42 CFR 412.513 - Patient classification system. | Title 42 - Public Health | Code of Federal Regulations

§ 412.513

Patient classification system.

(a) Classification methodology. CMS classifies specific inpatient hospital discharges from long-term care hospitals by long-term care diagnosis-related groups (LTC-DRGs) to ensure that each hospital discharge is appropriately assigned based on essential data abstracted from the inpatient bill for that discharge.

(b) Assignment of discharges to LTC-DRGs. (1) The classification of a particular discharge is based, as appropriate, on the patient's age, sex, principal diagnosis (that is, the diagnosis established after study to be chiefly responsible for causing the patient's admission to the hospital), secondary diagnoses, procedures performed, and the patient's discharge status.

(2) Each discharge from a long-term care hospital is assigned to only one LTC-DRG (related, except as provided in paragraph (b)(3) of this section, to the patient's principal diagnosis), regardless of the number of conditions treated or services furnished during the patient's stay.

(3) When the discharge data submitted by a hospital show a surgical procedure unrelated to a patient's principal diagnosis, the bill is returned to the hospital for validation and reverification. The LTC-DRG classification system provides a LTC-DRG, and an appropriate weighting factor, for those cases for which none of the surgical procedures performed are related to the principal diagnosis.

(c) Review of LTC-DRG assignment. (1) A hospital has 60 days after the date of the notice of the initial assignment of a discharge to a LTC-DRG to request a review of that assignment. The hospital may submit additional information as a part of its request.

(2) The intermediary reviews that hospital's request and any additional information and decides whether a change in the LTC-DRG assignment is appropriate. If the intermediary decides that a different LTC-DRG should be assigned, the case will be reviewed by the appropriate QIO as specified in § 476.71(c)(2) of this chapter.

(3) Following the 60-day period described in paragraph (c)(1) of this section, the hospital may not submit additional information with respect to the DRG assignment or otherwise revise its claim.

Title 42 published on 2012-10-01

The following are only the Rules published in the Federal Register after the published date of Title 42.

For a complete list of all Rules, Proposed Rules, and Notices view the Rulemaking tab.

2013-03-18; vol. 78 # 52 - Monday, March 18, 2013

78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B)

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2013-06159
RIN
	CMS-1455-NR

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Notice of CMS ruling.

The CMS ruling announced in this notice is effective on March 13, 2013.

42 CFR Parts 405, 411, 412, 419, 424, and 489

Summary

This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register , we published a proposed rule entitled, “Medicare Program; Part B Inpatient Billing in Hospitals,” to propose a permanent policy that would apply on a prospective basis.

2013-03-13; vol. 78 # 49 - Wednesday, March 13, 2013

78 FR 15882 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2013-05724
RIN	0938-AR12
	CMS-1588-CN4

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective date: This correcting document is effective March 12, 2013. Applicability Date: This correcting document is applicable to discharges on or after October 1, 2012.

42 CFR Parts 412, 413, 424, and 476

Summary

This document corrects technical errors in the correcting document that appeared in the October 3, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Correction.”

2013-03-07; vol. 78 # 45 - Thursday, March 7, 2013

78 FR 14689 - Medicare Program; Extension of the Payment Adjustment for Low-volume Hospitals and the Medicare-dependent Hospital (MDH) Program Under the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals for Fiscal Year 2013

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2013-05263
RIN	0938-AR12
	CMS-1588-N

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Notice of extension.

Effective date: March 4, 2013. Applicability dates: The provisions described in this notice are applicable for discharges on or after October 1, 2012 and on or before September 30, 2013.

42 CFR Part 412

Summary

This notice announces changes to the payment adjustment for low-volume hospitals and to the Medicare-dependent hospital (MDH) program under the hospital inpatient prospective payment systems (IPPS) for FY 2013 in accordance with sections 605 and 606, respectively, of the American Taxpayer Relief Act of 2012.

2012-10-29; vol. 77 # 209 - Monday, October 29, 2012

77 FR 65495 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-26505
RIN	0938-AR12
	CMS-1588-CN3

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective Date: October 26, 2012.

42 CFR Parts 412, 413, 424, and 476

Summary

This document corrects technical errors that appeared in the final rule that appeared in the August 31, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers.”

2012-10-23; vol. 77 # 205 - Tuesday, October 23, 2012

77 FR 64755 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-25975
RIN	-0938-AQ84
	CMS-0044-CN2

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective Date: This document is effective on November 12, 2012, except that the correction to instruction 8.NN (77 FR 54149) is effective October 23, 2012.

42 CFR Parts 412, 413, and 495

Summary

This document corrects technical errors and typographical errors in the final rule entitled “Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2” which appeared in the September 4, 2012 issue of the Federal Register .

2012-10-17; vol. 77 # 201 - Wednesday, October 17, 2012

77 FR 63751 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Correcting Amendment

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-25464
RIN	0938-AR12
	CMS-1588-F2

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correcting amendment.

Effective Date: This correcting amendment is effective October 12, 2012. Applicability Date: The provisions of this correcting amendment are applicable October 1, 2012.

42 CFR Parts 412

Summary

This document corrects technical errors in the regulations text of the final rule that appeared in the August 31, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers” (hereinafter referred to as the FY 2013 IPPS/LTCH PPS final rule).

2012-10-03; vol. 77 # 192 - Wednesday, October 3, 2012

77 FR 60315 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-24307
RIN	0938-AR12
	CMS-1588-CN2

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective Date: October 1, 2012.

42 CFR Parts 412, 413, 424, and 476

Summary

This document corrects technical errors in the final rule that appeared in the August 31, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers.”

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].

It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.

United States Code

U.S.C. : Title 42 - THE PUBLIC HEALTH AND WELFARE

§ 1302 - Rules and regulations; impact analyses of Medicare and Medicaid rules and regulations on small rural hospitals

§ 1395y - Exclusions from coverage and medicare as secondary payer

Title 42 published on 2012-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR 412 after this date.

2013-03-18; vol. 78 # 52 - Monday, March 18, 2013

78 FR 16614 - Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B)

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2013-06159
RIN
	CMS-1455-NR

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Notice of CMS ruling.

The CMS ruling announced in this notice is effective on March 13, 2013.

42 CFR Parts 405, 411, 412, 419, 424, and 489

Summary

This notice announces a CMS Ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim by a Medicare review contractor on the basis that the inpatient admission was determined not reasonable and necessary. This revised policy is intended as an interim measure until CMS can finalize a policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward. To that end, elsewhere in this issue of the Federal Register , we published a proposed rule entitled, “Medicare Program; Part B Inpatient Billing in Hospitals,” to propose a permanent policy that would apply on a prospective basis.

2013-03-13; vol. 78 # 49 - Wednesday, March 13, 2013

78 FR 15882 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2013-05724
RIN	0938-AR12
	CMS-1588-CN4

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective date: This correcting document is effective March 12, 2013. Applicability Date: This correcting document is applicable to discharges on or after October 1, 2012.

42 CFR Parts 412, 413, 424, and 476

Summary

This document corrects technical errors in the correcting document that appeared in the October 3, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Correction.”

2013-03-07; vol. 78 # 45 - Thursday, March 7, 2013

78 FR 14689 - Medicare Program; Extension of the Payment Adjustment for Low-volume Hospitals and the Medicare-dependent Hospital (MDH) Program Under the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals for Fiscal Year 2013

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2013-05263
RIN	0938-AR12
	CMS-1588-N

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Notice of extension.

Effective date: March 4, 2013. Applicability dates: The provisions described in this notice are applicable for discharges on or after October 1, 2012 and on or before September 30, 2013.

42 CFR Part 412

Summary

This notice announces changes to the payment adjustment for low-volume hospitals and to the Medicare-dependent hospital (MDH) program under the hospital inpatient prospective payment systems (IPPS) for FY 2013 in accordance with sections 605 and 606, respectively, of the American Taxpayer Relief Act of 2012.

2012-10-29; vol. 77 # 209 - Monday, October 29, 2012

77 FR 65495 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-26505
RIN	0938-AR12
	CMS-1588-CN3

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective Date: October 26, 2012.

42 CFR Parts 412, 413, 424, and 476

Summary

This document corrects technical errors that appeared in the final rule that appeared in the August 31, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers.”

2012-10-23; vol. 77 # 205 - Tuesday, October 23, 2012

77 FR 64755 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-25975
RIN	-0938-AQ84
	CMS-0044-CN2

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective Date: This document is effective on November 12, 2012, except that the correction to instruction 8.NN (77 FR 54149) is effective October 23, 2012.

42 CFR Parts 412, 413, and 495

Summary

This document corrects technical errors and typographical errors in the final rule entitled “Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2” which appeared in the September 4, 2012 issue of the Federal Register .

2012-10-17; vol. 77 # 201 - Wednesday, October 17, 2012

77 FR 63751 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Correcting Amendment

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-25464
RIN	0938-AR12
	CMS-1588-F2

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correcting amendment.

Effective Date: This correcting amendment is effective October 12, 2012. Applicability Date: The provisions of this correcting amendment are applicable October 1, 2012.

42 CFR Parts 412

Summary

This document corrects technical errors in the regulations text of the final rule that appeared in the August 31, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers” (hereinafter referred to as the FY 2013 IPPS/LTCH PPS final rule).

2012-10-03; vol. 77 # 192 - Wednesday, October 3, 2012

77 FR 60315 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers; Corrections

GPO FDSys XML | Text

Additional Documents

type	regulations.gov
FR Doc.	2012-24307
RIN	0938-AR12
	CMS-1588-CN2

DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services

Final rule; correction.

Effective Date: October 1, 2012.

42 CFR Parts 412, 413, 424, and 476

Summary

This document corrects technical errors in the final rule that appeared in the August 31, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers.”

42 CFR 412.513 - Patient classification system.

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