Centers for Medicare & Medicaid Services Issues 2016 Inpatient Psychiatric Facilities Prospective Payment System Rates Update
Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal Year Beginning
A Proposed Rule by the
Publication Date:
Agencies:
Dates: To be assured consideration, comments must be received at one of
Entry Type: Proposed Rule
Action: Proposed rule.
Document Citation: 80 FR 25011
Page: 25011 -25065 (55 pages)
CFR: 42 CFR 412
Agency/Docket Number: CMS-1627-P
RIN: 0938-AS47
Document Number: 2015-09880
Shorter URL: https://federalregister.gov/a/2015-09880
Action
Proposed Rule.
Summary
This proposed rule would update the prospective payment rates for
DATES:
To be assured consideration, comments must be received at one of the addresses provided below, no later than
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SUPPLEMENTARY INFORMATION:
I. Executive Summary
A. Purpose
This proposed rule would update the prospective payment rates for
B. Summary of the Major Provisions
In this proposed rule, we would update the IPF Prospective Payment System (PPS), as specified in 42 CFR 412.428. The updates include the following:
Effective for FY 2016 IPF PPS update, we are proposing to adopt a FY 2012-based IPF-specific market basket. We propose to adjust the FY 2012-based IPF market basket update (currently estimated to be 2.7 percent) by a reduction for economy-wide productivity (currently estimated to be 0.6 percentage point) as required by section 1886(s)(2)(A)(i) of the Social Security Act (the Act), and further reduced by 0.2 percentage point as required by section 1886(s)(2)(A)(ii) of the Act, resulting in an estimated market basket update of 1.9 percent.
We propose to update the IPF per diem rate from
We propose to update the electroconvulsive therapy (ECT) payment from
We propose to adopt new
We propose to phase out the rural adjustment for the 37 rural IPFs that would be re-designated as urban IPFs due to the OMB CBSA changes. Specifically, we propose to phase out the 17 percent rural adjustment for these 37 providers over 3 years (2-thirds of the adjustment given in FY 2016, one-third of the adjustment given in FY 2017, and no rural adjustment thereafter).
We propose to use the updated Labor Related Share of 74.9 percent and
We propose to update the fixed dollar loss threshold amount from
We propose that the national urban and rural cost-to-charge ratio (CCR) ceilings for FY 2016 would be 1.6881 and 1.9041, respectively, and the national median CCR would be 0.4675 for urban IPFs and 0.6210 for rural IPFs. The national median CCR is applied to new IPFs that have not yet submitted their first
We note that IPF PPS patient-level and facility-level adjustments, other than those mentioned above, would remain the same as in FY 2015.
In addition:
We remind providers that International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) will be implemented on
As we continue our analysis for future IPF PPS refinements, we find, from preliminary analysis of 2012 to 2013 data, that over 20 percent of IPF stays reported no ancillary costs, such as laboratory and drug costs, in their cost reports, or laboratory or drug charges on their claims. Because we expect that most patients requiring hospitalization for active psychiatric treatment would need drugs and laboratory services, we remind providers that the IPF per diem payment rate includes the cost of all ancillary services, including drugs and laboratory services. CMS pays only the inpatient psychiatric facility for services furnished to a
For the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program, we are making several proposals related to measures and several proposals related to data submission for the IPFQR Program measures. We are proposing to adopt five new measures beginning with the fiscal year (FY) 2018 payment determination:
TOB-3--Tobacco Use Treatment Provided or Offered at Discharge and the subset measure TOB-3a Tobacco Use Treatment at Discharge (
SUB-2--Alcohol Use Brief Intervention Provided or Offered and the subset measure SUB-2a (NQF #1663);
Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF) #0647);
Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF #0648); and
Screening for Metabolic Disorders.
If Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) is adopted, we are proposing to remove Hospital Based Inpatient Psychiatric Services (HBIPS)-6 Post-Discharge Continuing Care Plan (NQF #0557). Likewise, if Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (NQF #0648) is adopted, we are proposing to remove HBIPS-7 Post-Discharge Continuing Care Plan Transmitted to the Next Level of Care Provider Upon Discharge (NQF #0558). We are also proposing to remove one measure, HBIPS-4 Patients Discharged on Multiple Antipsychotic Medications, beginning with the FY 2017 payment determination.
We are also making several proposals regarding how facilities should report data for IPFQR Program measures:
We are proposing to require that measures be reported as a single yearly count rather than by quarter and age beginning with the FY 2017 payment determination;
We are proposing to require that aggregate population counts be reported as a single yearly number rather than by quarter beginning with the FY 2017 payment determination; and
We are proposing to allow uniform sampling for certain measures beginning with the FY 2018 payment determination.
C. Summary of Impacts
Provision description ..... Total transfers
FY 2016 IPF PPS payment rate update ..... The overall economic impact of this proposed rule is an estimated
Provision description ..... Costs
New quality reporting program requirements ..... The total costs beginning in FY 2016 for IPFs as a result of the proposed new quality reporting requirements are estimated to be
II. Background
A. Overview of the Legislative Requirements for the IPF PPS
Section 124 of the
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 subsection (s) to section 1886 of the Act.
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 Rate Year (RY) beginning in 2012 (that is, a RY that coincides with a FY) and each subsequent RY. For the RY beginning in 2015 (that is, FY 2016), the current estimate of the productivity adjustment would be equal to 0.6 percentage point, which we are proposing in this FY 2016 proposed 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 2015 (that is, FY 2016), section 1886(s)(3)(D) of the Act requires the reduction to be 0.2 percentage point. We are proposing that reduction in this FY 2016 IPF PPS proposed 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.
To implement and periodically update these provisions, we have published various proposed and final rules in the
B. Overview of the IPF PPS
The
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,
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
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
Calculate the final Federal per diem base rate to be budget-neutral for the 18-month period of
Use a
Allow the IPF PPS first update to be effective for discharges on or after
In RY 2012, we proposed and finalized switching the IPF PPS payment rate update from a rate year that begins on
C. Annual Requirements for Updating the IPF PPS
In
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
In the
Our most recent IPF PPS annual update occurred in an
III. Provisions of the Proposed Rule
A. Proposed Market Basket for the IPF PPS
1. Background
The input price index that was used to develop the IPF PPS was the
Beginning with the
In the
Beginning with the RY 2012 IPF PPS final rule (76 FR 26432), IPF PPS payments were updated using a 2008-based RPL market basket reflecting the operating and capital cost structures for freestanding IRFs, freestanding IPFs, and LTCHs. The major changes for RY 2012 included: Updating the base year from FY 2002 to FY 2008; using a more specific composite chemical price proxy; breaking the professional fees cost category into 2 separate categories (Labor-related and Nonlabor-related); and adding 2 additional cost categories (Administrative and
For FY 2016, we are proposing to create a 2012-based IPF market basket, using
The proposed 2012-based IPF market basket is a fixed-weight, Laspeyres-type price index. A Laspeyres price index measures the change in price, over time, of the same mix of goods and services purchased in the base period. Any changes in the quantity or mix of goods and services (that is, intensity) purchased over time relative to a base period are not measured.
The index itself is constructed in 3 steps. First, a base period is selected (in this proposed rule, the base period is FY 2012) and total base period expenditures are estimated for a set of mutually exclusive and exhaustive spending categories with the proportion of total costs that each category represents being calculated. These proportions are called cost or expenditure weights. Second, each expenditure category is matched to an appropriate price or wage variable, referred to as a price proxy. In nearly every instance, these price proxies are derived from publicly available statistical series that are published on a consistent schedule (preferably at least on a quarterly basis). Finally, the expenditure weight for each cost category is multiplied by the level of its respective price proxy. The sum of these products (that is, the expenditure weights multiplied by their price levels) for all cost categories yields the composite index level of the market basket in a given period. Repeating this step for other periods produces a series of market basket levels over time. Dividing an index level for a given period by an index level for an earlier period produces a rate of growth in the input price index over that timeframe.
As noted above, the market basket is described as a fixed-weight index because it represents the change in price over time of a constant mix (quantity and intensity) of goods and services needed to furnish IPF services. The effects on total expenditures resulting from changes in the mix of goods and services purchased subsequent to the base period are not measured. For example, an IPF hiring more nurses to accommodate the needs of patients would increase the volume of goods and services purchased by the IPF, but would not be factored into the price change measured by a fixed-weight IPF market basket. Only when the index is rebased would changes in the quantity and intensity be captured, with those changes being reflected in the cost weights. Therefore, we rebase the market basket periodically so that the cost weights reflect recent changes in the mix of goods and services that IPFs purchase (facility inputs) to furnish inpatient care between base periods.
