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Electronic Code of Federal Regulations

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e-CFR Data is current as of July 30, 2014

TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED)

SUBCHAPTER B—MEDICARE PROGRAM (CONTINUED)

PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

rule

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.
rule

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
Review, revision, and addition of RVUs for physician services.
§414.26
Determining the GAF.
§414.28
Conversion factors.
§414.30
Conversion factor update.
§414.32
Determining payments for certain physicians' services furnished in facility settings.
§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.
§414.54
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.
§414.90
Physician Quality Reporting System (PQRS).
§414.92
Electronic Prescribing Incentive Program.
rule

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.
§414.106
XXX
§414.108
XXX
rule

Subpart D—PAYMENT FOR DURABLE MEDICAL EQUIPMENT, PROSTHETIC AND ORTHOTIC DEVICES, AND SURGICAL DRESSINGS

§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).
rule

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.
rule

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.
§414.410
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 Termination of Competitive Bidding Contract.
§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.
rule

Subpart G—PAYMENT FOR NEW CLINICAL DIAGNOSTIC LABORATORY TESTS

§414.500
Basis and scope.
§414.502
Definitions.
§414.504
[Reserved]
§414.506
Procedures for public consultation for payment for a new clinical diagnostic laboratory test.
§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.
§414.511
Adjustments to the Clinical Laboratory Fee Schedule based on Technological Changes.
rule

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.
rule

Subpart I—PAYMENT FOR DRUGS AND BIOLOGICALS

§414.701
Purpose.
§414.704
Definitions.
§414.707
Basis of payment.
rule

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 the failure to submit timely and accurate ASP data.
rule

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.
rule

Subpart L—SUPPLYING AND DISPENSING FEES

§414.1000
Purpose.
§414.1001
Basis of payment.
rule

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.
rule

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 of physicians.
§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.


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