Title 42

PART 414

Part 414 - Payment For Part B Medical And Other Health Services

PART 414 - PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Authority:42 U.S.C. 1302, 1395hh, and 1395rr(b)(l). Source:55 FR 23441, June 8, 1990, unless otherwise noted. Editorial Note:Nomenclature changes to part 414 appear at 60 FR 50442, Sept. 29, 1995, and 60 FR 53877, Oct. 18, 1995.

42:3.0.1.1.1.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.1.1.3.1SECTION 414.1
   414.1 Basis and scope.
42:3.0.1.1.1.1.3.2SECTION 414.2
   414.2 Definitions.
42:3.0.1.1.1.1.3.3SECTION 414.4
   414.4 Fee schedule areas.
42:3.0.1.1.1.1.3.4SECTION 414.5
   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
42:3.0.1.1.1.2SUBPART B
Subpart B - Physicians and Other Practitioners
42:3.0.1.1.1.2.3.1SECTION 414.20
   414.20 Formula for computing fee schedule amounts.
42:3.0.1.1.1.2.3.2SECTION 414.21
   414.21 Medicare payment basis.
42:3.0.1.1.1.2.3.3SECTION 414.22
   414.22 Relative value units (RVUs).
42:3.0.1.1.1.2.3.4SECTION 414.24
   414.24 Publication of RVUs and direct PE inputs.
42:3.0.1.1.1.2.3.5SECTION 414.26
   414.26 Determining the GAF.
42:3.0.1.1.1.2.3.6SECTION 414.28
   414.28 Conversion factors.
42:3.0.1.1.1.2.3.7SECTION 414.30
   414.30 Conversion factor update.
42:3.0.1.1.1.2.3.8SECTION 414.34
   414.34 Payment for services and supplies incident to a physician's service.
42:3.0.1.1.1.2.3.9SECTION 414.36
   414.36 Payment for drugs incident to a physician's service.
42:3.0.1.1.1.2.3.10SECTION 414.39
   414.39 Special rules for payment of care plan oversight.
42:3.0.1.1.1.2.3.11SECTION 414.40
   414.40 Coding and ancillary policies.
42:3.0.1.1.1.2.3.12SECTION 414.42
   414.42 Adjustment for first 4 years of practice.
42:3.0.1.1.1.2.3.13SECTION 414.44
   414.44 Transition rules.
42:3.0.1.1.1.2.3.14SECTION 414.46
   414.46 Additional rules for payment of anesthesia services.
42:3.0.1.1.1.2.3.15SECTION 414.48
   414.48 Limits on actual charges of nonparticipating suppliers.
42:3.0.1.1.1.2.3.16SECTION 414.50
   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.
