United States Code (Last Updated: May 24, 2014) |
Title 42. THE PUBLIC HEALTH AND WELFARE |
Chapter 7. SOCIAL SECURITY |
SubChapter XVIII. HEALTH INSURANCE FOR AGED AND DISABLED |
Part B. Supplementary Medical Insurance Benefits for Aged and Disabled |
§ 1395w–4. Payment for physicians’ services
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(a) Payment based on fee schedule (1) In general Effective for all physicians’ services (as defined in subsection (j)(3) of this section) furnished under this part during a year (beginning with 1992) for which payment is otherwise made on the basis of a reasonable charge or on the basis of a fee schedule under section 1395m(b) of this title, payment under this part shall instead be based on the lesser of— (A) the actual charge for the service, or (B) subject to the succeeding provisions of this subsection, the amount determined under the fee schedule established under subsection (b) of this section for services furnished during that year (in this subsection referred to as the “fee schedule amount”). (2) Transition to full fee schedule (A) Limiting reductions and increases to 15 percent in 1992 (i) Limit on increase In the case of a service in a fee schedule area (as defined in subsection (j)(2) of this section) for which the adjusted historical payment basis (as defined in subparagraph (D)) is less than 85 percent of the fee schedule amount for services furnished in 1992, there shall be substituted for the fee schedule amount an amount equal to the adjusted historical payment basis plus 15 percent of the fee schedule amount otherwise established (without regard to this paragraph).
(ii) Limit in reduction In the case of a service in a fee schedule area for which the adjusted historical payment basis exceeds 115 percent of the fee schedule amount for services furnished in 1992, there shall be substituted for the fee schedule amount an amount equal to the adjusted historical payment basis minus 15 percent of the fee schedule amount otherwise established (without regard to this paragraph).
(B) Special rule for 1993, 1994, and 1995 If a physicians’ service in a fee schedule area is subject to the provisions of subparagraph (A) in 1992, for physicians’ services furnished in the area— (i) during 1993, there shall be substituted for the fee schedule amount an amount equal to the sum of— (I) 75 percent of the fee schedule amount determined under subparagraph (A), adjusted by the update established under subsection (d)(3) of this section for 1993, and (II) 25 percent of the fee schedule amount determined under paragraph (1) for 1993 without regard to this paragraph; (ii) during 1994, there shall be substituted for the fee schedule amount an amount equal to the sum of— (I) 67 percent of the fee schedule amount determined under clause (i), adjusted by the update established under subsection (d)(3) of this section for 1994 and as adjusted under subsection (c)(2)(F)(ii) of this section and under section 13515(b) of the Omnibus Budget Reconciliation Act of 1993, and (II) 33 percent of the fee schedule amount determined under paragraph (1) for 1994 without regard to this paragraph; and (iii) during 1995, there shall be substituted for the fee schedule amount an amount equal to the sum of— (I) 50 percent of the fee schedule amount determined under clause (ii) adjusted by the update established under subsection (d)(3) of this section for 1995, and (II) 50 percent of the fee schedule amount determined under paragraph (1) for 1995 without regard to this paragraph. (C) Special rule for anesthesia and radiology services With respect to physicians’ services which are anesthesia services, the Secretary shall provide for a transition in the same manner as a transition is provided for other services under subparagraph (B). With respect to radiology services, “109 percent” and “9 percent” shall be substituted for “115 percent” and “15 percent”, respectively, in subparagraph (A)(ii).
(D) “Adjusted historical payment basis” defined (i) In general In this paragraph, the term “adjusted historical payment basis” means, with respect to a physicians’ service furnished in a fee schedule area, the weighted average prevailing charge applied in the area for the service in 1991 (as determined by the Secretary without regard to physician specialty and as adjusted to reflect payments for services with customary charges below the prevailing charge or other payment limitations imposed by law or regulation) adjusted by the update established under subsection (d)(3) of this section for 1992.
(ii) Application to radiology services In applying clause (i) in the case of physicians’ services which are radiology services (including radiologist services, as defined in section 1395m(b)(6) of this title), but excluding nuclear medicine services that are subject to section 6105(b) of the Omnibus Budget Reconciliation Act of 1989, there shall be substituted for the weighted average prevailing charge the amount provided under the fee schedule established for the service for the fee schedule area under section 1395m(b) of this title.
(iii) Nuclear medicine services In applying clause (i) in the case of physicians’ services which are nuclear medicine services, there shall be substituted for the weighted average prevailing charge the amount provided under section 6105(b) of the Omnibus Budget Reconciliation Act of 1989.
(3) Incentives for participating physicians and suppliers In applying paragraph (1)(B) in the case of a nonparticipating physician or a nonparticipating supplier or other person, the fee schedule amount shall be 95 percent of such amount otherwise applied under this subsection (without regard to this paragraph). In the case of physicians’ services (including services which the Secretary excludes pursuant to subsection (j)(3) of this section) of a nonparticipating physician, supplier, or other person for which payment is made under this part on a basis other than the fee schedule amount, the payment shall be based on 95 percent of the payment basis for such services furnished by a participating physician, supplier, or other person.
(4) Special rule for medical direction (A) In general With respect to physicians’ services furnished on or after
January 1, 1994 , and consisting of medical direction of two, three, or four concurrent anesthesia cases, except as provided in paragraph (5), the fee schedule amount to be applied shall be equal to one-half of the amount described in subparagraph (B).(B) Amount The amount described in this subparagraph, for a physician’s medical direction of the performance of anesthesia services, is the following percentage of the fee schedule amount otherwise applicable under this section if the anesthesia services were personally performed by the physician alone: (i) For services furnished during 1994, 120 percent. (ii) For services furnished during 1995, 115 percent. (iii) For services furnished during 1996, 110 percent. (iv) For services furnished during 1997, 105 percent. (v) For services furnished after 1997, 100 percent. (5) Incentives for electronic prescribing (A) Adjustment (i) In general Subject to subparagraph (B) and subsection (m)(2)(B), with respect to covered professional services furnished by an eligible professional during 2012, 2013 or 2014, if the eligible professional is not a successful electronic prescriber for the reporting period for the year (as determined under subsection (m)(3)(B)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraph (3) but without regard to this paragraph).
(ii) Applicable percent For purposes of clause (i), the term “applicable percent” means— (I) for 2012, 99 percent; (II) for 2013, 98.5 percent; and (III) for 2014, 98 percent. (B) Significant hardship exception The Secretary may, on a case-by-case basis, exempt an eligible professional from the application of the payment adjustment under subparagraph (A) if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access.
(C) Application (i) Physician reporting system rules Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection.
(ii) Incentive payment validation rules Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply for purposes of this paragraph in a similar manner as they apply for purposes of such subsection.
(D) Definitions For purposes of this paragraph: (i) Eligible professional; covered professional services The terms “eligible professional” and “covered professional services” have the meanings given such terms in subsection (k)(3).
(ii) Physician reporting system The term “physician reporting system” means the system established under subsection (k).
(iii) Reporting period The term “reporting period” means, with respect to a year, a period specified by the Secretary.
(6) Special rule for teaching anesthesiologists With respect to physicians’ services furnished on or after January 1, 2010 , in the case of teaching anesthesiologists involved in the training of physician residents in a single anesthesia case or two concurrent anesthesia cases, the fee schedule amount to be applied shall be 100 percent of the fee schedule amount otherwise applicable under this section if the anesthesia services were personally performed by the teaching anesthesiologist alone and paragraph (4) shall not apply if—(A) the teaching anesthesiologist is present during all critical or key portions of the anesthesia service or procedure involved; and (B) the teaching anesthesiologist (or another anesthesiologist with whom the teaching anesthesiologist has entered into an arrangement) is immediately available to furnish anesthesia services during the entire procedure. (7) Incentives for meaningful use of certified EHR technology (A) Adjustment (i) In general Subject to subparagraphs (B) and (D), with respect to covered professional services furnished by an eligible professional during 2015 or any subsequent payment year, if the eligible professional is not a meaningful EHR user (as determined under subsection (o)(2)) for an EHR reporting period for the year, the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraph (3) but without regard to this paragraph).
(ii) Applicable percent Subject to clause (iii), for purposes of clause (i), the term “applicable percent” means— (I) for 2015, 99 percent (or, in the case of an eligible professional who was subject to the application of the payment adjustment under subsection (a)(5) for 2014, 98 percent); (II) for 2016, 98 percent; and (III) for 2017 and each subsequent year, 97 percent. (iii) Authority to decrease applicable percentage for 2018 and subsequent years For 2018 and each subsequent year, if the Secretary finds that the proportion of eligible professionals who are meaningful EHR users (as determined under subsection (o)(2)) is less than 75 percent, the applicable percent shall be decreased by 1 percentage point from the applicable percent in the preceding year, but in no case shall the applicable percent be less than 95 percent.
(B) Significant hardship exception The Secretary may, on a case-by-case basis, exempt an eligible professional from the application of the payment adjustment under subparagraph (A) if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a meaningful EHR user would result in a significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access. In no case may an eligible professional be granted an exemption under this subparagraph for more than 5 years.
(C) Application of physician reporting system rules Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection.
(D) Non-application to hospital-based eligible professionals No payment adjustment may be made under subparagraph (A) in the case of hospital-based eligible professionals (as defined in subsection (o)(1)(C)(ii)).
(E) Definitions For purposes of this paragraph: (i) Covered professional services The term “covered professional services” has the meaning given such term in subsection (k)(3).
(ii) EHR reporting period The term “EHR reporting period” means, with respect to a year, a period (or periods) specified by the Secretary.
(iii) Eligible professional The term “eligible professional” means a physician, as defined in section 1395x(r) of this title.
(8) Incentives for quality reporting (A) Adjustment (i) In general With respect to covered professional services furnished by an eligible professional during 2015 or any subsequent year, if the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reporting period for the year (as determined under subsection (m)(3)(A)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraphs (3), (5), and (7), but without regard to this paragraph).
(ii) Applicable percent For purposes of clause (i), the term “applicable percent” means— (I) for 2015, 98.5 percent; and (II) for 2016 and each subsequent year, 98 percent. (B) Application (i) Physician reporting system rules Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection.
(ii) Incentive payment validation rules Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply for purposes of this paragraph in a similar manner as they apply for purposes of such subsection.
(C) Definitions For purposes of this paragraph: (i) Eligible professional; covered professional services The terms “eligible professional” and “covered professional services” have the meanings given such terms in subsection (k)(3).
(ii) Physician reporting system The term “physician reporting system” means the system established under subsection (k).
(iii) Quality reporting period The term “quality reporting period” means, with respect to a year, a period specified by the Secretary.
(b) Establishment of fee schedules (1) In general Before November 1 of the preceding year, for each year beginning with 1998, subject to subsection (p), the Secretary shall establish, by regulation, fee schedules that establish payment amounts for all physicians’ services furnished in all fee schedule areas (as defined in subsection (j)(2) of this section) for the year. Except as provided in paragraph (2), each such payment amount for a service shall be equal to the product of— (A) the relative value for the service (as determined in subsection (c)(2) of this section), (B) the conversion factor (established under subsection (d) of this section) for the year, and (C) the geographic adjustment factor (established under subsection (e)(2) of this section) for the service for the fee schedule area. (2) Treatment of radiology services and anesthesia services (A) Radiology services With respect to radiology services (including radiologist services, as defined in section 1395m(b)(6) of this title), the Secretary shall base the relative values on the relative value scale developed under section 1395m(b)(1)(A) of this title, with appropriate modifications of the relative values to assure that the relative values established for radiology services which are similar or related to other physicians’ services are consistent with the relative values established for those similar or related services.
