42 C.F.R. §§ 414.1–414.48

§414.1. Basis and scope.

42 C.F.R. § 414.1

This part implements the following provisions of the Act:

Notes, amendments, and revision history

Amendments

[67 FR 9132, Feb. 27, 2002, as amended at 69 FR 1116, Jan. 7, 2004; 71 FR 48409, Aug. 18, 2006; 81 FR 41098, June 23, 2016; 90 FR 20808, May 16, 2025]

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[67 FR 9132, Feb. 27, 2002, as amended at 69 FR 1116, Jan. 7, 2004; 71 FR 48409, Aug. 18, 2006; 81 FR 41098, June 23, 2016; 90 FR 20808, May 16, 2025]

§414.2. Definitions.

42 C.F.R. § 414.2

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

AA stands for anesthesiologist assistant.

AHPB stands for adjusted historical payment basis.

CF stands for conversion factor.

CRNA stands for certified registered nurse anesthetist.

CY stands for calendar year.

FY stands for fiscal year.

GAF stands for geographic adjustment factor.

GPCI stands for geographic practice cost index.

HCPCS stands for CMS Common Procedure Coding System.

Health Professional Shortage Area (HPSA) means an area designated under section 332(a)(1)(A) of the Public Health Service Act as identified by the Secretary prior to the beginning of such year.

Major surgical procedure means a surgical procedure for which a 10-day or 90-day global period is used for payment under the physician fee schedule and section 1848(b) of the Act.

Physician services means the following services to the extent that they are covered by Medicare:

(1)

Professional services of doctors of medicine and osteopathy (including osteopathic practitioners), doctors of optometry, doctors of podiatry, doctors of dental surgery and dental medicine, and chiropractors.

(2)

Supplies and services covered “incident to” physician services (excluding drugs as specified in § 414.36).

(3)

Outpatient physical and occupational therapy services if furnished by a person or an entity that is not a Medicare provider of services as defined in § 400.202 of this chapter.

(4)

Diagnostic x-ray tests and other diagnostic tests (excluding diagnostic laboratory tests paid under the fee schedule established under section 1833(h) of the Act).

(5)

X-ray, radium, and radioactive isotope therapy, including materials and services of technicians.

(6)

Antigens, as described in section 1861(s)(2)(G) of the Act.

(7)

Bone mass measurement. RVU stands for relative value unit.

(8)

Screening mammography services.

Notes, amendments, and revision history

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 58 FR 63686, Dec. 2, 1993; 59 FR 63463, Dec. 8, 1994; 60 FR 63177, Dec. 8, 1995; 63 FR 34328, June 24, 1998; 66 FR 55322, Nov. 1, 2001; 75 FR 73616, Nov. 29, 2010]

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 58 FR 63686, Dec. 2, 1993; 59 FR 63463, Dec. 8, 1994; 60 FR 63177, Dec. 8, 1995; 63 FR 34328, June 24, 1998; 66 FR 55322, Nov. 1, 2001; 75 FR 73616, Nov. 29, 2010]

§414.4. Fee schedule areas.

42 C.F.R. § 414.4

(a)

General. CMS establishes physician fee schedule areas that generally conform to the geographic localities in existence before January 1, 1992.

(b)

Changes. CMS announces proposed changes to fee schedule areas in the Federal Register and provides an opportunity for public comment. After considering public comments, CMS publishes the final changes in the Federal Register.

Notes, amendments, and revision history

Amendments

[59 FR 63463, Dec. 8, 1994]

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[59 FR 63463, Dec. 8, 1994]

§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.

42 C.F.R. § 414.5

(a)

If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under § 482.30(d) of this chapter or § 485.641 of this chapter after a beneficiary is discharged that the beneficiary's inpatient admission was not reasonable and necessary, the hospital may be paid for any of the following Part B inpatient services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, provided the beneficiary is enrolled in Medicare Part B:

(1)

Services described in § 419.21(a) of this chapter that do not require an outpatient status.

(2)

Physical therapy services, speech-language pathology services, and occupational therapy services.

(3)

Ambulance services, as described in section 1861(v)(1)(U) of the Act, or, if applicable, the fee schedule established under section 1834(l) of Act.

(4)

Except as provided in § 419.2(b)(11) of this chapter, prosthetic devices, prosthetics, prosthetic supplies, and orthotic devices.

(5)

Except as provided in § 419.2(b)(10) of this chapter, durable medical equipment supplied by the hospital for the patient to take home.

(6)

Clinical diagnostic laboratory services.

(7)

(i)

Effective December 8, 2003, screening mammography services; and

(ii)

Effective January 1, 2005, diagnostic mammography services.

