42 CFR Part 412
PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
- PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter B—Medicare Program
- Subpart A—General Provisions
- § 412.1 Scope of part.
- § 412.2 Basis of payment.
- § 412.3 Admissions.
- § 412.4 Discharges and transfers.
- § 412.6 Cost reporting periods subject to the prospective payment systems.
- § 412.8 Publication of schedules for determining prospective payment rates.
- § 412.10 Changes in the DRG classification system.
- Subpart B—Hospital Services Subject to and Excluded From the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs
- § 412.20 Hospital services subject to the prospective payment systems.
- § 412.22 Excluded hospitals and hospital units: General rules.
- § 412.23 Excluded hospitals: Classifications.
- § 412.24 Requirements under the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.
- § 412.25 Excluded hospital units: Common requirements.
- § 412.27 Excluded psychiatric units: Additional requirements.
- § 412.29 Classification criteria for payment under the inpatient rehabilitation facility prospective payment system.
- § 412.30 [Reserved]
- Subpart C—Conditions for Payment Under the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs
- § 412.40 General requirements.
- § 412.42 Limitations on charges to beneficiaries.
- § 412.44 Medical review requirements: Admissions and quality review.
- § 412.46 Medical review requirements.
- § 412.48 Denial of payment as a result of admissions and quality review.
- § 412.50 Furnishing of inpatient hospital services directly or under arrangements.
- § 412.52 Reporting and recordkeeping requirements.
- Subpart D—Basic Methodology for Determining Prospective Payment Federal Rates for Inpatient Operating Costs
- § 412.60 DRG classification and weighting factors.
- § 412.62 Federal rates for inpatient operating costs for fiscal year 1984.
- § 412.63 Federal rates for inpatient operating costs for Federal fiscal years 1984 through 2004.
- § 412.64 Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.
- Subpart E—Determination of Transition Period Payment Rates for the Prospective Payment System for Inpatient Operating Costs
- § 412.70 General description.
- § 412.71 Determination of base-year inpatient operating costs.
- § 412.72 Modification of base-year costs.
- § 412.73 Determination of the hospital-specific rate based on a Federal fiscal year 1982 base period.
- § 412.75 Determination of the hospital-specific rate for inpatient operating costs based on a Federal fiscal year 1987 base period.
- § 412.76 Recovery of excess transition period payment amounts resulting from unlawful claims.
- § 412.77 Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 1996 base period.
- § 412.78 Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 2006 base period.
- § 412.79 Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period.
- Subpart F—Payments for Outlier Cases, Special Treatment Payment for New Technology, and Payment Adjustment for Certain Replaced Devices
- Payment for Outlier Cases
- § 412.80 Outlier cases: General provisions.
- § 412.82 Payment for extended length-of-stay cases (day outliers).
- § 412.84 Payment for extraordinarily high-cost cases (cost outliers).
- Payment Adjustment for Certain Clinical Trial Cases and Expanded Access Use Immunotherapy
- § 412.85 Payment adjustment for certain immunotherapy cases.
- § 412.83 Payment for extraordinarily high-cost day outliers.
- 412.86 [Reserved]
- Additional Special Payment for Certain New Technology
- § 412.87 Additional payment for new medical services and technologies: General provisions.
- § 412.88 Additional payment for new medical service or technology.
- Payment Adjustment for Certain Replaced Devices
- § 412.89 Payment adjustment for certain replaced devices.
- Subpart G—Special Treatment of Certain Facilities Under the Prospective Payment System for Inpatient Operating Costs
- § 412.90 General rules.
- § 412.92 Special treatment: Sole community hospitals.
- § 412.96 Special treatment: Referral centers.
- § 412.98 [Reserved]
- § 412.100 Special treatment: Kidney transplant programs.
- § 412.101 Special treatment: Inpatient hospital payment adjustment for low-volume hospitals.
- § 412.102 Special treatment: Hospitals located in areas that are changing from urban to rural as a result of a geographic redesignation.
- § 412.103 Special treatment: Hospitals located in urban areas and that apply for reclassification as rural.
- § 412.104 Special treatment: Hospitals with high percentage of ESRD discharges.
- § 412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
- § 412.106 Special treatment: Hospitals that serve a disproportionate share of low-income patients.
- § 412.107 Special treatment: Hospitals that receive an additional update for FYs 1998 and 1999.
- § 412.108 Special treatment: Medicare-dependent, small rural hospitals.
- § 412.109 Special treatment: Essential access community hospitals (EACHs).
- Subpart H—Payments to Hospitals Under the Prospective Payment Systems
- § 412.110 Total Medicare payment.