(B) Anesthesia services In establishing the fee schedule for anesthesia services for which a relative value guide has been established under section 4048(b) of the Omnibus Budget Reconciliation Act of 1987, the Secretary shall use, to the extent practicable, such relative value guide, with appropriate adjustment of the conversion factor, in a manner to assure that the fee schedule amounts for anesthesia services are consistent with the fee schedule amounts for other services determined by the Secretary to be of comparable value. In applying the previous sentence, the Secretary shall adjust the conversion factor by geographic adjustment factors in the same manner as such adjustment is made under paragraph (1)(C).
(C) Consultation The Secretary shall consult with the Physician Payment Review Commission and organizations representing physicians or suppliers who furnish radiology services and anesthesia services in applying subparagraphs (A) and (B).
(3) Treatment of interpretation of electrocardiograms The Secretary— (A) shall make separate payment under this section for the interpretation of electrocardiograms performed or ordered to be performed as part of or in conjunction with a visit to or a consultation with a physician, and (B) shall adjust the relative values established for visits and consultations under subsection (c) of this section so as not to include relative value units for interpretations of electrocardiograms in the relative value for visits and consultations. (4) Special rule for imaging services (A) In general In the case of imaging services described in subparagraph (B) furnished on or after January 1, 2007 , if—(i) the technical component (including the technical component portion of a global fee) of the service established for a year under the fee schedule described in paragraph (1) without application of the geographic adjustment factor described in paragraph (1)(C), exceeds (ii) the Medicare OPD fee schedule amount established under the prospective payment system for hospital outpatient department services under paragraph (3)(D) of section 1395l(t) of this title for such service for such year, determined without regard to geographic adjustment under paragraph (2)(D) of such section, the Secretary shall substitute the amount described in clause (ii), adjusted by the geographic adjustment factor described in paragraph (1)(C), for the fee schedule amount for such technical component for such year. (B) Imaging services described For purposes of subparagraph (A), imaging services described in this subparagraph are imaging and computer-assisted imaging services, including X-ray, ultrasound (including echocardiography), nuclear medicine (including positron emission tomography), magnetic resonance imaging, computed tomography, and fluoroscopy, but excluding diagnostic and screening mammography, and for 2010, 2011, and the first 2 months of 2012, dual-energy x-ray absorptiometry services (as described in paragraph (6)).
(C) Adjustment in imaging utilization rate With respect to fee schedules established for 2011, 2012, and 2013, in the methodology for determining practice expense relative value units for expensive diagnostic imaging equipment under the final rule published by the Secretary in the Federal Register on
November 25, 2009 (42 CFR 410 et al.), the Secretary shall use a 75 percent assumption instead of the utilization rates otherwise established in such final rule. With respect to fee schedules established for 2014 and subsequent years, in such methodology, the Secretary shall use a 90 percent utilization rate.(D) Adjustment in technical component discount on single-session imaging involving consecutive body parts For services furnished on or after
July 1, 2010 , the Secretary shall increase the reduction in payments attributable to the multiple procedure payment reduction applicable to the technical component for imaging under the final rule published by the Secretary in the Federal Register onNovember 21, 2005 (part 405 of title 42, Code of Federal Regulations) from 25 percent to 50 percent.(5) Treatment of intensive cardiac rehabilitation program (A) In general In the case of an intensive cardiac rehabilitation program described in section 1395x(eee)(4) of this title, the Secretary shall substitute the Medicare OPD fee schedule amount established under the prospective payment system for hospital outpatient department service under paragraph (3)(D) of section 1395l(t) of this title for cardiac rehabilitation (under HCPCS codes 93797 and 93798 for calendar year 2007, or any succeeding HCPCS codes for cardiac rehabilitation).
(B) Definition of session Each of the services described in subparagraphs (A) through (E) of section 1395x(eee)(3) of this title, when furnished for one hour, is a separate session of intensive cardiac rehabilitation.
(C) Multiple sessions per day Payment may be made for up to 6 sessions per day of the series of 72 one-hour sessions of intensive cardiac rehabilitation services described in section 1395x(eee)(4)(B) of this title.
(6) Treatment of bone mass scans For dual-energy x-ray absorptiometry services (identified in 2006 by HCPCS codes 76075 and 76077 (and any succeeding codes)) furnished during 2010, 2011, and the first 2 months of 2012, instead of the payment amount that would otherwise be determined under this section for such years, the payment amount shall be equal to 70 percent of the product of— (A) the relative value for the service (as determined in subsection (c)(2)) for 2006; (B) the conversion factor (established under subsection (d)) for 2006; and (C) the geographic adjustment factor (established under subsection (e)(2)) for the service for the fee schedule area for 2010, 2011, and the first 2 months of 2012, respectively. (7) Adjustment in discount for certain multiple therapy services In the case of therapy services furnished on or after
January 1, 2011 , and beforeApril 1, 2013 , and for which payment is made under fee schedules established under this section, instead of the 25 percent multiple procedure payment reduction specified in the final rule published by the Secretary in the Federal Register onNovember 29, 2010 , the reduction percentage shall be 20 percent. In the case of such services furnished on or afterApril 1, 2013 , and for which payment is made under such fee schedules, instead of the 25 percent multiple procedure payment reduction specified in such final rule, the reduction percentage shall be 50 percent.(c) Determination of relative values for physicians’ services (1) Division of physicians’ services into components In this section, with respect to a physicians’ service: (A) “Work component” defined The term “work component” means the portion of the resources used in furnishing the service that reflects physician time and intensity in furnishing the service. Such portion shall— (i) include activities before and after direct patient contact, and (ii) be defined, with respect to surgical procedures, to reflect a global definition including pre-operative and post-operative physicians’ services. (B) “Practice expense component” defined The term “practice expense component” means the portion of the resources used in furnishing the service that reflects the general categories of expenses (such as office rent and wages of personnel, but excluding malpractice expenses) comprising practice expenses.
(C) “Malpractice component” defined The term “malpractice component” means the portion of the resources used in furnishing the service that reflects malpractice expenses in furnishing the service.
(2) Determination of relative values (A) In general (i) Combination of units for components The Secretary shall develop a methodology for combining the work, practice expense, and malpractice relative value units, determined under subparagraph (C), for each service in a manner to produce a single relative value for that service. Such relative values are subject to adjustment under subparagraph (F)(i) and section 13515(b) of the Omnibus Budget Reconciliation Act of 1993.
(ii) Extrapolation The Secretary may use extrapolation and other techniques to determine the number of relative value units for physicians’ services for which specific data are not available and shall take into account recommendations of the Physician Payment Review Commission and the results of consultations with organizations representing physicians who provide such services.
(B) Periodic review and adjustments in relative values (i) Periodic review The Secretary, not less often than every 5 years, shall review the relative values established under this paragraph for all physicians’ services.
(ii) Adjustments (I) In general The Secretary shall, to the extent the Secretary determines to be necessary and subject to subclause (II) and paragraph (7), adjust the number of such units to take into account changes in medical practice, coding changes, new data on relative value components, or the addition of new procedures. The Secretary shall publish an explanation of the basis for such adjustments.
(II) Limitation on annual adjustments Subject to clauses (iv) and (v), the adjustments under subclause (I) for a year may not cause the amount of expenditures under this part for the year to differ by more than $20,000,000 from the amount of expenditures under this part that would have been made if such adjustments had not been made.
(iii) Consultation The Secretary, in making adjustments under clause (ii), shall consult with the Medicare Payment Advisory Commission and organizations representing physicians.
(iv) Exemption of certain additional expenditures from budget neutrality The additional expenditures attributable to— (I) subparagraph (H) shall not be taken into account in applying clause (ii)(II) for 2004; (II) subparagraph (I) insofar as it relates to a physician fee schedule for 2005 or 2006 shall not be taken into account in applying clause (ii)(II) for drug administration services under the fee schedule for such year for a specialty described in subparagraph (I)(ii)(II); (III) subparagraph (J) insofar as it relates to a physician fee schedule for 2005 or 2006 shall not be taken into account in applying clause (ii)(II) for drug administration services under the fee schedule for such year; and (IV) subsection (b)(6) shall not be taken into account in applying clause (ii)(II) for 2010, 2011, or the first 2 months of 2012. (v) Exemption of certain reduced expenditures from budget-neutrality calculation The following reduced expenditures, as estimated by the Secretary, shall not be taken into account in applying clause (ii)(II): (I) Reduced payment for multiple imaging procedures Effective for fee schedules established beginning with 2007, reduced expenditures attributable to the multiple procedure payment reduction for imaging under the final rule published by the Secretary in the Federal Register on
November 21, 2005 (42 CFR 405, et al.) insofar as it relates to the physician fee schedules for 2006 and 2007.(II) OPD payment cap for imaging services Effective for fee schedules established beginning with 2007, reduced expenditures attributable to subsection (b)(4).
(III) Change in utilization rate for certain imaging services Effective for fee schedules established beginning with 2011, reduced expenditures attributable to the changes in the utilization rate applicable to 2011 and 2014, as described in the first and second sentence, respectively, of subsection (b)(4)(C).
(IV) , (V) Repealed. Pub. L. 111–152, title I, § 1107(2), Mar. 30, 2010 , 124 Stat. 1050(VI) Additional reduced payment for multiple imaging procedures Effective for fee schedules established beginning with 2010 (but not applied for services furnished prior to
July 1, 2010 ), reduced expenditures attributable to the increase in the multiple procedure payment reduction from 25 to 50 percent (as described in subsection (b)(4)(D)).(VII) Reduced expenditures for multiple therapy services Effective for fee schedules established beginning with 2011, reduced expenditures attributable to the multiple procedure payment reduction for therapy services (as described in subsection (b)(7)).
(VIII) and other factors determined appropriate by the Secretary. (4) Implementation (A) Publication of measures, dates of implementation, performance period Not later than January 1, 2012 , the Secretary shall publish the following:(i) The measures of quality of care and costs established under paragraphs (2) and (3), respectively. (ii) The dates for implementation of the payment modifier (as determined under subparagraph (B)). (iii) The initial performance period (as specified under subparagraph (B)(ii)). (B) Deadlines for implementation (i) Initial implementation Subject to the preceding provisions of this subparagraph, the Secretary shall begin implementing the payment modifier established under this subsection through the rulemaking process during 2013 for the physician fee schedule established under subsection (b).
(ii) Initial performance period (I) In general The Secretary shall specify an initial performance period for application of the payment modifier established under this subsection with respect to 2015.
(II) Provision of information during initial performance period During the initial performance period, the Secretary shall, to the extent practicable, provide information to physicians and groups of physicians about the quality of care furnished by the physician or group of physicians to individuals enrolled under this part compared to cost (as determined under paragraphs (2) and (3), respectively) with respect to the performance period.
(iii) Application The Secretary shall apply the payment modifier established under this subsection for items and services furnished— (I) beginning on January 1, 2015 , with respect to specific physicians and groups of physicians the Secretary determines appropriate; and(II) beginning not later than January 1, 2017 , with respect to all physicians and groups of physicians.(C) Budget neutrality The payment modifier established under this subsection shall be implemented in a budget neutral manner.
