42 CFR Part 414
PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
- PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter B—Medicare Program
- Subpart A—General Provisions
- § 414.1 Basis and scope.
- § 414.2 Definitions.
- § 414.4 Fee schedule areas.
- § 414.5 Hospital services paid under Medicare Part B when a Part A hospital inpatient claim is denied because the inpatient admission was not reasonable and necessary, but hospital outpatient services would have been reasonable and necessary in treating the beneficiary.
- Subpart B—Physicians and Other Practitioners
- § 414.20 Formula for computing fee schedule amounts.
- § 414.21 Medicare payment basis.
- § 414.22 Relative value units (RVUs).
- § 414.24 Publication of RVUs and direct PE inputs.
- § 414.26 Determining the GAF.
- § 414.28 Conversion factors.
- § 414.30 Conversion factor update.
- § 414.34 Payment for services and supplies incident to a physician's service.
- § 414.36 Payment for drugs incident to a physician's service.
- § 414.39 Special rules for payment of care plan oversight.
- § 414.40 Coding and ancillary policies.
- § 414.42 Adjustment for first 4 years of practice.
- § 414.44 Transition rules.
- § 414.46 Additional rules for payment of anesthesia services.
- § 414.48 Limits on actual charges of nonparticipating suppliers.
- § 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.
- § 414.52 Payment for physician assistants' services.
- § 414.53 Fee schedule for clinical social worker, marriage and family therapist, and mental health counselor services.
- § 414.54 Payment for certified nurse-midwives' services.
- § 414.56 Payment for nurse practitioners' and clinical nurse specialists' services.
- § 414.58 Payment of charges for physician services to patients in providers.
- § 414.60 Payment for the services of CRNAs.
- § 414.61 Payment for anesthesia services furnished by a teaching CRNA.
- § 414.62 Fee schedule for clinical psychologist services.
- § 414.63 Payment for outpatient diabetes self-management training.
- § 414.64 Payment for medical nutrition therapy.
- § 414.65 Payment for telehealth services.
- § 414.66 Incentive payments for physician scarcity areas.
- § 414.67 Incentive payments for services furnished in Health Professional Shortage Areas.
- § 414.68 Imaging accreditation.
- § 414.80 Incentive payment for primary care services.
- § 414.84 Payment for MDPP services.
- § 414.90 Physician Quality Reporting System (PQRS).
- § 414.92 Electronic Prescribing Incentive Program.
- § 414.94 [Reserved]
- Subpart C—Fee Schedules for Parenteral and Enteral Nutrition (PEN) Nutrients, Equipment and Supplies, Splints, Casts, and Certain Intraocular Lenses (IOLs)
- § 414.100 Purpose.
- § 414.102 General payment rules.
- § 414.104 PEN Items and Services.
- § 414.105 Application of competitive bidding information.
- § 414.106 Splints and casts.
- § 414.108 IOLs inserted in a physician's office.
- § 414.110 Continuity of pricing when HCPCS codes are divided or combined.
- § 414.112 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
- § 414.114 Procedures for making benefit category determinations and payment determinations for new PEN items and services covered under the prosthetic device benefit; splints and casts; and IOLs inserted in a physician's office covered under the prosthetic device benefit.
- Subpart D—Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
- § 414.200 Purpose.
- § 414.202 Definitions.
- § 414.210 General payment rules.
- § 414.220 Inexpensive or routinely purchased items.
- § 414.222 Items requiring frequent and substantial servicing.
- § 414.224 Customized items.
- § 414.226 Oxygen and oxygen equipment.
- § 414.228 Prosthetic and orthotic devices.
- § 414.229 Other durable medical equipment—capped rental items.
- § 414.230 Determining a period of continuous use.
- § 414.232 Special payment rules for transcutaneous electrical nerve stimulators (TENS).
- § 414.234 Prior authorization for items frequently subject to unnecessary utilization.
- § 414.236 Continuity of pricing when HCPCS codes are divided or combined.
- § 414.238 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
- § 414.240 Procedures for making benefit category determinations and payment determinations for new durable medical equipment, prosthetic devices, orthotics and prosthetics, surgical dressings, and therapeutic shoes and inserts.
