Payment for Part B Medical and Other Health Services

Basis and scope.

This provision establishes the regulatory basis and scope for Part 414 regarding payment for Part B medical and other health services.

Purpose.

This provision outlines the purpose of implementing fee schedules for parenteral and enteral nutrition, splints, casts, and intraocular lenses.

Purpose.

This provision specifies the purpose of implementing supplying fees for drugs and biologicals covered under Part B of Title XVIII.

Basis of payment.

This provision establishes the specific fee amounts for pharmacy supplying and dispensing fees for drugs and inhalation drugs covered under Part B.

General payment rules.

This provision defines the general payment methodology and fee schedule updates for PEN items, splints, casts, and IOLs.

PEN Items and Services.

This provision specifies the payment rules and fee schedule determination for parenteral and enteral nutrition items and services.

Application of competitive bidding information.

For enteral nutrients, equipment and supplies furnished on or after January 1, 2011, the fee schedule amounts may be adjusted based on information on the payment determined as part of implementation of the programs under subpart F using...

Splints and casts.

This provision outlines the payment rules and fee schedule calculation for splints and casts.

IOLs inserted in a physician's office.

This provision specifies the payment rules and fee schedule calculation for intraocular lenses inserted in a physician's office.

Continuity of pricing when HCPCS codes are divided or combined.

This provision establishes the methodology for maintaining fee schedule pricing continuity when HCPCS codes are divided, combined, or added.

Basis and scope.

This provision defines the scope of the subpart regarding the payment methodology for comprehensive outpatient rehabilitation facility services.

Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.

This provision establishes the payment methodology for Comprehensive Outpatient Rehabilitation Facility (CORF) services, including physician services, supplies, and drugs, under the Medicare physician fee schedule.

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

This provision outlines the methodology for setting fee schedule amounts for new HCPCS codes that lack pricing history, utilizing comparability analysis or commercial price lists.

Procedures for making benefit category determinations and payment determinations for new PEN items and services covered under the prosthetic device benefit; splints and casts; a...

This provision describes the CMS process for determining whether new items and services qualify for Medicare coverage under specific benefit categories like prosthetic devices, splints, or casts.

Basis and scope.

This provision establishes the basis and scope for the Medicare value-based payment modifier, which adjusts physician payments based on quality and cost performance.

Definitions.

This provision provides definitions for terms used in the value-based payment modifier subpart, including ACOs, eligible professionals, and performance metrics.

Application of the value-based payment modifier.

This provision establishes the applicability, exceptions, and calculation methodology for the Medicare value-based payment modifier for physicians and nonphysician eligible professionals, including adjustments related to ACO participation and quality reporting.

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

This provision defines the specific calendar years for performance and subsequent payment adjustment periods under the value-based payment modifier program.

Reporting mechanisms for the value-based payment modifier.

This provision specifies that practitioners subject to the value-based payment modifier may use established Physician Quality Reporting System mechanisms to submit quality data.

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

This provision establishes that quality measures reported under the Physician Quality Reporting System are utilized to calculate the value-based payment modifier.

Additional measures for groups and solo practitioners.

This provision identifies specific outcome measures, including hospital admission and readmission rates, used to calculate the value-based payment modifier.

Cost measures.

This provision details the cost measures, including per capita costs and Medicare spending per beneficiary, used to assess groups under the value-based payment modifier.

Attribution for quality of care and cost measures.

This provision describes the methodology for attributing beneficiaries to groups and solo practitioners for the purpose of calculating quality and cost measures.

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

This provision outlines the mathematical formula for calculating standardized scores for quality and cost measures using a quality-tiering approach.

Benchmarks for quality of care measures.

This provision establishes the national mean benchmarks used to evaluate performance rates for quality of care measures.

Benchmarks for cost measures.

This provision defines the national mean benchmarks used to evaluate cost measures for groups and solo practitioners.

Composite scores.