(5) Systems-based care The Secretary shall, as appropriate, apply the payment modifier established under this subsection in a manner that promotes systems-based care.
(6) Consideration of special circumstances of certain providers In applying the payment modifier under this subsection, the Secretary shall, as appropriate, take into account the special circumstances of physicians or groups of physicians in rural areas and other underserved communities.
(7) Application For purposes of the initial application of the payment modifier established under this subsection during the period beginning on
January 1, 2015 , and ending onDecember 31, 2016 , the term “physician” has the meaning given such term in section 1395x(r) of this title. On or afterJanuary 1, 2017 , the Secretary may apply this subsection to eligible professionals (as defined in subsection (k)(3)(B)) as the Secretary determines appropriate.(8) Definitions For purposes of this subsection: (A) Costs The term “costs” means expenditures per individual as determined appropriate by the Secretary. In making the determination under the preceding sentence, the Secretary may take into account the amount of growth in expenditures per individual for a physician compared to the amount of such growth for other physicians.
(B) Performance period The term “performance period” means a period specified by the Secretary.
(9) Coordination with other value-based purchasing reforms The Secretary shall coordinate the value-based payment modifier established under this subsection with the Physician Feedback Program under subsection (n) and, as the Secretary determines appropriate, other similar provisions of this subchapter.
(10) Limitations on review There shall be no administrative or judicial review under section 1395ff of this title, section 1395oo of this title, or otherwise of— (A) the establishment of the value-based payment modifier under this subsection; (B) the evaluation of quality of care under paragraph (2), including the establishment of appropriate measures of the quality of care under paragraph (2)(B); (C) the evaluation of costs under paragraph (3), including the establishment of appropriate measures of costs under such paragraph; (D) the dates for implementation of the value-based payment modifier; (E) the specification of the initial performance period and any other performance period under paragraphs (4)(B)(ii) and (8)(B), respectively; (F) the application of the value-based payment modifier under paragraph (7); and (G) the determination of costs under paragraph (8)(A).
References In Text
Section 13515(b) of the Omnibus Budget Reconciliation Act of 1993, referred to in subsecs. (a)(2)(B)(ii)(I), (c)(2)(A)(i), and (i)(1)(B), is section 13515(b) of Pub. L. 103–66, which is set out as a note under section 1395u of this title.
Section 6105(b) of the Omnibus Budget Reconciliation Act of 1989, referred to in subsec. (a)(2)(D)(ii), (iii), is section 6105(b) of Pub. L. 101–239, which is set out as a note under section 1395m of this title.
Section 4048(b) of the Omnibus Budget Reconciliation Act of 1987, referred to in subsec. (b)(2)(B), is section 4048(b) of Pub. L. 100–203, which is set out as a note under section 1395u of this title.
Section 13514(a) of the Omnibus Budget Reconciliation Act of 1993, referred to in subsec. (c)(2)(F), is section 13514(a) of Pub. L. 103–66, which amended subsec. (b)(3) of this section. See 1993 Amendment note below.
Section 212 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, referred to in subsec. (c)(2)(H)(i), (I)(ii)(I), is section 1000(a)(6) [title II, § 212] of Pub. L. 106–113, which is set out as a note under this section.
The Balanced Budget Act of 1997, referred to in subsec. (d)(1)(C), is Pub. L. 105–33,
Section 225(c)(1) and section 524 of the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008, referred to in subsec. (l)(2)(A)(ii)(I), (II), are sections 225(c)(1) of title II and 524 of title V of div. G of Pub. L. 110–161,
Codification
The text of section 101(c) of Pub. L. 109–432, div. B, title I,
Amendments
2014—Subsec. (c)(2)(B)(ii)(I). Pub. L. 113–93, § 220(e)(2)(A), substituted “subclause (II) and paragraph (7)” for “subclause (II)”.
Subsec. (c)(2)(B)(v)(VIII). Pub. L. 113–93, § 220(d)(2), added subcl. (VIII) relating to reductions for misvalued services if target not met.
Pub. L. 113–93, § 218(a)(2)(B), added subcl. (VIII) relating to reduced expenditures attributable to application of quality incentives for computed tomography.
Subsec. (c)(2)(C)(i). Pub. L. 113–93, § 220(f)(1), substituted “the service or group of services” for “the service” in two places.
Subsec. (c)(2)(C)(ii). Pub. L. 113–93, § 220(f)(2), inserted “or group of services” after “furnishing the service” the first time appearing in concluding provisions.
Subsec. (c)(2)(C)(iii). Pub. L. 113–93, § 220(f)(1), substituted “the service or group of services” for “the service” wherever appearing.
Subsec. (c)(2)(K)(ii). Pub. L. 113–93, § 220(c), amended cl. (ii) generally. Prior to amendment, text read as follows: “For purposes of identifying potentially misvalued services pursuant to clause (i)(I), the Secretary shall examine (as the Secretary determines to be appropriate) codes (and families of codes as appropriate) for which there has been the fastest growth; codes (and families of codes as appropriate) that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period (such as 3 years) after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called ‘Harvard-valued codes’); and such other codes determined to be appropriate by the Secretary.”
Subsec. (c)(2)(K)(iii)(VI). Pub. L. 113–93, § 220(e)(2)(B), substituted “provisions of subparagraph (B)(ii)(II) and paragraph (7)” for “provisions of subparagraph (B)(ii)(II)” and “under subparagraph (B)(ii)(I)” for “under subparagraph (B)(ii)(II)”.
Subsec. (c)(2)(M). Pub. L. 113–93, § 220(a)(1), added subpar. (M).
Subsec. (c)(2)(N). Pub. L. 113–93, § 220(b), added subpar. (N).
Subsec. (c)(2)(O). Pub. L. 113–93, § 220(d)(1), added subpar. (O).
Subsec. (c)(7). Pub. L. 113–93, § 220(e)(1), added par. (7).
Subsec. (d)(15). Pub. L. 113–93, § 101(1)(A), struck out “January through March of” before “2014” in heading.
Subsec. (d)(15)(A). Pub. L. 113–93, § 101(1)(B), struck out “for the period beginning on
Subsec. (d)(15)(B). Pub. L. 113–93, § 101(1)(C), struck out “remaining portion of 2014 and” before “subsequent years” in heading and “the period beginning on
Subsec. (d)(16). Pub. L. 113–93, § 101(2), added par. (16).
Subsec. (e)(1)(E). Pub. L. 113–93, § 102, substituted “
Subsec. (e)(6). Pub. L. 113–93, § 220(h)(1), added par. (6).
Subsec. (i)(1)(F). Pub. L. 113–93, § 220(a)(2), added subpar. (F).
Subsec. (j)(2). Pub. L. 113–93, § 220(h)(2), substituted “Except as provided in subsection (e)(6)(D), the term” for “The term”.
2013—Subsec. (b)(4)(C). Pub. L. 112–240, § 635(1), substituted “, 2012, and 2013” for “and subsequent years” and inserted at end “With respect to fee schedules established for 2014 and subsequent years, in such methodology, the Secretary shall use a 90 percent utilization rate.”
Subsec. (b)(7). Pub. L. 112–240, § 633(a), substituted “2011, and before
Subsec. (c)(2)(B)(v)(III). Pub. L. 112–240, § 635(2), substituted “changes in the utilization rate applicable to 2011 and 2014, as described in the first and second sentence, respectively, of” for “change in the utilization rate applicable to 2011, as described in”.
Subsec. (d)(14). Pub. L. 112–240, § 601(a), added par. (14).
Subsec. (d)(15). Pub. L. 113–67, § 1101, added par. (15).
Subsec. (e)(1)(E). Pub. L. 113–67, § 1102, substituted “
Pub. L. 112–240, § 602, substituted “before
Subsec. (m)(3)(D) to (F). Pub. L. 112–240, § 601(b)(1), added subpars. (D) and (E) and redesignated former subpar. (D) as (F).
2012—Subsec. (d)(13). Pub. L. 112–96, § 3003(a)(1), substituted “2012” for “first two months of 2012” in heading.
Subsec. (d)(13)(A). Pub. L. 112–96, § 3003(a)(2), substituted “2012” for “the period beginning on
Subsec. (d)(13)(B). Pub. L. 112–96, § 3003(a)(3), (4), substituted “2013” for “remaining portion of 2012” in heading and “for 2013” for “for the period beginning on
Subsec. (e)(1)(E). Pub. L. 112–96, § 3004(a), substituted “before
2011—Subsec. (b)(4)(B), (6). Pub. L. 112–78, § 309(1), substituted “, 2011, and the first 2 months of 2012” for “and 2011” wherever appearing.
Subsec. (c)(2)(B)(iv)(IV). Pub. L. 112–78, § 309(2), substituted “, 2011, or the first 2 months of 2012” for “or 2011”.
Subsec. (d)(13). Pub. L. 112–78, § 301, added par. (13).
Subsec. (e)(1)(E). Pub. L. 112–78, § 303, substituted “before
2010—Subsec. (a)(8). Pub. L. 111–148, § 3002(b), added par. (8).
Subsec. (b)(1). Pub. L. 111–148, § 3007(1), inserted “subject to subsection (p),” after “1998,” in introductory provisions.
Subsec. (b)(4)(B). Pub. L. 111–152, § 1107(1)(A), substituted “subparagraph (A)” for “this paragraph”.
Pub. L. 111–148, § 3135(a)(1)(A), substituted “this paragraph” for “subparagraph (A)”.
Pub. L. 111–148, § 3111(a)(1)(A)(i), inserted “, and for 2010 and 2011, dual-energy x-ray absorptiometry services (as described in paragraph (6))” before the period.
Subsec. (b)(4)(C). Pub. L. 111–152, § 1107(1)(B), amended subpar. (C) generally. Prior to amendment, text read as follows: “Consistent with the methodology for computing the number of practice expense relative value units under subsection (c)(2)(C)(ii) with respect to advanced diagnostic imaging services (as defined in section 1395m(e)(1)(B) of this title) furnished on or after
“(i) in the case of services furnished on or after
“(ii) in the case of services furnished on or after
“(iii) in the case of services furnished on or after
Pub. L. 111–148, § 3135(a)(1)(B), added subpar. (C).
Subsec. (b)(4)(D). Pub. L. 111–148, § 3135(b)(1), added subpar. (D).
Subsec. (b)(6). Pub. L. 111–148, § 3111(a)(1)(A)(ii), added par. (6).
Subsec. (b)(7). Pub. L. 111–286, § 3(a), added par. (7).
Subsec. (c)(2)(B)(iv)(IV). Pub. L. 111–148, § 3111(a)(1)(B), added subcl. (IV).
Subsec. (c)(2)(B)(v)(III) to (V). Pub. L. 111–152, § 1107(2), added subcl. (III) and struck out former subcls. (III) to (V), which read as follows:
“(III) Change in presumed utilization level of certain advanced diagnostic imaging services for 2010 through 2012.—Effective for fee schedules established beginning with 2010 and ending with 2012, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 65 percent under subsection (b)(4)(C)(i) instead of a presumed rate of utilization of such equipment of 50 percent.
“(IV) Change in presumed utilization level of certain advanced diagnostic imaging services for 2013.—Effective for fee schedules established for 2013, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 70 percent under subsection (b)(4)(C)(ii) instead of a presumed rate of utilization of such equipment of 50 percent.