- Subpart E—Determination of Reasonable Charges Under the ESRD Program
- § 414.300 Scope of subpart.
- § 414.310 Determination of reasonable charges for physician services furnished to renal dialysis patients.
- § 414.313 Initial method of payment.
- § 414.314 Monthly capitation payment method.
- § 414.316 Payment for physician services to patients in training for self-dialysis and home dialysis.
- § 414.320 Determination of reasonable charges for physician renal transplantation services.
- § 414.330 Payment for home dialysis equipment, supplies, and support services.
- § 414.335 Payment for EPO furnished to a home dialysis patient for use in the home.
- Subpart F—Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
- § 414.400 Purpose and basis.
- § 414.402 Definitions.
- § 414.404 Scope and applicability.
- § 414.406 Implementation of programs.
- § 414.408 Payment rules.
- § 414.409 Special payment rules.
- § 414.410 Phased-in implementation of competitive bidding programs.
- § 414.411 Special rule in case of competitions for diabetic testing strips conducted on or after January 1, 2011.
- § 414.412 Submission of bids under a competitive bidding program.
- § 414.414 Conditions for awarding contracts.
- § 414.416 Determination of competitive bidding payment amounts.
- § 414.418 Opportunity for networks.
- § 414.420 Physician or treating practitioner authorization and consideration of clinical efficiency and value of items.
- § 414.422 Terms of contracts.
- § 414.423 Appeals process for breach of a DMEPOS competitive bidding program contract actions.
- § 414.424 Administrative or judicial review.
- § 414.425 Claims for damages.
- § 414.426 Adjustments to competitively bid payment amounts to reflect changes in the HCPCS.
- Subpart G—Payment for Clinical Diagnostic Laboratory Tests
- § 414.500 Basis and scope.
- § 414.502 Definitions.
- § 414.504 Data reporting requirements.
- § 414.506 Procedures for public consultation for payment for a new clinical diagnostic laboratory test.
- § 414.507 Payment for clinical diagnostic laboratory tests.
- § 414.508 Payment for a new clinical diagnostic laboratory test.
- § 414.509 Reconsideration of basis for and amount of payment for a new clinical diagnostic laboratory test.
- § 414.510 Laboratory date of service for clinical laboratory and pathology specimens.
- § 414.522 Payment for new advanced diagnostic laboratory tests.
- § 414.523 Payment for laboratory specimen collection fee and travel allowance.
- Subpart H—Fee Schedule for Ambulance Services
- § 414.601 Purpose.
- § 414.605 Definitions.
- § 414.610 Basis of payment.
- § 414.615 Transition to the ambulance fee schedule.
- § 414.617 Transition from regional to national ambulance fee schedule.
- § 414.620 Publication of the ambulance fee schedule.
- § 414.625 Limitation on review.
- § 414.626 Data reporting by ground ambulance organizations.
- Subpart I—Payment for Drugs and Biologicals
- § 414.701 Purpose.
- § 414.704 Definitions.
- § 414.707 Basis of payment.
- Subpart J—Submission of Manufacturer's Average Sales Price Data
- § 414.800 Purpose.
- § 414.802 Definitions.
- § 414.804 Basis of payment.
- § 414.806 Penalties associated with misrepresentation and the failure to submit timely and accurate ASP data.
- Subpart K—Payment for Drugs and Biologicals Under Part B
- § 414.900 Basis and scope.
- § 414.902 Definitions.
- § 414.904 Average sales price as the basis for payment.
- § 414.906 Competitive acquisition program as the basis for payment.
- § 414.908 Competitive acquisition program.
- § 414.910 Bidding process.
- § 414.912 Conflicts of interest.
- § 414.914 Terms of contract.
- § 414.916 Dispute resolution for vendors and beneficiaries.
- § 414.917 Dispute resolution and process for suspension or termination of approved CAP contract and termination of physician participation under exigent circumstances.
- § 414.918 Assignment.
- § 414.920 Judicial review.
- § 414.930 Compendia for determination of medically-accepted indications for off-label uses of drugs and biologicals in an anti-cancer chemotherapeutic regimen.
- § 414.940 Refund for certain discarded single-dose container or single-use package drugs.