(8)

Effective January 1, 2011, annual wellness visit providing personalized prevention plan services as defined in § 410.15 of this chapter.

(b)

If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under § 482.30(d) of this chapter or § 485.641 of this chapter after a beneficiary is discharged that the beneficiary's inpatient admission was not reasonable and necessary, the hospital may be paid for hospital outpatient services described in § 412.2(c)(5), § 412.405, § 412.540, or § 412.604(f) of this chapter or § 413.40(c)(2) of this chapter that are furnished to the beneficiary prior to the point of inpatient admission (that is, the inpatient admission order).

(c)

The claims for the Part B services filed under the circumstances described in this section must be filed in accordance with the time limits for filing claims specified in § 424.44(a) of this chapter.

Notes, amendments, and revision history

Amendments

[78 FR 50968, Aug. 19, 2013]

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[78 FR 50968, Aug. 19, 2013]

§414.20. Formula for computing fee schedule amounts.

42 C.F.R. § 414.20

(a)

Participating supplier. The fee schedule amount for a participating supplier for a physician service as defined in § 414.2 is computed as the product of the following amounts:

(1)

The RVUs for the service.

(2)

The GAF for the fee schedule area.

(3)

The CF.

(b)

Nonparticipating supplier. The fee schedule amount for a nonparticipating supplier for a physician service as defined in § 414.2 is 95 percent of the fee schedule amount as calculated in paragraph (a) of this section.

Notes, amendments, and revision history

Amendments

[62 FR 59101, Oct. 31, 1997]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[62 FR 59101, Oct. 31, 1997]

§414.21. Medicare payment basis.

42 C.F.R. § 414.21

Medicare payment is based on the lesser of the actual charge or the applicable fee schedule amount.

Notes, amendments, and revision history

Amendments

[62 FR 59101, Oct. 31, 1997]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[62 FR 59101, Oct. 31, 1997]

§414.22. Relative value units (RVUs).

42 C.F.R. § 414.22

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

(a)

Physician work RVUs—

(1)

General rule. Physician work RVUs are established using a relative value scale in which the value of physician work for a particular service is rated relative to the value of work for other physician services.

(2)

Special RVUs for anesthesia and radiology services)—

(i)

Anesthesia services. The rules for determining RVUs for anesthesia services are set forth in § 414.46.

(ii)

Radiology services. CMS bases the RVUs for all radiology services on the relative value scale developed under section 1834(b)(1)(A) of the Act, with appropriate modifications to ensure that the RVUs established for radiology services that are similar or related to other physician services are consistent with the RVUs established for those similar or related services.

(b)

Practice expense RVUs.

(1)

Practice expense RVUs are computed for each service or class of service by applying average historical practice cost percentages to the estimated average allowed charge during the 1991 base period.

(2)

The average practice expense percentage for a service or class of services is computed as follows—

(i)

Multiply the average practice expense percentage for each specialty by the proportion of a particular service or class of service performed by that specialty.

(ii)

Add the products for all specialties.

(3)

For services furnished beginning calendar year (CY) 1994, for which 1994 practice expense RVUs exceed 1994 work RVUs and that are performed in office settings less than 75 percent of the time, the 1994, 1995, and 1996 practice expense RVUs are reduced by 25 percent of the amount by which they exceed the number of 1994 work RVUs. Practice expense RVUs are not reduced to less than 128 percent of 1994 work RVUs.

(4)

For services furnished beginning January 1, 1998, practice expense RVUs for certain services are reduced to 110 percent of the work RVUs for those services. The following two categories of services are excluded from this limitation:

(i)

The service is provided more than 75 percent of the time in an office setting; or

(ii)

The service is one described in section 1848(c)(2)(G)(v) of the Act, codified at 42 U.S.C. 1395w-4(c)(2)(G). Section 1848(c)(2)(G)(v) of the Act refers to the 1998 proposed resource-based practice expense RVUs (as specified in the June 18, 1997 physician fee schedule proposed rule (62 FR 33158)) for the specific site, either in-office or out-of-office, increased from its 1997 practice expense RVUs.)

(5)

For services furnished in 2002 and subsequent years, the practice expense RVUs are based entirely on relative practice expense resources.

(i)

Usually there are two levels of practice expense RVUs that correspond to each code.

(A)

Facility practice expense RVUs. The facility practice expense RVUs apply to services furnished to patients in a hospital, a skilled nursing facility, a community mental health center, a hospice, or an ambulatory surgical center, or in a wholly owned or wholly operated entity providing preadmission services under § 412.2(c)(5) of this chapter, or via telehealth under § 410.78 of this chapter.