3. Creating an IPF-Specific Market Basket
As discussed in section III.A.1, over the last several years we have been exploring the possibility of creating a stand-alone, or IPF-specific, market basket that reflects the cost structures of only IPF providers. The major cost weights for the 2008-based RPL market basket were calculated using
Since the FY 2015 IPF PPS final rule, we have performed additional research on the
One concern we discussed in the FY 2015 IPF PPS final rule (79 FR 45941) about using the hospital-based IPF Medicare cost report data was the cost level differences for hospital-based IPFs relative to freestanding IPFs were not readily explained by the specific characteristics of the individual providers and the patients that they serve (for example, characteristics related to case mix, urban/rural status, teaching status, or presence of a qualified emergency department). To address this concern, we used regression analysis to evaluate the effect of including hospital-based IPF Medicare cost report data in the calculation of cost distributions. A more detailed description of these regression models can be found in the FY 2015 IPF final rule (79 FR 45941). Based on this analysis, we concluded that the inclusion of those IPF providers with unexplained variability in costs did not significantly impact the cost weights and, therefore, should not be a major cause of concern.
Another concern regarding the incorporation of hospital-based IPF data into the calculation of the market basket cost weights was the complexity of the
We also evaluated the differences in cost weights for hospital-based and freestanding IPFs and found the most significant differences occurred for salaries and pharmaceutical costs. Specifically, the hospital-based IPF salary cost weights tend to be lower than those of freestanding IPFs while hospital-based IPF pharmaceutical cost weights tend to be higher than those of freestanding IPFs. Our proposed methodology for deriving costs for each of these categories can be found in section III.A.3.a.i below. We will continue to research and monitor these cost shares to ensure that the differences are explainable.
In summary, our research over the past year allowed us to evaluate the appropriateness of including hospital-based IPF data in the calculation of the major cost weights for an IPF market basket. We believe that the proposed methodologies for deriving the cost weights give us the ability to create a stand-alone IPF market basket that reflects the cost structure of the universe of IPF providers. Therefore, we believe that the use of this proposed 2012-based IPF market basket to update IPF PPS payments is an improvement over the current 2008-based RPL market basket.
a. Development of Cost Categories and Weights
i. Medicare Cost Reports
The proposed 2012-based IPF market basket consists of seven major cost categories derived from the FY 2012
Prior
To create the proposed 2012-based IPF market basket, we reevaluated the LOS trim based on FY 2012
This less restrictive trim increases the number of IPFs included in the derivation of the market basket, particularly for those providers where the Medicare LOS and facility LOS is within 5 days. Applying the proposed trim results in IPF Medicare cost reports with an average Medicare LOS of 12 days, average facility LOS of 10 days, and
We applied this LOS trim to first obtain a set of cost reports for facilities that have a Medicare LOS within a comparable range of their total facility LOS. Using the resulting set of FY 2012
Similar to the 2008-based RPL market basket major cost weights, the proposed 2012-based IPF market basket cost weights reflect
Below we provide a description of the proposed methodologies used to derive costs for the six major cost categories.
Wages and Salaries Costs
For freestanding IPFs, Wages and Salaries costs are derived as the sum of routine inpatient salaries, ancillary salaries, and a proportion of overhead (or general service cost center) salaries as reported on Worksheet A, column 1. Since overhead salary costs are attributable to the entire IPF, we only include the proportion attributable to the
For hospital-based IPFs, Wages and Salaries costs are derived as the sum of inpatient unit wages and salaries (Worksheet A, column 1, line 40) and a portion of salary costs attributable to total facility ancillary and overhead cost centers as these cost centers are shared with the entire facility. We calculate the portion of ancillary salaries attributable to the hospital-based IPF for a given ancillary cost center by multiplying total facility ancillary salary costs for the specific cost center (as reported on Worksheet A, column 1) by the ratio of IPF Medicare ancillary costs for the cost center (as reported on Worksheet D-3, column 3 for IPF subproviders) to total
We calculate the portion of overhead salary costs attributable to hospital-based IPFs by multiplying the total overhead costs attributable to the hospital-based IPF (sum of columns 4 through18 on Worksheet B, part I, line 40) by the ratio of total facility overhead salaries (as reported on Worksheet A, column 1, lines 4 through18) to total facility overhead costs (as reported on Worksheet A, column 7, lines 4 through18). This methodology assumes the proportion of total costs related to salaries for the overhead cost centers is similar for all inpatient units (that is, acute inpatient or inpatient psychiatric). Since the 2008-based RPL market basket did not include hospital-based providers, this proposed methodology cannot be compared to the derivation of Wages and Salaries costs in the 2008-based RPL market basket.
Employee Benefits Costs
Effective with our implementation of CMS Form 2552-10, CMS began collecting Employee Benefits and Contract Labor data on Worksheet S-3, Part V. Previously, with CMS Form 2540-96, Employee Benefits and Contract Labor data were reported on Worksheet S-3, part II, which was applicable to only IPPS providers and, therefore, these data were not available for the derivation of the RPL market basket. Due to the lack of such data, the Employee Benefits cost weight for the 2008-based RPL market basket was derived by multiplying the 2008-based RPL market basket Wages and Salaries cost weight by the ratio of the IPPS hospital market basket Employee Benefits cost weight to the IPPS hospital market basket Wages and Salaries cost weight. Similarly, the Contract Labor cost weight for the 2008-based RPL market basket was derived by multiplying the 2008-based RPL market basket Wages and Salaries cost weight by the ratio of the IPPS hospital market basket Contract Labor cost weight to the IPPS hospital market basket Wages and Salaries cost weight.
For FY 2012
For freestanding IPFs, Employee Benefits costs are equal to the data reported on Worksheet S-3, Part V, line 2, column 2.
For hospital-based IPFs, we calculate total benefits as the sum of benefit costs reported on Worksheet S-3 Part V, line 3, column 2, and a portion of ancillary benefits and overhead benefits for the total facility. Ancillary benefits attributable to the hospital-based IPF are calculated by multiplying ancillary salaries for the hospital-based IPF as determined in the derivation of Wages and Salaries for the hospital-based IPF by the ratio of total facility benefits to total facility salaries. Similarly, overhead benefits attributable to the hospital-based IPF are calculated by multiplying overhead salaries for the hospital-based IPF as determined in the derivation of Wages and Salaries for the hospital-based IPF by the ratio of total facility benefits to total facility salaries.
Contract Labor Costs
Similar to the RPL and IPPS market baskets, Contract Labor costs are primarily associated with direct patient care services. Contract labor costs for other services such as accounting, billing, and legal are calculated separately using other government data sources as described in section III.A.3.a.ii. As discussed above in the Employee Benefits section, we now have data reported on Worksheet S-3, Part V that we can use to derive the Contract Labor cost weight for the 2012-based IPF market basket. For freestanding IPFs, Contract Labor costs are based on data reported on Worksheet S-3, part V, column 1, line 2 and for hospital-based IPFs Contract Labor costs are based on line 3 of this same worksheet. As previously noted, for FY 2012
Pharmaceuticals Costs
For freestanding IPFs, pharmaceuticals costs are based on non-salary costs reported on Worksheet A, column 7 less Worksheet A, column 1 for the pharmacy cost center (line 15) and drugs charged to patients cost center (line 73).
For hospital-based IPFs, pharmaceuticals costs are based on a portion of the non-salary pharmacy costs and a portion of the non-salary drugs charged to patient costs reported for the total facility. Non-salary pharmacy costs attributable to the hospital-based IPF are calculated by multiplying total pharmacy costs attributable to the hospital-based IPF (as reported on Worksheet B, column 15, line 40) by the ratio of total non-salary pharmacy costs (Worksheet A, column 2, line 15) to total pharmacy costs (sum of Worksheet A, column 1 and 2 for line 15) for the total facility. Non-salary drugs charged to patient costs attributable to the hospital-based IPF are calculated by multiplying total non-salary drugs charged to patient costs (Worksheet B, part I, column 0, line 73 plus Worksheet B, part I, column 15, line 73 less Worksheet A, column 1, line 73) for the total facility by the ratio of
For freestanding IPFs, PLI costs (often referred to as malpractice costs) are equal to premiums, paid losses and self-insurance costs reported on Worksheet S-2, line 118, columns 1 through 3.
For hospital-based IPFs, we assume that the PLI weight for the total facility is similar to the hospital-based IPF unit since the only data reported on this worksheet is for the entire facility. Therefore, hospital-based IPF PLI costs are equal to total facility PLI (as reported on Worksheet S-2, line 118, columns 1 through 3) divided by total facility costs (as reported on Worksheet A, line 200) times hospital-based IPF Medicare allowable total costs.
Capital Costs
For freestanding IPFs, capital costs are equal to
For hospital-based IPFs, capital costs are equal to IPF inpatient capital costs (as reported on Worksheet B, part II, column 26, line 40) and a portion of IPF ancillary capital costs. We calculate the portion of ancillary capital costs attributable to the hospital-based IPF for a given cost center by multiplying total facility ancillary capital costs for the specific ancillary cost center (as reported on Worksheet B, Part II, column 26) by the ratio of IPF Medicare ancillary costs for the cost center (as reported on Worksheet D-3, column 3 for IPF subproviders) to total
i. Final Major Cost Category Computation
After we derive costs for the six major cost categories for each provider using the
Table 1--Major Cost Categories as Derived From Medicare Cost Reports
Major cost categories ..... 2012-Based IPF (percent) ..... 2008-Based RPL (percent)
* Total may not sum to 100 due to rounding.
1Due to the lack of
Wages and Salaries ..... 50.8 ..... 47.4
Employee Benefits1 ..... 13.0 ..... 12.3
Contract Labor1 ..... 1.4 ..... 2.6
Pharmaceuticals ..... 4.8 ..... 6.5
Capital ..... 7.0 ..... 8.4
All Other ..... 22.0 ..... 22.0
The Wages and Salaries cost weight obtained directly from the
As we did for the 2008-based RPL market basket, we propose to allocate the Contract Labor cost weight to the Wages and Salaries and Employee Benefits cost weights based on their relative proportions under the assumption that contract labor costs are comprised of both wages and salaries and employee benefits. The Contract Labor allocation proportion for Wages and Salaries is equal to the Wages and Salaries cost weight as a percent of the sum of the Wages and Salaries cost weight and the Employee Benefits cost weight. This rounded percentage is 80 percent; therefore, we propose to allocate 80 percent of the Contract Labor cost weight to the Wages and Salaries cost weight and 20 percent to the Employee Benefits cost weight. Table 2 shows the Wages and Salaries and Employee Benefit cost weights after Contract Labor cost weight allocation for both the proposed 2012-based IPF market basket and 2008-based RPL market basket.
Table 2--Wages and Salaries and Employee Benefits Cost Weights After Contract Labor Allocation
Major cost categories ..... 2012-Based IPF ..... 2008-Based RPL
Wages and Salaries ..... 51.9 ..... 49.4
Employee Benefits ..... 13.3 ..... 12.8
i. Derivation of the Detailed Operating Cost Weights
To further divide the "All Other" residual cost weight estimated from the FY 2012 Medicare Cost Report data into more detailed cost categories, we propose to use the 2007 Benchmark Input-Output (I-O) "Use Tables/Before Redefinitions/Purchaser Value" for North American Industry Classification System (NAICS) 622000 Hospitals, published by the
The BEA Benchmark I-O data are scheduled for publication every five years with the most recent data available for 2007. The 2007 Benchmark I-O data are derived from the 2007 Economic Census and are the building blocks for BEA's economic accounts. Thus, they represent the most comprehensive and complete set of data on the economic processes or mechanisms by which output is produced and distributed.1 BEA also produces Annual I-O estimates; however, while based on a similar methodology, these estimates reflect less comprehensive and less detailed data sources and are subject to revision when benchmark data becomes available. Instead of using the less detailed Annual I-O data, we inflate the 2007 Benchmark I-O data forward to 2012 by applying the annual price changes from the respective price proxies to the appropriate market basket cost categories that are obtained from the 2007 Benchmark I-O data. We repeat this practice for each year. We then calculate the cost shares that each cost category represents of the inflated 2012 data. These resulting 2012 cost shares are applied to the All Other residual cost weight to obtain the detailed cost weights for the proposed 2012-based IPF market basket. For example, the cost for Food: Direct Purchases represents 6.5 percent of the sum of the "All Other" 2007 Benchmark I-O Hospital Expenditures inflated to 2012; therefore, the Food: Direct Purchases cost weight represents 6.5 percent of the 2012-based IPF market basket's "All Other" cost category (22.0 percent), yielding a "final" Food: Direct Purchases cost weight of 1.4 percent in the proposed 2012-based IPF market basket (0.065 * 22.0 percent = 1.4 percent).
Using this methodology, we derive eighteen detailed IPF market basket cost category weights from the proposed 2012-based IPF market basket residual cost weight (22.0 percent). These categories are: (1) Electricity, (2) Fuel, Oil, and Gasoline (3) Water & Sewerage (4) Food: Direct Purchases, (5) Food: Contract Services, (6) Chemicals, (7) Medical Instruments, (8) Rubber & Plastics, (9) Paper and Printing Products, (10) Miscellaneous Products, (11) Professional Fees: Labor-related, (12) Administrative and
Dated:
Acting Administrator,
Approved:
Secretary.
Editor's note: For the full-text of this document, click this link or copy it into your browser: https://www.federalregister.gov/articles/2015/05/01/2015-09880/medicare-program-inpatient-psychiatric-facilities-prospective-payment-system-update-for-fiscal-year.
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