Part 414 — Payment for Part B Medical and Other Health Services
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.
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
Subpart J — Submission of Manufacturer's Average Sales Price 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
Subpart M — 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
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.