(B)

Nonfacility practice expense RVUs. The nonfacility practice expense RVUs apply to services furnished to patients in all locations other than those listed in paragraph (b)(5)(i)(A) of this section, but not limited to, a physician's office, the patient's home, a nursing facility, or a comprehensive outpatient rehabilitation facility (CORF).

(C)

Outpatient therapy and CORF services. Outpatient therapy services (including physical therapy, occupational therapy, and speech-language pathology services) and CORF services billed under the physician fee schedule are paid using the nonfacility practice expense RVUs.

(ii)

[Reserved]

(6)

(i)

CMS establishes criteria for supplemental surveys regarding specialty practice expenses submitted to CMS that may be used in determining practice expense RVUs.

(ii)

Any CMS-designated specialty group may submit a supplemental survey.

(iii)

CMS will consider for use in determining practice expense RVUs for the physician fee schedule survey data and related materials submitted to CMS by March 1, 2004 to determine CY 2005 practice expense RVUs and by March 1, 2005 to determine CY 2006 practice expense RVUs.

(c)

Malpractice insurance RVUs.

(1)

Malpractice insurance RVUs are computed for each service or class of services by applying average malpractice insurance historical practice cost percentages to the estimated average allowed charge during the 1991 base period.

(2)

The average historical malpractice insurance percentage for a service or class of services is computed as follows:

(i)

Multiply the average malpractice insurance percentage for each specialty by the proportion of a particular service or class of services performed by that specialty.

(ii)

Add all the products for all the specialties.

(3)

For services furnished in the year 2000 and subsequent years, the malpractice RVUs are based on the relative malpractice insurance resources.

Notes, amendments, and revision history

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42493, Sept. 15, 1992; 58 FR 63687, Dec. 2, 1993; 62 FR 59102, Oct. 31, 1997; 63 FR 58910, Nov. 2, 1998; 64 FR 59441, Nov. 2, 1999; 65 FR 25668, May 3, 2000; 65 FR 65440, Nov. 1, 2000; 67 FR 43558, June 28, 2002; 68 FR 63261, Nov. 7, 2003; 72 FR 66932, Nov. 27, 2007; 73 FR 69935, Nov. 19, 2008; 76 FR 73471, Nov. 28, 2011; 81 FR 79879, Nov. 14, 2016; 81 FR 80553, Nov. 15, 2016]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42493, Sept. 15, 1992; 58 FR 63687, Dec. 2, 1993; 62 FR 59102, Oct. 31, 1997; 63 FR 58910, Nov. 2, 1998; 64 FR 59441, Nov. 2, 1999; 65 FR 25668, May 3, 2000; 65 FR 65440, Nov. 1, 2000; 67 FR 43558, June 28, 2002; 68 FR 63261, Nov. 7, 2003; 72 FR 66932, Nov. 27, 2007; 73 FR 69935, Nov. 19, 2008; 76 FR 73471, Nov. 28, 2011; 81 FR 79879, Nov. 14, 2016; 81 FR 80553, Nov. 15, 2016]

§414.24. Publication of RVUs and direct PE inputs.

42 C.F.R. § 414.24

(a)

Definitions. For purposes of this section, the following definitions apply:

Existing code means a code that is not a new code under paragraph (c)(2) of this section, and includes codes for which the descriptor is revised and codes that are combinations or subdivisions of previously existing codes.

New code means a code that describes a service that was not previously described or valued under the PFS using any other code or combination of codes.

(b)

Revisions of RVUs and Direct PE Inputs. For valuations for calendar year 2017 and beyond, CMS publishes, through notice and comment rulemaking in the Federal Register (including proposals in a proposed rule), changes in RVUs or direct PE inputs for existing codes.

(c)

Establishing RVUs and Direct PE inputs for new codes—

(1)

General rule. CMS establishes RVUs and direct PE inputs for new codes in the manner described in paragraph (b) of this section.

(2)

Exception for new codes for which CMS does not have sufficient information. When CMS determines for a new code that it does not have sufficient information to include proposed RVUs or direct PE inputs in the proposed rule, but that it is in the public interest for Medicare to use a new code during a payment year, CMS will publish in the Federal Register RVUs and direct PE inputs that are applicable on an interim basis subject to public comment. After considering public comments and other information on interim RVUs and PE inputs for the new code, CMS publishes in the Federal Register the final RVUs and PE inputs for the code.

(d)

Values for local codes (HCPCS Level 3).

(1)

Carriers establish relative values for local codes for services not included in HCPCS levels 1 or 2.

(2)

Carriers must obtain prior approval from CMS to establish local codes for services that meet the definition of “physician services” in § 414.2.

Notes, amendments, and revision history

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 79 FR 68003, Nov. 13, 2014]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 79 FR 68003, Nov. 13, 2014]

§414.26. Determining the GAF.