- § 412.112 Payments determined on a per case basis.
- § 412.113 Other payments.
- § 412.115 Additional payments.
- § 412.116 Method of payment.
- § 412.120 Reductions to total payments.
- § 412.125 Effect of change of ownership on payments under the prospective payment systems.
- § 412.130 Retroactive adjustments for incorrectly excluded hospitals and units.
- § 412.140 Participation, data submission, and validation requirements under the Hospital Inpatient Quality Reporting (IQR) Program.
- Subpart I—Adjustments to the Base Operating DRG Payment Amounts Under the Prospective Payment Systems for Inpatient Operating Costs
- § 412.150 Basis and scope of subpart.
- Payment Adjustments Under the Hospital Readmissions Reduction Program
- § 412.152 Definitions for the Hospital Readmissions Reduction Program.
- § 412.154 Payment adjustments under the Hospital Readmissions Reduction Program.
- §§ 412.155-412.159 [Reserved]
- Incentive Payments Under the Hospital Value-Based Purchasing Program
- § 412.160 Definitions for the Hospital Value-Based Purchasing (VBP) Program.
- § 412.161 Applicability of the Hospital Value-Based Purchasing (VBP) Program.
- § 412.162 Process for reducing the base operating DRG payment amount and applying the value-based incentive payment amount adjustment under the Hospital Value-Based Purchasing (VBP) Program.
- § 412.163 Process for making hospital-specific performance information under the Hospital Value-Based Purchasing (VBP) Program available to the public.
- § 412.164 Measure selection under the Hospital Value-Based Purchasing (VBP) Program.
- § 412.165 Performance scoring under the Hospital Value-Based Purchasing (VBP) Program.
- § 412.167 Appeal under the Hospital Value-Based Purchasing (VBP) Program.
- § 412.168 Special rules for FY 2022 and FY 2023.
- § 412.169 [Reserved]
- Payment Adjustments Under the Hospital-Acquired Condition Reduction Program
- § 412.170 Definitions for the Hospital-Acquired Condition Reduction Program.
- § 412.172 Payment adjustments under the Hospital-Acquired Condition Reduction Program.
- § 412.190 Overall Hospital Quality Star Rating.
- Subpart J [Reserved]
- Subpart K—Prospective Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico
- § 412.200 General provisions.
- § 412.204 Payment to hospitals located in Puerto Rico.
- § 412.208 Puerto Rico rates for Federal fiscal year 1988.
- § 412.210 Puerto Rico rates for Federal fiscal years 1989 through 2003.
- § 412.211 Puerto Rico rates for Federal fiscal year 2004 and subsequent fiscal years.
- § 412.212 National rate.
- § 412.220 Special treatment of certain hospitals located in Puerto Rico.
- Subpart L—The Medicare Geographic Classification Review Board
- Criteria and Conditions for Redesignation
- § 412.230 Criteria for an individual hospital seeking redesignation to another rural area or an urban area.
- § 412.232 Criteria for all hospitals in a rural county seeking urban redesignation.
- § 412.234 Criteria for all hospitals in an urban county seeking redesignation to another urban area.
- § 412.235 Criteria for all hospitals in a State seeking a statewide wage index redesignation.
- Composition and Procedures
- § 412.246 MGCRB members.
- § 412.248 Number of members needed for a decision or a hearing.
- § 412.250 Sources of MGCRB's authority.
- § 412.252 Applications.
- § 412.254 Proceedings before MGCRB.
- § 412.256 Application requirements.
- § 412.258 Parties to MGCRB proceeding.
- § 412.260 Time and place of the oral hearing.
- § 412.262 Disqualification of an MGCRB member.
- § 412.264 Evidence and comments in MGCRB proceeding.
- § 412.266 Availability of wage data.
- § 412.268 Subpoenas.
- § 412.270 Witnesses.
- § 412.272 Record of proceedings before the MGCRB.
- § 412.273 Withdrawing an application, terminating an approved 3-year reclassification, or reinstating a previous termination.
- § 412.274 Scope and effect of an MGCRB decision.
- § 412.276 Timing of MGCRB decision and its appeal.
- § 412.278 Administrator's review.
- § 412.280 Representation.
- Subpart M—Prospective Payment System for Inpatient Hospital Capital Costs
- General Provisions
- § 412.300 Scope of subpart and definition.
- § 412.302 Introduction to capital costs.
- § 412.304 Implementation of the capital prospective payment system.
- Basic Methodology for Determining the Federal Rate for Capital-Related Costs
- § 412.308 Determining and updating the Federal rate.
- § 412.312 Payment based on the Federal rate.
- § 412.316 Geographic adjustment factors.
- § 412.320 Disproportionate share adjustment factor.
- § 412.322 Indirect medical education adjustment factor.
- Determination of Transition Period Payment Rates for Capital-Related Costs
- § 412.324 General description.
- § 412.328 Determining and updating the hospital-specific rate.
- § 412.331 Determining hospital-specific rates in cases of hospital merger, consolidation, or dissolution.
- § 412.332 Payment based on the hospital-specific rate.
- § 412.336 Transition period payment methodologies.
- § 412.340 Fully prospective payment methodology.
- § 412.344 Hold-harmless payment methodology.
- § 412.348 Exception payments.
- § 412.352 Budget neutrality adjustment.
- Special Rules for Puerto Rico Hospitals
- § 412.370 General provisions for hospitals located in Puerto Rico.
- § 412.374 Payments to hospitals located in Puerto Rico.
- Subpart N—Prospective Payment System for Inpatient Hospital Services of Inpatient Psychiatric Facilities
- § 412.400 Basis and scope of subpart.
- § 412.402 Definitions.
- § 412.404 Conditions for payment under the prospective payment system for inpatient hospital services of psychiatric facilities.
- § 412.405 Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system.
- § 412.422 Basis of payment.
- § 412.424 Methodology for calculating the Federal per diem payment amount.
- § 412.426 Transition period.
- § 412.428 Publication of changes to the inpatient psychiatric facility prospective payment system.
- § 412.432 Method of payment under the inpatient psychiatric facility prospective payment system.
- § 412.433 Procedural requirements under the IPFQR Program.
- § 412.434 Reconsideration and appeals procedures of Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program decisions.
- Subpart O—Prospective Payment System for Long-Term Care Hospitals
- § 412.500 Basis and scope of subpart.
- § 412.503 Definitions.
- § 412.505 Conditions for payment under the prospective payment system for long-term care hospitals.
- § 412.507 Limitation on charges to beneficiaries.
- § 412.508 Medical review requirements.
- § 412.509 Furnishing of inpatient hospital services directly or under arrangement.
- § 412.511 Reporting and recordkeeping requirements.
- § 412.513 Patient classification system.
- § 412.515 LTC-DRG weighting factors.
- § 412.517 Revision of LTC-DRG group classifications and weighting factors.
- § 412.521 Basis of payment.
- § 412.522 Application of site neutral payment rate.
- § 412.523 Methodology for calculating the Federal prospective payment rates.
- § 412.525 Adjustments to the Federal prospective payment.
- § 412.526 Payment provisions for a “subclause (II)” long-term care hospital.
- § 412.529 Special payment provision for short-stay outliers.
- § 412.531 Special payment provisions when an interruption of a stay occurs in a long-term care hospital.
- § 412.533 Transition payments.
- § 412.534 Special payment provisions for long-term care hospitals-within-hospitals and satellites of long-term care hospitals, effective for discharges occurring in cost reporting periods beginning on or before September 30, 2016.
- § 412.535 Publication of the Federal prospective payment rates.
- § 412.536 Special payment provisions for long-term care hospitals and satellites of long-term care hospitals that discharge Medicare patients admitted from a hospital not located in the same building or on the same campus as the long-term care hospital or satellite of the long-term care hospital, effective for discharges occurring on or before September 30, 2016 or in cost reporting periods beginning on or before June 30, 2016.
- § 412.538 [Reserved]
- § 412.540 Method of payment for preadmission services under the long-term care hospital prospective payment system.
- § 412.541 Method of payment under the long-term care hospital prospective payment system.
- § 412.560 Requirements under the Long-Term Care Hospital Quality Reporting Program (LTCH QRP).
- Subpart P—Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
- § 412.600 Basis and scope of subpart.
- § 412.602 Definitions.
- § 412.604 Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.
- § 412.606 Patient assessments.
- § 412.608 Patients' rights regarding the collection of patient assessment data.
- § 412.610 Assessment schedule.
- § 412.612 Coordination of the collection of patient assessment data.
- § 412.614 Transmission of patient assessment data.
- § 412.616 Release of information collected using the patient assessment instrument.
- § 412.618 Assessment process for interrupted stays.
- § 412.620 Patient classification system.
- § 412.622 Basis of payment.
- § 412.624 Methodology for calculating the Federal prospective payment rates.
- § 412.626 Transition period.
- § 412.628 Publication of the Federal prospective payment rates.
- § 412.630 Limitation on review.
- § 412.632 Method of payment under the inpatient rehabilitation facility prospective payment system.
- § 412.634 Requirements under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP).
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