42:3.0.1.1.1.2.3.17SECTION 414.52
   414.52 Payment for physician assistants' services.
42:3.0.1.1.1.2.3.18SECTION 414.54
   414.54 Payment for certified nurse-midwives' services.
42:3.0.1.1.1.2.3.19SECTION 414.56
   414.56 Payment for nurse practitioners' and clinical nurse specialists' services.
42:3.0.1.1.1.2.3.20SECTION 414.58
   414.58 Payment of charges for physician services to patients in providers.
42:3.0.1.1.1.2.3.21SECTION 414.60
   414.60 Payment for the services of CRNAs.
42:3.0.1.1.1.2.3.22SECTION 414.61
   414.61 Payment for anesthesia services furnished by a teaching CRNA.
42:3.0.1.1.1.2.3.23SECTION 414.62
   414.62 Fee schedule for clinical psychologist services.
42:3.0.1.1.1.2.3.24SECTION 414.63
   414.63 Payment for outpatient diabetes self-management training.
42:3.0.1.1.1.2.3.25SECTION 414.64
   414.64 Payment for medical nutrition therapy.
42:3.0.1.1.1.2.3.26SECTION 414.65
   414.65 Payment for telehealth services.
42:3.0.1.1.1.2.3.27SECTION 414.66
   414.66 Incentive payments for physician scarcity areas.
42:3.0.1.1.1.2.3.28SECTION 414.67
   414.67 Incentive payments for services furnished in Health Professional Shortage Areas.
42:3.0.1.1.1.2.3.29SECTION 414.68
   414.68 Imaging accreditation.
42:3.0.1.1.1.2.3.30SECTION 414.80
   414.80 Incentive payment for primary care services.
42:3.0.1.1.1.2.3.31SECTION 414.84
   414.84 Payment for MDPP services.
42:3.0.1.1.1.2.3.32SECTION 414.90
   414.90 Physician Quality Reporting System (PQRS).
42:3.0.1.1.1.2.3.33SECTION 414.92
   414.92 Electronic Prescribing Incentive Program.
42:3.0.1.1.1.2.3.34SECTION 414.94
   414.94 Appropriate use criteria for advanced diagnostic imaging services.
42:3.0.1.1.1.3SUBPART C
Subpart C - Fee Schedules for Parenteral and Enteral Nutrition (PEN) Nutrients, Equipment and Supplies, Splints, Casts, and Certain Intraocular Lenses (IOLs)