“(V) Change in presumed utilization level of certain advanced diagnostic imaging services for 2014 and subsequent years.—Effective for fee schedules established beginning with 2014, reduced expenditures attributable to the presumed rate of utilization of imaging equipment of 75 percent under subsection (b)(4)(C)(iii) instead of a presumed rate of utilization of such equipment of 50 percent.”
Pub. L. 111–148, § 3135(a)(2), added subcls. (III) to (V).
Subsec. (c)(2)(B)(v)(VI). Pub. L. 111–148, § 3135(b)(2), added subcl. (VI).
Subsec. (c)(2)(B)(v)(VII). Pub. L. 111–286, § 3(b), added subcl. (VII).
Subsec. (c)(2)(B)(vii). Pub. L. 111–148, § 5501(c), which directed the addition of cl. (vii), was repealed by Pub. L. 111–148, § 10501(h). As enacted, text read as follows: “Fifty percent of the additional expenditures under this part attributable to subsections (x) and (y) of section 1395l of this title for a year (as estimated by the Secretary) shall be taken into account in applying clause (ii)(II) for 2011 and subsequent years. In lieu of applying the budget-neutrality adjustments required under clause (ii)(II) to relative value units to account for such costs for the year, the Secretary shall apply such budget-neutrality adjustments to the conversion factor otherwise determined for the year. For 2011 and subsequent years, the Secretary shall increase the incentive payment otherwise applicable under section 1395l(m) of this title by a percent estimated to be equal to the additional expenditures estimated under the first sentence of this clause for such year that is applicable to physicians who primarily furnish services in areas designated (under section 254e(a)(1)(A) of this title) as health professional shortage areas.”
Subsec. (c)(2)(K), (L). Pub. L. 111–148, § 3134(a), added subpars. (K) and (L).
Subsec. (d)(10). Pub. L. 111–192, § 101(a)(1), substituted “January through May” for “portion” in heading.
Pub. L. 111–148, § 3101, which directed the addition of par. (10) relating to update for 2010, was repealed by Pub. L. 111–148, § 10310. As enacted, text read as follows:
“(A) In general.—Subject to paragraphs (7)(B), (8)(B), and (9)(B), in lieu of the update to the single conversion factor established in paragraph (1)(C) that would otherwise apply for 2010, the update to the single conversion factor shall be 0.5 percent.
“(B) No effect on computation of conversion factor for 2011 and subsequent years.—The conversion factor under this subsection shall be computed under paragraph (1)(A) for 2011 and subsequent years as if subparagraph (A) had never applied.”
Subsec. (d)(10)(A). Pub. L. 111–157, § 4(1), substituted “
Pub. L. 111–144, § 5(1), substituted “
Subsec. (d)(10)(B). Pub. L. 111–157, § 4(2), substituted “
Pub. L. 111–144, § 5(2), substituted “
Subsec. (d)(11). Pub. L. 111–286, § 2(1), substituted “December” for “November” in heading.
Pub. L. 111–192, § 101(a)(2), added par. (11).
Subsec. (d)(11)(A). Pub. L. 111–286, § 2(2), substituted “December 31” for “November 30”.
Subsec. (d)(11)(B). Pub. L. 111–286, § 2(3), substituted “2011” for “remaining portion of 2010” in heading and struck out “the period beginning on
Subsec. (d)(12). Pub. L. 111–309, § 101, added par. (12).
Subsec. (e)(1)(A). Pub. L. 111–148, § 10324(c)(1), substituted “(H), and (I)” for “and (H)” in introductory provisions.
Pub. L. 111–148, § 3102(b)(1), substituted “(G), and (H)” for “and (G)” in introductory provisions.
Subsec. (e)(1)(E). Pub. L. 111–309, § 103, substituted “before
Pub. L. 111–148, § 3102(a), substituted “before
Subsec. (e)(1)(H). Pub. L. 111–148, § 3102(b)(2), added subpar. (H).
Subsec. (e)(1)(H)(i). Pub. L. 111–152, § 1108, substituted “½” for “¾”.
Subsec. (e)(1)(I). Pub. L. 111–148, § 10324(c)(2), added subpar. (I).
Subsec. (j)(3). Pub. L. 111–148, § 4103(c)(2), inserted “(2)(FF) (including administration of the health risk assessment),” after “(2)(EE),”.
Subsec. (k)(4). Pub. L. 111–148, § 3002(c)(1), inserted “or through a Maintenance of Certification program operated by a specialty body of the American Board of Medical Specialties that meets the criteria for such a registry” after “Database)”.
Subsec. (m)(1)(A). Pub. L. 111–148, § 3002(a)(1)(A), substituted “2014” for “2010” in introductory provisions.
Subsec. (m)(1)(B)(iii), (iv). Pub. L. 111–148, § 3002(a)(1)(B), added cls. (iii) and (iv).
Subsec. (m)(3)(A). Pub. L. 111–148, § 3002(a)(2)(A), inserted “(or, for purposes of subsection (a)(8), for the quality reporting period for the year)” after “reporting period” in introductory provisions.
Subsec. (m)(3)(C)(i). Pub. L. 111–148, § 3002(a)(2)(B), inserted “, or, for purposes of subsection (a)(8), for a quality reporting period for the year” after “(a)(5), for a reporting period for a year”.
Subsec. (m)(5)(E). Pub. L. 111–148, § 3002(f)(1), substituted “Except as provided in subparagraph (I), there shall” for “There shall” in introductory provisions.
Subsec. (m)(5)(E)(iv). Pub. L. 111–148, § 3002(a)(3), substituted “paragraphs (5)(A) and (8)(A) of subsection (a)” for “subsection (a)(5)(A)”.
Subsec. (m)(5)(H), (I). Pub. L. 111–148, § 3002(e), (f)(2), added subpars. (H) and (I).
Subsec. (m)(6)(C)(i)(II). Pub. L. 111–148, § 3002(a)(4)(A), substituted “and subsequent years” for “, 2009, 2010, and 2011”.
Subsec. (m)(6)(C)(iii). Pub. L. 111–148, § 3002(a)(4)(B), inserted “(a)(8)” after “(a)(5)” and substituted “under subsection (a)(5)(D)(iii) or the quality reporting period under subsection (a)(8)(D)(iii), respectively” for “under subparagraph (D)(iii) of such subsection”.
Subsec. (m)(7). Pub. L. 111–148, § 10327(a), added par. (7) relating to additional incentive payment.
Pub. L. 111–148, § 3002(d), added par. (7) relating to integration of physician quality reporting and EHR reporting.
Subsec. (n)(1)(A). Pub. L. 111–148, § 3003(a)(1)(A), designated existing provisions as cl. (i), inserted heading, substituted “the ‘Program’).” for “the ‘Program’) under which the Secretary shall use claims data under this subchapter (and may use other data) to provide confidential reports to physicians (and, as determined appropriate by the Secretary, to groups of physicians) that measure the resources involved in furnishing care to individuals under this subchapter. If determined appropriate by the Secretary, the Secretary may include information on the quality of care furnished to individuals under this subchapter by the physician (or group of physicians) in such reports.”, and added cls. (ii) and (iii).
Subsec. (n)(1)(B). Pub. L. 111–148, § 3003(a)(1)(B), substituted “subparagraph (A)(ii)” for “subparagraph (A)” in introductory provisions.
Subsec. (n)(4). Pub. L. 111–148, § 3003(a)(2)(B), inserted “initial” after “focus the” in introductory provisions.
Pub. L. 111–148, § 3003(a)(2)(A), inserted “initial” after “focus” in heading.
Subsec. (n)(6). Pub. L. 111–148, § 3003(a)(3), inserted at end “For adjustments for reports on utilization under paragraph (9), see subparagraph (D) of such paragraph.”
Subsec. (n)(9), (10). Pub. L. 111–148, § 3003(a)(4), added pars. (9) and (10).
Subsec. (o)(1)(C)(ii). Pub. L. 111–157, § 5(a)(1), substituted “inpatient or emergency room setting” for “setting (whether inpatient or outpatient)”.
Subsec. (p). Pub. L. 111–148, § 3007(2), added subsec. (p).
2009—Subsec. (a)(5)(A)(i). Pub. L. 111–5, § 4101(f)(1)(A), substituted “, 2013 or 2014” for “or any subsequent year”.
Subsec. (a)(5)(A)(ii)(III). Pub. L. 111–5, § 4101(f)(1)(B), struck out “and each subsequent year” after “2014”.
Subsec. (a)(7). Pub. L. 111–5, § 4101(b), added par. (7).
Subsec. (d)(10). Pub. L. 111–118 added par. (10).
Subsec. (m)(2)(A). Pub. L. 111–5, § 4101(f)(2)(A), substituted “Subject to subparagraph (D), for 2009” for “For 2009”.
Subsec. (m)(2)(D). Pub. L. 111–5, § 4101(f)(2)(B), added subpar. (D).
Subsec. (o). Pub. L. 111–5, § 4101(a), added subsec. (o).
2008—Subsec. (a)(4)(A). Pub. L. 110–275, § 139(a)(1), inserted “except as provided in paragraph (5),” after “anesthesia cases,”.
Subsec. (a)(5). Pub. L. 110–275, § 132(b), added par. (5).
Subsec. (a)(6). Pub. L. 110–275, § 139(a)(2), added par. (6).
Subsec. (b)(5). Pub. L. 110–275, § 144(a)(2)(B), added par. (5).
Subsec. (c)(2)(B)(vi). Pub. L. 110–275, § 133(b), added cl. (vi).
Subsec. (d)(8). Pub. L. 110–275, § 131(a)(1)(A)(i), struck out “a portion of” before “2008” in heading.
Subsec. (d)(8)(A). Pub. L. 110–275, § 131(a)(1)(A)(ii), struck out “for the period beginning on
Subsec. (d)(8)(B). Pub. L. 110–275, § 131(a)(1)(A)(iii), struck out “the remaining portion of 2008 and” before “2009” in heading and “for the period beginning on
Subsec. (d)(9). Pub. L. 110–275, § 131(a)(1)(B), added par. (9).
Subsec. (e)(1)(A). Pub. L. 110–275, § 134(c), amended Pub. L. 108–173, § 602(1). See 2003 Amendment note below.
Subsec. (e)(1)(E). Pub. L. 110–275, § 134(a), substituted “before
Subsec. (e)(1)(G). Pub. L. 110–275, § 134(b), inserted at end “For purposes of payment for services furnished in the State described in the preceding sentence on or after
Subsec. (j)(3). Pub. L. 110–275, § 152(b)(1)(C), inserted “(2)(EE),” after “(2)(DD),”.
Pub. L. 110–275, § 144(a)(2)(A), inserted “(2)(DD),” after “(2)(AA),”.
Subsec. (k)(2)(C), (D). Pub. L. 110–275, § 131(b)(1), added subpars. (C) and (D).
Subsec. (k)(3)(B)(iv). Pub. L. 110–275, § 131(b)(4)(A), added cl. (iv).
Subsec. (l)(2)(A)(i)(III). Pub. L. 110–275, § 131(a)(3)(C)(i)(I), struck out subcl. (III) which read as follows: “For expenditures during 2013, an amount equal to $4,670,000,000.”
Pub. L. 110–252, § 7002(c)(1)(A), substituted “$4,670,000,000” for “$4,960,000,000”.
Subsec. (l)(2)(A)(i)(IV). Pub. L. 110–275, § 131(a)(3)(C)(i)(I), struck out subcl. (IV) which read as follows: “For expenditures during 2014, an amount equal to $290,000,000.”
Pub. L. 110–252, § 7002(c)(1)(B), added subcl. (IV).
Subsec. (l)(2)(A)(ii)(III). Pub. L. 110–275, § 131(a)(3)(C)(i)(II), struck out subcl. (III). Text read as follows: “The amount available for expenditures during 2013 shall only be available for an adjustment to the update of the conversion factor under subsection (d) for that year.”
Subsec. (l)(2)(A)(ii)(IV). Pub. L. 110–275, § 131(a)(3)(C)(i)(II), struck out subcl. (IV). Text read as follows: “The amount available for expenditures during 2014 shall only be available for an adjustment to the update of the conversion factor under subsection (d) for that year.”
Pub. L. 110–252, § 7002(c)(2), added subcl. (IV).
Subsec. (l)(2)(B). Pub. L. 110–275, § 131(a)(3)(C)(ii), inserted “and” at end of cl. (i), substituted period for semicolon at end of cl. (ii), and struck out cls. (iii) and (iv) which read as follows:
“(iii) 2013 for payment with respect to physicians’ services furnished during 2013; and
“(iv) 2014 for payment with respect to physicians’ services furnished during 2014.”
Subsec. (l)(2)(B)(iv). Pub. L. 110–252, § 7002(c)(3), added cl. (iv).
Subsec. (m). Pub. L. 110–275, § 131(b)(2), (3)(A), transferred subsec. (c) of section 101 of title I of div. B of Pub. L. 109–432 to subsec. (m) of this section and amended heading generally. Prior to amendment, heading read “Transitional Bonus Incentive Payments for Quality Reporting in 2007 and 2008”. See Codification note above.
Subsec. (m)(1). Pub. L. 110–275, § 131(b)(3)(B), added par. (1) and struck out former par. (1) which provided for an additional payment for certain covered professional services furnished by an eligible professional.
Subsec. (m)(2). Pub. L. 110–275, § 132(a)(1), added par. (2). Former par. (2) redesignated (3).
Subsec. (m)(3). Pub. L. 110–275, §132(a)(2)(A), inserted “and successful electronic prescriber” after “reporting” in heading.
Pub. L. 110–275, § 131(b)(3)(D)(i), (ii), designated existing provisions as subpar. (A) and inserted heading, redesignated former subpars. (A) and (B) as cls. (i) and (ii), respectively, of subpar. (A), and realigned margins.
Pub. L. 110–275, § 131(b)(3)(C), redesignated par. (2) as (3) and struck out former par. (3) which provided for payment limitation.
Subsec. (m)(3)(A). Pub. L. 110–275, § 131(b)(3)(D)(iii), inserted concluding provisions.
Subsec. (m)(3)(B). Pub. L. 110–275, § 132(a)(2)(B), added subpar. (B). Former subpar. (B) redesignated cl. (i) of subpar. (A).
Subsec. (m)(3)(C), (D). Pub. L. 110–275, § 131(b)(3)(D)(iv), added subpars. (C) and (D).
Subsec. (m)(5)(A). Pub. L. 110–275, § 131(b)(5)(A)(i), substituted “subsection (k)” for “section 1848(k) of the Social Security Act, as added by subsection (b),” and “such subsection” for “such section”.
Subsec. (m)(5)(B). Pub. L. 110–275, § 131(b)(5)(A)(ii), struck out “of the Social Security Act (42 U.S.C. 1395l)” before “and any payment”.
Subsec. (m)(5)(C). Pub. L. 110–275, § 131(b)(3)(E)(i), inserted “for 2007, 2008, and 2009,” after “provision of law,”.
Subsec. (m)(5)(D)(i). Pub. L. 110–275, § 131(b)(3)(E)(ii)(I), which directed amendment of cl. (i) by inserting “for 2007 and 2008” after “under this subsection” and then substituting “this subsection” for “paragraph (2)”, was executed by substituting “under this subsection for 2007 and 2008” for “under paragraph (2)” to reflect the probable intent of Congress.
Subsec. (m)(5)(D)(ii). Pub. L. 110–275, § 131(b)(3)(E)(ii)(II), substituted “may establish procedures to” for “shall”.
Subsec. (m)(5)(D)(iii). Pub. L. 110–275, § 131(b)(3)(E)(ii)(III), inserted “(or, in the case of a group practice under paragraph (3)(C), the group practice)” after “an eligible professional”, substituted “incentive payment under this subsection” for “bonus incentive payment”, and inserted at end “If such payments for such period have already been made, the Secretary shall recoup such payments from the eligible professional (or the group practice).”
Subsec. (m)(5)(E). Pub. L. 110–275, § 131(b)(5)(A)(iii), substituted “1395ff of this title, section 1395oo of this title, or otherwise” for “1869 or 1878 of the Social Security Act or otherwise”.
Pub. L. 110–275, § 131(b)(3)(E)(iii)(I)–(III), struck out cl. (i) designation and heading before “There shall be”, redesignated subcls. (I) to (IV) as cls. (i) to (iv), respectively, and struck out former cl. (ii). Prior to amendment, text of cl. (ii) read as follows: “A determination under this subsection shall not be treated as a determination for purposes of section 1869 of the Social Security Act.”
Subsec. (m)(5)(E)(ii). Pub. L. 110–275, § 131(b)(3)(E)(iii)(IV), substituted “this subsection” for “paragraph (2)”.
Subsec. (m)(5)(E)(iii). Pub. L. 110–275, § 132(a)(3), added cl. (iii) and struck out former cl. (iii) which read as follows: “the determination of the payment limitation under paragraph (3); and”.
Subsec. (m)(5)(E)(iv). Pub. L. 110–275, § 131(b)(3)(E)(iii)(V), substituted “any” for “the bonus” and inserted “and the payment adjustment under subsection (a)(5)(A)” before period at end.
Subsec. (m)(5)(F). Pub. L. 110–275, § 131(b)(3)(E)(iv), (5)(A)(iv), substituted “subsequent years,” for “2009, paragraph (3) shall not apply, and”, “this subsection” for “paragraph (2)”, “subsection (k)(2)(B)” for “paragraph (2)(B) of section 1848(k)” of the Social Security Act (42 U.S.C. 1395w–4(k))”, and “subsection (k)(4)” for “paragraph (4) of such section”.
Subsec. (m)(5)(G). Pub. L. 110–275, § 131(b)(3)(E)(v), added subpar. (G).
Subsec. (m)(6)(A). Pub. L. 110–275, § 131(b)(5)(B)(i), substituted “subsection (k)(3)” for “section 1848(k)(3) of the Social Security Act, as added by subsection (b)”.
Subsec. (m)(6)(B). Pub. L. 110–275, § 131(b)(5)(B)(ii), substituted “subsection (k)” for “section 1848(k) of the Social Security Act, as added by subsection (b)”.
Subsec. (m)(6)(C). Pub. L. 110–275, § 131(b)(3)(F), added subpar. (C) and struck out former subpar. (C). Prior to amendment, text read as follows: “The term ‘reporting period’ means—
“(i) for 2007, the period beginning on
“(ii) for 2008, all of 2008.”
Subsec. (m)(6)(D). Pub. L. 110–275, § 131(b)(5)(C), struck out subpar. (D). Text read as follows: “The term ‘Secretary’ means the Secretary of Health and Human Services.”
Subsec. (n). Pub. L. 110–275, § 131(c)(1), added subsec. (n).
2007—Subsec. (d)(4)(B). Pub. L. 110–173, § 101(a)(1)(A), substituted “and the succeeding paragraphs of this subsection” for “and paragraphs (5) and (6)” in introductory provisions.
Subsec. (d)(8). Pub. L. 110–173, § 101(a)(1)(B), added par. (8).
Subsec. (e)(1)(E). Pub. L. 110–173, § 103, substituted “before
Subsec. (k)(2)(B). Pub. L. 110–173, § 101(b)(1), in heading and cl. (i), inserted “and 2009” after “2008”, and, in cls. (ii) and (iii), substituted “of each of 2007 and 2008” for “, 2007” and inserted “or 2009, as applicable” after “2008”.
Subsec. (l)(2)(A). Pub. L. 110–173, § 101(a)(2)(A)(i), added subpar. (A) and struck out former subpar. (A), which read as follows: “There shall be available to the Fund for expenditures an amount equal to $1,200,000,000, as reduced by section 524 and section 225(c)(1)(A) of the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008 (division G of the Consolidated Appropriations Act, 2008). In addition, there shall be available to the Fund for expenditures during 2009 an amount equal to $325,000,000, as reduced by section 225(c)(1)(B) of such Act, and for expenditures during or after 2013 an amount equal to $60,000,000.”
Pub. L. 110–161, § 524, which directed amendment of subpar. (A) by reducing the dollar amount in the first sentence by $150,000,000, was executed by substituting “$1,200,000,000” for “$1,350,000,000” in first sentence.
Pub. L. 110–161, § 225(c)(2), inserted, in first sentence, “, as reduced by section 524 and section 225(c)(1)(A) of the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008 (division G of the Consolidated Appropriations Act, 2008)” after “$1,350,000,000” and, in second sentence, “, as reduced by section 225(c)(1)(B) of such Act,” after “$325,000,000”.
Pub. L. 110–90, § 6(1), inserted at end: “In addition, there shall be available to the Fund for expenditures during 2009 an amount equal to $325,000,000 and for expenditures during or after 2013 an amount equal to $60,000,000.”
Subsec. (l)(2)(B). Pub. L. 110–173, § 101(a)(2)(A)(ii), substituted “entire amount available for expenditures, after application of subparagraph (A)(ii), during—” and cls. (i) to (iii) for “entire amount specified in the first sentence of subparagraph (A) for payment with respect to physicians’ services furnished during 2008 and for the obligation of the entire first amount specified in the second sentence of such subparagraph for payment with respect to physicians’ services furnished during 2009 and of the entire second amount so specified for payment with respect to physicians’ services furnished on or after
Pub. L. 110–90, § 6(2), in heading, struck out “furnished during 2008” after “services” and, in text, substituted “specified in the first sentence of subparagraph (A)” for “specified in subparagraph (A)” and inserted “and for the obligation of the entire first amount specified in the second sentence of such subparagraph for payment with respect to physicians’ services furnished during 2009 and of the entire second amount so specified for payment with respect to physicians’ services furnished on or after
2006—Subsec. (b)(4). Pub. L. 109–171, § 5102(b)(1), added par. (4).
Subsec. (c)(2)(B)(ii)(II). Pub. L. 109–171, § 5102(a)(1), substituted “clauses (iv) and (v)” for “clause (iv)”.
Subsec. (c)(2)(B)(iv). Pub. L. 109–171, § 5102(a)(2), inserted “of certain additional expenditures” after “Exemption” in heading.
Subsec. (c)(2)(B)(v). Pub. L. 109–171, § 5102(a)(3), added cl. (v).
Subsec. (c)(2)(B)(v)(II). Pub. L. 109–171, § 5102(b)(2), added subcl. (II).
Subsec. (d)(4)(B). Pub. L. 109–171, § 5104(a)(1), substituted “paragraphs (5) and (6)” for “paragraph (5)” in introductory provisions.