- Subpart L—Supplying and Dispensing Fees
- § 414.1000 Purpose.
- § 414.1001 Basis of payment.
- Subpart M—Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) Services
- § 414.1100 Basis and scope.
- § 414.1105 Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.
- Subpart N—Value-Based Payment Modifier Under the Physician Fee Schedule
- § 414.1200 Basis and scope.
- § 414.1205 Definitions.
- § 414.1210 Application of the value-based payment modifier.
- § 414.1215 Performance and payment adjustment periods for the value-based payment modifier.
- § 414.1220 Reporting mechanisms for the value-based payment modifier.
- § 414.1225 Alignment of Physician Quality Reporting System quality measures and quality measures for the value-based payment modifier.
- § 414.1230 Additional measures for groups and solo practitioners.
- § 414.1235 Cost measures.
- § 414.1240 Attribution for quality of care and cost measures.
- § 414.1245 Scoring methods for the value-based payment modifier using the quality-tiering approach.
- § 414.1250 Benchmarks for quality of care measures.
- § 414.1255 Benchmarks for cost measures.
- § 414.1260 Composite scores.
- § 414.1265 Reliability of measures.
- § 414.1270 Determination and calculation of Value-Based Payment Modifier adjustments.
- § 414.1275 Value-based payment modifier quality-tiering scoring methodology.
- § 414.1280 Limitation on review.
- § 414.1285 Informal inquiry process.
- Subpart O—Merit-Based Incentive Payment System and Alternative Payment Model Incentive
- § 414.1300 Basis and scope.
- § 414.1305 Definitions.
- § 414.1310 Applicability.
- § 414.1315 Virtual groups.
- § 414.1317 APM Entity groups.
- § 414.1318 Subgroups.
- § 414.1320 MIPS performance period.
- § 414.1325 Data submission requirements.
- § 414.1330 Quality performance category.
- § 414.1335 Data submission criteria for the quality performance category.
- § 414.1340 Data completeness criteria for the quality performance category.
- § 414.1350 Cost performance category.
- § 414.1355 Improvement activities performance category.
- § 414.1360 Data submission criteria for the improvement activities performance category.
- § 414.1365 MIPS Value Pathways.
- § 414.1367 APM performance pathway.
- § 414.1370 APM scoring standard under MIPS.
- § 414.1375 Promoting Interoperability (PI) performance category.
- § 414.1380 Scoring.
- § 414.1385 Targeted review and review limitations.
- § 414.1390 Data validation and auditing.
- § 414.1395 Public reporting.
- § 414.1400 Third party intermediaries.
- § 414.1405 Payment.
- § 414.1410 Advanced APM determination.
- § 414.1415 Advanced APM criteria.
- § 414.1420 Other payer advanced APM criteria.
- § 414.1425 Qualifying APM participant determination: In general.
- § 414.1430 Qualifying APM participant determination: QP and partial QP thresholds.
- § 414.1435 Qualifying APM participant determination: Medicare option.
- § 414.1440 Qualifying APM participant determination: All-payer combination option.
- § 414.1445 Determination of other payer advanced APMs.
- § 414.1450 APM incentive payment.
- § 414.1455 Limitation on review.
- § 414.1460 Monitoring and program integrity.
- § 414.1465 Physician-focused payment models.
- Subpart P—Home Infusion Therapy Services Payment
- Conditions for Payment
- § 414.1500 Basis, purpose, and scope.
- § 414.1505 Requirement for payment.
- § 414.1510 Beneficiary qualifications for coverage of services.
- § 414.1515 Plan of care requirements.
- Payment System
- § 414.1550 Basis of payment.
- Subpart Q—Payment for Lymphedema Compression Treatment Items
- § 414.1600 Purpose and definitions.
- § 414.1650 Payment basis for lymphedema compression treatment items.
- § 414.1660 Continuity of pricing when HCPCS codes are divided or combined.
- § 414.1670 Procedures for making benefit category determinations and payment determinations for new lymphedema compression treatment items.
- § 414.1680 Frequency limitations.
- § 414.1690 Application of competitive bidding information.
- Subpart R—Home Intravenous Immunoglobulin (IVIG) Items and Services Payment
- § 414.1700 Basis of payment.
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