendall, FL ...........................................................................................................................
Miami-Dade County, FL.
Michigan City-La Porte, IN ...................................................................................................................................
LaPorte County, IN.
Midland, TX ..........................................................................................................................................................
Midland County, TX.
Milwaukee-Waukesha-West Allis, WI ...................................................................................................................
Milwaukee County, WI.
Ozaukee County, WI.
Washington County, WI.
Waukesha County, WI.
Minneapolis-St. Paul-Bloomington, MN-WI ..........................................................................................................
Anoka County, MN.
Carver County, MN.

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0.8771

0.9014

0.8317
1.1414

1.0057
0.7843

0.9277
0.8509
0.3762
0.8393
1.0690
0.9038

1.2734
0.9870
0.9216
1.0049
0.9856

1.1213

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

45999

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

33540 ........................
33660 ........................
33700 ........................
33740 ........................
33780 ........................
33860 ........................

34060 ........................
34100 ........................

34580 ........................
34620 ........................
34740 ........................
34820 ........................
34900 ........................
34940 ........................
34980 ........................

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35004 ........................
35084 ........................

35300 ........................

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Chisago County, MN.
Dakota County, MN.
Hennepin County, MN.
Isanti County, MN.
Ramsey County, MN.
Scott County, MN.
Sherburne County, MN.
Washington County, MN.
Wright County, MN.
Pierce County, WI.
St. Croix County, WI.
Missoula, MT ........................................................................................................................................................
Missoula County, MT.
Mobile, AL .............................................................................................................................................................
Mobile County, AL.
Modesto, CA .........................................................................................................................................................
Stanislaus County, CA.
Monroe, LA ...........................................................................................................................................................
Ouachita Parish, LA.
Union Parish, LA.
Monroe, MI ...........................................................................................................................................................
Monroe County, MI.
Montgomery, AL ...................................................................................................................................................
Autauga County, AL.
Elmore County, AL.
Lowndes County, AL.
Montgomery County, AL.
Morgantown, WV ..................................................................................................................................................
Monongalia County, WV.
Preston County, WV.
Morristown, TN .....................................................................................................................................................
Grainger County, TN.
Hamblen County, TN.
Jefferson County, TN.
Mount Vernon-Anacortes, WA ..............................................................................................................................
Skagit County, WA.
Muncie, IN ............................................................................................................................................................
Delaware County, IN.
Muskegon-Norton Shores, MI ..............................................................................................................................
Muskegon County, MI.
Myrtle Beach-North Myrtle Beach-Conway, SC ...................................................................................................
Horry County, SC.
Napa, CA ..............................................................................................................................................................
Napa County, CA.
Naples-Marco Island, FL ......................................................................................................................................
Collier County, FL.
Nashville-Davidson—Murfreesboro-Franklin, TN .................................................................................................
Cannon County, TN.
Cheatham County, TN.
Davidson County, TN.
Dickson County, TN.
Hickman County, TN.
Macon County, TN.
Robertson County, TN.
Rutherford County, TN.
Smith County, TN.
Sumner County, TN.
Trousdale County, TN.
Williamson County, TN.
Wilson County, TN.
Nassau-Suffolk, NY ..............................................................................................................................................
Nassau County, NY.
Suffolk County, NY.
Newark-Union, NJ-PA ...........................................................................................................................................
Essex County, NJ.
Hunterdon County, NJ.
Morris County, NJ.
Sussex County, NJ.
Union County, NJ.
Pike County, PA.
New Haven-Milford, CT ........................................................................................................................................

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0.7507
1.3629
0.7530
0.8718
0.7475

0.8339
0.6861

1.0652
0.8743
1.1076
0.8700
1.5375
0.9108
0.9141

1.2755
1.1268

1.1883

46000

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

35380 ........................

35644 ........................

35660 ........................
35840 ........................
35980 ........................
36084 ........................
36100 ........................
36140 ........................
36220 ........................
36260 ........................

36420 ........................

36500 ........................
36540 ........................

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36740 ........................

36780 ........................
36980 ........................