Subsec. (d)(6). Pub. L. 109–171, § 5104(a)(2), added par. (6).
Subsec. (d)(7). Pub. L. 109–432, § 101(a), added par. (7).
Subsec. (e)(1)(E). Pub. L. 109–432, § 102, substituted “2008” for “2007”.
Subsec. (j)(3). Pub. L. 109–171, § 5112(c), inserted “(2)(AA),” after “(2)(W),”.
Subsec. (k). Pub. L. 109–432, § 101(b), added subsec. (k).
Subsec. (l). Pub. L. 109–432, § 101(d), added subsec. (l).
2003—Subsec. (c)(2)(B)(ii)(II). Pub. L. 108–173, § 303(a)(1)(A)(i), substituted “Subject to clause (iv), the adjustments” for “The adjustments”.
Subsec. (c)(2)(B)(iv). Pub. L. 108–173, § 303(a)(1)(A)(ii), added cl. (iv).
Subsec. (c)(2)(H) to (J). Pub. L. 108–173, § 303(a)(1)(B), added subpars. (H) to (J).
Subsec. (d)(4)(B). Pub. L. 108–173, § 601(a)(2), inserted “and paragraph (5)” after “subparagraph (D)” in introductory provisions.
Subsec. (d)(5). Pub. L. 108–173, § 601(a)(1), added par. (5).
Subsec. (e)(1)(A). Pub. L. 108–173, § 602(1), as amended by Pub. L. 110–275, § 134(c), substituted “subparagraphs (B), (C), (E), and (G)” for “subparagraphs (B), (C), and (E)”.
Pub. L. 108–173, § 412(1), substituted “subparagraphs (B), (C), and (E)” for “subparagraphs (B) and (C)”.
Subsec. (e)(1)(E). Pub. L. 108–173, § 412(2), added subpar. (E).
Subsec. (e)(1)(G). Pub. L. 108–173, § 602(2), added subpar. (G).
Subsec. (f)(2)(C). Pub. L. 108–173, § 601(b)(1), substituted “annual average” for “projected” and “during the 10-year period ending with the applicable period involved” for “from the previous applicable period to the applicable period involved”.
Subsec. (i)(1)(B). Pub. L. 108–173, § 303(g)(2), substituted “subsections (c)(2)(F), (c)(2)(H), and (c)(2)(I) of this section” for “subsection (c)(2)(F) of this section”.
Subsec. (i)(1)(C). Pub. L. 108–7 amended subpar. (C) generally. Prior to amendment, subpar. (C) read as follows: “the determination of conversion factors under subsection (d) of this section,”.
Subsec. (i)(3)(A). Pub. L. 108–173, § 736(b)(10), substituted “comparable services” for “a comparable services”.
Subsec. (j)(3). Pub. L. 108–173, § 611(c), inserted “(2)(W),” after “(2)(S),”.
2000—Subsec. (j)(3). Pub. L. 106–554 inserted “(13),” after “(4),”.
1999—Subsec. (d)(1)(A). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(3)(A)(i)], inserted “(for years before 2001) and, for years beginning with 2001, multiplied by the update (established under paragraph (4)) for the year involved” before period at end.
Subsec. (d)(1)(E). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(2)(A)], amended heading and text of subpar. (E) generally. Prior to amendment, text read as follows: “The Secretary shall cause to have published in the Federal Register, during the last 15 days of October of—
“(i) 1991, the conversion factor which will apply to physicians’ services for 1992, and the update determined under paragraph (3) for 1992; and
“(ii) each succeeding year, the conversion factor which will apply to physicians’ services for the following year and the update determined under paragraph (3) for such year.”
Subsec. (d)(3). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(1)(A)(i)], inserted “for 1999 and 2000” after “Update” in heading.
Subsec. (d)(3)(A). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(1)(A)(ii)], substituted “1999 and 2000” for “a year beginning with 1999” in introductory provisions.
Subsec. (d)(3)(C). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(1)(A)(iii)], inserted “and paragraph (4)” after “For purposes of this paragraph” in introductory provisions.
Subsec. (d)(4). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(1)(B)], added par. (4).
Subsec. (f)(1). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(b)(1)], amended heading and text of par. (1) generally. Prior to amendment, text read as follows: “The Secretary shall cause to have published in the Federal Register the sustainable growth rate for each fiscal year beginning with fiscal year 1998. Such publication shall occur by not later than August 1 before each fiscal year, except that such rate for fiscal year 1998 shall be published not later than
Subsec. (f)(2). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(b)(2)(A)], substituted “fiscal year 1998 and ending with fiscal year 2000) and a year beginning with 2000” for “fiscal year 1998)” in introductory provisions.
Subsec. (f)(2)(A). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(b)(2)(B)], substituted “applicable period” for “fiscal year”.
Subsec. (f)(2)(B), (C). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(b)(2)(B)], substituted “applicable period” for “fiscal year” in two places.
Subsec. (f)(2)(D). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(a)(3)(A)(ii), (b)(2)(B)], substituted “applicable period” for “fiscal year” in two places and “subsection (d)(3)(B) or (d)(4)(B) of this section, as the case may be” for “subsection (d)(3)(B) of this section”.
Subsec. (f)(3). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(b)(5)], added par. (3). Former par. (3) redesignated (4).
Subsec. (f)(3)(C). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(b)(3)], added subpar. (C).
Subsec. (f)(4). Pub. L. 106–113, § 1000(a)(6) [title II, § 211(b)(4)], redesignated par. (3) as (4).
Subsec. (j)(3). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(k)(5)], substituted “section 1395x(oo)(2) of this title)” for “section 1395x(oo)(2) of this title,”, “(B),” for “(B),”, and “, and (15)” for “and (15)”.
1997—Subsec. (b)(1). Pub. L. 105–33, § 4644(d), substituted “Before November 1 of the preceding year, for each year beginning with 1998” for “Before January 1 of each year beginning with 1992” in introductory provisions.
Subsec. (c)(2)(B)(iii). Pub. L. 105–33, § 4022(b)(2)(C), substituted “Medicare Payment Advisory Commission” for “Physician Payment Review Commission”.
Subsec. (c)(2)(C)(ii). Pub. L. 105–33, § 4505(b)(1)(A), which directed an amendment striking the comma at the end of cl. (ii) and inserting a period and the following: “For 1999, such number of units shall be determined based 75 percent on such product and based 25 percent on the relative practice expense resources involved in furnishing the service. For 2000, such number of units shall be determined based 50 percent on such product and based 50 percent on such relative practice expense resources. For 2001, such number of units shall be determined based 25 percent on such product and based 75 percent on such relative practice expense resources. For a subsequent year, such number of units shall be determined based entirely on such relative practice expense resources.”, was executed by making the insertion at end of cl. (ii) to reflect the probable intent of Congress, because cl. (ii) ended with a period rather than a comma.
Pub. L. 105–33, § 4505(a)(1), substituted “1999” for “1998” in two places.
Subsec. (c)(2)(C)(iii). Pub. L. 105–33, § 4505(f)(1)(A), inserted “for the service for years before 2000” before “equal” in introductory provisions, substituted comma for period at end of subcl. (II), and inserted concluding provisions.
Subsec. (c)(2)(G). Pub. L. 105–33, § 4505(e), added subpar. (G).
Subsec. (c)(3)(C)(ii). Pub. L. 105–33, § 4505(b)(2), substituted “2002” for “1999” in introductory provisions.
Pub. L. 105–33, § 4505(a)(2), substituted “1999” for “1998” in introductory provisions.
Subsec. (c)(3)(C)(iii). Pub. L. 105–33, § 4505(f)(1)(B), substituted “For years before 1999, the malpractice” for “The malpractice” in introductory provisions.
Subsec. (d)(1)(A). Pub. L. 105–33, § 4501(b)(1), (2), struck out “(or factors)” after “conversion factor” in two places and struck out “or updates” after “update”.
Subsec. (d)(1)(C). Pub. L. 105–33, § 4504(a)(1), substituted “Except as provided in subparagraph (D), the single conversion factor” for “The single conversion factor”.
Pub. L. 105–33, § 4501(a)(2), added subpar. (C). Former subpar. (C) redesignated (D).
Subsec. (d)(1)(D). Pub. L. 105–33, § 4504(a)(3), added subpar. (D). Former subpar. (D) redesignated (E).
Pub. L. 105–33, § 4501(b)(1), (3), struck out “(or updates)” after “update” in two places and struck out “(or factors)” after “conversion factor” in cl. (ii).
Pub. L. 105–33, § 4501(a)(1), redesignated subpar. (C) as (D).
Subsec. (d)(1)(E). Pub. L. 105–33, § 4504(a)(2), redesignated subpar. (D) as (E).
Subsec. (d)(2). Pub. L. 105–33, § 4502(b), struck out heading and text of par. (2) which related to recommendation of update.
Subsec. (d)(2)(F). Pub. L. 105–33, § 4022(b)(1)(B)(i), struck out heading and text of subpar. (F). Text read as follows: “The Physician Payment Review Commission shall review the report submitted under subparagraph (A) in a year and shall submit to the Congress, by not later than May 15 of the year, a report including its recommendations respecting the update (or updates) in the conversion factor (or factors) for the following year.”
Subsec. (d)(3). Pub. L. 105–33, § 4502(a)(1), amended heading and text generally. Prior to amendment, text related to updates of conversion factor based on index and made provision for adjustments in update.
Subsec. (f). Pub. L. 105–33, § 4503(b), amended subsec. heading and heading and text of par. (1) generally. Prior to amendment, par. (1) related to process for establishing medicare volume performance standard rates of increase.
Subsec. (f)(1)(B). Pub. L. 105–33, § 4022(b)(2)(B)(ii), struck out heading and text of subpar. (B). Text read as follows: “The Physician Payment Review Commission shall review the recommendation transmitted during a year under subparagraph (A) and shall make its recommendation to Congress, by not later than May 15 of the year, respecting the performance standard rates of increase for the fiscal year beginning in that year.”
Subsec. (f)(2). Pub. L. 105–33, § 4503(a), added par. (2) and struck out heading and text of former par. (2) which related to specification of performance standard rates of increase for physician services for fiscal years beginning in 1991.
Subsec. (f)(3). Pub. L. 105–33, § 4503(a), added par. (3) and struck out heading and text of former par. (3). Text read as follows: “The Secretary shall establish procedures for providing, on a quarterly basis to the the Congressional Budget Office, the Congressional Research Service, the Committees on Ways and Means and Energy and Commerce of the House of Representatives, and the Committee on Finance of the Senate, information on compliance with performance standard rates of increase established under this subsection.”
Pub. L. 105–33, § 4022(b)(2)(B)(iii), struck out “Physician Payment Review Commission,” before “the Congressional Budget Office”.
Subsec. (f)(4), (5). Pub. L. 105–33, § 4503(a), struck out heading and text of par. (4) which related to separate group-specific performance standard rates of increase and par. (5) which defined “physicians’ services” and “HMO enrollee”.
Subsec. (g)(3)(A). Pub. L. 105–33, § 4714(b)(2), inserted before period at end “and the provisions of section 1396a(n)(3)(A) of this title apply to further limit permissible charges under this section”.
Subsec. (g)(6)(C), (7)(C). Pub. L. 105–33, § 4022(b)(2)(C), substituted “Medicare Payment Advisory Commission” for “Physician Payment Review Commission”.
