Contents
- 414.1 Basis and scope.
- 414.100 Purpose.
- 414.1000 Purpose.
- 414.1001 Basis of payment.
- 414.102 General payment rules.
- 414.104 PEN Items and Services.
- 414.105 Application of competitive bidding information.
- 414.106 Splints and casts.
- 414.108 IOLs inserted in a physician's office.
- 414.110 Continuity of pricing when HCPCS codes are divided or combined.
- 414.1100 Basis and scope.
- 414.1105 Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.
- 414.112 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
- 414.114 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.
- 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 and solo practitioners.
- 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.
- 414.1300 Basis and scope.
- 414.1305 Definitions.
- 414.1310 Applicability.
- 414.1315 Virtual groups.
- 414.1317 APM Entity groups.
- 414.1318 Subgroups.
- 414.1320 MIPS performance period.
- 414.1325 Data submission requirements.
- 414.1330 Quality performance category.
- 414.1335 Data submission criteria for the quality performance category.
- 414.1340 Data completeness criteria for the quality performance category.
- 414.1350 Cost performance category.
- 414.1355 Improvement activities performance category.
- 414.1360 Data submission criteria for the improvement activities performance category.
- 414.1365 MIPS Value Pathways.
- 414.1367 APM performance pathway.
- 414.1370 APM scoring standard under MIPS.
- 414.1375 Promoting Interoperability (PI) performance category.
- 414.1380 Scoring.
- 414.1385 Targeted review and review limitations.
- 414.1390 Data validation and auditing.
- 414.1395 Public reporting.
- 414.1400 Third party intermediaries.
- 414.1405 Payment.
- 414.1410 Advanced APM determination.
- 414.1415 Advanced APM criteria.
- 414.1420 Other payer advanced APM criteria.
- 414.1425 Qualifying APM participant determination: In general.
- 414.1430 Qualifying APM participant determination: QP and partial QP thresholds.
- 414.1435 Qualifying APM participant determination: Medicare option.
- 414.1440 Qualifying APM participant determination: All-payer combination option.
- 414.1445 Determination of other payer advanced APMs.
- 414.1450 APM incentive payment.
- 414.1455 Limitation on review.
- 414.1460 Monitoring and program integrity.
- 414.1465 Physician-focused payment models.
- 414.1500 Basis, purpose, and scope.
- 414.1505 Requirement for payment.
- 414.1510 Beneficiary qualifications for coverage of services.
- 414.1515 Plan of care requirements.
- 414.1550 Basis of payment.
- 414.1600 Purpose and definitions.
- 414.1650 Payment basis for lymphedema compression treatment items.
- 414.1660 Continuity of pricing when HCPCS codes are divided or combined.
- 414.1670 Procedures for making benefit category determinations and payment determinations for new lymphedema compression treatment items.
- 414.1680 Frequency limitations.
- 414.1690 Application of competitive bidding information.
- 414.1700 Basis of payment.
- 414.2 Definitions.
- 414.20 Formula for computing fee schedule amounts.
- 414.200 Purpose.
- 414.202 Definitions.
- 414.21 Medicare payment basis.
- 414.210 General payment rules.
- 414.22 Relative value units (RVUs).
- 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).
- 414.234 Prior authorization for items frequently subject to unnecessary utilization.
- 414.236 Continuity of pricing when HCPCS codes are divided or combined.
- 414.238 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
- 414.24 Publication of RVUs and direct PE inputs.
- 414.240 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.
- 414.26 Determining the GAF.
- 414.28 Conversion factors.
- 414.30 Conversion factor update.
- 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.
- 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.
- 414.4 Fee schedule areas.
- 414.40 Coding and ancillary policies.
- 414.400 Purpose and basis.
- 414.402 Definitions.
- 414.404 Scope and applicability.
- 414.406 Implementation of programs.
- 414.408 Payment rules.
- 414.409 Special 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.
- 414.42 Adjustment for first 4 years of practice.
- 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 breach of a DMEPOS competitive bidding program contract actions.
- 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.
- 414.44 Transition rules.
- 414.46 Additional rules for payment of anesthesia services.