42 C.F.R. § 414.26

CMS establishes a GAF for each service in each fee schedule area.

(a)

Geographic indices. CMS uses the following indices to establish the GAF:

(1)

An index that reflects one-fourth of the difference between the relative value of physicians' work effort in each of the different fee schedule areas as determined under § 414.22(a) and the national average of that work effort.

(2)

An index that reflects the relative costs of the mix of goods and services comprising practice expenses (other than malpractice expenses) in each of the different fee schedule areas as determined under § 414.22(b) compared to the national average of those costs.

(3)

An index that reflects the relative costs of malpractice expenses in each of the different fee schedule areas as determined under § 414.22(c) compared to the national average of those costs.

(b)

Class-specific practice cost indices. If the application of a single index to different classes of services would be substantially inequitable because of differences in the mix of goods and services comprising practice expenses for the different classes of services, more than one index may be established under paragraph (a)(2) of this section.

(c)

Adjusting the practice expense index to account for the Frontier State floor—

(1)

General criteria. Effective on or after January 1, 2011, CMS will adjust the practice expense index for physicians' services furnished in qualifying States to recognize the practice expense index floor established for Frontier States. A qualifying State must meet the following criteria:

(i)

At least 50 percent of counties located within the State have a population density less than 6 persons per square mile.

(ii)

The State does not receive a non-labor related share adjustment determined by the Secretary to take into account the unique circumstances of hospitals located in Alaska and Hawaii.

(2)

Amount of adjustment. The practice expense value applied for physicians' services furnished in a qualifying State will be not less than 1.00.

(3)

Process for determining adjustment.

(i)

CMS will use the most recent population estimate data published by the U.S. Census Bureau to determine county definitions and population density. This analysis will be periodically revised, such as for updates to the decennial census data.

(ii)

CMS will publish annually a listing of qualifying Frontier States receiving a practice expense index floor attributable to this provision.

(d)

Computation of GAF. The GAF for each fee schedule area is the sum of the physicians' work adjustment factor, the practice expense adjustment factor, and the malpractice cost adjustment factor, as defined in this section:

(1)

The geographic physicians' work adjustment factor for a service is the product of the proportion of the total relative value for the service that reflects the RVUs for the work component and the geographic physicians' work index value established under paragraph (a)(1) of this section.

(2)

The geographic practice expense adjustment factor for a service is the product of the proportion of the total relative value for the service that reflects the RVUs for the practice expense component, multiplied by the geographic practice cost index (GPCI) value established under paragraph (a)(2) of this section.

(3)

The geographic malpractice adjustment factor for a service is the product of the proportion of the total relative value for the service that reflects the RVUs for the malpractice component, multiplied by the GPCI value established under paragraph (a)(3) of this section.

Notes, amendments, and revision history

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 75 FR 73616, Nov. 29, 2010]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 75 FR 73616, Nov. 29, 2010]

§414.28. Conversion factors.

42 C.F.R. § 414.28

CMS establishes CFs in accordance with section 1848(d) of the Act.

(a)

Base-year CFs. CMS established the CF for 1992 so that had section 1848 of the Act applied during 1991, it would have resulted in the same aggregate amount of payments for physician services as the estimated aggregate amount of these payments in 1991, adjusted by the update for 1992 computed as specified in § 414.30.

(b)

Subsequent CFs. For calendar years 1993 through 1995, the CF for each year is equal to the CF for the previous year, adjusted in accordance with § 414.30. Beginning January 1, 1996, the CF for each calendar year may be further adjusted so that adjustments to the fee schedule in accordance with section 1848(c)(2)(B)(ii) of the Act do not cause total expenditures under the fee schedule to differ by more than $20 million from the amount that would have been spent if these adjustments had not been made.

Notes, amendments, and revision history

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 60 FR 53877, Oct. 18, 1995; 60 FR 63177, Dec. 8, 1995]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 60 FR 53877, Oct. 18, 1995; 60 FR 63177, Dec. 8, 1995]

§414.30. Conversion factor update.

42 C.F.R. § 414.30

Unless Congress acts in accordance with section 1848(d)(3) of the Act—

(a)

General rule. The CF update for a CY equals the Medicare Economic Index increased or decreased by the number of percentage points by which the percentage increase in expenditures for physician services (or for a particular category of physician services, such as surgical services) in the second preceding FY over the third preceding FY exceeds the performance standard rate of increase established for the second preceding FY.

(b)

Downward adjustment. The downward adjustment may not exceed the following:

(1)

For CYs 1992 and 1993, 2 percentage points.

(2)

For CY 1994, 2.5 percentage points.