This provision details the domain-based weighting and grouping of quality and cost measures to determine final composite scores for the value-based payment modifier.

Reliability of measures.

This provision establishes the minimum case volume requirements for quality and cost measures used to calculate composite scores for the value-based payment modifier.

Determination and calculation of Value-Based Payment Modifier adjustments.

This provision outlines the methodology for applying downward and upward payment adjustments to groups of physicians based on their performance under the value-based payment modifier program.

Value-based payment modifier quality-tiering scoring methodology.

This provision defines the scoring methodology for classifying quality and cost composites into high, average, and low categories to determine value-based payment modifier percentages.

Limitation on review.

This provision specifies that there is no administrative or judicial review available for the establishment, evaluation, and application of the value-based payment modifier.

Informal inquiry process.

This provision allows groups and solo practitioners to contact CMS to inquire about their annual Physician Feedback reports and the calculation of their value-based payment modifier.

Basis and scope.

This provision outlines the statutory basis and regulatory scope for the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Definitions.

As used in this section, unless otherwise indicated—

Applicability.

This provision defines the applicability, exclusions, and group participation requirements for clinicians under the Merit-based Incentive Payment System (MIPS).

Virtual groups.

This provision outlines the eligibility, formation, and reporting requirements for solo practitioners and small groups electing to participate in MIPS as a virtual group.

APM Entity groups.

This provision establishes the determination, scoring, and performance category weighting for APM Entity groups within the MIPS framework.

Subgroups.

This provision defines the eligibility, scoring, and reporting requirements for individual clinicians participating in MIPS as a subgroup.

MIPS performance period.

This provision defines the specific calendar year performance periods required for MIPS payment year eligibility across various performance categories.

Data submission requirements.

This provision outlines the methods, deadlines, and submission types for reporting MIPS data, including quality, improvement activities, and promoting interoperability categories.

Quality performance category.

This provision establishes the quality measures, scoring weights, and criteria for measure removal within the MIPS quality performance category.

Data submission criteria for the quality performance category.

This provision specifies the criteria for submitting quality measure data, including requirements for eCQMs, Medicare Part B claims, and CAHPS for MIPS survey participation.

Data completeness criteria for the quality performance category.

This provision establishes the data completeness requirements for MIPS eligible clinicians and groups submitting quality measures data for the MIPS quality performance category.

Cost performance category.

This provision defines the cost performance category for MIPS, including attribution methods, case minimums, scoring weights, and criteria for removing cost measures.

Improvement activities performance category.

This provision outlines the improvement activities performance category for MIPS, including subcategories of activities and criteria for adding or removing activities from the inventory.

Data submission criteria for the improvement activities performance category.

This provision specifies the methods and requirements for MIPS eligible clinicians and groups to submit data for the improvement activities performance category.

MIPS Value Pathways.

This provision establishes the registration, reporting, and scoring requirements for MIPS Value Pathways (MVPs) within the Medicare Merit-based Incentive Payment System.

APM performance pathway.

This provision defines the APM Performance Pathway scoring methodology for MIPS eligible clinicians participating in MIPS APMs, including performance category weights and reporting requirements.

APM scoring standard under MIPS.

This provision establishes the scoring methodology for Alternative Payment Model (APM) entities under the Merit-based Incentive Payment System (MIPS), including performance category weights and reporting requirements.

Promoting Interoperability (PI) performance category.

This provision outlines the requirements for MIPS eligible clinicians to report on Promoting Interoperability objectives, including the use of certified EHR technology, security risk analysis, and attestations regarding information blocking and interoperability.

Scoring.

This provision establishes the scoring methodology for the Merit-based Incentive Payment System (MIPS) across quality, cost, improvement activities, and promoting interoperability performance categories.

Targeted review and review limitations.

This provision establishes the process for MIPS eligible clinicians to request a targeted review of payment adjustment factor calculations and mandates a six-year documentation retention period.

Data validation and auditing.

This provision outlines CMS audit requirements for MIPS participants, including data sharing, primary source document submission, data certification, and a six-year record retention mandate.

Public reporting.

This provision governs the public reporting of MIPS performance data on the Physician Compare website, including data standards, new measure reporting timelines, and the clinician preview period.

Third party intermediaries.

This provision establishes the qualification, data submission, validation, and remedial action requirements for third-party intermediaries, such as QCDRs and qualified registries, participating in the Merit-based Incentive Payment System (MIPS).

Payment.

This provision establishes the methodology for calculating MIPS payment adjustment factors, including performance thresholds, applicable percentages, and budget neutrality scaling for eligible clinicians.

Advanced APM determination.

This provision outlines the process by which CMS determines whether an Alternative Payment Model (APM) qualifies as an Advanced APM for a given payment year.

Advanced APM criteria.

This provision specifies the requirements for an Alternative Payment Model to be designated as an Advanced APM, including the use of certified EHR technology, quality measure performance, and financial risk standards.

Other payer advanced APM criteria.

This provision establishes the criteria for Other Payer Advanced Alternative Payment Models, including requirements for CEHRT usage, quality measure reporting, and financial risk standards.

Qualifying APM participant determination: In general.

This provision outlines the methodology and criteria used by CMS to determine whether eligible clinicians qualify as Qualifying APM Participants (QPs) or Partial QPs based on their participation in Advanced Alternative Payment Models.

Qualifying APM participant determination: QP and partial QP thresholds.

This provision establishes the specific payment amount and patient count thresholds required for eligible clinicians to achieve Qualifying APM Participant (QP) or Partial QP status under Medicare and All-Payer Combination options.

Qualifying APM participant determination: Medicare option.

This provision defines the methodology for calculating Threshold Scores for APM Entities and eligible clinicians, including payment amount and patient count methods for determining QP status.

Qualifying APM participant determination: All-payer combination option.

This provision establishes the methodology for calculating threshold scores and determining qualifying APM participant status under the All-Payer Combination Option for Advanced APMs.

Determination of other payer advanced APMs.

This provision outlines the process and criteria for requesting and obtaining CMS determinations regarding whether specific payment arrangements qualify as Other Payer Advanced APMs.

APM incentive payment.

This provision outlines the calculation, eligibility, and distribution of lump sum incentive payments for clinicians participating in Alternative Payment Models.

Limitation on review.

This provision establishes the limitations on administrative and judicial review for determinations regarding QP status and APM incentive payment amounts.

Monitoring and program integrity.

This provision details the requirements for vetting eligible clinicians, auditing information, and maintaining records for APM participation and incentive payments.

Physician-focused payment models.

This provision defines physician-focused payment models and outlines the criteria used by the PTAC to assess proposals for these models.

Basis, purpose, and scope.

This provision defines the scope of Medicare payment requirements for home infusion services furnished to eligible beneficiaries.

Requirement for payment.

This provision outlines the requirements for home infusion therapy suppliers to qualify for Medicare payment, including adherence to health and safety standards and enrollment requirements.

Beneficiary qualifications for coverage of services.

This provision specifies the requirements a beneficiary must meet to qualify for Medicare coverage of home infusion therapy, including being under the care of an applicable provider and a physician-ordered plan of care.

Plan of care requirements.

This provision details the required contents, physician order specifications, and signature requirements for a home infusion therapy plan of care.

Basis of payment.

This provision establishes the methodology for Medicare payment for home infusion therapy services, including fee schedule amounts, unit of payment, and medical review adjustments.

Purpose and definitions.

This provision defines the scope and key terms for Medicare benefit category and payment determinations for lymphedema compression treatment items.

Payment basis for lymphedema compression treatment items.

This provision outlines the payment methodology for lymphedema compression treatment items, including the use of Medicaid and TRICARE data for establishing payment amounts.

Continuity of pricing when HCPCS codes are divided or combined.

This provision establishes rules for maintaining continuity of payment amounts when HCPCS codes for lymphedema compression treatment items are divided or combined.

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

This provision describes the CMS process for determining whether new items qualify as lymphedema compression treatment items and establishing their payment amounts.

Frequency limitations.

This provision sets the frequency limitations for the initial furnishing and replacement of lymphedema compression treatment items.

Application of competitive bidding information.

The payment amounts for lymphedema compression treatment items under § 414.1650(b) may be adjusted using information on the payment determined as part of implementation of the programs under subpart F using the methodologies set forth at...

Basis of payment.

This provision establishes the Medicare payment methodology for home intravenous immunoglobulin (IVIG) items and services, including per-visit amounts and annual adjustments.

Definitions.

As used in this part, unless the context indicates otherwise—

Formula for computing fee schedule amounts.

This provision establishes the mathematical formula for calculating Medicare Part B fee schedule amounts for participating and nonparticipating suppliers.

Purpose.

This provision defines the scope and applicability of Medicare payment rules for durable medical equipment, prosthetics, orthotics, and surgical dressings.

Definitions.

For purposes of this subpart, the following definitions apply:

Medicare payment basis.

This provision establishes that Medicare payment is determined by the lesser of the actual charge or the applicable fee schedule amount.

General payment rules.

This provision establishes the Medicare payment methodology, fee schedule adjustments, and maintenance and servicing requirements for durable medical equipment, prosthetics, and orthotics.

Relative value units (RVUs).

CMS establishes RVUs for physicians' work, practice expense, and malpractice insurance.

Inexpensive or routinely purchased items.

This provision establishes the payment methodology, fee schedule calculations, and national limited payment amounts for inexpensive or routinely purchased medical equipment under Medicare Part B.

Items requiring frequent and substantial servicing.

This provision defines items requiring frequent and substantial servicing, such as ventilators, and outlines the monthly rental payment rules and fee schedule adjustments for these items.

Customized items.

This provision defines criteria for customized medical items and establishes that payment is made on a lump sum basis based on individual consideration of labor and material costs.

Oxygen and oxygen equipment.

This provision establishes Medicare Part B fee schedule amounts, payment methodologies, volume adjustments, and supplier obligations for the rental and provision of oxygen and oxygen equipment.

Prosthetic and orthotic devices.

This provision establishes the Medicare Part B payment methodology, fee schedule calculations, and regional pricing adjustments for prosthetic and orthotic devices, including therapeutic shoes.

Other durable medical equipment—capped rental items.

This provision establishes Medicare payment methodologies, rental and purchase options, maintenance requirements, and supplier obligations for capped rental durable medical equipment.

Determining a period of continuous use.

This provision establishes the rules for determining the period of continuous use for rental durable medical equipment, including criteria for temporary interruptions and new rental periods.

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

This provision outlines the specific payment methodology for transcutaneous electrical nerve stimulators, including purchase price reductions and rental payment exceptions.

Prior authorization for items frequently subject to unnecessary utilization.

This provision establishes the prior authorization process for DMEPOS items, including criteria for master list inclusion, conditions of payment, and submission requirements.

Continuity of pricing when HCPCS codes are divided or combined.

This provision sets forth the methodology for maintaining fee schedule pricing continuity when HCPCS codes for items and services are modified, divided, or combined.

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

This provision outlines the methodology for establishing Medicare fee schedule amounts for new HCPCS codes that lack a prior pricing history.

Publication of RVUs and direct PE inputs.

This provision establishes the process for CMS to publish and revise relative value units and direct practice expense inputs for physician services.

Procedures for making benefit category determinations and payment determinations for new durable medical equipment, prosthetic devices, orthotics and prosthetics, surgical dress...

This provision details the administrative process for determining whether new items qualify for specific Medicare benefit categories and their associated payment status.