e-CFR data is current as of July 6, 2020
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
Subpart A—GENERAL PROVISIONS
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| 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. |
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Subpart B—PHYSICIANS AND OTHER PRACTITIONERS
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| Formula for computing fee schedule amounts. |
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| Relative value units (RVUs). |
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| Publication of RVUs and direct PE inputs. |
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| Conversion factor update. |
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| Payment for services and supplies incident to a physician's service. |
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| Payment for drugs incident to a physician's service. |
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| Special rules for payment of care plan oversight. |
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| Coding and ancillary policies. |
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| Adjustment for first 4 years of practice. |
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| Additional rules for payment of anesthesia services. |
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| Limits on actual charges of nonparticipating suppliers. |
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| 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. |
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| Payment for physician assistants' services. |
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| Payment for certified nurse-midwives' services. |
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| Payment for nurse practitioners' and clinical nurse specialists' services. |
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| Payment of charges for physician services to patients in providers. |
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| Payment for the services of CRNAs. |
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| Payment for anesthesia services furnished by a teaching CRNA. |
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| Fee schedule for clinical psychologist services. |
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| Payment for outpatient diabetes self-management training. |
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| Payment for medical nutrition therapy. |
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| Payment for telehealth services. |
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| Incentive payments for physician scarcity areas. |
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| Incentive payments for services furnished in Health Professional Shortage Areas. |
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| Incentive payment for primary care services. |
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| Payment for MDPP services. |
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| Physician Quality Reporting System (PQRS). |
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| Electronic Prescribing Incentive Program. |
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| Appropriate use criteria for advanced diagnostic imaging services. |
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Subpart C—FEE SCHEDULES FOR PARENTERAL AND ENTERAL NUTRITION (PEN) NUTRIENTS, EQUIPMENT AND SUPPLIES, SPLINTS, CASTS, AND CERTAIN INTRAOCULAR LENSES (IOLS)
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| Application of competitive bidding information. |
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| IOLs inserted in a physician's office. |
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| Continuity of pricing when HCPCS codes are divided or combined. |
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| Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history. |
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Subpart D—PAYMENT FOR DURABLE MEDICAL EQUIPMENT AND PROSTHETIC AND ORTHOTIC DEVICES
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| Inexpensive or routinely purchased items. |
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| Items requiring frequent and substantial servicing. |
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| Oxygen and oxygen equipment. |
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| Prosthetic and orthotic devices. |
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| Other durable medical equipment—capped rental items. |
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| Determining a period of continuous use. |
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| Special payment rules for transcutaneous electrical nerve stimulators (TENS). |
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| Prior authorization for items frequently subject to unnecessary utilization. |
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| Continuity of pricing when HCPCS codes are divided or combined. |
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| Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history. |
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Subpart E—DETERMINATION OF REASONABLE CHARGES UNDER THE ESRD PROGRAM
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| Determination of reasonable charges for physician services furnished to renal dialysis patients. |
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| Initial method of payment. |
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| Monthly capitation payment method. |
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| Payment for physician services to patients in training for self-dialysis and home dialysis. |
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| Determination of reasonable charges for physician renal transplantation services. |
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| Payment for home dialysis equipment, supplies, and support services. |
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| Payment for EPO furnished to a home dialysis patient for use in the home. |
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Subpart F—COMPETITIVE BIDDING FOR CERTAIN DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES (DMEPOS)
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| Implementation of programs. |
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| Phased-in implementation of competitive bidding programs. |
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| Special rule in case of competitions for diabetic testing strips conducted on or after January 1, 2011. |
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| Submission of bids under a competitive bidding program. |
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| Conditions for awarding contracts. |
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| Determination of competitive bidding payment amounts. |
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| Opportunity for networks. |
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| Physician or treating practitioner authorization and consideration of clinical efficiency and value of items. |
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| Appeals process for breach of a DMEPOS competitive bidding program contract actions. |
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| Administrative or judicial review. |
