[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR412.10]



[Page 461-462]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 412_PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

--Table of Contents

 

                      Subpart A_General Provisions

 

Sec. 412.10  Changes in the DRG classification system.



    (a) General rule. CMS issues changes in the DRG classification 

system in a Federal Register notice at least annually. Except as 

specified in paragraphs (c) and (d) of this section, the DRG changes are 

effective prospectively with discharges occurring on or after the same 

date the payment rates are effective.

    (b) Basis for changes in the DRG classification system. All changes 

in the DRG classification system are made using the principles 

established for the DRG system. This means that cases are classified so 

each DRG is--

    (1) Clinically coherent; and

    (2) Embraces an acceptable range of resource consumption.

    (c) Interim coverage changes--(1) Criteria. CMS makes interim 

changes to the DRG classification system during the Federal fiscal year 

to incorporate items and services newly covered under Medicare.

    (2) Implementation and effective date. CMS issues interim coverage 

changes through its administrative issuance system and makes the change 

effective as soon as is administratively feasible.

    (3) Publication for comment. CMS publishes any change made under 

paragraph (c)(1) of this section in the next annual notice of changes to 

the DRG classification system published in accordance with paragraph (a) 

of this section.

    (d) Interim changes to correct omissions and inequities--(1) 

Criteria. CMS makes interim changes to the DRG classification system to 

correct a serious omission or inequity in the system only if failure to 

make the changes would have--

    (i) A potentially substantial adverse impact on the health and 

safety of beneficiaries; or

    (ii) A significant and unwarranted fiscal impact on hospitals or the 

Medicare program.

    (2) Publication and effective date. CMS publishes these changes in 

the Federal Register in a final notice with comment period with a 

prospective effective date. The change is also published for public 

information in the next annual notice of changes to the DRG 

classification system published in accordance with paragraph (a) of this 

section.

    (e) Review by ProPAC. Changes published annually in accordance with 

paragraph (a) of this section are subject to review and comment by 

ProPAC upon publication. Interim changes to the DRG classification 

system that are made in accordance with paragraphs (c)



[[Page 462]]



and (d) of this section are subject to review by ProPAC before 

implementation.



[50 FR 35688, Sept. 3, 1985, as amended at 51 FR 31496, Sept. 3, 1986; 

57 FR 39820, Sept. 1, 1992]