(3)

For CYs 1995 and thereafter, 5 percentage points.

Notes, amendments, and revision history

Amendments

[55 FR 23441, June 8, 1990, as amended at 60 FR 63177, Dec. 8, 1995; 61 FR 42385, Aug. 15, 1996]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[55 FR 23441, June 8, 1990, as amended at 60 FR 63177, Dec. 8, 1995; 61 FR 42385, Aug. 15, 1996]

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

42 C.F.R. § 414.34

(a)

Medical supplies.

(1)

Except as otherwise specified in this paragraph, office medical supplies are considered to be part of a physician's practice expense, and payment for them is included in the practice expense portion of the payment to the physician for the medical or surgical service to which they are incidental.

(2)

If physician services of the type routinely furnished in provider settings are furnished in a physician's office, separate payment may be made for certain supplies furnished incident to that physician service if the following requirements are met:

(i)

It is a procedure that can safely be furnished in the office setting in appropriate circumstances.

(ii)

It requires specialized supplies that are not routinely available in physicians' offices and that are generally disposable.

(iii)

It is furnished before January 1, 1999.

(3)

For the purpose of paragraph (a)(2) of this section, provider settings include only the following settings:

(i)

Hospital inpatient and outpatient departments.

(ii)

Ambulatory surgical centers.

(4)

For the purpose of paragraph (a)(2) of this section, “routinely furnished in provider settings” means furnished in inpatient or outpatient hospital settings or ambulatory surgical centers more than 50 percent of the time.

(5)

CMS establishes a list of services for which a separate supply payment may be made under this section.

(6)

The fee schedule amount for supplies billed separately is not subject to a GPCI adjustment.

(b)

Services of nonphysicians that are incident to a physician's service. Services of nonphysicians that are covered as incident to a physician's service are paid as if the physician had personally furnished the service.

Notes, amendments, and revision history

Amendments

[56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, as amended at 63 FR 58911, Nov. 2, 1998]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, as amended at 63 FR 58911, Nov. 2, 1998]

§414.36. Payment for drugs incident to a physician's service.

42 C.F.R. § 414.36

Payment for drugs incident to a physician's service is made in accordance with § 405.517 of this chapter.

Notes, amendments, and revision history

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

§414.39. Special rules for payment of care plan oversight.

42 C.F.R. § 414.39

(a)

General. Except as specified in paragraphs (b) and (c) of this section, payment for care plan oversight is included in the payment for visits and other services under the physician fee schedule. For purposes of this section a nonphysician practitioner (NPP) is a nurse practitioner, clinical nurse specialist or physician assistant.

(b)

Exception. Separate payment is made under the following conditions for physician care plan oversight services furnished to beneficiaries who receive HHA and hospice services that are covered by Medicare:

(1)

The care plan oversight services require recurrent physician supervision of therapy involving 30 or more minutes of the physician's time per month.

(2)

Payment is made to only one physician per patient for services furnished during a calendar month period. The physician must have furnished a service requiring a face-to-face encounter with the patient at least once during the 6-month period before the month for which care plan oversight payment is first billed. The physician may not have a significant ownership interest in, or financial or contractual relationship with, the HHA in accordance with § 424.22(d) of this chapter. The physician may not be the medical director or employee of the hospice and may not furnish services under an arrangement with the hospice.

(3)

If a physician furnishes care plan oversight services during a postoperative period, payment for care plan oversight services is made if the services are documented in the patient's medical record as unrelated to the surgery.

(c)

Special rules for payment of care plan oversight provided by nonphysician practitioners for beneficiaries who receive HHA services covered by Medicare.

(1)

An NPP can furnish physician care plan oversight (but may not certify a patient as needing home health services) only if the physician who signs the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for care plan oversight and either—

(i)

The physician and NPP are part of the same group practice; or

(ii)

If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or

(iii)

If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.

(2)

Payment may be made for care plan oversight services furnished by an NPP when:

(i)

The NPP providing the care plan oversight has seen and examined the patient;

(ii)

The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multi-disciplinary coordination of care; and

(iii)

The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care.

Notes, amendments, and revision history

Amendments

[59 FR 63463, Dec. 8, 1994; 60 FR 49, Jan. 3, 1995; 60 FR 36733, July 18, 1995, as amended at 69 FR 66423, Nov. 15, 2004; 70 FR 16722, Apr. 1, 2005]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[59 FR 63463, Dec. 8, 1994; 60 FR 49, Jan. 3, 1995; 60 FR 36733, July 18, 1995, as amended at 69 FR 66423, Nov. 15, 2004; 70 FR 16722, Apr. 1, 2005]

§414.40. Coding and ancillary policies.

42 C.F.R. § 414.40

(a)

General rule. CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes.

(b)

Specific types of policies. CMS establishes uniform national ancillary policies necessary to implement the fee schedule for physician services. These include, but are not limited to, the following policies:

(1)

Global surgery policy (for example, post- and pre-operative periods and services, and intra-operative services).

(2)

Professional and technical components (for example, payment for services, such as an EEG, which typically comprise a technical component (the taking of the test) and a professional component (the interpretation)).

(3)

Payment modifiers (for example, assistant-at-surgery, multiple surgery, bilateral surgery, split surgical global services, team surgery, and unusual services).

Notes, amendments, and revision history

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

§414.42. Adjustment for first 4 years of practice.

42 C.F.R. § 414.42

(a)

General rule. For services furnished during CYs 1992 and 1993, except as specified in paragraph (b) of this section, the fee schedule payment amount or prevailing charge must be phased in as specified in paragraph (d) of this section for physicians, physical therapists (PTs), occupational therapists (OTs), and all other health care practitioners who are in their first through fourth years of practice.

(b)

Exception. The reduction required in paragraph (d) of this section does not apply to primary care services or to services furnished in a rural area as defined in section 1886(d)(2)(D) of the Act that is designated under section 332(a)(1)(A) of the Public Health Service Act as a Health Professional Shortage Area.

(c)

Definition of years of practice.

(1)

The “first year of practice“ is the first full CY during the first 6 months of which the physician, PT, OT, or other health care practitioner furnishes professional services for which payment may be made under Medicare Part B, plus any portion of the prior CY if that prior year does not meet the first 6 months test.

(2)

The “second, third, and fourth years of practice“ are the first, second, and third CYs following the first year of practice, respectively.

(d)

Amounts of adjustment. The fee schedule payment for the service of a new physician, PT, OT, or other health care practitioner is limited to the following percentages for each of the indicated years:

(1)

First year— 80 percent

(2)

Second year— 85 percent

(3)

Third year— 90 percent

(4)

Fourth year— 95 percent

Notes, amendments, and revision history

Amendments

[57 FR 42493, Sept. 15, 1992, as amended at 58 FR 63687, Dec. 2, 1993]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[57 FR 42493, Sept. 15, 1992, as amended at 58 FR 63687, Dec. 2, 1993]

§414.44. Transition rules.

42 C.F.R. § 414.44

(a)

Adjusted historical payment basis—

(1)

All services other than radiology and nuclear medicine services. For all physician services other than radiology services, furnished in a fee schedule area, the adjusted historical payment basis (AHPB) is the estimated weighted average prevailing charge applied in the fee schedule area for the service in CY 1991, as determined by CMS without regard to physician specialty and as adjusted to reflect payments for services below the prevailing charge, adjusted by the update established for CY 1992.

(2)

Radiology services. For radiology services, the AHPB is the amount paid for the service in the fee schedule area in CY 1991 under the fee schedule established under section 1834(b), adjusted by the update established for CY 1992.

(3)

Nuclear medicine services. For nuclear medicine services, the AHPB is the amount paid for the service in the fee schedule area in CY 1991 under the fee schedule established under section 6105(b) of Public Law 101-239 and section 4102(g) of Public Law 101-508, adjusted by the update established for CY 1992.

(4)

Transition adjustment. CMS adjusts the AHPB for all services by 5.5 percent to produce budget-neutral payments for 1992.

(b)

Adjustment of 1992 payments for physician services other than radiology services. For physician services furnished during CY 1992 the following rules apply:

(1)

If the AHPB determined under paragraph (a) of this section is from 85 percent to 115 percent of the fee schedule amount for the area for services furnished in 1992, payment is at the fee schedule amount.

(2)

If the AHPB determined under paragraph (a) of this section is less than 85 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB plus 15 percent of the fee schedule amount is substituted for the fee schedule amount.

(3)

If the AHPB determined under paragraph (a) of this section is greater than 115 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB minus 15 percent of the fee schedule amount is substituted for the fee schedule amount.

(c)

Adjustment of 1992 payments for radiology services. For radiology services furnished during CY 1992 the following rules apply:

(1)

If the AHPB determined under paragraph (a) of this section is from 85 percent to 109 percent of the fee schedule amount for the area for services furnished in 1992, payment is at the fee schedule amount.

(2)

If the AHPB determined under paragraph (a) of this section is less than 85 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB plus 15 percent of the fee schedule amount is substituted for the fee schedule amount.

(3)

If the AHPB determined under paragraph (a) of this section is greater than 109 percent of the fee schedule amount for the area for services furnished in 1992, an amount equal to the AHPB minus 9 percent of the fee schedule amount is substituted for the fee schedule amount.

(d)

Computation of payments for CY 1993. For physician services subject to the transition rules in CY 1992 and furnished during CY 1993, the fee schedule is equal to 75 percent of the amount that would have been paid in the fee schedule area under the 1992 transition rules, adjusted by the amount of the 1993 update, plus 25 percent of the 1993 fee schedule amount.

(e)

Computation of payments for CY 1994. For physician services subject to the transition rules in CY 1993, and furnished during CY 1994, the fee schedule is equal to 67 percent of the amount that would have been paid in the fee schedule area under the 1993 transition rules, adjusted by the amount of the 1994 update, plus 33 percent of the 1994 fee schedule amount.

(f)

Computation of payments for CY 1995. For physician services subject to the transition rules in CY 1994 and furnished during CY 1995, the fee schedule is equal to 50 percent of the amount that would have been paid in the fee schedule area under the 1994 transition rules, adjusted by the amount of the 1995 update, plus 50 percent of the 1995 fee schedule amount.

Notes, amendments, and revision history

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

§414.46. Additional rules for payment of anesthesia services.

42 C.F.R. § 414.46

(a)

Definitions. For purposes of this section, the following definitions apply:

(1)

Base unit means the value for each anesthesia code that reflects all activities other than anesthesia time. These activities include usual preoperative and postoperative visits, the administration of fluids and blood incident to anesthesia care, and monitoring services.

(2)

Anesthesia practitioner,— for the purpose of anesthesia time, means a physician who performs the anesthesia service alone, a CRNA who is not medically directed who performs the anesthesia service alone, or a medically directed CRNA.

(3)

Anesthesia time means the time during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the beneficiary, that is, when the beneficiary may be placed safely under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time, the anesthesia practitioner can add blocks of anesthesia time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.

(b)

Determinations of payment amount—Basic rule. For anesthesia services performed, medically directed, or medically supervised by a physician, CMS pays the lesser of the actual charge or the anesthesia fee schedule amount.

(1)

The carrier bases the fee schedule amount for an anesthesia service on the product of the sum of allowable base and time units and an anesthesia-specific CF. The carrier calculates the time units from the anesthesia time reported by the anesthesia practitioner for the anesthesia procedure. The physician who fulfills the conditions for medical direction in § 415.110 (Conditions for payment: Anesthesiology services) reports the same anesthesia time as the medically-directed CRNA.

(2)

CMS furnishes the carrier with the base units for each anesthesia procedure code. The base units are derived from the 1988 American Society of Anesthesiologists' Relative Value Guide except that the number of base units recognized for anesthesia services furnished during cataract or iridectomy surgery is four units.

(3)

Modifier units are not allowed. Modifier units include additional units charged by a physician or a CRNA for patient health status, risk, age, or unusual circumstances.

(c)

Physician personally performs the anesthesia procedure.

(1)

CMS considers an anesthesia service to be personally performed under any of the following circumstances:

(i)

The physician performs the entire anesthesia service alone.

(ii)

The physician establishes an attending physician relationship in one or two concurrent cases involving an intern or resident and the service was furnished before January 1, 1994.

(iii)

The physician establishes an attending physician relationship in one case involving an intern or resident and the service was furnished on or after January 1, 1994 but prior to January 1, 1996. For services on or after January 1, 1996, the physician must be the teaching physician as defined in §§ 415.170 through 415.184 of this chapter.

(iv)

The physician and the CRNA or AA are involved in a single case and the services of each are found to be medically necessary.

(v)

The physician is continuously involved in a single case involving a student nurse anesthetist.

(vi)

The physician is continuously involved in a single case involving a CRNA or AA and the service was furnished prior to January 1, 1998.

(2)

CMS determines the fee schedule amount for an anesthesia service personally performed by a physician on the basis of an anesthesia-specific fee schedule CF and unreduced base units and anesthesia time units. One anesthesia time unit is equivalent to 15 minutes of anesthesia time, and fractions of a 15-minute period are recognized as fractions of an anesthesia time unit.

(d)

Anesthesia services medically directed by a physician.

(1)

CMS considers an anesthesia service to be medically directed by a physician if—

(i)

The physician performs the activities described in § 415.110 of this chapter.

(ii)

The physician directs qualified individuals involved in two, three, or four concurrent cases.

(iii)

Medical direction can occur for a single case furnished on or after January 1, 1998 if the physician performs the activities described in § 415.110 of this chapter and medically directs a single CRNA or AA.

(2)

The rules for medical direction differ for certain time periods depending on the nature of the qualified individual who is directed by the physician.