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| Adjustments to competitively bid payment amounts to reflect changes in the HCPCS. |
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Subpart G—PAYMENT FOR CLINICAL DIAGNOSTIC LABORATORY TESTS
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| Data reporting requirements. |
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| Procedures for public consultation for payment for a new clinical diagnostic laboratory test. |
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| Payment for clinical diagnostic laboratory tests. |
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| Payment for a new clinical diagnostic laboratory test. |
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| Reconsideration of basis for and amount of payment for a new clinical diagnostic laboratory test. |
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| Laboratory date of service for clinical laboratory and pathology specimens. |
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| Payment for new advanced diagnostic laboratory tests. |
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Subpart H—FEE SCHEDULE FOR AMBULANCE SERVICES
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| Transition to the ambulance fee schedule. |
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| Transition from regional to national ambulance fee schedule. |
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| Publication of the ambulance fee schedule. |
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| Data reporting by ground ambulance organizations. |
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Subpart I—PAYMENT FOR DRUGS AND BIOLOGICALS
Subpart J—SUBMISSION OF MANUFACTURER'S AVERAGE SALES PRICE DATA
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| Penalties associated with the failure to submit timely and accurate ASP data. |
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Subpart K—PAYMENT FOR DRUGS AND BIOLOGICALS UNDER PART B
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| Average sales price as the basis for payment. |
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| Competitive acquisition program as the basis for payment. |
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| Competitive acquisition program. |
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| Dispute resolution for vendors and beneficiaries. |
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| Dispute resolution and process for suspension or termination of approved CAP contract and termination of physician participation under exigent circumstances. |
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| Compendia for determination of medically-accepted indications for off-label uses of drugs and biologicals in an anti-cancer chemotherapeutic regimen. |
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Subpart L—SUPPLYING AND DISPENSING FEES
Subpart M—PAYMENT FOR COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF) SERVICES
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| Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services. |
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Subpart N—VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN FEE SCHEDULE
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| Application of the value-based payment modifier. |
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| Performance and payment adjustment periods for the value-based payment modifier. |
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| Reporting mechanisms for the value-based payment modifier. |
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| Alignment of Physician Quality Reporting System quality measures and quality measures for the value-based payment modifier. |
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| Additional measures for groups and solo practitioners. |
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| Attribution for quality of care and cost measures. |
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| Scoring methods for the value-based payment modifier using the quality-tiering approach. |
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| Benchmarks for quality of care measures. |
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| Benchmarks for cost measures. |
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| Determination and calculation of Value-Based Payment Modifier adjustments. |
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| Value-based payment modifier quality-tiering scoring methodology. |
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| Informal inquiry process. |
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Subpart O—MERIT-BASED INCENTIVE PAYMENT SYSTEM AND ALTERNATIVE PAYMENT MODEL INCENTIVE
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| Data submission requirements. |
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| Quality performance category. |
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| Data submission criteria for the quality performance category. |
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| Data completeness criteria for the quality performance category. |
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| Cost performance category. |
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| Improvement activities performance category. |
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| Data submission criteria for the improvement activities performance category. |
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| APM scoring standard under MIPS. |
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| Promoting Interoperability (PI) performance category. |
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| Targeted review and review limitations. |
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| Data validation and auditing. |
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| Third party intermediaries. |
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| Advanced APM determination. |
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| Other payer advanced APM criteria. |
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| Qualifying APM participant determination: In general. |
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| Qualifying APM participant determination: QP and partial QP thresholds. |
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| Qualifying APM participant determination: Medicare option. |
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| Qualifying APM participant determination: All-payer combination option. |
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| Determination of other payer advanced APMs. |
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| Monitoring and program integrity. |
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| Physician-focused payment models. |
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Subpart P—HOME INFUSION THERAPY SERVICES PAYMENT
Conditions for Payment
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| Basis, purpose, and scope. |
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| Beneficiary qualifications for coverage of services. |
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| Plan of care requirements. |
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Payment System
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