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Code of Federal Regulations (Last Updated: November 8, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter B - Medicare Program |
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Part 414 - Payment for Part B Medical and Other Health Services |
| Subpart A - General Provisions |
| § 414.1 - Basis and scope. |
| § 414.2 - Definitions. |
| § 414.4 - Fee schedule areas. |
| Subpart B - Physicians and Other Practitioners |
| § 414.20 - Formula for computing fee schedule amounts. |
| § 414.21 - Medicare payment basis. |
| § 414.22 - Relative value units (RVUs). |
| § 414.24 - Publication of RVUs and direct PE inputs. |
| § 414.26 - Determining the GAF. |
| § 414.28 - Conversion factors. |
| § 414.30 - Conversion factor update. |
| § 414.32 - Determining payments for certain physicians' services furnished in facility settings. |
| § 414.34 - Payment for services and supplies incident to a physician's service. |
| § 414.36 - Payment for drugs incident to a physician's service. |
| § 414.38 - Special rules for payment of low osmolar contrast media. |
| § 414.39 - Special rules for payment of care plan oversight. |
| § 414.40 - Coding and ancillary policies. |
| § 414.42 - Adjustment for first 4 years of practice. |
| § 414.44 - Transition rules. |
| § 414.46 - Additional rules for payment of anesthesia services. |
| § 414.48 - Limits on actual charges of nonparticipating suppliers. |
| § 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. |
| § 414.52 - Payment for physician assistants' services. |
| § 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. |
| § 414.61 - Payment for anesthesia services furnished by a teaching CRNA. |
| § 414.62 - Fee schedule for clinical psychologist services. |
| § 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. |
| § 414.80 - Incentive payment for primary care services. |
| § 414.84 - Payment for MDPP services. |
| § 414.90 - Physician Quality Reporting System (PQRS). |
| § 414.92 - Electronic Prescribing Incentive Program. |
| § 414.94 - [Reserved] |
| Subpart C - Fee Schedules for Parenteral and Enteral Nutrition (PEN) Nutrients, Equipment and Supplies, Splints, Casts, and Certain Intraocular Lenses (IOLs) |
| § 414.100 - Purpose. |
| § 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 - xxx |
| § 414.112 - xxx |
| § 414.114 - xxx |
| Subpart D - Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices |
| § 414.200 - Purpose. |
| § 414.202 - Definitions. |
| § 414.210 - General payment rules. |
| § 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 - xxx |
| § 414.238 - xxx |
| § 414.240 - xxx |
| Subpart E - Determination of Reasonable Charges Under the ESRD Program |
| § 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. |
| Subpart F - Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) |
| § 414.400 - Purpose and basis. |
| § 414.402 - Definitions. |
| §§ 414.400--414.404 - [Reserved] |
| § 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. |
| § 414.420 - 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. |
| §§ 414.408--414.426 - [Reserved] |
| Subpart G - Payment for Clinical Diagnostic Laboratory Tests |
| § 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. |
| § 414.511 - Adjustments to the Clinical Laboratory Fee Schedule based on Technological Changes. |
| § 414.522 - Payment for new advanced diagnostic laboratory tests. |
| § 414.523 - Payment for laboratory specimen collection fee and travel allowance. |
| Subpart H - Fee Schedule for Ambulance Services |
| § 414.601 - Purpose. |
| § 414.605 - Definitions. |
| § 414.610 - Basis of payment. |
| § 414.615 - Transition to the ambulance fee schedule. |
| § 414.617 - Transition from regional to national ambulance fee schedule. |
| § 414.620 - Publication of the ambulance fee schedule. |
| § 414.625 - Limitation on review. |
| § 414.626 - xxx |
| Subpart I - Payment for Drugs and Biologicals |
| § 414.701 - Purpose. |
| § 414.704 - Definitions. |
| § 414.707 - Basis of payment. |
| Subpart J - Submission of Manufacturer's Average Sales Price Data |
| § 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. |
| Subpart K - Payment for Drugs and Biologicals Under Part B |
| § 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. |
| § 414.920 - 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. |
| § 414.940 - Refund for certain discarded single-dose container or single-use package drugs. |
| Subpart L - Supplying and Dispensing Fees |
| § 414.1000 - Purpose. |
| § 414.1001 - Basis of payment. |
| Subpart M - Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) Services |
| § 414.1100 - Basis and scope. |
| § 414.1105 - Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services. |
| Subpart N - Value-Based Payment Modifier Under the Physician Fee Schedule |
| § 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. |
| Subpart O - Merit-Based Incentive Payment System and Alternative Payment Model Incentive |
| § 414.1300 - Basis and scope. |
| § 414.1305 - Definitions. |
| § 414.1310 - Applicability. |
| § 414.1315 - Virtual groups. |
| § 414.1317 - xxx |
| § 414.1318 - xxx |
| § 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 - xxx |
| § 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. |
| Subpart P - Home Infusion Therapy Services Payment |
| Payment System |
| § 414.1550 - Basis of payment. |
| Conditions for Payment |
| § 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. |
| Subpart Q - Payment for Lymphedema Compression Treatment Items |
| § 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. |
| Subpart R - Home Intravenous Immunoglobulin (IVIG) Items and Services Payment |
| § 414.1700 - Basis of payment. |