- 414.48 Limits on actual charges of nonparticipating suppliers.
- 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.
- 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.
- 414.500 Basis and scope.
- 414.502 Definitions.
- 414.504 Data reporting requirements.
- 414.506 Procedures for public consultation for payment for a new clinical diagnostic laboratory test.
- 414.507 Payment for clinical diagnostic laboratory tests.
- 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.
- 414.52 Payment for physician assistants' services.
- 414.522 Payment for new advanced diagnostic laboratory tests.
- 414.523 Payment for laboratory specimen collection fee and travel allowance.
- 414.53 Fee schedule for clinical social worker, marriage and family therapist, and mental health counselor 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.
- 414.601 Purpose.
- 414.605 Definitions.
- 414.61 Payment for anesthesia services furnished by a teaching CRNA.
- 414.610 Basis of payment.
- 414.615 Transition to the ambulance fee schedule.
- 414.617 Transition from regional to national ambulance fee schedule.
- 414.62 Fee schedule for clinical psychologist services.
- 414.620 Publication of the ambulance fee schedule.
- 414.625 Limitation on review.
- 414.626 Data reporting by ground ambulance organizations.
- 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.
- 414.701 Purpose.
- 414.704 Definitions.
- 414.707 Basis of payment.
- 414.80 Incentive payment for primary care services.
- 414.800 Purpose.
- 414.802 Definitions.
- 414.804 Basis of payment.
- 414.806 Penalties associated with misrepresentation and the failure to submit timely and accurate ASP data.
- 414.84 Payment for MDPP services.
- 414.90 Physician Quality Reporting System (PQRS).
- 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.
- 414.92 Electronic Prescribing Incentive Program.
- 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.
- 414.94 [Reserved]
- 414.940 Refund for certain discarded single-dose container or single-use package drugs.
Contents
3,626 provisions, too many to show on one page. Open a part or section to read it with its history and connections, or search inside the text.
- 414.1 · Basis and scope.
- 414.100 · Purpose.
- 414.1000 · Purpose.
- 414.1001 · Basis of payment.
- 414.102 · General payment rules.
- 414.104 · PEN Items and Services.
- 414.105 · Application of competitive bidding information.
- 414.106 · Splints and casts.
- 414.108 · IOLs inserted in a physician's office.
- 414.110 · Continuity of pricing when HCPCS codes are divided or combined.
- 414.1100 · Basis and scope.
- 414.1105 · Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.
- 414.112 · Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
- 414.114 · 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.
- 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 and solo practitioners.
- 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.
- 414.1300 · Basis and scope.
- 414.1305 · Definitions.
- 414.1310 · Applicability.
- 414.1315 · Virtual groups.
- 414.1317 · APM Entity groups.
- 414.1318 · Subgroups.
- 414.1320 · MIPS performance period.
- 414.1325 · Data submission requirements.
- 414.1330 · Quality performance category.
- 414.1335 · Data submission criteria for the quality performance category.
- 414.1340 · Data completeness criteria for the quality performance category.
- 414.1350 · Cost performance category.
- 414.1355 · Improvement activities performance category.
- 414.1360 · Data submission criteria for the improvement activities performance category.
- 414.1365 · MIPS Value Pathways.
- 414.1367 · APM performance pathway.
- 414.1370 · APM scoring standard under MIPS.
- 414.1375 · Promoting Interoperability (PI) performance category.
- 414.1380 · Scoring.
- 414.1385 · Targeted review and review limitations.
- 414.1390 · Data validation and auditing.
- 414.1395 · Public reporting.
- 414.1400 · Third party intermediaries.
- 414.1405 · Payment.
- 414.1410 · Advanced APM determination.
- 414.1415 · Advanced APM criteria.
- 414.1420 · Other payer advanced APM criteria.
- 414.1425 · Qualifying APM participant determination: In general.
- 414.1430 · Qualifying APM participant determination: QP and partial QP thresholds.
- 414.1435 · Qualifying APM participant determination: Medicare option.
- 414.1440 · Qualifying APM participant determination: All-payer combination option.