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New Haven County, CT.
New Orleans-Metairie-Kenner, LA ........................................................................................................................
Jefferson Parish, LA.
Orleans Parish, LA.
Plaquemines Parish, LA.
St. Bernard Parish, LA.
St. Charles Parish, LA.
St. John the Baptist Parish, LA.
St. Tammany Parish, LA.
New York-White Plains-Wayne, NY-NJ ................................................................................................................
Bergen County, NJ.
Hudson County, NJ.
Passaic County, NJ.
Bronx County, NY.
Kings County, NY.
New York County, NY.
Putnam County, NY.
Queens County, NY.
Richmond County, NY.
Rockland County, NY.
Westchester County, NY.
Niles-Benton Harbor, MI .......................................................................................................................................
Berrien County, MI.
North Port-Bradenton-Sarasota-Venice, FL .........................................................................................................
Manatee County, FL.
Sarasota County, FL.
Norwich-New London, CT ....................................................................................................................................
New London County, CT.
Oakland-Fremont-Hayward, CA ...........................................................................................................................
Alameda County, CA.
Contra Costa County, CA.
Ocala, FL ..............................................................................................................................................................
Marion County, FL.
Ocean City, NJ .....................................................................................................................................................
Cape May County, NJ.
Odessa, TX ...........................................................................................................................................................
Ector County, TX.
Ogden-Clearfield, UT ............................................................................................................................................
Davis County, UT.
Morgan County, UT.
Weber County, UT.
Oklahoma City, OK ...............................................................................................................................................
Canadian County, OK.
Cleveland County, OK.
Grady County, OK.
Lincoln County, OK.
Logan County, OK.
McClain County, OK.
Oklahoma County, OK.
Olympia, WA .........................................................................................................................................................
Thurston County, WA.
Omaha-Council Bluffs, NE-IA ...............................................................................................................................
Harrison County, IA.
Mills County, IA.
Pottawattamie County, IA.
Cass County, NE.
Douglas County, NE.
Sarpy County, NE.
Saunders County, NE.
Washington County, NE.
Orlando-Kissimmee-Sanford, FL ..........................................................................................................................
Lake County, FL.
Orange County, FL.
Osceola County, FL.
Seminole County, FL.
Oshkosh-Neenah, WI ...........................................................................................................................................
Winnebago County, WI.
Owensboro, KY ....................................................................................................................................................
Daviess County, KY.
Hancock County, KY.
McLean County, KY.

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0.8444
0.9428
1.1821
1.7048
0.8425
1.0584
0.9661
0.9170

0.8879

1.1601
0.9756

0.9063

0.9398
0.7790

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

46001

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA Code

Urban area
(constituent counties)

37100 ........................

Oxnard-Thousand Oaks-Ventura, CA ..................................................................................................................
Ventura County, CA.
Palm Bay-Melbourne-Titusville, FL .......................................................................................................................
Brevard County, FL.
Palm Coast, FL .....................................................................................................................................................
Flagler County, FL.
Panama City-Lynn Haven-Panama City Beach, FL .............................................................................................
Bay County, FL.
Parkersburg-Marietta-Vienna, WV-OH .................................................................................................................
Washington County, OH.
Pleasants County, WV.
Wirt County, WV.
Wood County, WV.
Pascagoula, MS ...................................................................................................................................................
George County, MS.
Jackson County, MS.
Peabody, MA ........................................................................................................................................................
Essex County, MA.
Pensacola-Ferry Pass-Brent, FL ..........................................................................................................................
Escambia County, FL.
Santa Rosa County, FL.
Peoria, IL ..............................................................................................................................................................
Marshall County, IL.
Peoria County, IL.
Stark County, IL.
Tazewell County, IL.
Woodford County, IL.
Philadelphia, PA ...................................................................................................................................................
Bucks County, PA.
Chester County, PA.
Delaware County, PA.
Montgomery County, PA.
Philadelphia County, PA.
Phoenix-Mesa-Scottsdale, AZ ..............................................................................................................................
Maricopa County, AZ.
Pinal County, AZ.
Pine Bluff, AR .......................................................................................................................................................
Cleveland County, AR.
Jefferson County, AR.
Lincoln County, AR.
Pittsburgh, PA .......................................................................................................................................................
Allegheny County, PA.
Armstrong County, PA.
Beaver County, PA.
Butler County, PA.
Fayette County, PA.
Washington County, PA.
Westmoreland County, PA.
Pittsfield, MA .........................................................................................................................................................
Berkshire County, MA.
Pocatello, ID .........................................................................................................................................................
Bannock County, ID.
Power County, ID.
Ponce, PR ............................................................................................................................................................
Juana Dı´az Municipio, PR.
Ponce Municipio, PR.
Villalba Municipio, PR.
Portland-South Portland-Biddeford, ME ...............................................................................................................
Cumberland County, ME.
Sagadahoc County, ME.
York County, ME.
Portland-Vancouver-Hillsboro, OR-WA ................................................................................................................
Clackamas County, OR.
Columbia County, OR.
Multnomah County, OR.
Washington County, OR.
Yamhill County, OR.
Clark County, WA.
Skamania County, WA.
Port St. Lucie, FL .................................................................................................................................................
Martin County, FL.

37340 ........................
37380 ........................
37460 ........................
37620 ........................

37700 ........................
37764 ........................
37860 ........................
37900 ........................

37964 ........................

38060 ........................
38220 ........................

38300 ........................

38340 ........................
38540 ........................
38660 ........................

38860 ........................

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38900 ........................

38940 ........................

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1.3113
0.8790
0.8174
0.7876
0.7569

0.7542
1.0553
0.7767
0.8434

1.0849

1.0465
0.8069

0.8669

1.0920
0.9754
0.4594

0.9981

1.1766

0.9352

46002

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

39100 ........................
39140 ........................
39300 ........................

39340 ........................
39380 ........................
39460 ........................
39540 ........................
39580 ........................

39660 ........................
39740 ........................
39820 ........................
39900 ........................
40060 ........................

40140 ........................

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40220 ........................

40340 ........................

VerDate Mar<15>2010

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St. Lucie County, FL.
Poughkeepsie-Newburgh-Middletown, NY ...........................................................................................................
Dutchess County, NY.
Orange County, NY.
Prescott, AZ ..........................................................................................................................................................
Yavapai County, AZ.
Providence-New Bedford-Fall River, RI-MA .........................................................................................................
Bristol County, MA.
Bristol County, RI.
Kent County, RI.
Newport County, RI.
Providence County, RI.
Washington County, RI.
Provo-Orem, UT ...................................................................................................................................................
Juab County, UT.
Utah County, UT.
Pueblo, CO ...........................................................................................................................................................
Pueblo County, CO.
Punta Gorda, FL ...................................................................................................................................................
Charlotte County, FL.
Racine, WI ............................................................................................................................................................
Racine County, WI.
Raleigh-Cary, NC .................................................................................................................................................
Franklin County, NC.
Johnston County, NC.
Wake County, NC.
Rapid City, SD ......................................................................................................................................................
Meade County, SD.
Pennington County, SD.
Reading, PA .........................................................................................................................................................
Berks County, PA.
Redding, CA .........................................................................................................................................................
Shasta County, CA.
Reno-Sparks, NV ..................................................................................................................................................
Storey County, NV.
Washoe County, NV.
Richmond, VA .......................................................................................................................................................
Amelia County, VA.
Caroline County, VA.
Charles City County, VA.
Chesterfield County, VA.
Cumberland County, VA.
Dinwiddie County, VA.
Goochland County, VA.
Hanover County, VA.
Henrico County, VA.
King and Queen County, VA.
King William County, VA.
Louisa County, VA.
New Kent County, VA.
Powhatan County, VA.
Prince George County, VA.
Sussex County, VA.
Colonial Heights City, VA.
Hopewell City, VA.
Petersburg City, VA.
Richmond City, VA.
Riverside-San Bernardino-Ontario, CA ................................................................................................................
Riverside County, CA.
San Bernardino County, CA.
Roanoke, VA ........................................................................................................................................................
Botetourt County, VA.
Craig County, VA.
Franklin County, VA.
Roanoke County, VA.
Roanoke City, VA.
Salem City, VA.
Rochester, MN ......................................................................................................................................................
Dodge County, MN.
Olmsted County, MN.
Wabasha County, MN.

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1.0161
1.0539

0.9461
0.8215
0.8734
0.8903
0.9304

0.9568
0.9220
1.4990
1.0326
0.9723

1.1497
0.9195

1.1662

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

46003

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA Code

Urban area
(constituent counties)

40380 ........................

Rochester, NY ......................................................................................................................................................
Livingston County, NY.
Monroe County, NY.
Ontario County, NY.
Orleans County, NY.
Wayne County, NY.
Rockford, IL ..........................................................................................................................................................
Boone County, IL.
Winnebago County, IL.
Rockingham County-Strafford County, NH ..........................................................................................................
Rockingham County, NH.
Strafford County, NH.
Rocky Mount, NC .................................................................................................................................................
Edgecombe County, NC.
Nash County, NC.
Rome, GA .............................................................................................................................................................
Floyd County, GA.
Sacramento-Arden-Arcade-Roseville, CA ............................................................................................................
El Dorado County, CA.
Placer County, CA.
Sacramento County, CA.
Yolo County, CA.
Saginaw-Saginaw Township North, MI ................................................................................................................
Saginaw County, MI.
St. Cloud, MN .......................................................................................................................................................
Benton County, MN.
Stearns County, MN.
St. George, UT .....................................................................................................................................................
Washington County, UT.
St. Joseph, MO-KS ...............................................................................................................................................
Doniphan County, KS.
Andrew County, MO.
Buchanan County, MO.
DeKalb County, MO.
St. Louis, MO-IL ...................................................................................................................................................
Bond County, IL.
Calhoun County, IL.
Clinton County, IL.
Jersey County, IL.
Macoupin County, IL.
Madison County, IL.
Monroe County, IL.
St. Clair County, IL.
Crawford County, MO.
Franklin County, MO.
Jefferson County, MO.
Lincoln County, MO.
St. Charles County, MO.
St. Louis County, MO.
Warren County, MO.
Washington County, MO.
St. Louis City, MO.
Salem, OR ............................................................................................................................................................
Marion County, OR.
Polk County, OR.
Salinas, CA ...........................................................................................................................................................
Monterey County, CA.
Salisbury, MD .......................................................................................................................................................
Somerset County, MD.
Wicomico County, MD.
Salt Lake City, UT ................................................................................................................................................
Salt Lake County, UT.
Summit County, UT.
Tooele County, UT.
San Angelo, TX ....................................................................................................................................................
Irion County, TX.
Tom Green County, TX.
San Antonio-New Braunfels, TX ...........................................................................................................................
Atascosa County, TX.
Bandera County, TX.
Bexar County, TX.

40420 ........................
40484 ........................
40580 ........................
40660 ........................
40900 ........................

40980 ........................
41060 ........................
41100 ........................
41140 ........................

41180 ........................

41420 ........................
41500 ........................
41540 ........................

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41620 ........................

41660 ........................
41700 ........................

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0.8749

0.9751
1.0172
0.8750
0.8924
1.5498

0.8849
1.0658
0.9345
0.9834

0.9336

1.1148
1.5820
0.8948
0.9350

0.8169
0.8911

46004

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

41740 ........................
41780 ........................
41884 ........................

41900 ........................

41940 ........................

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41980 ........................

42020 ........................
42044 ........................
42060 ........................
42100 ........................

VerDate Mar<15>2010

Wage
index

Comal County, TX.
Guadalupe County, TX.
Kendall County, TX.
Medina County, TX.
Wilson County, TX.
San Diego-Carlsbad-San Marcos, CA ..................................................................................................................
San Diego County, CA.
Sandusky, OH ......................................................................................................................................................
Erie County, OH.
San Francisco-San Mateo-Redwood City, CA .....................................................................................................
Marin County, CA.
San Francisco County, CA.
San Mateo County, CA.
San Germa´n-Cabo Rojo, PR ................................................................................................................................
Cabo Rojo Municipio, PR.
Lajas Municipio, PR.
Sabana Grande Municipio, PR.
San Germa´n Municipio, PR.
San Jose-Sunnyvale-Santa Clara, CA .................................................................................................................
San Benito County, CA.
Santa Clara County, CA.
San Juan-Caguas-Guaynabo, PR ........................................................................................................................
Aguas Buenas Municipio, PR.
Aibonito Municipio, PR.
Arecibo Municipio, PR.
Barceloneta Municipio, PR.
Barranquitas Municipio, PR.
Bayamo´n Municipio, PR.
Caguas Municipio, PR.
Camuy Municipio, PR.
Cano´vanas Municipio, PR.
Carolina Municipio, PR.
Catan˜o Municipio, PR.
Cayey Municipio, PR.
Ciales Municipio, PR.
Cidra Municipio, PR.
Comerı´o Municipio, PR.
Corozal Municipio, PR.
Dorado Municipio, PR.
Florida Municipio, PR.
Guaynabo Municipio, PR.
Gurabo Municipio, PR.
Hatillo Municipio, PR.
Humacao Municipio, PR.
Juncos Municipio, PR.
Las Piedras Municipio, PR.
Loı´za Municipio, PR.
Manatı´ Municipio, PR.
Maunabo Municipio, PR.
Morovis Municipio, PR.
Naguabo Municipio, PR.
Naranjito Municipio, PR.
Orocovis Municipio, PR.
Quebradillas Municipio, PR.
Rı´o Grande Municipio, PR.
San Juan Municipio, PR.
San Lorenzo Municipio, PR.
Toa Alta Municipio, PR.
Toa Baja Municipio, PR.
Trujillo Alto Municipio, PR.
Vega Alta Municipio, PR.
Vega Baja Municipio, PR.
Yabucoa Municipio, PR.
San Luis Obispo-Paso Robles, CA ......................................................................................................................
San Luis Obispo County, CA.
Santa Ana-Anaheim-Irvine, CA ............................................................................................................................
Orange County, CA.
Santa Barbara-Santa Maria-Goleta, CA ...............................................................................................................
Santa Barbara County, CA.
Santa Cruz-Watsonville, CA .................................................................................................................................
Santa Cruz County, CA.

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1.2213
0.7788
1.6743

0.4550

1.7086
0.4356

1.3036
1.2111
1.2825
1.7937

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

46005

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA Code

Urban area
(constituent counties)

42140 ........................

Santa Fe, NM .......................................................................................................................................................
Santa Fe County, NM.
Santa Rosa-Petaluma, CA ...................................................................................................................................
Sonoma County, CA.
Savannah, GA ......................................................................................................................................................
Bryan County, GA.
Chatham County, GA.
Effingham County, GA.
Scranton-Wilkes-Barre, PA ...................................................................................................................................
Lackawanna County, PA.
Luzerne County, PA.
Wyoming County, PA.
Seattle-Bellevue-Everett, WA ...............................................................................................................................
King County, WA.
Snohomish County, WA.
Sebastian-Vero Beach, FL ...................................................................................................................................
Indian River County, FL.
Sheboygan, WI .....................................................................................................................................................
Sheboygan County, WI.
Sherman-Denison, TX ..........................................................................................................................................
Grayson County, TX.
Shreveport-Bossier City, LA .................................................................................................................................
Bossier Parish, LA.
Caddo Parish, LA.
De Soto Parish, LA.
Sioux City, IA-NE-SD ............................................................................................................................................
Woodbury County, IA.
Dakota County, NE.
Dixon County, NE.
Union County, SD.
Sioux Falls, SD .....................................................................................................................................................
Lincoln County, SD.
McCook County, SD.
Minnehaha County, SD.
Turner County, SD.
South Bend-Mishawaka, IN-MI .............................................................................................................................
St. Joseph County, IN.
Cass County, MI.
Spartanburg, SC ...................................................................................................................................................
Spartanburg County, SC.
Spokane, WA ........................................................................................................................................................
Spokane County, WA.
Springfield, IL ........................................................................................................................................................
Menard County, IL.
Sangamon County, IL.
Springfield, MA .....................................................................................................................................................
Franklin County, MA.
Hampden County, MA.
Hampshire County, MA.
Springfield, MO .....................................................................................................................................................
Christian County, MO.
Dallas County, MO.
Greene County, MO.
Polk County, MO.
Webster County, MO.
Springfield, OH .....................................................................................................................................................
Clark County, OH.
State College, PA .................................................................................................................................................
Centre County, PA.
Steubenville-Weirton, OH-WV ..............................................................................................................................
Jefferson County, OH.
Brooke County, WV.
Hancock County, WV.
Stockton, CA .........................................................................................................................................................
San Joaquin County, CA.
Sumter, SC ...........................................................................................................................................................
Sumter County, SC.
Syracuse, NY ........................................................................................................................................................
Madison County, NY.
Onondaga County, NY.
Oswego County, NY.

42220 ........................
42340 ........................

42540 ........................

42644 ........................
42680 ........................
43100 ........................
43300 ........................
43340 ........................

43580 ........................

43620 ........................

43780 ........................
43900 ........................
44060 ........................
44100 ........................
44140 ........................

44180 ........................

44220 ........................
44300 ........................

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44600 ........................

44700 ........................
44940 ........................
45060 ........................

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1.0136
1.6679
0.8757

0.8331

1.1733
0.8760
0.9203
0.8723
0.8262

0.9163

0.8275

0.9425
0.8782
1.1174
0.9165
1.0383

0.8440

0.8447
0.9575
0.7598

1.3734
0.7594
0.9897

46006

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA Code

Urban area
(constituent counties)

45104 ........................

Tacoma, WA .........................................................................................................................................................
Pierce County, WA.
Tallahassee, FL ....................................................................................................................................................
Gadsden County, FL.
Jefferson County, FL.
Leon County, FL.
Wakulla County, FL.
Tampa-St. Petersburg-Clearwater, FL .................................................................................................................
Hernando County, FL.
Hillsborough County, FL.
Pasco County, FL.
Pinellas County, FL.
Terre Haute, IN .....................................................................................................................................................
Clay County, IN.
Sullivan County, IN.
Vermillion County, IN.
Vigo County, IN.
Texarkana, TX-Texarkana, AR .............................................................................................................................
Miller County, AR.
Bowie County, TX.
Toledo, OH ...........................................................................................................................................................
Fulton County, OH.
Lucas County, OH.
Ottawa County, OH.
Wood County, OH.
Topeka, KS ...........................................................................................................................................................
Jackson County, KS.
Jefferson County, KS.
Osage County, KS.
Shawnee County, KS.
Wabaunsee County, KS.
Trenton-Ewing, NJ ................................................................................................................................................
Mercer County, NJ.
Tucson, AZ ...........................................................................................................................................................
Pima County, AZ.
Tulsa, OK ..............................................................................................................................................................
Creek County, OK.
Okmulgee County, OK.
Osage County, OK.
Pawnee County, OK.
Rogers County, OK.
Tulsa County, OK.
Wagoner County, OK.
Tuscaloosa, AL .....................................................................................................................................................
Greene County, AL.
Hale County, AL.
Tuscaloosa County, AL.
Tyler, TX ...............................................................................................................................................................
Smith County, TX.
Utica-Rome, NY ....................................................................................................................................................
Herkimer County, NY.
Oneida County, NY.
Valdosta, GA ........................................................................................................................................................
Brooks County, GA.
Echols County, GA.
Lanier County, GA.
Lowndes County, GA.
Vallejo-Fairfield, CA ..............................................................................................................................................
Solano County, CA.
Victoria, TX ...........................................................................................................................................................
Calhoun County, TX.
Goliad County, TX.
Victoria County, TX.
Vineland-Millville-Bridgeton, NJ ............................................................................................................................
Cumberland County, NJ.
Virginia Beach-Norfolk-Newport News, VA-NC ....................................................................................................
Currituck County, NC.
Gloucester County, VA.
Isle of Wight County, VA.
James City County, VA.
Mathews County, VA.

45220 ........................

45300 ........................

45460 ........................

45500 ........................
45780 ........................

45820 ........................

45940 ........................
46060 ........................
46140 ........................

46220 ........................

46340 ........................
46540 ........................
46660 ........................

46700 ........................

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47020 ........................

47220 ........................
47260 ........................

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1.1574
0.8391

0.9075

0.9706

0.7428
0.9013

0.8974

1.0648
0.8953
0.8145

0.8500

0.8526
0.8769
0.7527

1.6286
0.8949

1.0759
0.9121

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

46007

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

47300 ........................
47380 ........................
47580 ........................
47644 ........................

47894 ........................

47940 ........................

48140 ........................
48300 ........................
48424 ........................
48540 ........................

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48620 ........................

48660 ........................

48700 ........................
48864 ........................

VerDate Mar<15>2010

Wage
index

Surry County, VA.
York County, VA.
Chesapeake City, VA.
Hampton City, VA.
Newport News City, VA.
Norfolk City, VA.
Poquoson City, VA.
Portsmouth City, VA.
Suffolk City, VA.
Virginia Beach City, VA.
Williamsburg City, VA.
Visalia-Porterville, CA ...........................................................................................................................................
Tulare County, CA.
Waco, TX ..............................................................................................................................................................
McLennan County, TX.
Warner Robins, GA ..............................................................................................................................................
Houston County, GA.
Warren-Troy-Farmington Hills, MI ........................................................................................................................
Lapeer County, MI.
Livingston County, MI.
Macomb County, MI.
Oakland County, MI.
St. Clair County, MI.
Washington-Arlington-Alexandria, DC-VA-MD-WV ..............................................................................................
District of Columbia, DC.
Calvert County, MD.
Charles County, MD.
Prince George’s County, MD.
Arlington County, VA.
Clarke County, VA.
Fairfax County, VA.
Fauquier County, VA.
Loudoun County, VA.
Prince William County, VA.
Spotsylvania County, VA.
Stafford County, VA.
Warren County, VA.
Alexandria City, VA.
Fairfax City, VA.
Falls Church City, VA.
Fredericksburg City, VA.
Manassas City, VA.
Manassas Park City, VA.
Jefferson County, WV.
Waterloo-Cedar Falls, IA ......................................................................................................................................
Black Hawk County, IA.
Bremer County, IA.
Grundy County, IA.
Wausau, WI ..........................................................................................................................................................
Marathon County, WI.
Wenatchee-East Wenatchee, WA ........................................................................................................................
Chelan County, WA.
Douglas County, WA.
West Palm Beach-Boca Raton-Boynton Beach, FL .............................................................................................
Palm Beach County, FL.
Wheeling, WV-OH ................................................................................................................................................
Belmont County, OH.
Marshall County, WV.
Ohio County, WV.
Wichita, KS ...........................................................................................................................................................
Butler County, KS.
Harvey County, KS.
Sedgwick County, KS.
Sumner County, KS.
Wichita Falls, TX ..................................................................................................................................................
Archer County, TX.
Clay County, TX.
Wichita County, TX.
Williamsport, PA ...................................................................................................................................................
Lycoming County, PA.
Wilmington, DE-MD-NJ .........................................................................................................................................

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0.9947
0.8213
0.7732
0.9432

1.0533

0.8331

0.8802
1.0109
0.9597
0.6673

0.8674

0.9537

0.8268
1.0593

46008

Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

TABLE 1—FY 2015 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
Urban area
(constituent counties)

CBSA Code

48900 ........................

49020 ........................

49180 ........................

49340 ........................
49420 ........................
49500 ........................

49620 ........................
49660 ........................

49700 ........................
49740 ........................
1 At

New Castle County, DE.
Cecil County, MD.
Salem County, NJ.
Wilmington, NC .....................................................................................................................................................
Brunswick County, NC.
New Hanover County, NC.
Pender County, NC.
Winchester, VA-WV ..............................................................................................................................................
Frederick County, VA.
Winchester City, VA.
Hampshire County, WV.
Winston-Salem, NC ..............................................................................................................................................
Davie County, NC.
Forsyth County, NC.
Stokes County, NC.
Yadkin County, NC.
Worcester, MA ......................................................................................................................................................
Worcester County, MA.
Yakima, WA ..........................................................................................................................................................
Yakima County, WA.
Yauco, PR ............................................................................................................................................................
Gua´nica Municipio, PR.
Guayanilla Municipio, PR.
Pen˜uelas Municipio, PR.
Yauco Municipio, PR.
York-Hanover, PA .................................................................................................................................................
York County, PA.
Youngstown-Warren-Boardman, OH-PA ..............................................................................................................
Mahoning County, OH.
Trumbull County, OH.
Mercer County, PA.
Yuba City, CA .......................................................................................................................................................
Sutter County, CA.
Yuba County, CA.
Yuma, AZ ..............................................................................................................................................................
Yuma County, AZ.

0.8862

0.9034

0.8560

1.1584
1.0355
0.3782

0.9540
0.8262

1.1759
0.9674

this time, there are no hospitals located in this urban area on which to base a wage index.

TABLE 2—FY 2015 WAGE INDEX
BASED ON CBSA LABOR MARKET
AREAS FOR RURAL AREAS

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Wage
index

State
code

Nonurban area

1 ..................
2 ..................
3 ..................
4 ..................
5 ..................
6 ..................
7 ..................
8 ..................
10 ................
11 ................
12 ................
13 ................
14 ................
15 ................
16 ................
17 ................
18 ................
19 ................
20 ................
21 ................
22 ................
23 ................

Alabama ..............
Alaska .................
Arizona ................
Arkansas .............
California .............
Colorado ..............
Connecticut .........
Delaware .............
Florida .................
Georgia ...............
Hawaii .................
Idaho ...................
Illinois ..................
Indiana ................
Iowa .....................
Kansas ................
Kentucky .............
Louisiana .............
Maine ..................
Maryland .............
Massachusetts ....
Michigan ..............

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TABLE 2—FY 2015 WAGE INDEX
BASED ON CBSA LABOR MARKET
AREAS FOR RURAL AREAS—Continued

Wage
index
0.7147
1.3662
0.9166
0.7343
1.2788
0.9802
1.1311
1.0092
0.7985
0.7459
1.0739
0.7605
0.8434
0.8513
0.8434
0.7929
0.7784
0.7585
0.8238
0.8696
1.3614
0.8270

Jkt 232001

State
code
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

................
................
................
................
................
................
................
................
................
................
................
................
................
................
................
................
................
................
................
................

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Nonurban area

Wage
index

Minnesota ............
Mississippi ...........
Missouri ...............
Montana ..............
Nebraska .............
Nevada ................
New Hampshire ..
New Jersey 1 .......
New Mexico ........
New York ............
North Carolina .....
North Dakota .......
Ohio .....................
Oklahoma ............
Oregon ................
Pennsylvania .......
Puerto Rico 1 .......
Rhode Island 1 .....
South Carolina ....
South Dakota ......

0.9133
0.7568
0.7775
0.9098
0.8855
0.9781
1.0339
................
0.8922
0.8220
0.8100
0.6785
0.8377
0.7704
0.9435
0.8430
0.4047
................
0.8329
0.8164

Fmt 4701

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TABLE 2—FY 2015 WAGE INDEX
BASED ON CBSA LABOR MARKET
AREAS FOR RURAL AREAS—Continued
State
code
44
45
46
47
48
49
50
51
52
53
65

................
................
................
................
................
................
................
................
................
................
................

Nonurban area
Tennessee ..........
Texas ..................
Utah .....................
Vermont ...............
Virgin Islands ......
Virginia ................
Washington .........
West Virginia .......
Wisconsin ............
Wyoming .............
Guam ..................

Wage
index
0.7444
0.7874
0.8732
0.9740
0.7060
0.7758
1.0529
0.7407
0.8904
0.9243
0.9611

1 All counties within the State are classified
as urban, with the exception of Puerto Rico.
Puerto Rico has areas designated as rural;
however, no short-term, acute care hospitals
are located in the area(s) for FY 2015. The
Puerto Rico wage index is the same as FY
2014.

Addendum C

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Federal Register / Vol. 79, No. 151 / Wednesday, August 6, 2014 / Rules and Regulations

46009

IPF CODE FIRST TABLE
Code

Code first instructions ICD–10–CM
(effective October 1, 2014)

F01.50 ...........
F01.51 ...........
F02.80 ...........

Code first the underlying physiological condition or sequelae of cerebrovascular disease.
Code first the underlying physiological condition or sequelae of cerebrovascular disease.
Code first the underlying physiological condition, such as: A52.17, A81.0–A81.9, E75.00–E75.09, E75.10–E75.19, E75.4,
E83.00–E83.09, G10, G30.0–G30.9, G31.01, G31.09, G31.83, G35, G40.001–G40.319, G40.401–G40.919, G40.A01–
G40.B19, M30.8. This list is a translation of the ICD–9 codes rather than a list of the conditions in the ICD–10 codebook code
first note for category F02.
Code first the underlying physiological condition, such as: A52.17, A81.0–A81.9, E75.00–E75.09, E75.10–E75.19, E75.4,
E83.00–E83.09, G10, G30.0–G30.9, G31.01, G31.09, G31.83, G35, G40.001–G40.319, G40.401–G40.919, G40.A01–
G40.B19, M30.8.
Code first the underlying physiological condition.
Code first the underlying physiological condition, such as: A52.17, A81.0–A81.9, E75.00–E75.09, E75.10–E75.19, E75.4,
E83.00–E83.09, G10, G30.0–G30.9, G31.01, G31.09, G31.83, G35, G40.001–G40.319, G40.401–G40.919, G40.A01–
G40.B19, M30.8.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code first the underlying physiological condition.
Code also associated acute or chronic pain.

F02.81 ...........
F04 ................
F05 ................
F06.0 .............
F06.1 .............
F06.2 .............
F06.30 ...........
F06.31 ...........
F06.32 ...........
F06.33 ...........
F06.34 ...........
F06.4 .............
F06.8 .............
F45.42 ...........

[FR Doc. 2014–18329 Filed 7–31–14; 4:15 pm]

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