Title 42, Part 414 — Payment for Part B Medical and Other Health Services

Basis and scope.

Definitions.

Fee schedule areas.

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.

Formula for computing fee schedule amounts.

Medicare payment basis.

Relative value units (RVUs).

Publication of RVUs and direct PE inputs.

Determining the GAF.

Conversion factors.

Conversion factor update.

Payment for services and supplies incident to a physician's service.

Payment for drugs incident to a physician's service.

Special rules for payment of care plan oversight.

Coding and ancillary policies.

Adjustment for first 4 years of practice.

Transition rules.

Additional rules for payment of anesthesia services.

Limits on actual charges of nonparticipating suppliers.

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.

Payment for physician assistants' services.

Fee schedule for clinical social worker, marriage and family therapist, and mental health counselor services.

Payment for certified nurse-midwives' services.

Payment for nurse practitioners' and clinical nurse specialists' services.

Payment of charges for physician services to patients in providers.

Payment for the services of CRNAs.

Payment for anesthesia services furnished by a teaching CRNA.

Fee schedule for clinical psychologist services.

Payment for outpatient diabetes self-management training.

Payment for medical nutrition therapy.

Payment for telehealth services.

Incentive payments for physician scarcity areas.

Incentive payments for services furnished in Health Professional Shortage Areas.

Imaging accreditation.

Incentive payment for primary care services.

Payment for MDPP services.

Physician Quality Reporting System (PQRS).

Electronic Prescribing Incentive Program.

[Reserved]

Purpose.

General payment rules.

PEN Items and Services.

Application of competitive bidding information.

Splints and casts.

IOLs inserted in a physician's office.

Continuity of pricing when HCPCS codes are divided or combined.

Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.

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.

Purpose.

Definitions.

General payment rules.

Inexpensive or routinely purchased items.

Items requiring frequent and substantial servicing.

Customized items.

Oxygen and oxygen equipment.

Prosthetic and orthotic devices.

Other durable medical equipment—capped rental items.

Determining a period of continuous use.

Special payment rules for transcutaneous electrical nerve stimulators (TENS).

Prior authorization for items frequently subject to unnecessary utilization.

Continuity of pricing when HCPCS codes are divided or combined.

Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.

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.

Scope of subpart.

Determination of reasonable charges for physician services furnished to renal dialysis patients.

Initial method of payment.

Monthly capitation payment method.

Payment for physician services to patients in training for self-dialysis and home dialysis.

Determination of reasonable charges for physician renal transplantation services.

Payment for home dialysis equipment, supplies, and support services.

Payment for EPO furnished to a home dialysis patient for use in the home.

Purpose and basis.

Definitions.

Scope and applicability.

Implementation of programs.

Payment rules.

Special payment rules.

Phased-in implementation of competitive bidding programs.

Special rule in case of competitions for diabetic testing strips conducted on or after January 1, 2011.

Submission of bids under a competitive bidding program.

Conditions for awarding contracts.

Determination of competitive bidding payment amounts.

Opportunity for networks.

Physician or treating practitioner authorization and consideration of clinical efficiency and value of items.

Terms of contracts.

Appeals process for breach of a DMEPOS competitive bidding program contract actions.

Administrative or judicial review.

Claims for damages.

Adjustments to competitively bid payment amounts to reflect changes in the HCPCS.

Basis and scope.

Definitions.

Data reporting requirements.

Procedures for public consultation for payment for a new clinical diagnostic laboratory test.

Payment for clinical diagnostic laboratory tests.

Payment for a new clinical diagnostic laboratory test.

Reconsideration of basis for and amount of payment for a new clinical diagnostic laboratory test.

Laboratory date of service for clinical laboratory and pathology specimens.

Payment for new advanced diagnostic laboratory tests.

Payment for laboratory specimen collection fee and travel allowance.

Purpose.

Definitions.

Basis of payment.

Transition to the ambulance fee schedule.

Transition from regional to national ambulance fee schedule.

Publication of the ambulance fee schedule.

Limitation on review.

Data reporting by ground ambulance organizations.

Purpose.

Definitions.

Basis of payment.

Purpose.

Definitions.

Basis of payment.

Penalties associated with misrepresentation and the failure to submit timely and accurate ASP data.

Basis and scope.

Definitions.

Average sales price as the basis for payment.

Competitive acquisition program as the basis for payment.

Competitive acquisition program.

Bidding process.

Conflicts of interest.

Terms of contract.

Dispute resolution for vendors and beneficiaries.

Dispute resolution and process for suspension or termination of approved CAP contract and termination of physician participation under exigent circumstances.

Assignment.

Judicial review.

Compendia for determination of medically-accepted indications for off-label uses of drugs and biologicals in an anti-cancer chemotherapeutic regimen.

Refund for certain discarded single-dose container or single-use package drugs.

Purpose.

Basis of payment.

Basis and scope.

Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.

Basis and scope.

Definitions.

Application of the value-based payment modifier.

Performance and payment adjustment periods for the value-based payment modifier.

Reporting mechanisms for the value-based payment modifier.

Alignment of Physician Quality Reporting System quality measures and quality measures for the value-based payment modifier.

Additional measures for groups and solo practitioners.

Cost measures.

Attribution for quality of care and cost measures.

Scoring methods for the value-based payment modifier using the quality-tiering approach.

Benchmarks for quality of care measures.

Benchmarks for cost measures.

Composite scores.

Reliability of measures.

Determination and calculation of Value-Based Payment Modifier adjustments.

Value-based payment modifier quality-tiering scoring methodology.

Limitation on review.

Informal inquiry process.

Basis and scope.

Definitions.

Applicability.

Virtual groups.

APM Entity groups.

Subgroups.

MIPS performance period.

Data submission requirements.

Quality performance category.

Data submission criteria for the quality performance category.

Data completeness criteria for the quality performance category.

Cost performance category.

Improvement activities performance category.

Data submission criteria for the improvement activities performance category.

MIPS Value Pathways.

APM performance pathway.

APM scoring standard under MIPS.

Promoting Interoperability (PI) performance category.

Scoring.

Targeted review and review limitations.

Data validation and auditing.

Public reporting.

Third party intermediaries.

Payment.

Advanced APM determination.

Advanced APM criteria.

Other payer advanced APM criteria.

Qualifying APM participant determination: In general.

Qualifying APM participant determination: QP and partial QP thresholds.

Qualifying APM participant determination: Medicare option.

Qualifying APM participant determination: All-payer combination option.

Determination of other payer advanced APMs.

APM incentive payment.

Limitation on review.

Monitoring and program integrity.

Physician-focused payment models.

Basis, purpose, and scope.

Requirement for payment.

Beneficiary qualifications for coverage of services.

Plan of care requirements.

Basis of payment.

Purpose and definitions.

Payment basis for lymphedema compression treatment items.

Continuity of pricing when HCPCS codes are divided or combined.

Procedures for making benefit category determinations and payment determinations for new lymphedema compression treatment items.

Frequency limitations.

Application of competitive bidding information.

Basis of payment.