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FEDERAL · 42 CFR

Part 412 — Prospective Payment Systems for Inpatient Hospital Services

186 sections · Title 42: Public Health

§ 412.1Scope of part.
§ 412.2Basis of payment.
§ 412.3Admissions.
§ 412.4Discharges and transfers.
§ 412.6Cost reporting periods subject to the prospective payment systems.
§ 412.8Publication of schedules for determining prospective payment rates.
§ 412.10Changes in the DRG classification system.
§ 412.20Hospital services subject to the prospective payment systems.
§ 412.22Excluded hospitals and hospital units: General rules.
§ 412.23Excluded hospitals: Classifications.
§ 412.24Requirements under the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program.
§ 412.25Excluded hospital units: Common requirements.
§ 412.27Excluded psychiatric units: Additional requirements.
§ 412.29Classification criteria for payment under the inpatient rehabilitation facility prospective payment system.
§ 412.30§ 412.30 [Reserved]
§ 412.40General requirements.
§ 412.42Limitations on charges to beneficiaries.
§ 412.44Medical review requirements: Admissions and quality review.
§ 412.46Medical review requirements.
§ 412.48Denial of payment as a result of admissions and quality review.
§ 412.50Furnishing of inpatient hospital services directly or under arrangements.
§ 412.52Reporting and recordkeeping requirements.
§ 412.60DRG classification and weighting factors.
§ 412.62Federal rates for inpatient operating costs for fiscal year 1984.
§ 412.63Federal rates for inpatient operating costs for Federal fiscal years 1984 through 2004.
§ 412.64Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.
§ 412.70General description.
§ 412.71Determination of base-year inpatient operating costs.
§ 412.72Modification of base-year costs.
§ 412.73Determination of the hospital-specific rate based on a Federal fiscal year 1982 base period.
§ 412.75Determination of the hospital-specific rate for inpatient operating costs based on a Federal fiscal year 1987 base period.
§ 412.76Recovery of excess transition period payment amounts resulting from unlawful claims.
§ 412.77Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 1996 base period.
§ 412.78Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 2006 base period.
§ 412.79Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period.
§ 412.80Outlier cases: General provisions.
§ 412.82Payment for extended length-of-stay cases (day outliers).
§ 412.84Payment for extraordinarily high-cost cases (cost outliers).
§ 412.85Payment adjustment for certain immunotherapy cases.
§ 412.83Payment for extraordinarily high-cost day outliers.
§ 412.86412.86 [Reserved]
§ 412.87Additional payment for new medical services and technologies: General provisions.
§ 412.88Additional payment for new medical service or technology.
§ 412.89Payment adjustment for certain replaced devices.
§ 412.90General rules.
§ 412.92Special treatment: Sole community hospitals.
§ 412.96Special treatment: Referral centers.
§ 412.98§ 412.98 [Reserved]
§ 412.100Special treatment: Kidney transplant programs.
§ 412.101Special treatment: Inpatient hospital payment adjustment for low-volume hospitals.
§ 412.102Special treatment: Hospitals located in areas that are changing from urban to rural as a result of a geographic redesignation.
§ 412.103Special treatment: Hospitals located in urban areas and that apply for reclassification as rural.
§ 412.104Special treatment: Hospitals with high percentage of ESRD discharges.
§ 412.105Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
§ 412.106Special treatment: Hospitals that serve a disproportionate share of low-income patients.
§ 412.107Special treatment: Hospitals that receive an additional update for FYs 1998 and 1999.
§ 412.108Special treatment: Medicare-dependent, small rural hospitals.
§ 412.109Special treatment: Essential access community hospitals (EACHs).
§ 412.110Total Medicare payment.
§ 412.112Payments determined on a per case basis.
§ 412.113Other payments.
§ 412.115Additional payments.
§ 412.116Method of payment.
§ 412.120Reductions to total payments.
§ 412.125Effect of change of ownership on payments under the prospective payment systems.
§ 412.130Retroactive adjustments for incorrectly excluded hospitals and units.
§ 412.140Participation, data submission, and validation requirements under the Hospital Inpatient Quality Reporting (IQR) Program.
§ 412.150Basis and scope of subpart.
§ 412.152Definitions for the Hospital Readmissions Reduction Program.
§ 412.154Payment adjustments under the Hospital Readmissions Reduction Program.
§ 412.155-412.159§§ 412.155-412.159 [Reserved]
§ 412.160Definitions for the Hospital Value-Based Purchasing (VBP) Program.
§ 412.161Applicability of the Hospital Value-Based Purchasing (VBP) Program.
§ 412.162Process 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.
§ 412.163Process for making hospital-specific performance information under the Hospital Value-Based Purchasing (VBP) Program available to the public.
§ 412.164Measure selection under the Hospital Value-Based Purchasing (VBP) Program.
§ 412.165Performance scoring under the Hospital Value-Based Purchasing (VBP) Program.
§ 412.167Appeal under the Hospital Value-Based Purchasing (VBP) Program.
§ 412.168Special rules for FY 2022 and FY 2023.
§ 412.169§ 412.169 [Reserved]
§ 412.170Definitions for the Hospital-Acquired Condition Reduction Program.
§ 412.172Payment adjustments under the Hospital-Acquired Condition Reduction Program.
§ 412.190Overall Hospital Quality Star Rating.
§ 412.200General provisions.
§ 412.204Payment to hospitals located in Puerto Rico.
§ 412.208Puerto Rico rates for Federal fiscal year 1988.