(i)

If more than two procedures are directed on or after January 1, 1994, the qualified individuals could be AAs, CRNAs, interns, or residents. The medical direction rules apply to student nurse anesthetists only if the physician directs two concurrent cases, each of which involves a student nurse anesthetist or the physician directs one case involving a student nurse anesthetist and the other involving a CRNA, AA, intern, or resident.

(ii)

For services furnished on or after January 1, 2010, the medical direction rules do not apply to a single anesthesia resident case that is concurrent to another case which is paid under the medical direction payment rules as specified in paragraph (e) of this section.

(3)

Payment for medical direction is based on a specific percentage of the payment allowance recognized for the anesthesia service personally performed by a physician alone. The following percentages apply for the years specified:

(i)

CY 1994— 60 percent of the payment allowance for personally performed procedures.

(ii)

CY 1995— 57.5 percent of the payment allowance for personally performed services.

(iii)

CY 1996— 55 percent of the payment allowance for personally performed services.

(iv)

CY 1997— 52.5 percent of the payment allowance for personally performed services.

(v)

CY 1998 and thereafter— 50 percent of the payment allowance for personally performed services.

(e)

Special payment rule for teaching anesthesiologist involved in a single resident case or two concurrent cases. For physicians' services furnished on or after January 1, 2010, if the teaching anesthesiologist is involved in the training of physician residents in a single anesthesia case or two concurrent anesthesia cases, the fee schedule amount must be 100 percent of the fee schedule amount otherwise applicable if the anesthesia services were personally performed by the teaching anesthesiologist and the teaching anesthesiologist fulfilled the criteria in § 415.178 of this chapter. This special payment rule also applies if the teaching anesthesiologist is involved in one resident case that is concurrent to another case paid under the medical direction payment rules.

(f)

Physician medically supervises anesthesia services. If the physician medically supervises more than four concurrent anesthesia services, CMS bases the fee schedule amount on an anesthesia-specific CF and three base units. This represents payment for the physician's involvement in the pre-surgical anesthesia services.

(g)

Payment for medical or surgical services furnished by a physician while furnishing anesthesia services.

(1)

CMS allows separate payment under the fee schedule for certain reasonable and medically necessary medical or surgical services furnished by a physician while furnishing anesthesia services to the patient. CMS makes payment for these services in accordance with the general physician fee schedule rules in § 414.20. These services are described in program operating instructions.

(2)

CMS makes no separate payment for other medical or surgical services, such as the pre-anesthetic examination of the patient, pre- or post-operative visits, or usual monitoring functions, that are ordinarily included in the anesthesia service.

(h)

Physician involved in multiple anesthesia services. If the physician is involved in multiple anesthesia services for the same patient during the same operative session, the carrier makes payment according to the base unit associated with the anesthesia service having the highest base unit value and anesthesia time that encompasses the multiple services. The carrier makes payment for add-on anesthesia codes according to program operating instructions.

Notes, amendments, and revision history

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 58 FR 63687, Dec. 2, 1993; 60 FR 63177, Dec. 8, 1995; 64 FR 59441, Nov. 2, 1999; 67 FR 80041, Dec. 31, 2002; 68 FR 63261, Nov. 7, 2003; 74 FR 62006, Nov. 25, 2009]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[56 FR 59624, Nov. 25, 1991, as amended at 57 FR 42492, Sept. 15, 1992; 58 FR 63687, Dec. 2, 1993; 60 FR 63177, Dec. 8, 1995; 64 FR 59441, Nov. 2, 1999; 67 FR 80041, Dec. 31, 2002; 68 FR 63261, Nov. 7, 2003; 74 FR 62006, Nov. 25, 2009]

§414.48. Limits on actual charges of nonparticipating suppliers.

42 C.F.R. § 414.48

(a)

General rule. A supplier, as defined in § 400.202 of this chapter, who is nonparticipating and does not accept assignment may charge a beneficiary an amount up to the limiting charge described in paragraph (b) of this section.

(b)

Specific limits. For items or services paid under the physician fee schedule, the limiting charge is 115 percent of the fee schedule amount for nonparticipating suppliers. For items or services CMS excludes from payment under the physician fee schedule (in accordance with section 1848 (j)(3) of the Act), the limiting charge is 115 percent of 95 percent of the payment basis applicable to participating suppliers as calculated in § 414.20(b).

Notes, amendments, and revision history

Amendments

[58 FR 63687, Dec. 2, 1993, as amended at 62 FR 59102, Oct. 31, 1997]

Source

Source: 56 FR 59624, Nov. 25, 1991; 57 FR 42492, Sept. 15, 1992, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

Amendments

[58 FR 63687, Dec. 2, 1993, as amended at 62 FR 59102, Oct. 31, 1997]