- 414.1445 · Determination of other payer advanced APMs.
- 414.1450 · APM incentive payment.
- 414.1455 · Limitation on review.
- 414.1460 · Monitoring and program integrity.
- 414.1465 · Physician-focused payment models.
- 414.1500 · Basis, purpose, and scope.
- 414.1505 · Requirement for payment.
- 414.1510 · Beneficiary qualifications for coverage of services.
- 414.1515 · Plan of care requirements.
- 414.1550 · Basis of payment.
- 414.1600 · Purpose and definitions.
- 414.1650 · Payment basis for lymphedema compression treatment items.
- 414.1660 · Continuity of pricing when HCPCS codes are divided or combined.
- 414.1670 · Procedures for making benefit category determinations and payment determinations for new lymphedema compression treatment items.
- 414.1680 · Frequency limitations.
- 414.1690 · Application of competitive bidding information.
- 414.1700 · Basis of payment.
- 414.2 · Definitions.
- 414.20 · Formula for computing fee schedule amounts.
- 414.200 · Purpose.
- 414.202 · Definitions.
- 414.21 · Medicare payment basis.
- 414.210 · General payment rules.
- 414.22 · Relative value units (RVUs).
- 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).
- 414.234 · Prior authorization for items frequently subject to unnecessary utilization.
- 414.236 · Continuity of pricing when HCPCS codes are divided or combined.
- 414.238 · Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
- 414.24 · Publication of RVUs and direct PE inputs.
- 414.240 · 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.
- 414.26 · Determining the GAF.
- 414.28 · Conversion factors.
- 414.30 · Conversion factor update.
- 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.
- 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.
- 414.4 · Fee schedule areas.
- 414.40 · Coding and ancillary policies.
- 414.400 · Purpose and basis.
- 414.402 · Definitions.
- 414.404 · Scope and applicability.
- 414.406 · Implementation of programs.
- 414.408 · Payment rules.
- 414.409 · Special 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.
- 414.42 · Adjustment for first 4 years of practice.
- 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 breach of a DMEPOS competitive bidding program contract actions.
- 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.
- 414.44 · Transition rules.
- 414.46 · Additional rules for payment of anesthesia services.
- 414.48 · Limits on actual charges of nonparticipating suppliers.
- 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.
- 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.
- 414.500 · Basis and scope.
- 414.502 · Definitions.
- 414.504 · Data reporting requirements.
- 414.506 · Procedures for public consultation for payment for a new clinical diagnostic laboratory test.
- 414.507 · Payment for clinical diagnostic laboratory tests.
- 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.
- 414.52 · Payment for physician assistants' services.
- 414.522 · Payment for new advanced diagnostic laboratory tests.
- 414.523 · Payment for laboratory specimen collection fee and travel allowance.
- 414.53 · Fee schedule for clinical social worker, marriage and family therapist, and mental health counselor 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.
- 414.601 · Purpose.
- 414.605 · Definitions.
- 414.61 · Payment for anesthesia services furnished by a teaching CRNA.
- 414.610 · Basis of payment.
- 414.615 · Transition to the ambulance fee schedule.
- 414.617 · Transition from regional to national ambulance fee schedule.
- 414.62 · Fee schedule for clinical psychologist services.
- 414.620 · Publication of the ambulance fee schedule.
- 414.625 · Limitation on review.
- 414.626 · Data reporting by ground ambulance organizations.
- 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.
- 414.701 · Purpose.
- 414.704 · Definitions.
- 414.707 · Basis of payment.
- 414.80 · Incentive payment for primary care services.
- 414.800 · Purpose.
- 414.802 · Definitions.
- 414.804 · Basis of payment.
- 414.806 · Penalties associated with misrepresentation and the failure to submit timely and accurate ASP data.
- 414.84 · Payment for MDPP services.
- 414.90 · Physician Quality Reporting System (PQRS).
- 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.
- 414.92 · Electronic Prescribing Incentive Program.
- 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.
- 414.94 · [Reserved]
- 414.940 · Refund for certain discarded single-dose container or single-use package drugs.
United States Government work; public domain under 17 U.S.C. § 105.