§ 412.210Puerto Rico rates for Federal fiscal years 1989 through 2003.
§ 412.211Puerto Rico rates for Federal fiscal year 2004 and subsequent fiscal years.
§ 412.212National rate.
§ 412.220Special treatment of certain hospitals located in Puerto Rico.
§ 412.230Criteria for an individual hospital seeking redesignation to another rural area or an urban area.
§ 412.232Criteria for all hospitals in a rural county seeking urban redesignation.
§ 412.234Criteria for all hospitals in an urban county seeking redesignation to another urban area.
§ 412.235Criteria for all hospitals in a State seeking a statewide wage index redesignation.
§ 412.246MGCRB members.
§ 412.248Number of members needed for a decision or a hearing.
§ 412.250Sources of MGCRB's authority.
§ 412.252Applications.
§ 412.254Proceedings before MGCRB.
§ 412.256Application requirements.
§ 412.258Parties to MGCRB proceeding.
§ 412.260Time and place of the oral hearing.
§ 412.262Disqualification of an MGCRB member.
§ 412.264Evidence and comments in MGCRB proceeding.
§ 412.266Availability of wage data.
§ 412.268Subpoenas.
§ 412.270Witnesses.
§ 412.272Record of proceedings before the MGCRB.
§ 412.273Withdrawing an application, terminating an approved 3-year reclassification, or reinstating a previous termination.
§ 412.274Scope and effect of an MGCRB decision.
§ 412.276Timing of MGCRB decision and its appeal.
§ 412.278Administrator's review.
§ 412.280Representation.
§ 412.300Scope of subpart and definition.
§ 412.302Introduction to capital costs.
§ 412.304Implementation of the capital prospective payment system.
§ 412.308Determining and updating the Federal rate.
§ 412.312Payment based on the Federal rate.
§ 412.316Geographic adjustment factors.
§ 412.320Disproportionate share adjustment factor.
§ 412.322Indirect medical education adjustment factor.
§ 412.324General description.
§ 412.328Determining and updating the hospital-specific rate.
§ 412.331Determining hospital-specific rates in cases of hospital merger, consolidation, or dissolution.
§ 412.332Payment based on the hospital-specific rate.
§ 412.336Transition period payment methodologies.
§ 412.340Fully prospective payment methodology.
§ 412.344Hold-harmless payment methodology.
§ 412.348Exception payments.
§ 412.352Budget neutrality adjustment.
§ 412.370General provisions for hospitals located in Puerto Rico.
§ 412.374Payments to hospitals located in Puerto Rico.
§ 412.400Basis and scope of subpart.
§ 412.402Definitions.
§ 412.404Conditions for payment under the prospective payment system for inpatient hospital services of psychiatric facilities.
§ 412.405Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system.
§ 412.422Basis of payment.
§ 412.424Methodology for calculating the Federal per diem payment amount.
§ 412.426Transition period.
§ 412.428Publication of changes to the inpatient psychiatric facility prospective payment system.
§ 412.432Method of payment under the inpatient psychiatric facility prospective payment system.
§ 412.433Procedural requirements under the IPFQR Program.
§ 412.434Reconsideration and appeals procedures of Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program decisions.
§ 412.500Basis and scope of subpart.
§ 412.503Definitions.
§ 412.505Conditions for payment under the prospective payment system for long-term care hospitals.
§ 412.507Limitation on charges to beneficiaries.
§ 412.508Medical review requirements.
§ 412.509Furnishing of inpatient hospital services directly or under arrangement.
§ 412.511Reporting and recordkeeping requirements.
§ 412.513Patient classification system.
§ 412.515LTC-DRG weighting factors.
§ 412.517Revision of LTC-DRG group classifications and weighting factors.
§ 412.521Basis of payment.
§ 412.522Application of site neutral payment rate.
§ 412.523Methodology for calculating the Federal prospective payment rates.
§ 412.525Adjustments to the Federal prospective payment.
§ 412.526Payment provisions for a “subclause (II)” long-term care hospital.
§ 412.529Special payment provision for short-stay outliers.
§ 412.531Special payment provisions when an interruption of a stay occurs in a long-term care hospital.
§ 412.533Transition payments.
§ 412.534Special 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.
§ 412.535Publication of the Federal prospective payment rates.
§ 412.536Special 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§ 412.538 [Reserved]
§ 412.540Method of payment for preadmission services under the long-term care hospital prospective payment system.
§ 412.541Method of payment under the long-term care hospital prospective payment system.
§ 412.560Requirements under the Long-Term Care Hospital Quality Reporting Program (LTCH QRP).
§ 412.600Basis and scope of subpart.
§ 412.602Definitions.
§ 412.604Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.
§ 412.606Patient assessments.
§ 412.608Patients' rights regarding the collection of patient assessment data.
§ 412.610Assessment schedule.
§ 412.612Coordination of the collection of patient assessment data.
§ 412.614Transmission of patient assessment data.
§ 412.616Release of information collected using the patient assessment instrument.
§ 412.618Assessment process for interrupted stays.
§ 412.620Patient classification system.
§ 412.622Basis of payment.
§ 412.624Methodology for calculating the Federal prospective payment rates.
§ 412.626Transition period.
§ 412.628Publication of the Federal prospective payment rates.
§ 412.630Limitation on review.
§ 412.632Method of payment under the inpatient rehabilitation facility prospective payment system.
§ 412.634Requirements under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP).