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Code of Federal Regulations (Last Updated: May 6, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter B - Medicare Program |
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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 - xxx |
| § 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 Replaced Devices |
| § 412.89 - Payment adjustment for certain replaced devices. |
| Payment Adjustment for Certain Clinical Trial Cases and Expanded Access Use Immunotherapy |
| § 412.83 - Payment for extraordinarily high-cost day outliers. |
| § 412.85 - xxx |
| § 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. |
| 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] |
| §§ 412.168--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 - xxx |
| Subpart J - XXX |
| 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 |
| 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 canceling a previous withdrawal or 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. |
| 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. |
| § 412.236 - Alternative criteria for hospitals located in an NECMA. |
| Subpart M - Prospective Payment System for Inpatient Hospital Capital Costs |
| 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. |
| 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. |
| General Provisions |
| § 412.300 - Scope of subpart and definition. |
| § 412.302 - Introduction to capital costs. |
| § 412.304 - Implementation of the capital prospective payment system. |
| 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. |
| § 412.532 - Special payment provisions for patients who are transferred to onsite providers and readmitted to a long-term care hospital. |
| § 412.533 - Transition payments. |
| § 412.535 - Publication of the Federal prospective payment rates. |
| § 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). |