AHLA MM. 2014 OPPS Update Valerie Rinkle Navigant Consulting Seattle, WA Christina Ritter, PhD Center for Medicare Management Centers for Medicare and Medicaid Services Baltimore, MD Institute on Medicare and Medicaid Payment Issues March 26-28, 2014
2014 OPPS Update Valerie A. Rinkle, MPA Associate Director PRESENTER Valerie A. Rinkle, MPA Associate Director Navigant Consulting, Inc. linked to the NCI Seattle Office living in Medford, OR traveling to??? 2 1
AGENDA» Brief review of annual and routine updates» Significant CY 2014 Policy & Payment Changes» Examples of Financial Impact» Implications for Providers 3 Annual System Updates» APC payments to increase by a 1.7% (market basket increase less certain factors).» CMS projects to spend more on OPPS in CY 2014 due to the inclusion of costs currently payable under other payment systems, such as the clinical laboratory fee schedule (CLFS) and the Durable Medical Equipment Prosthetic Orthotic Schedule (DMEPOS)» Beneficiaries can expect to see changes in their copayments in CY 2014 due to a number of the policies CMS has finalized. In the aggregate, beneficiary copayments are 21.7%.» No change to outlier formula, but the threshold increased from $2,025 to $2,900» Children s hospitals and cancer centers have a permanent hold harmless protection and CMS will continue a payment adjustment so that cancer centers OPPS payment-to-cost ratio (PCR) is equivalent to the average PCR of all other OPPS hospitals; PCR of 0.89 finalized for CY 2014.» Rural SCHs and EACHs will continue to receive a 7.1% payment adjustment for OPPS services, excluding separately payable drugs, biologicals and devices paid under the pass-through payment policy, and items paid at cost. CMS may evaluate this in the future 4 2
ADDENDUM B & OPPS STATUS INDICATORS Status indicators (SI) are assigned to each CPT/HCPCS code and tell us something about how the service is paid Services paid under OPPS (SI = G, H, K, N, P, Q, R, S*, T*, U, V & X) Services paid under another payment system (SI = A, C, F, L, & Y) Services not recognized under OPPS but may be recognized by other institutional providers or there may be a better HCPCS code (SI = B) Services not payable by Medicare (SI = M, E) Services/CPT codes deleted (SI = D) J1= new status indicator for comprehensive APCs beginning CY 2015 * The word significant has been removed from the description of these status indicators in 2014 Remember: Changes in status indicators can result in APC payment changes from one year to the next 5 REVIEW OF PACKAGING & STATUS INDICATORS» Unconditionally packaged status N ALWAYS packaged services no separate payment» Conditionally packaged status Q Sometimes packaged services - services OFTEN packaged, but also separately payable in certain circumstances Q1 ( STVX packaged codes) Q2 ( T packaged codes) Q3 (codes that may be paid through a composite APC)» CMS continues to remind providers that they SHOULD report ALL services regardless of whether they are always or sometimes separately payable. In other words, just because a service is packaged doesn t mean providers should stop reporting it! 6 3
COMMENT INDICATORS CH & NI» CH: Active HCPCS codes in current and next calendar year; status indicator and/or APC assignment changes that need to be studied 2727 HCPCS/CPT codes flagged as CH 569 with payment decreases 292 codes with payment being eliminated 277 with payment decreases 11 new codes with APC payment being proposed for 2014 744 with payment increases 454 due to APC assignment changes 290 with no APC assignment change but with payment increases 1403 codes with status indicator changes but no payment impact since they are also not payable today 398 HCPCS/CPT codes designated as NI for new codes 7 SIGNIFICANT 2014 CHANGES» Use of new cost centers to calculate relative weights» Collapsing E/M clinic visit codes and payment» Packaging expansion and its implications» Coming in 2015 Comprehensive APCs» Examining overall financial impact complicated! 8 4
COST REPORTING, CHARGING AND PRICING» The 2013 OPPS rule contained the most extensive preamble discussion of the relationship between these functions and their importance to OPPS (and IPPS) rate setting. Page 9 CORRECT PRICING MATTERS 10 5
USE OF 3 NEW COST CENTERS TO CALCULATE APC RELATIVE WEIGHTS» Implemented in 2013, CMS will continue to use CCRs from the implantable device cost center (2,936 hospitals reported the implantable device cost center).» CMS will use new cost centers for MRI, CT, and cardiac catheterization to calculate APC relative weights for 2014.» CMS has data from the following number of hospitals: 1,853 hospitals for MRI (53% use direct assignment or dollar value) 1,956 hospitals for CT (54% use direct assignment or dollar value) 1,367 hospitals for cardiac catheterization» Commenters raised significant concerns regarding CT & MRI because of inaccurate cost report allocation based on square footage rather than direct assignment of MME» CMS adjusted CT & MRI CCRs to exclude square footage hospitals applicable for 4 years to give these hospitals time to change their allocation methodology» Significant impacts to certain APCs is depicted in Table 3 and Table 4 shows the uptick in CT & MRI CCRs by excluding square footage hospitals 11 SIGNIFICANT CHANGES TO IMAGING APC PAYMENT RATES 12 6
SIGNIFICANT CHANGES TO IMAGING APC PAYMENT RATES (CONT.) 13 CORRECT COST REPORTING MATTERS» CMS responded to commenters that hospitals should review their cost reports and their allocation method for major moveable equipment (MME).» Ensure the recommended methods of direct assignment or dollar value for Worksheet A, Column 2 for Capital- Related Costs Moveable Equipment are used» If not, request approval from the MAC 90 days in advance of making the appropriate changes.» In the Final Rule, CMS states, We believe that, by adopting more refined CCRs, we are fostering more careful cost reporting. 14 7
RECONFIGURATION OF VISIT APCS» CMS proposed replacing the current five levels of ED visit codes for each visit type (i.e., Type A ED, Type B ED, & new and established clinic visits) with three HCPCS codes representing a single level of payment for each of the three visit types. CMS did not finalize this so all 5 levels of existing CPT and HCPCS G-codes for Type A and Type B EDs should be reported for 2014.» CMS finalized the collapsing of E/M codes for non-ed outpatient hospital visits (i.e., clinic visits) For CY 2014, HCPCS code G0463 replaces 20 CPT codes 99201-99205 & 99211-99215 and is assigned to APC 0634 There is no longer a distinction between new and established patients with this new G code which simplifies coding. This issue is now an investigation topic of the 2014 OIG work plan. The payment rate for this new clinic visit APC is based on the mean costs of Level 1 through Level 5 visit codes from CY 2012 OPPS claims data and is $92.53. 15 Payment Impact for E/M Clinic &ED Visit Codes 16 8
IMPLICATIONS OF CMS APC RECONFIGURATION OF HOSPITAL CLINIC VISITS» All visit levels will be paid at a single rate regardless of the acuity of the patients or the types of hospital/nursing services rendered.» CMS says with a prospective payment system based on averages, payments across low vs. high acuity patients will average out.» Correct CPT coding is always critical, but this is an opportunity for providers to review all remaining SI = V CPT/HCPCS codes to see if other specific codes more appropriately describe the services being rendered compared to the single new HCPCS G-code» For Medicare billing, facility specific visit guidelines may not be needed, but other payers are likely to require CPT reporting which means guidelines will continue to be needed» Providers will need to report all clinic E/M CPT codes to payers who do not recognize CMS single HCPCS, and map these codes in the CDM to the single new HCPCS code for Medicare patients. 17 Status Indicator V CPT/HCPCS Codes 18 9
OPTIMAL CDM UPDATE FOR NEW G0463 Current CMS Regulations Governing Hospital Charges and charge practices CMS Program Manuals Provider Reimbursement (PUB. 15) Provider Reimbursement Manual Part I, Chapter 22 Determination Of Cost Of Services To Beneficiaries Section 2202.4 Definition of Charges Section 2203. Provider Charge Structure As Basis For Apportionment Charges refer to the regular rates established by the provider for services rendered to both beneficiaries and to other paying patients. Charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient. 19 LOOKING AT FINANCIAL IMPACT FOR CLINIC CLAIMS (CONT.) 20 10
EXTENDED ASSESSMENT & MANAGEMENT SERVICES» CMS is replacing the two Composite APCs, APC 8002 (Level I extended assessment and management composite) and APC 8003 (Level II extended assessment and management composite) with a SINGLE new EAM Composite APC.» To generate the new EAM Composite APC 8009, the following criteria must be met: Single new HCPCS clinic visit code, a Level 4 or 5 Type A ED visit, or a Level 5 Type B ED visit must be present along with 8 or more hours of observation time. The HCPCS code for a direct admit to observation and the CPT codes for critical care remain in place No SI = T procedure on the same claim CY 2014 payment rate for new EAM APC is $1,199 compared to existing payment rates of $440 for APC 8002 and $798 for APC 8003 The payment rate does increase dramatically but this is in part due to many other services no longer generating separate payment under CMS expanded packaging. 21 LOOKING AT FINANCIAL IMPACT FOR EXTENDED ASSESSMENT AND MANAGEMENT CLAIMS 22 11
OPPS PACKAGING POLICY REVIEW» REMINDER: CMS made its first extensive expansion of packaging policy in 2008 by creating 7 broad categories of services to be packaged to their primary diagnostic or therapeutic service: (1) guidance services (2) image processing services (3) intraoperative services (4) imaging supervision and interpretation services (5) diagnostic radiopharmaceuticals (6) contrast media (7) observation services CMS added implantable biologicals in 2009» CMS would like to shift the OPPS away from a per-service fee schedule-like payment system to more of a prospective payment system by creating larger bundles of payment. 23 EXPANDED OPPS PACKAGING FOR CY 2014» CMS proposed to package an additional 7 different categories of services that it believes to be integral, ancillary, supportive, dependent, or adjunctive to other services.» CMS modified its proposals and is finalizing 5 of the 7 categories for CY 2014 Addendum P lists specific CPT codes 1. Drugs, biologicals, and radiopharmaceuticals that function as supplies in a diagnostic test or procedure 2. Drugs and biologicals that function as supplies or devices in a surgical procedure 3. Certain clinical laboratory tests 4. Certain procedures described by add-on codes; and 5. Device removal procedures» CMS also packaged take home surgical dressings» CMS updated the list of OPPS packaged items and services in 42 CFR 419.2(b) 24 12
Drugs, Biologicals, and Radiopharmaceuticals that Function as Supplies in a Diagnostic Test or Procedure (cont)» CMS has identified one new class of drugs and one specific drug that fits within the category of drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure: Stress agents Drugs used in diagnostic tests to evaluate certain aspects of cardiac function and used in performing myocardial perfusion imaging (MPI), primarily reported with CPT code 78452. HCPCS J0151 (replaces J0152) and J2785 are assigned status indicator N for CY 2014. Cysview Used for cystoscopic detection of non-muscle invasive papillary cancer of the bladder, which is diagnostic. Cysview is more of a drug that functions a supply when used in a diagnostic test or procedure. HCPCS code C9275 (Cysview) is assigned status indicator N for CY 2014. 25 Biologicals that Function as Supplies in a Surgical Procedure» Skin substitutes are mostly used in the outpatient setting for treatment of diabetic foot ulcers and venous leg ulcers.» Currently skin substitutes are paid as biologicals under OPPS under the ASP methodology and subject to the drug packaging threshold.» But CMS believes they fit into the packaging category of drugs and biologicals that function as supplies in a surgical procedure» CMS states because a skin substitute must be used to perform surgical procedures in the CPT range of 15271-15278, they function as necessary supplies for the repair procedures and should be packaged. 26 13
Biologicals that Function as Supplies in a Surgical Procedure (cont)» Commenters raised concerns about CMS packaging skin substitutes equally into procedures since they have widely varying costs.» CMS agreed and modified its proposal by creating two groups for packaging. See Table 13 & be sure to check your cost & charges for these items: High = weighted average cost > $32 per square cm Low = weighted average cost < $32 per square cm Liquid or powder skin substitutes that are per milliliter or per milligram will simply be packaged into the surgical procedure in which they are used.» New coding requirements necessary to implement this policy High cost skin substitutes to be billed using existing skin substitute application CPT codes 15271-15278. New HCPCS C-codes to be reported for low cost skin substitutes in CY 2014: C5271, C5272, C5273, C5274, C5275, C5276, C5277, & C5278. Code edits will be in place checking for high cost skin substitutes reported with CPT codes and low cost with the new C-codes. 27 EXAMPLE OF FINANCIAL IMPACT FOR SKIN SUBSTITUTES AND ADD-ON CODES 28 14
Clinical Laboratory Tests» Clinical laboratory tests currently paid under the Clinical Laboratory Fee Schedule (CLFS) will be packaged (status indicator N ) when the labs are ordered by the same practitioner who performs the primary service & are related and supportive to the primary service and performed on the same date of service as any other OPPS service.» Molecular pathology tests will continue to be paid under the CLFS even when included on the 13x claim (CPT codes 81200-81333 and 81400 81408, and 81479).» Additionally, clinical lab tests will be paid separately only when billed on a 14x claim and meet one of the two following criteria. Further instructions forthcoming. 1. The lab test is the only service provided on that date of service 2. The lab test is on the same date of service as the primary service but is ordered for a different purpose than the primary service by a practitioner different than the practitioner who ordered the primary service. This is a change in billing practice and in the definition of a 14x claim. 29 EXAMPLE OF LAB PACKAGING» A beneficiary has eye surgery scheduled with physician A, an ophthalmologist, but also has an order from physician B, a cardiologist, for unrelated laboratory tests. The beneficiary goes to the hospital for the eye procedure and decides to have the laboratory tests that have been ordered by physician B for a different purpose than the eye procedure on the same date of service.» While the laboratory test is on the same date of service as the eye procedure, the laboratory tests are ordered for a different purpose than the primary service by a practitioner different than the practitioner who ordered the eye procedure.» In this situation, the hospital can bill Medicare for the unrelated laboratory tests on a 14x claim and receive separate payment under the CLFS, similar to when the laboratory tests are the only service performed in the hospital outpatient department on a given date of service. 30 15
EXAMPLE OF LAB PACKAGING» However, if, in this example, physician A also ordered some laboratory tests as a part of a preoperative evaluation for the eye procedure and the beneficiary had the tests on the same date of service as the eye procedure, then the hospital would report those laboratory tests on a 13x claim along with the eye surgery.» Payment for those preoperative laboratory tests would be packaged into the payment for the surgery, which is the primary procedure that would be paid separately.» If the patient remains overnight in the hospital and physician C, rounding for physician A, orders post-operative lab tests on the next day, these tests are related to the surgery and are also packaged and must be billed on the 13x claim.» It will be the hospital s responsibility to determine when to separately bill laboratory tests on the 14x claim according to this description of these limited exceptions. 31 CLINICAL LABORATORY TESTS (CONT.)» For all hospitals (including CAHs) except Maryland waiver hospitals, if a patient receives hospital outpatient services on the same day as a specimen collection and laboratory test, then the patient is considered to be a registered hospital outpatient and cannot be considered to be a non-patient on that day for purposes of the specimen collection and laboratory test» This is the requirement CMS is supposedly changing the specimen collection and lab test (i.e., reference test) presumably ordered by a different physician for a different purpose can be billed on a 14X bill for CLFS payment» If any hospital (other than a CAH or a Maryland waiver hospital) only collects or draws a specimen from the patient and the patient does not also receive hospital outpatient services on that day, the hospital may choose to register the patient as an outpatient for the specimen collection or bill for these services as non- patient on the 14x bill type.» Unintended consequence for SCHs lab billing on 14x claim and NUBC definition of 14x. MLN SE1412 allows this up to July 1 when a new modifier will be released. 32 16
Certain Categories of Add On Codes» CMS had proposed to unconditionally package 273 add-on codes but is only finalizing packaging of 243 as shown in Addendum P» Examples of codes: Surgery range such as skin graft add-on codes (15111 & 15131) Imaging codes such as x-ray in surgery and ultrasound vascular access codes (74301 & 76937) Cardiology codes such as color Doppler and electrophysiology 3D (93325 & 93613)» CMS modified its proposal and did NOT finalize packaging device-dependent addon codes or drug administration add-on codes such as additional infusion hours or additional injections based on the comments it received, but says it will review these in the future. 33 Device Removal Procedure Codes» Device removal procedures are sometimes described by a code that may include repair or replacement. Other times, device removal procedures are described by separate codes that only describe the surgical procedure to remove a device.» Device removal procedures are frequently performed with procedures to repair or replace devices, but not always.» As a result, for CY 2014 CMS will package all separately coded device removal procedures when performed with a separately coded device repair or replacement procedure.» There are 68 device removal procedure codes being conditionally packaged (status indicator Q2 ) and they are listed in Addendum P.» Remember, status indicator Q2 means no separate payment is made when the CPT code occurs on the same date of service as another procedure code with status indicator T. 34 17
Additional Supplies Packaged» CMS says that supplies are a large category of items typically either for single patient use or with a shorter life than equipment.» Packaged supplies can include certain drugs, biologicals, and radiopharmaceuticals.» As part of its annual review of OPPS for CY 2014, CMS found that it was paying for many supplies separately that should be packaged.» Take home surgical dressings will no longer receive separate payment when billed by an outpatient hospital. This will require a prescription to a DMEPOS to be paid or the hospital will no longer receive separate payment and eat the cost.» The only supplies that are sometimes paid separately via the DMEPOS are prosthetic supplies.» For CY 2014, CMS has finalized revising the status indicator for all supplies described by HCPCS A-codes (except for prosthetic supplies) from status indicator A to N,. 35 NOT FINALIZED FOR CY 2014 PACKAGING» CMS did not finalize conditional packaging (status indicator of Q1) for 425 ancillary codes due to concerns raised by commenters. The following codes WILL continue to be separately payable in CY 2014: Surgery range such as remove nasal foreign body code (30300) Numerous imaging codes such as chest x-rays (71021 71035) Radiation oncology codes such as radiation therapy dose plan (77300) Blood bank codes such as fresh frozen plasma (96927) Pathology codes such as tissue exam by pathologists (88302 88309) Respiratory & pulmonary codes such as pulmonary stress tests (94620 & 94621)» CMS also did not finalize the packaging of diagnostic tests for CY 2014, but plans to continue studying these services for future packaging. Exception: CMS DID finalize conditional packaging of CPT 93107 Stress Test 36 18
LOOKING AHEAD EXPECT MORE PACKAGING» CMS says the packaging finalized here is not exhaustive and that it will continue analyzing other services» More packaging proposals likely for 2015, especially for the areas that CMS did not finalize in CY 2014 such as imaging services with associated surgical procedures or packaging of therapy services when related to and included with any other OPPS services on the same claim» Comprehensive APCs coming in 2015» Beyond 2015 even more bundles, packaging, and comprehensive style APCs» Indirect influence on hospitals to bundle services to a single price Caution: many cost report and future rate setting implications! 37 COMPREHENSIVE APCS» CMS proposed to create 29 comprehensive APCs from the 39 existing devicedependent APCs. CMS chose this first set of comprehensive APCs based on the most costly device-dependent services. 29 Comprehensive APCs calculated using 136 HCPCS codes from 2012 data and a new status indicator J1 was created for these APCs. A single APC payment would be based on costs of all individually reported services on the claim that would be categorically assumed to be adjunctive and supportive of the primary service by virtue of being on the same claim (Line item date of service would not apply for claims spanning dates). In the proposed rule, CMS did not address how claims with more than one of the 136 HCPCS (i.e., multiple J1 HCPCS) would be treated or which HCPCS would be defined as the primary service. CMS finalized its plan to move forward with 29 comprehensive APCs, but will delay implementation until 2015 and will make modifications. 38 19
COMPREHENSIVE APCS (CONT.)» CMS listened to comments and made several policy changes and specifically will address how to pay for cases with multiple J1 HCPCS codes to respond to commenters concerns about more complex cases.» For the comprehensive APCs in CY 2015, expanded packaging will include all services in support of the primary procedure - all supplies, lab, DMEPOS, diagnostic tests, drugs and therapy services are also packaged. CMS acknowledged that for outpatient claims, room & board is included in ancillary charges, so these revenue codes are not applicable.» PT, OT & SLP therapies provided during an encounter for one of these primary procedures is not the same as outpatient therapy ordered as part of a continuing care plan, and therefore, it is categorically defined as adjunctive and supportive and will be packaged. Functional status codes and modifiers will not be required for these adjunctive therapy services billed on comprehensive APC claims; more instructions forthcoming. 39 PHYSICIAN SUPERVISION AND THE INPATIENT-ONLY LIST» Physician supervision All rules remain in effect CMS to begin enforcing physician supervision requirements for CAHs and rural hospitals starting January 1, 2014» Inpatient-Only List (status indicator C) The list continues, which means Medicare will only provide payment for services on the list when provided in the inpatient setting due to the nature of the procedure and the need for postoperative recovery time/monitoring. New 2-midnight benchmark for assuming medical necessity of inpatient status will not be required for stays where an inpatient-only procedure is performed. Caution: cancelled inpatient-only procedures!! 40 20
THE INPATIENT-ONLY LIST (CONTINUED)» Inpatient-Only List (status indicator C) CMS reviews the list annually and typically identifies codes to remove For CY 2014, CMS didn t propose removal of any procedures Instead, CMS added the codes in the table below to the Inpatient-Only list 41 PASS-THROUGH DEVICES, NEW VALUE CODE FD FOR DEVICE CREDITS AND DEVICE-RELATED EDITS» No devices to receive pass-through payment for CY 2014» CMS is eliminating hospital reporting of modifiers FB/FC when a device is received at no charge/full credit or if a device is replaced with at least 50% partial credit from the manufacturer. Instead, hospitals are to report regular/full marked up charge for the device under RC 278 and the actual amount of the credit with new value code FD (Credit Received from the Manufacturer for a Replaced Medical Device).» This will result in a dollar for dollar offset up to the amount of the device offset. Note the regulation text states is it a 50% reduction and CMS has confirmed that the regulation will need to be changed.» At least for 2014, CMS will retain device to procedure edits, but is eliminating radiopharmaceutical to nuclear medicine procedure edits since the agency no longer believes they are necessary. Providers are duly warned to continue reporting as if the edits were in place.» One reason for eliminating edits is to indirectly influence and encourage bundling of services for pricing. 42 21
PART A TO PART B BILLING» In response to comment, CMS clarified that Part B outpatient claims are considered for the HOQRP, including those claims for services in the 3-day payment window split from Part B Inpatient-Only claims submitted for medical necessity cases» Concern about transmittal 2877- Medicare will allow payment under Part B of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient» Transmittal includes a table of revenue codes not to be billed on 12x for OPPS payment to include blood administration 391 and the following statement: a re not separately billable Inpatient Part B ancillary services. They include routine nursing services that are captured in the Room and Board rate (such as IV infusions and injections, blood administration, and nebulizer treatments), which are not separately billable Inpatient Part B ancillary services? 43 IMPORTANT NEW MEDICARE COP FOR OUTPATIENT THERAPEUTIC SERVICES CMS finalized its revisions to the Medicare conditions of participation (COP) for outpatient therapeutic services in hospitals or CAHs that are furnished incident to a physician s or NPP s services to require that individuals furnishing these services do so in compliance with applicable state law. Several cases have commanded CMS attention where Medicare was billed for incident to services that were performed by an individual who did not meet State standards for furnishing those services (e.g., scope or licensure or certification). Current Medicare requirements for hospital outpatient therapeutic services do not specifically make compliance with State law a condition of payment for services, the Medicare program has had limited recourse to recoup payments when hospital outpatient therapeutic incident-to services are not furnished in compliance with state law. 44 22
OFF-CAMPUS PROVIDER BASED DEPARTMENTS» CMS is interested in studying the impact of the increasing trend of hospitals acquiring physician practices and converting those practices into hospital outpatient departments on Medicare program payments and beneficiary costs.» In the proposed rule, CMS suggested several methods to collect data so it can analyze the frequency, type, and payment for services furnished in off-campus provider-based hospital departments.» CMS requested comments on the following and other types of methods: New location/service code for all off-campus-based departments Use of a new modifier on all services provided in off-campus-based departments New cost centers for off-campus departments» CMS received numerous comments and in the CY 2014 OPPS Final rule indicated that it would continue to study the best way to collect this data nothing finalized for CY 2014! 45 Summary» Cost reporting and charging are very important» Unstated pressure on hospitals to bundle services and charge a single price this has significant cost reporting and rate setting implications if not correctly performed with MAC auditor approval/awareness» Billing and clearinghouse edits must be scrutinized for accuracy packaged services can and should be billed separately!» Significant organizational impact of packaged lab services» Think about operational implications and potential unintended consequences for 2014 and beyond» Consider and monitor the types of implications CMS proposals will have on other payers 46 23