Title 42, Part 412 — Prospective Payment Systems for Inpatient Hospital Services

Scope of part.

Basis of payment.

Admissions.

Discharges and transfers.

Cost reporting periods subject to the prospective payment systems.

Publication of schedules for determining prospective payment rates.

Changes in the DRG classification system.

Hospital services subject to the prospective payment systems.

Excluded hospitals and hospital units: General rules.

Excluded hospitals: Classifications.

Requirements under the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.

Excluded hospital units: Common requirements.

Excluded psychiatric units: Additional requirements.

Classification criteria for payment under the inpatient rehabilitation facility prospective payment system.

[Reserved]

General requirements.

Limitations on charges to beneficiaries.

Medical review requirements: Admissions and quality review.

Medical review requirements.

Denial of payment as a result of admissions and quality review.

Furnishing of inpatient hospital services directly or under arrangements.

Reporting and recordkeeping requirements.

DRG classification and weighting factors.

Federal rates for inpatient operating costs for fiscal year 1984.

Federal rates for inpatient operating costs for Federal fiscal years 1984 through 2004.

Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.

General description.

Determination of base-year inpatient operating costs.

Modification of base-year costs.

Determination of the hospital-specific rate based on a Federal fiscal year 1982 base period.

Determination of the hospital-specific rate for inpatient operating costs based on a Federal fiscal year 1987 base period.

Recovery of excess transition period payment amounts resulting from unlawful claims.

Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 1996 base period.

Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 2006 base period.

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.

Outlier cases: General provisions.

Payment for extended length-of-stay cases (day outliers).

Payment for extraordinarily high-cost cases (cost outliers).

Payment adjustment for certain immunotherapy cases.

Payment for extraordinarily high-cost day outliers.

412.86 [Reserved]

Additional payment for new medical services and technologies: General provisions.

Additional payment for new medical service or technology.

Payment adjustment for certain replaced devices.

General rules.

Special treatment: Sole community hospitals.

Special treatment: Referral centers.

[Reserved]

Special treatment: Kidney transplant programs.

Special treatment: Inpatient hospital payment adjustment for low-volume hospitals.

Special treatment: Hospitals located in areas that are changing from urban to rural as a result of a geographic redesignation.

Special treatment: Hospitals located in urban areas and that apply for reclassification as rural.

Special treatment: Hospitals with high percentage of ESRD discharges.

Special treatment: Hospitals that incur indirect costs for graduate medical education programs.

Special treatment: Hospitals that serve a disproportionate share of low-income patients.

Special treatment: Hospitals that receive an additional update for FYs 1998 and 1999.

Special treatment: Medicare-dependent, small rural hospitals.

Special treatment: Essential access community hospitals (EACHs).

Total Medicare payment.

Payments determined on a per case basis.

Other payments.

Additional payments.

Method of payment.

Reductions to total payments.

Effect of change of ownership on payments under the prospective payment systems.

Retroactive adjustments for incorrectly excluded hospitals and units.

Participation, data submission, and validation requirements under the Hospital Inpatient Quality Reporting (IQR) Program.

Basis and scope of subpart.

Definitions for the Hospital Readmissions Reduction Program.

Payment adjustments under the Hospital Readmissions Reduction Program.

§§ 412.155-412.159 [Reserved]

Definitions for the Hospital Value-Based Purchasing (VBP) Program.

Applicability of the Hospital Value-Based Purchasing (VBP) Program.

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.

Process for making hospital-specific performance information under the Hospital Value-Based Purchasing (VBP) Program available to the public.

Measure selection under the Hospital Value-Based Purchasing (VBP) Program.

Performance scoring under the Hospital Value-Based Purchasing (VBP) Program.

Appeal under the Hospital Value-Based Purchasing (VBP) Program.

Special rules for FY 2022 and FY 2023.

[Reserved]

Definitions for the Hospital-Acquired Condition Reduction Program.

Payment adjustments under the Hospital-Acquired Condition Reduction Program.

Overall Hospital Quality Star Rating.

General provisions.

Payment to hospitals located in Puerto Rico.

Puerto Rico rates for Federal fiscal year 1988.

Puerto Rico rates for Federal fiscal years 1989 through 2003.

Puerto Rico rates for Federal fiscal year 2004 and subsequent fiscal years.

National rate.

Special treatment of certain hospitals located in Puerto Rico.

Criteria for an individual hospital seeking redesignation to another rural area or an urban area.

Criteria for all hospitals in a rural county seeking urban redesignation.

Criteria for all hospitals in an urban county seeking redesignation to another urban area.

Criteria for all hospitals in a State seeking a statewide wage index redesignation.

MGCRB members.

Number of members needed for a decision or a hearing.

Sources of MGCRB's authority.

Applications.

Proceedings before MGCRB.

Application requirements.

Parties to MGCRB proceeding.

Time and place of the oral hearing.

Disqualification of an MGCRB member.

Evidence and comments in MGCRB proceeding.

Availability of wage data.

Subpoenas.

Witnesses.

Record of proceedings before the MGCRB.

Withdrawing an application, terminating an approved 3-year reclassification, or reinstating a previous termination.

Scope and effect of an MGCRB decision.

Timing of MGCRB decision and its appeal.

Administrator's review.

Representation.

Scope of subpart and definition.

Introduction to capital costs.

Implementation of the capital prospective payment system.

Determining and updating the Federal rate.

Payment based on the Federal rate.

Geographic adjustment factors.

Disproportionate share adjustment factor.

Indirect medical education adjustment factor.

General description.

Determining and updating the hospital-specific rate.

Determining hospital-specific rates in cases of hospital merger, consolidation, or dissolution.

Payment based on the hospital-specific rate.

Transition period payment methodologies.

Fully prospective payment methodology.

Hold-harmless payment methodology.

Exception payments.

Budget neutrality adjustment.

General provisions for hospitals located in Puerto Rico.

Payments to hospitals located in Puerto Rico.

Basis and scope of subpart.

Definitions.

Conditions for payment under the prospective payment system for inpatient hospital services of psychiatric facilities.

Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system.

Basis of payment.

Methodology for calculating the Federal per diem payment amount.

Transition period.

Publication of changes to the inpatient psychiatric facility prospective payment system.

Method of payment under the inpatient psychiatric facility prospective payment system.

Procedural requirements under the IPFQR Program.

Reconsideration and appeals procedures of Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program decisions.

Basis and scope of subpart.

Definitions.

Conditions for payment under the prospective payment system for long-term care hospitals.

Limitation on charges to beneficiaries.

Medical review requirements.

Furnishing of inpatient hospital services directly or under arrangement.

Reporting and recordkeeping requirements.

Patient classification system.

LTC-DRG weighting factors.

Revision of LTC-DRG group classifications and weighting factors.

Basis of payment.

Application of site neutral payment rate.

Methodology for calculating the Federal prospective payment rates.

Adjustments to the Federal prospective payment.

Payment provisions for a “subclause (II)” long-term care hospital.

Special payment provision for short-stay outliers.

Special payment provisions when an interruption of a stay occurs in a long-term care hospital.

Transition payments.

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.

Publication of the Federal prospective payment rates.

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.

[Reserved]

Method of payment for preadmission services under the long-term care hospital prospective payment system.

Method of payment under the long-term care hospital prospective payment system.

Requirements under the Long-Term Care Hospital Quality Reporting Program (LTCH QRP).

Basis and scope of subpart.

Definitions.

Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.

Patient assessments.

Patients' rights regarding the collection of patient assessment data.

Assessment schedule.

Coordination of the collection of patient assessment data.

Transmission of patient assessment data.

Release of information collected using the patient assessment instrument.

Assessment process for interrupted stays.

Patient classification system.

Basis of payment.

Methodology for calculating the Federal prospective payment rates.

Transition period.

Publication of the Federal prospective payment rates.

Limitation on review.

Method of payment under the inpatient rehabilitation facility prospective payment system.

Requirements under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP).