(a) General. For discharges in cost reporting periods beginning on or after October 1, 2015--
(1) Except as provided for in paragraph (b) of this section, all discharges are paid based on the site neutral payment rate as determined under the provisions of paragraph (c) of this section.
(2) Discharges that meet the criteria for exclusion from site neutral payment rate specified in paragraph (b) of this section are paid based on the standard Federal prospective payment rate established under Sec. 412.523.
(b) Criteria for exclusion from the site neutral payment rate--(1) General. A discharge that meets the following criteria is excluded from the site neutral payment rate specified under this section.
(1) General. A discharge that meets the following criteria is excluded from the site neutral payment rate specified under this section.
(i) The discharge from the long-term care hospital does not have a principal diagnosis relating to a psychiatric diagnosis or to rehabilitation based on the LTC-DRG assignment of the discharge under Sec. 412.513; and
(ii) The admission to the long-term care hospital was immediately preceded by a discharge from a subsection (d) hospital and meets either the intensive care unit criterion specified in paragraph (b)(2) of this section or the ventilator criterion specified in paragraph (b)(3) of this section. In order for an admission to a long-term care hospital to be considered immediately preceded for purposes of this section, the patient discharged from the subsection (d) hospital must be directly admitted to the long-term care hospital.
(2) Intensive care unit criterion. In addition to meeting the requirements of paragraph (b)(1) of this section, the discharge from the subsection (d) hospital that immediately preceded the admission to the long-term care hospital includes at least 3 days in an intensive care unit (as defined in Sec. 413.53(d) of this chapter), as evidenced by at least one of the revenue center codes on the claim for the discharge that indicate such services were provided for the requisite number of days during the stay.
(3) Ventilator criterion. In addition to meeting the requirements of paragraph (b)(1) of this section, the discharge from the long-term care hospital is assigned to a LTC-DRG based on the patient's receipt of ventilator services of at least 96 hours, as evidenced by the procedure code on the discharge bill indicating such services were provided during the stay.
(c) Site neutral payment rate--(1) General. Subject to the provisions of paragraph (c)(2) of this section, the site neutral payment rate is the lower of--
(1) General. Subject to the provisions of paragraph (c)(2) of this section, the site neutral payment rate is the lower of--
(i) The inpatient hospital prospective payment system comparable per diem amount determined under Sec. 412.529(d)(4), including any applicable outlier payments specified in Sec. 412.525(a); or
(ii) 100 percent of the estimated cost of the case determined under the provisions of Sec. 412.529(d)(2). The provisions for cost-to-charge ratios at Sec. 412.529(f)(4)(i) through (iii) apply to the calculation of the estimated cost of the case under this paragraph.
(2) Adjustments. CMS adjusts the payment rate determined under paragraph (c)(1) of this section to account for--
(i) Outlier payments, by applying a reduction factor equal to the estimated proportion of outlier payments under Sec. 412.525(a) payable for discharges from a long-term care hospital described in paragraph (a)(1) of this section to total estimated payments under the long-term care hospital prospective payment system to discharges from a long-term care hospital described in paragraph (a)(1) of this section. The adjustment under this paragraph (c)(2)(i) does not include the portion of the blended payment rate described in paragraph (c)(3)(ii) of this section.
(ii) A 3-day or less interruption of a stay and a greater than 3-day interruption of a stay, as provided for in Sec. 412.531. For purposes of the application of the provisions of Sec. 412.531 to discharges from a long-term care hospital described under paragraph (a)(1) of this section, the long-term care hospital prospective payment system standard Federal payment-related terms, such as ``LTC-DRG payment,'' ``full Federal LTC-DRG prospective payment,'' and ``Federal prospective payment,'' mean the site neutral payment rate calculated under paragraph (c) of this section.
(iii) The special payment provisions for long-term care hospitals-within-hospitals and satellite facilities of long-term care hospitals specified in Sec. 412.534.
(iv) The special payment provisions for long-term care hospitals and satellite facilities of long-term care hospitals that discharged 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 facility of the long-term care hospital, as provided in Sec. 412.536.
(3) Transition. For discharges in cost reporting periods beginning on or after October 1, 2015 and on or before September 30, 2017, payment for discharges under paragraph (c)(1) of this section are made using a blended payment rate, which is determined as--
(i) 50 percent of the site neutral payment rate amount for the discharge as determined under paragraph (c)(1) of this section; and
(ii) 50 percent of the standard Federal prospective payment rate amount for the discharge as determined under Sec. 412.523.
(d) Discharge payment percentage. (1) For purposes of this section, the discharge payment percentage is a ratio, expressed as a percentage, of Medicare discharges that meet the criteria for exclusion from the site neutral payment rate as described under paragraph (a)(2) of this section to total Medicare discharges paid under this subpart during the cost reporting period.
(1) For purposes of this section, the discharge payment percentage is a ratio, expressed as a percentage, of Medicare discharges that meet the criteria for exclusion from the site neutral payment rate as described under paragraph (a)(2) of this section to total Medicare discharges paid under this subpart during the cost reporting period.
(2) CMS will inform each long-term care hospital of its discharge payment percentage, as determined under paragraph (d)(1) of this section, for each cost reporting period beginning on or after October 1, 2015. [80 FR 49768, Sept. 1, 2015]