42:3.0.1.1.1.3.3.1SECTION 414.100
   414.100 Purpose.
42:3.0.1.1.1.3.3.2SECTION 414.102
   414.102 General payment rules.
42:3.0.1.1.1.3.3.3SECTION 414.104
   414.104 PEN Items and Services.
42:3.0.1.1.1.3.3.4SECTION 414.105
   414.105 Application of competitive bidding information.
42:3.0.1.1.1.3.3.5SECTION 414.106
   414.106 Splints and casts.
42:3.0.1.1.1.3.3.6SECTION 414.108
   414.108 IOLs inserted in a physician's office.
42:3.0.1.1.1.3.3.7SECTION 414.110
   414.110 Continuity of pricing when HCPCS codes are divided or combined.
42:3.0.1.1.1.3.3.8SECTION 414.112
   414.112 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
42:3.0.1.1.1.4SUBPART D
Subpart D - Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
42:3.0.1.1.1.4.3.1SECTION 414.200
   414.200 Purpose.
42:3.0.1.1.1.4.3.2SECTION 414.202
   414.202 Definitions.
42:3.0.1.1.1.4.3.3SECTION 414.210
   414.210 General payment rules.
42:3.0.1.1.1.4.3.4SECTION 414.220
   414.220 Inexpensive or routinely purchased items.
42:3.0.1.1.1.4.3.5SECTION 414.222
   414.222 Items requiring frequent and substantial servicing.
42:3.0.1.1.1.4.3.6SECTION 414.224
   414.224 Customized items.
42:3.0.1.1.1.4.3.7SECTION 414.226
   414.226 Oxygen and oxygen equipment.
42:3.0.1.1.1.4.3.8SECTION 414.228
   414.228 Prosthetic and orthotic devices.
42:3.0.1.1.1.4.3.9SECTION 414.229
   414.229 Other durable medical equipment - capped rental items.
42:3.0.1.1.1.4.3.10SECTION 414.230
   414.230 Determining a period of continuous use.
42:3.0.1.1.1.4.3.11SECTION 414.232
   414.232 Special payment rules for transcutaneous electrical nerve stimulators (TENS).
42:3.0.1.1.1.4.3.12SECTION 414.234
   414.234 Prior authorization for items frequently subject to unnecessary utilization.
42:3.0.1.1.1.4.3.13SECTION 414.236
   414.236 Continuity of pricing when HCPCS codes are divided or combined.
42:3.0.1.1.1.4.3.14SECTION 414.238
   414.238 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
42:3.0.1.1.1.5SUBPART E
Subpart E - Determination of Reasonable Charges Under the ESRD Program
42:3.0.1.1.1.5.3.1SECTION 414.300
   414.300 Scope of subpart.
42:3.0.1.1.1.5.3.2SECTION 414.310
   414.310 Determination of reasonable charges for physician services furnished to renal dialysis patients.
42:3.0.1.1.1.5.3.3SECTION 414.313
   414.313 Initial method of payment.
42:3.0.1.1.1.5.3.4SECTION 414.314
   414.314 Monthly capitation payment method.
42:3.0.1.1.1.5.3.5SECTION 414.316
   414.316 Payment for physician services to patients in training for self-dialysis and home dialysis.
42:3.0.1.1.1.5.3.6SECTION 414.320
   414.320 Determination of reasonable charges for physician renal transplantation services.
42:3.0.1.1.1.5.3.7SECTION 414.330
   414.330 Payment for home dialysis equipment, supplies, and support services.
42:3.0.1.1.1.5.3.8SECTION 414.335
   414.335 Payment for EPO furnished to a home dialysis patient for use in the home.
42:3.0.1.1.1.6SUBPART F
Subpart F - Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
42:3.0.1.1.1.6.3.1SECTION 414.400
   414.400 Purpose and basis.
42:3.0.1.1.1.6.3.2SECTION 414.402
   414.402 Definitions.
42:3.0.1.1.1.6.3.3SECTION 414.404
   414.404 Scope and applicability.
42:3.0.1.1.1.6.3.4SECTION 414.406
   414.406 Implementation of programs.
42:3.0.1.1.1.6.3.5SECTION 414.408
   414.408 Payment rules.
42:3.0.1.1.1.6.3.6SECTION 414.409
   414.409 Special payment rules.
42:3.0.1.1.1.6.3.7SECTION 414.410
   414.410 Phased-in implementation of competitive bidding programs.
42:3.0.1.1.1.6.3.8SECTION 414.411
   414.411 Special rule in case of competitions for diabetic testing strips conducted on or after January 1, 2011.
42:3.0.1.1.1.6.3.9SECTION 414.412
   414.412 Submission of bids under a competitive bidding program.
42:3.0.1.1.1.6.3.10SECTION 414.414
   414.414 Conditions for awarding contracts.
42:3.0.1.1.1.6.3.11SECTION 414.416
   414.416 Determination of competitive bidding payment amounts.
42:3.0.1.1.1.6.3.12SECTION 414.418
   414.418 Opportunity for networks.
42:3.0.1.1.1.6.3.13SECTION 414.420
   414.420 Physician or treating practitioner authorization and consideration of clinical efficiency and value of items.
42:3.0.1.1.1.6.3.14SECTION 414.422
   414.422 Terms of contracts.
42:3.0.1.1.1.6.3.15SECTION 414.423
   414.423 Appeals process for breach of a DMEPOS competitive bidding program contract actions.
42:3.0.1.1.1.6.3.16SECTION 414.424
   414.424 Administrative or judicial review.
42:3.0.1.1.1.6.3.17SECTION 414.425
   414.425 Claims for damages.
42:3.0.1.1.1.6.3.18SECTION 414.426
   414.426 Adjustments to competitively bid payment amounts to reflect changes in the HCPCS.
42:3.0.1.1.1.7SUBPART G
Subpart G - Payment for Clinical Diagnostic Laboratory Tests
42:3.0.1.1.1.7.3.1SECTION 414.500
   414.500 Basis and scope.
42:3.0.1.1.1.7.3.2SECTION 414.502
   414.502 Definitions.
42:3.0.1.1.1.7.3.3SECTION 414.504
   414.504 Data reporting requirements.
42:3.0.1.1.1.7.3.4SECTION 414.506
   414.506 Procedures for public consultation for payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.5SECTION 414.507
   414.507 Payment for clinical diagnostic laboratory tests.
42:3.0.1.1.1.7.3.6SECTION 414.508
   414.508 Payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.7SECTION 414.509
   414.509 Reconsideration of basis for and amount of payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.8SECTION 414.510
