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FEDERAL · 42 CFR

Part 414 — Payment for Part B Medical and Other Health Services

198 sections · Title 42: Public Health

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