OMB control number
Payment Adjustment for Low-Volume Hospitals Under the Hospital Inpatient Prospective Payment System (IPPS) (CMS-10857)
OMB 0938-1448 · HHS/CMS.
OMB 0938-1448
Section 1886(d)(12) of the Social Security Act (the Act) provides for additional Medicare payments to subsection (d) hospitals that meet the criteria for a low-volume hospital. The low-volume hospital payment adjustment is implemented in the regulations at 42 CFR 412.101, and identifies the criteria used to determine the additional payment adjustment.
The latest form for Payment Adjustment for Low-Volume Hospitals Under the Hospital Inpatient Prospective Payment System (IPPS) (CMS-10857) expires 2027-01-31 and is listed under ICR 202308-0938-004.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 CMS-10857 Low Volume Adj - Supporting Statement - Part A - 7-24-23.docx | Supporting Statement A |
 Verification of Current Requests and New requests for payment adjustments |
Information collection |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202308-0938-004 | New collection (Request for a new OMB Control Number) | 2023-08-29 | Approved with change | |
| 202304-0938-015 | New collection (Request for a new OMB Control Number) | 2023-05-11 | Comment filed on proposed rule |