   414.510 Laboratory date of service for clinical laboratory and pathology specimens.
42:3.0.1.1.1.7.3.9SECTION 414.522
   414.522 Payment for new advanced diagnostic laboratory tests.
42:3.0.1.1.1.8SUBPART H
Subpart H - Fee Schedule for Ambulance Services
42:3.0.1.1.1.8.3.1SECTION 414.601
   414.601 Purpose.
42:3.0.1.1.1.8.3.2SECTION 414.605
   414.605 Definitions.
42:3.0.1.1.1.8.3.3SECTION 414.610
   414.610 Basis of payment.
42:3.0.1.1.1.8.3.4SECTION 414.615
   414.615 Transition to the ambulance fee schedule.
42:3.0.1.1.1.8.3.5SECTION 414.617
   414.617 Transition from regional to national ambulance fee schedule.
42:3.0.1.1.1.8.3.6SECTION 414.620
   414.620 Publication of the ambulance fee schedule.
42:3.0.1.1.1.8.3.7SECTION 414.625
   414.625 Limitation on review.
42:3.0.1.1.1.8.3.8SECTION 414.626
   414.626 Data reporting by ground ambulance organizations.
42:3.0.1.1.1.9SUBPART I
Subpart I - Payment for Drugs and Biologicals
42:3.0.1.1.1.9.3.1SECTION 414.701
   414.701 Purpose.
42:3.0.1.1.1.9.3.2SECTION 414.704
   414.704 Definitions.
42:3.0.1.1.1.9.3.3SECTION 414.707
   414.707 Basis of payment.
42:3.0.1.1.1.10SUBPART J
Subpart J - Submission of Manufacturer's Average Sales Price Data
42:3.0.1.1.1.10.3.1SECTION 414.800
   414.800 Purpose.
42:3.0.1.1.1.10.3.2SECTION 414.802
   414.802 Definitions.
42:3.0.1.1.1.10.3.3SECTION 414.804
   414.804 Basis of payment.
42:3.0.1.1.1.10.3.4SECTION 414.806
   414.806 Penalties associated with the failure to submit timely and accurate ASP data.
42:3.0.1.1.1.11SUBPART K
Subpart K - Payment for Drugs and Biologicals Under Part B
42:3.0.1.1.1.11.3.1SECTION 414.900
   414.900 Basis and scope.
42:3.0.1.1.1.11.3.2SECTION 414.902
   414.902 Definitions.
42:3.0.1.1.1.11.3.3SECTION 414.904
   414.904 Average sales price as the basis for payment.
42:3.0.1.1.1.11.3.4SECTION 414.906
   414.906 Competitive acquisition program as the basis for payment.
42:3.0.1.1.1.11.3.5SECTION 414.908
   414.908 Competitive acquisition program.
42:3.0.1.1.1.11.3.6SECTION 414.910
   414.910 Bidding process.
42:3.0.1.1.1.11.3.7SECTION 414.912
   414.912 Conflicts of interest
42:3.0.1.1.1.11.3.8SECTION 414.914
   414.914 Terms of contract.
42:3.0.1.1.1.11.3.9SECTION 414.916
   414.916 Dispute resolution for vendors and beneficiaries.
42:3.0.1.1.1.11.3.10SECTION 414.917
   414.917 Dispute resolution and process for suspension or termination of approved CAP contract and termination of physician participation under exigent circumstances.
42:3.0.1.1.1.11.3.11SECTION 414.918
   414.918 Assignment.
42:3.0.1.1.1.11.3.12SECTION 414.920
   414.920 Judicial review.
42:3.0.1.1.1.11.3.13SECTION 414.930
   414.930 Compendia for determination of medically-accepted indications for off-label uses of drugs and biologicals in an anti-cancer chemotherapeutic regimen.
42:3.0.1.1.1.12SUBPART L
Subpart L - Supplying and Dispensing Fees
42:3.0.1.1.1.12.3.1SECTION 414.1000
   414.1000 Purpose.
42:3.0.1.1.1.12.3.2SECTION 414.1001
   414.1001 Basis of payment.
42:3.0.1.1.1.13SUBPART M
Subpart M - Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) Services
42:3.0.1.1.1.13.3.1SECTION 414.1100
   414.1100 Basis and scope.
42:3.0.1.1.1.13.3.2SECTION 414.1105
   414.1105 Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.
42:3.0.1.1.1.14SUBPART N
Subpart N - Value-Based Payment Modifier Under the Physician Fee Schedule
42:3.0.1.1.1.14.3.1SECTION 414.1200
   414.1200 Basis and scope.
42:3.0.1.1.1.14.3.2SECTION 414.1205
   414.1205 Definitions.
42:3.0.1.1.1.14.3.3SECTION 414.1210
   414.1210 Application of the value-based payment modifier.
42:3.0.1.1.1.14.3.4SECTION 414.1215
   414.1215 Performance and payment adjustment periods for the value-based payment modifier.
42:3.0.1.1.1.14.3.5SECTION 414.1220
   414.1220 Reporting mechanisms for the value-based payment modifier.
42:3.0.1.1.1.14.3.6SECTION 414.1225
   414.1225 Alignment of Physician Quality Reporting System quality measures and quality measures for the value-based payment modifier.
42:3.0.1.1.1.14.3.7SECTION 414.1230
   414.1230 Additional measures for groups and solo practitioners.
42:3.0.1.1.1.14.3.8SECTION 414.1235
   414.1235 Cost measures.
42:3.0.1.1.1.14.3.9SECTION 414.1240
   414.1240 Attribution for quality of care and cost measures.
42:3.0.1.1.1.14.3.10SECTION 414.1245
   414.1245 Scoring methods for the value-based payment modifier using the quality-tiering approach.
42:3.0.1.1.1.14.3.11SECTION 414.1250
   414.1250 Benchmarks for quality of care measures.
42:3.0.1.1.1.14.3.12SECTION 414.1255
   414.1255 Benchmarks for cost measures.
42:3.0.1.1.1.14.3.13SECTION 414.1260
   414.1260 Composite scores.
42:3.0.1.1.1.14.3.14SECTION 414.1265
   414.1265 Reliability of measures.
42:3.0.1.1.1.14.3.15SECTION 414.1270
   414.1270 Determination and calculation of Value-Based Payment Modifier adjustments.
42:3.0.1.1.1.14.3.16SECTION 414.1275
   414.1275 Value-based payment modifier quality-tiering scoring methodology.
42:3.0.1.1.1.14.3.17SECTION 414.1280
   414.1280 Limitation on review.
42:3.0.1.1.1.14.3.18SECTION 414.1285
   414.1285 Informal inquiry process.
42:3.0.1.1.1.15SUBPART O
Subpart O - Merit-Based Incentive Payment System and Alternative Payment Model Incentive
42:3.0.1.1.1.15.3.1SECTION 414.1300
   414.1300 Basis and scope.
42:3.0.1.1.1.15.3.2SECTION 414.1305
   414.1305 Definitions.
42:3.0.1.1.1.15.3.3SECTION 414.1310
   414.1310 Applicability.
42:3.0.1.1.1.15.3.4SECTION 414.1315
   414.1315 Virtual groups.
42:3.0.1.1.1.15.3.5SECTION 414.1320
   414.1320 MIPS performance period.
42:3.0.1.1.1.15.3.6SECTION 414.1325
   414.1325 Data submission requirements.
42:3.0.1.1.1.15.3.7SECTION 414.1330
   414.1330 Quality performance category.
42:3.0.1.1.1.15.3.8SECTION 414.1335
   414.1335 Data submission criteria for the quality performance category.
42:3.0.1.1.1.15.3.9SECTION 414.1340
   414.1340 Data completeness criteria for the quality performance category.
42:3.0.1.1.1.15.3.10SECTION 414.1350
   414.1350 Cost performance category.
42:3.0.1.1.1.15.3.11SECTION 414.1355
   414.1355 Improvement activities performance category.
42:3.0.1.1.1.15.3.12SECTION 414.1360
   414.1360 Data submission criteria for the improvement activities performance category.
42:3.0.1.1.1.15.3.13SECTION 414.1370
   414.1370 APM scoring standard under MIPS.
42:3.0.1.1.1.15.3.14SECTION 414.1375
   414.1375 Promoting Interoperability (PI) performance category.
42:3.0.1.1.1.15.3.15SECTION 414.1380
   414.1380 Scoring.
42:3.0.1.1.1.15.3.16SECTION 414.1385
   414.1385 Targeted review and review limitations.
42:3.0.1.1.1.15.3.17SECTION 414.1390
   414.1390 Data validation and auditing.
42:3.0.1.1.1.15.3.18SECTION 414.1395
   414.1395 Public reporting.
42:3.0.1.1.1.15.3.19SECTION 414.1400
   414.1400 Third party intermediaries.
42:3.0.1.1.1.15.3.20SECTION 414.1405
   414.1405 Payment.
42:3.0.1.1.1.15.3.21SECTION 414.1410
   414.1410 Advanced APM determination.
42:3.0.1.1.1.15.3.22SECTION 414.1415
   414.1415 Advanced APM criteria.
42:3.0.1.1.1.15.3.23SECTION 414.1420
   414.1420 Other payer advanced APM criteria.
42:3.0.1.1.1.15.3.24SECTION 414.1425
   414.1425 Qualifying APM participant determination: In general.
42:3.0.1.1.1.15.3.25SECTION 414.1430
   414.1430 Qualifying APM participant determination: QP and partial QP thresholds.
42:3.0.1.1.1.15.3.26SECTION 414.1435
   414.1435 Qualifying APM participant determination: Medicare option.
42:3.0.1.1.1.15.3.27SECTION 414.1440
   414.1440 Qualifying APM participant determination: All-payer combination option.
42:3.0.1.1.1.15.3.28SECTION 414.1445
   414.1445 Determination of other payer advanced APMs.
42:3.0.1.1.1.15.3.29SECTION 414.1450
   414.1450 APM incentive payment.
42:3.0.1.1.1.15.3.30SECTION 414.1455
   414.1455 Limitation on review.
42:3.0.1.1.1.15.3.31SECTION 414.1460
   414.1460 Monitoring and program integrity.
42:3.0.1.1.1.15.3.32SECTION 414.1465
   414.1465 Physician-focused payment models.
42:3.0.1.1.1.16SUBPART P
Subpart P - Home Infusion Therapy Services Payment
42:3.0.1.1.1.16.3SUBJGRP 3
   Conditions for Payment
42:3.0.1.1.1.16.3.1SECTION 414.1500
   414.1500 Basis, purpose, and scope.
42:3.0.1.1.1.16.3.2SECTION 414.1505
   414.1505 Requirement for payment.
42:3.0.1.1.1.16.3.3SECTION 414.1510
   414.1510 Beneficiary qualifications for coverage of services.
42:3.0.1.1.1.16.3.4SECTION 414.1515
   414.1515 Plan of care requirements.
42:3.0.1.1.1.16.4SUBJGRP 4
   Payment System
42:3.0.1.1.1.16.4.5SECTION 414.1550
   414.1550 Basis of payment.