[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: 42CFR412.82]



[Page 500-501]

 

                         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 F_Payment for Outlier Cases and Special Treatment Payment for 

                             New Technology

 

Sec. 412.82  Payment for extended length-of-stay cases (day outliers).



    (a) For discharges occurring before October 1, 1997, if the hospital 

stay reflected by a discharge includes covered days of care beyond the 

applicable threshold criterion, the intermediary



[[Page 501]]



will make an additional payment, on a per diem basis, to the discharging 

hospital for those days. A special request or submission by the hospital 

is not necessary to initiate this payment. However, a hospital may 

request payment for day outliers before the medical review required in 

paragraph (b) of this section.

    (b) The QIO must review and approve to the extent required by CMS--

    (1) The medical necessity and appropriateness of the admission and 

outlier services in the context of the entire stay;

    (2) The validity of the diagnostic and procedural coding; and

    (3) The granting of grace days.

    (c) Except as provided in Sec. 412.86, the per diem payment made 

under paragraph (a) of this section is derived by taking a percentage of 

the average per diem payment for the applicable DRG, as calculated by 

dividing the Federal prospective payment rate for inpatient operating 

costs and inpatient capital-related costs determined under subpart D of 

this part, by the arithmetic mean length of stay for that DRG. CMS 

issues the applicable percentage of the average per diem payment in the 

annual publication of the prospective payment rates in accordance with 

Sec. 412.8(b).

    (d) Any days in a covered stay identified as noncovered reduce the 

number of days reimbursed at the day outlier rate but not to exceed the 

number of days that occur after the day outlier threshold.



[50 FR 12741, Mar. 29, 1985, as amended at 50 FR 15326, Apr. 17, 1985; 

50 FR 35689, Sept. 3, 1985; 53 FR 38529, Sept. 30, 1988; 57 FR 39822, 

Sept. 1, 1992; 59 FR 45398, Sept. 1, 1994; 62 FR 46028, Aug. 29, 1997]