Part 412 — Prospective Payment Systems for Inpatient Hospital Services
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.
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
- § 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).
- § 412.85— Payment adjustment for certain immunotherapy cases.
- § 412.83— Payment for extraordinarily high-cost day outliers.
- § 412.87— Additional payment for new medical services and technologies: General provisions.
- § 412.88— Additional payment for new medical service or technology.
- § 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.
- § 412.100— 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.
- § 412.152— Definitions for the Hospital Readmissions Reduction Program.
- § 412.154— Payment adjustments under the Hospital Readmissions Reduction 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.
- § 412.170— 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 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
- § 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.
- § 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
- § 412.300— Scope of subpart and definition.
- § 412.302— Introduction to capital costs.
- § 412.304— Implementation of the capital prospective payment system.
- § 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.
- § 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.
- § 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.
- § 412.540— 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).