Subsec. (j)(1). Pub. L. 105–33, § 4501(b)(4), substituted “For services furnished before
Subsec. (j)(3). Pub. L. 105–33, § 4106(b), substituted “(4), (14)” for “(4) and (14)” and inserted “and (15)” after “1395x(nn)(2) of this title)”.
Pub. L. 105–33, § 4105(a)(2), inserted “(2)(S),” before “(3)”.
Pub. L. 105–33, § 4103(d), inserted “(2)(P) (with respect to services described in subparagraphs (A) and (C) of section 1395x(oo)(2) of this title,” after “(2)(G)”.
Pub. L. 105–33, §§ 4102(d), 4104(d), inserted “(2)(R) (with respect to services described in subparagraphs (B) , (C), and (D) of section 1395x(pp)(1) of this title),” before “(3)” and substituted “(4) and (14) (with respect to services described in section 1395x(nn)(2) of this title)” for “and (4)”.
1994—Subsec. (a)(2)(D)(iii). Pub. L. 103–432, § 126(b)(6), struck out “that are subject to section 6105(b) of the Omnibus Budget Reconciliation Act of 1989” after “nuclear medicine services” and substituted “provided under section 6105(b) of the Omnibus Budget Reconciliation Act of 1989” for “provided under such section”.
Subsec. (c)(2)(C)(ii). Pub. L. 103–432, § 121(b)(1), inserted “for the service for years before 1998” before “equal to” in introductory provisions, substituted comma for period at end of subcl. (II), and inserted “and for years beginning with 1998 based on the relative practice expense resources involved in furnishing the service.” as closing provisions.
Subsec. (c)(3)(C)(ii). Pub. L. 103–432, § 121(b)(2), substituted “For years before 1998, the practice” for “The practice”.
Subsec. (c)(4). Pub. L. 103–432, § 126(g)(6), made technical amendment to directory language of Pub. L. 101–508, § 4118(f)(1)(D). See 1990 Amendment note below.
Subsec. (e)(1)(C). Pub. L. 103–432, § 126(g)(5), inserted “date of the” before “last previous adjustment”.
Pub. L. 103–432, § 122(a), substituted “shall, in consultation with appropriate representatives of physicians, review” for “shall review”.
Subsec. (e)(1)(D). Pub. L. 103–432, § 122(b), added subpar. (D).
Subsec. (f)(2)(A)(i). Pub. L. 103–432, § 126(g)(7), made technical amendment to directory language of Pub. L. 101–508, § 4118(f)(1)(N)(ii). See 1990 Amendment note below.
Subsec. (f)(2)(C). Pub. L. 103–432, § 126(g)(2)(B), inserted heading.
Subsec. (g)(1). Pub. L. 103–432, § 123(a)(1), amended heading and text of par. (1) generally. Prior to amendment, text read as follows: “If a nonparticipating physician or nonparticipating supplier or other person (as defined in section 1395u(i)(2) of this title) knowingly and willfully bills on a repeated basis for physicians’ services (including services which the Secretary excludes pursuant to subsection (j)(3) of this section, furnished with respect to an individual enrolled under this part on or after
Subsec. (g)(3)(B). Pub. L. 103–432, § 123(a)(2), inserted after first sentence “No person is liable for payment of any amounts billed for such a service in violation of the previous sentence.” and in last sentence substituted “first sentence” for “previous sentence”.
Subsec. (g)(6)(B). Pub. L. 103–432, § 123(d), inserted “information on the extent to which actual charges exceed limiting charges, the number and types of services involved, and the average amount of excess charges and information” after “report to the Congress”.
Subsec. (i)(3). Pub. L. 103–432, § 126(g)(10)(A), struck out space before the period at end.
1993—Subsec. (a)(2)(B)(ii)(I). Pub. L. 103–66, § 13515(c)(1), inserted “and under section 13515(b) of the Omnibus Budget Reconciliation Act of 1993” after “subsection (c)(2)(F)(ii) of this section”.
Pub. L. 103–66, § 13514(c)(1), inserted “and as adjusted under subsection (c)(2)(F)(ii) of this section” after “for 1994”.
Subsec. (a)(3). Pub. L. 103–66, § 13517(a)(1), in heading inserted “and suppliers” after “physicians” and in text inserted “or a nonparticipating supplier or other person” after “nonparticipating physician” and inserted at end “In the case of physicians’ services (including services which the Secretary excludes pursuant to subsection (j)(3) of this section) of a nonparticipating physician, supplier, or other person for which payment is made under this part on a basis other than the fee schedule amount, the payment shall be based on 95 percent of the payment basis for such services furnished by a participating physician, supplier, or other person.”
Subsec. (a)(4). Pub. L. 103–66, § 13516(a)(1), added par. (4).
Pub. L. 103–66, § 13515(a)(1), struck out heading and text of par. (4). Text read as follows: “In the case of physicians’ services furnished by a physician before the end of the physician’s first full calendar year of furnishing services for which payment may be made under this part, and during each of the 3 succeeding years, the fee schedule amount to be applied shall be 80 percent, 85 percent, 90 percent, and 95 percent, respectively, of the fee schedule amount applicable to physicians who are not subject to this paragraph. The preceding sentence shall not apply to primary care services or services furnished in a rural area (as defined in section 1395ww(d)(2) of this title) that is designated under section 249(a)(1)(A) of this title as a health manpower shortage area.”
Subsec. (b)(3). Pub. L. 103–66, § 13514(a), amended heading and text of par. (3) generally. Prior to amendment, text read as follows: “If payment is made under this part for a visit to a physician or consultation with a physician and, as part of or in conjunction with the visit or consultation there is an electrocardiogram performed or ordered to be performed, no payment may be made under this part with respect to the interpretation of the electrocardiogram and no physician may bill an individual enrolled under this part separately for such an interpretation. If a physician knowingly and willfully bills one or more individuals in violation of the previous sentence, the Secretary may apply sanctions against the physician or entity in accordance with section 1395u(j)(2) of this title.”
Subsec. (c)(2)(A)(i). Pub. L. 103–66, § 13515(c)(2), inserted before period at end “and section 13515(b) of the Omnibus Budget Reconciliation Act of 1993”.
Pub. L. 103–66, § 13514(c)(2), inserted at end “Such relative values are subject to adjustment under subparagraph (F)(i).”
Subsec. (c)(2)(E). Pub. L. 103–66, § 13513, added subpar. (E).
Subsec. (c)(2)(F). Pub. L. 103–66, § 13514(b), added subpar. (F).
Subsec. (d)(3)(A)(i). Pub. L. 103–66, § 13511(a)(1)(A), substituted “clauses (iii) through (v)” for “clause (iii)”.
Subsec. (d)(3)(A)(iv) to (vi). Pub. L. 103–66, § 13511(a)(1)(B), added cls. (iv) to (vi).
Subsec. (d)(3)(B)(ii). Pub. L. 103–66, § 13512(b), substituted “1994” for “1994 or 1995” in subcl. (II) and “5” for “3” in subcl. (III).
Subsec. (f)(2)(B). Pub. L. 103–66, § 13512(a), added cls. (iii) to (v) and struck out former cl. (iii) which read as follows: “for each succeeding year is 2 percentage points.”
Subsec. (g)(1). Pub. L. 103–66, § 13517(a)(2)(C), (D), inserted “, supplier, or other person” after “such physician” and inserted at end “In applying this subparagraph, any reference in such section to a physician is deemed also to include a reference to a supplier or other person under this subparagraph.”
Pub. L. 103–66, § 13517(a)(2)(B), which directed insertion of “including services which the Secretary excludes pursuant to subsection (j)(3) of this section,” after “physician’s services (”, was executed by making the insertion after “physicians’ services (” to reflect the probable intent of Congress.
Pub. L. 103–66, § 13517(a)(2)(A), inserted “or nonparticipating supplier or other person (as defined in section 1395u(i)(2) of this title)” after “nonparticipating physician”.
Subsec. (g)(2)(C). Pub. L. 103–66, § 13517(a)(3), inserted “or for nonparticipating suppliers or other persons” after “nonparticipating physicians”.
Subsec. (g)(2)(D). Pub. L. 103–66, § 13517(a)(4), inserted “(or, if payment under this part is made on a basis other than the fee schedule under this section, 95 percent of the other payment basis)” after “subsection (a) of this section”.
Subsec. (h). Pub. L. 103–66, § 13517(a)(5), inserted “or nonparticipating supplier or other person furnishing physicians’ services (as defined in subsection (j)(3) of this section)” after “each physician”, inserted “, supplier, or other person” after “by the physician”, and inserted “, suppliers, and other persons” after “notices to physicians”.
Subsec. (i)(1)(B). Pub. L. 103–66, § 13515(c)(3), inserted “and section 13515(b) of the Omnibus Budget Reconciliation Act of 1993” after “subsection (c)(2)(F) of this section”.
Pub. L. 103–66, § 13514(c)(3), inserted at end “including adjustments under subsection (c)(2)(F) of this section,”.
Subsec. (j)(1). Pub. L. 103–66, § 13511(a)(2), substituted “Secretary and including anesthesia services), primary care services (as defined in section 1395u(i)(4) of this title),” for “Secretary)”.
Subsec. (j)(3). Pub. L. 103–66, § 13518(a), inserted “(2)(G),” after “(2)(D),”.
Pub. L. 103–66, § 13517(a)(6), inserted “, except for purposes of subsections (a)(3), (g), and (h) of this section” after “tests and”.
1990—Subsec. (a)(1). Pub. L. 101–508, § 4104(b)(2), struck out “or 1395m(f)” after “section 1395m(b)” in introductory provisions.
Subsec. (a)(2)(C). Pub. L. 101–508, § 4102(b), inserted “and radiology” after “Special rule for anesthesia” in heading and inserted at end “With respect to radiology services, ‘109 percent’ and ‘9 percent’ shall be substituted for ‘115 percent’ and ‘15 percent’, respectively, in subparagraph (A)(ii).”
Subsec. (a)(2)(D)(ii). Pub. L. 101–508, § 4102(g)(2)(A), inserted “, but excluding nuclear medicine services that are subject to section 6105(b) of the Omnibus Budget Reconciliation Act of 1989” after “section 1395m(b)(6) of this title)”.
Subsec. (a)(2)(D)(iii). Pub. L. 101–508, § 4102(g)(2)(B), added cl. (iii).
Subsec. (a)(4). Pub. L. 101–508, § 4106(b)(1), added par. (4).
Subsec. (b)(3). Pub. L. 101–508, § 4109(a), added par. (3).
Subsec. (c)(1)(B). Pub. L. 101–508, § 4118(f)(1)(A), struck out at end “In this subparagraph, the term ‘practice expenses’ includes all expenses for furnishing physicians’ services, excluding malpractice expenses, physician compensation, and other physician fringe benefits.”
Subsec. (c)(3). Pub. L. 101–508, § 4118(f)(1)(C), redesignated par. (3), relating to ancillary policies, as (4).
Subsec. (c)(3)(C)(ii)(II), (iii)(II). Pub. L. 101–508, § 4118(f)(1)(B), struck out “by” before “the proportion”.
Subsec. (c)(4). Pub. L. 101–508, § 4118(f)(1)(D), as amended by Pub. L. 103–432, § 126(g)(6), substituted “section” for “subsection”.
Pub. L. 101–508, § 4118(f)(1)(C), redesignated par. (3), relating to ancillary policies, as (4). Former par. (4) redesignated (5).
Pub. L. 101–508, § 4118(d), struck out “only for services furnished on or after
Subsec. (c)(5), (6). Pub. L. 101–508, § 4118(f)(1)(C), redesignated pars. (4) and (5) as (5) and (6), respectively.
Subsec. (d)(1)(A). Pub. L. 101–508, § 4118(f)(1)(E), (F)(i)(III), amended subpar. (A) identically, substituting “paragraph (3)” for “subparagraph (C)”.
Pub. L. 101–508, § 4118(f)(1)(F)(i)(I), (II), substituted “conversion factor (or factors)” for “conversion factor” in two places and “update or updates” for “update”.
Subsec. (d)(1)(C)(i). Pub. L. 101–508, § 4118(f)(1)(F)(ii)(I), substituted “conversion factor” for “conversion factor (or factors)”.
Subsec. (d)(1)(C)(ii). Pub. L. 101–508, § 4118(f)(1)(F)(ii)(II), inserted “the conversion factor (or factors) which will apply to physicians’ services for the following year and” before “the update (or updates)” and substituted “such year” for “the following year”.
Subsec. (d)(2)(A). Pub. L. 101–508, § 4118(f)(1)(G), (I), substituted “physicians’ services (as defined in subsection (f)(5)(A) of this section)” for “physicians’ services” in first sentence and “proportion of individuals who are enrolled under this part who are HMO enrollees” for “proportion of HMO enrollees” in last sentence.
Subsec. (d)(2)(A)(ii). Pub. L. 101–508, § 4118(f)(1)(H), substituted “and for the services involved” for “(as defined in subsection (f)(5)(A) of this section)” and “such services” for “all such physicians’ services”.
Subsec. (d)(2)(E)(i). Pub. L. 101–508, § 4118(f)(1)(J), inserted “the” before “most recent”.
Subsec. (d)(2)(E)(ii)(I). Pub. L. 101–508, § 4118(f)(1)(K), substituted “payments for physicians’ services” for “physicians’ services”.
Subsec. (d)(3)(A)(i). Pub. L. 101–508, § 4105(a)(3)(A), inserted “except as provided in clause (iii),” after “subparagraph (B),”.
Subsec. (d)(3)(A)(iii). Pub. L. 101–508, § 4105(a)(3)(B), added cl. (iii).
Subsec. (d)(3)(B)(i). Pub. L. 101–508, § 4118(f)(1)(L)(i)(II), which directed amendment of cl. (i) by substituting “services in such category” for “physicians’ services (as defined in subsection (f)(5)(A))”, was executed by making the substitution for “physicians’ services (as defined in section (f)(5)(A))” to reflect the probable intent of Congress.
Pub. L. 101–508, § 4118(f)(1)(L)(i)(I), substituted “update for a category of physicians’ services for a year” for “update for a year”.
Subsec. (d)(3)(B)(ii). Pub. L. 101–508, § 4118(f)(1)(L)(ii), inserted “more than” after “decrease of” in introductory provisions and struck out “more than” before “2 percentage points” in subcl. (I).
Subsec. (e)(1)(A). Pub. L. 101–508, § 4118(c)(1), substituted “subparagraphs (B) and (C)” for “subparagraph (B)” in introductory provisions.
Subsec. (e)(1)(C). Pub. L. 101–508, § 4118(c)(2), added subpar. (C).
Subsec. (f)(1)(C). Pub. L. 101–508, § 4105(c)(1), substituted “1991” for “1990” after “beginning with”.
Subsec. (f)(1)(D)(i). Pub. L. 101–508, § 4118(f)(1)(M), substituted “portions of calendar years” for “calendar years”.
Subsec. (f)(2)(A). Pub. L. 101–508, § 4118(b)(1), (f)(1)(N)(i), in introductory provisions, substituted “the performance standard rate of increase, for all physicians’ services and for each category of physicians’ services,” for “each performance standard rate of increase” and “product” for “sum”.
Pub. L. 101–508, § 4118(b)(6), substituted “minus 1, multiplied by 100, and reduced” for “reduced” in concluding provisions.
Subsec. (f)(2)(A)(i). Pub. L. 101–508, § 4118(f)(1)(N)(ii), as amended by Pub. L. 103–432, § 126(g)(7), substituted “all physicians’ services or for the category of physicians’ services, respectively,” for “physicians’ services (as defined in subsection (f)(5)(A) of this section)”.
Pub. L. 101–508, § 4118(f)(1)(M), substituted “portions of calendar years” for “calendar years”.
Pub. L. 101–508, § 4118(b)(2), (3), substituted “1 plus the Secretary’s” for “the Secretary’s” and “percentage increase (divided by 100)” for “percentage increase”.
Subsec. (f)(2)(A)(ii). Pub. L. 101–508, § 4118(b)(2), (4), substituted “1 plus the Secretary’s” for “the Secretary’s” and inserted “(divided by 100)” after “decrease”.
Subsec. (f)(2)(A)(iii). Pub. L. 101–508, § 4118(f)(1)(N)(iii), substituted “all physicians’ services or of the category of physicians’ services, respectively,” for “physicians’ services”.
Pub. L. 101–508, § 4118(b)(2), (5), substituted “1 plus the Secretary’s” for “the Secretary’s” and inserted “(divided by 100)” after “percentage growth”.
Subsec. (f)(2)(A)(iv). Pub. L. 101–508, § 4118(e), (f)(1)(N)(iv), substituted “all physicians’ services or of the category of physicians’ services, respectively,” for “physicians’ services (as defined in subsection (f)(5)(A) of this section)” and inserted “including changes in law and regulations affecting the percentage increase described in clause (i)” after “law or regulations”.
Pub. L. 101–508, § 4118(b)(2), (4), substituted “1 plus the Secretary’s” for “the Secretary’s” and “decrease (divided by 100)” for “decrease”.
Subsec. (f)(2)(C). Pub. L. 101–508, § 4105(c)(2), added subpar. (C).
Subsec. (f)(4)(A). Pub. L. 101–508, § 4118(f)(1)(O), substituted “subparagraph (B)” for “paragraph (B)”.
Subsec. (f)(4)(B). Pub. L. 101–508, § 4118(f)(1)(P), substituted “specifically approved by law” for “Congress specifically approves the plan”.
Subsec. (g)(2)(A). Pub. L. 101–508, § 4118(f)(1)(Q), inserted “other than radiologist services subject to section 1395m(b) of this title,” after “during 1991,” in introductory provisions.
Pub. L. 101–508, § 4116, inserted at end “In the case of evaluation and management services (as specified in section 1395u(b)(16)(B)(ii) of this title), the preceding sentence shall be applied by substituting ‘40 percent’ for ‘25 percent’.”
Subsec. (g)(2)(B). Pub. L. 101–508, § 4118(f)(1)(Q), inserted “other than radiologist services subject to section 1395m(b) of this title,” after “during 1992,” in introductory provisions.
Subsec. (i)(1)(A). Pub. L. 101–508, § 4118(f)(1)(R), substituted “adjusted historical payment basis (as defined in subsection (a)(2)(D)(i)” for “historical payment basis (as defined in subsection (a)(2)(C)(i)”.
Subsec. (i)(2). Pub. L. 101–508, § 4107(a)(1), added par. (2).
Subsec. (i)(3). Pub. L. 101–508, § 4118(k), added par. (3).
Subsec. (j)(1). Pub. L. 101–508, § 4118(f)(1)(S), which directed the amendment of par. (1) by substituting “(as defined by the Secretary) and all other physicians’ services” for “, and such other” and all that follows through the period was executed by making the substitution for “, and such other category or categories of physicians’ services as the Secretary, from time to time, defines in regulation.” to reflect the probable intent of Congress.
Change Of Name
References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Pub. L. 108–173, set out as a note under section 1395w–21 of this title.
Effective Date Of Amendment
Pub. L. 111–157, § 5(b),
Pub. L. 111–152, title I, § 1108,
Pub. L. 111–148, title III, § 3002(c)(2),
Amendment by section 4103(c)(2) of Pub. L. 111–148 applicable to services furnished on or after
Pub. L. 110–275, title I, § 144(a)(3),
Pub. L. 110–275, title I, § 152(b)(2),
Pub. L. 110–173, title I, § 101(a)(2)(B),
Amendment by section 5112(c) of Pub. L. 109–171 applicable to services furnished on or after
Pub. L. 108–173, title VI, § 601(b)(2),
Pub. L. 108–173, title VI, § 611(e),
Amendment by Pub. L. 106–554 applicable with respect to screening mammographies furnished on or after
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 211(d)],
Amendment by section 1000(a)(6) [title III, § 321(k)(5)] of Pub. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Pub. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Pub. L. 106–113, set out as a note under section 1395d of this title.
Amendment by section 4022(b)(2)(B), (C) of Pub. L. 105–33 effective
Amendment by section 4102(d) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4103(d) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4104(d) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4105(a)(2) of Pub. L. 105–33 applicable to items and services furnished on or after
Amendment by section 4106(b) of Pub. L. 105–33 applicable to bone mass measurements performed on or after
Pub. L. 105–33, title IV, § 4502(a)(2),
Pub. L. 105–33, title IV, § 4504(b),
Amendment by section 4714(b)(2) of Pub. L. 105–33 applicable to payment for (and with respect to provider agreements with respect to) items and services furnished on or after
Amendment by section 123(a) of Pub. L. 103–432 applicable to services furnished on or after
Pub. L. 103–432, title I, § 123(f)(5),
Amendment by section 126(b)(6), (g)(2)(B), (5)–(7), (10)(A) of Pub. L. 103–432 effective as if included in the enactment of Pub. L. 101–508, see section 126(i) of Pub. L. 103–432, set out as a note under section 1395m of this title.
Pub. L. 103–66, title XIII, § 13511(b),
Pub. L. 103–66, title XIII, § 13514(d),
Amendment by section 13515(a)(1) of Pub. L. 103–66 applicable to services furnished on or after
Pub. L. 103–66, title XIII, § 13517(c),
Pub. L. 103–66, title XIII, § 13518(c),
Amendment by section 4102(b), (g)(2) of Pub. L. 101–508 applicable to services furnished on or after
Amendment by section 4104(b)(2) of Pub. L. 101–508 applicable to services furnished on or after
Amendment by section 4106(b)(1) of Pub. L. 101–508 applicable to services furnished after 1991, see section 4106(d)(2) of Pub. L. 101–508, set out as a note under section 1395u of this title.
Pub. L. 101–508, title IV, § 4107(a)(2),
Pub. L. 101–508, title IV, § 4107(c),
Pub. L. 101–508, title IV, § 4109(b),
Transfer Of Functions
Physician Payment Review Commission (PPRC) was terminated and its assets and staff transferred to the Medicare Payment Advisory Commission (MedPAC) by section 4022(c)(2), (3) of Pub. L. 105–33, set out as a note under section 1395b–6 of this title. Section 4022(c)(2), (3) further provided that MedPAC was to be responsible for preparation and submission of reports required by law to be submitted by PPRC, and that, for that purpose, any reference in law to PPRC was to be deemed, after the appointment of MedPAC, to refer to MedPAC.
Miscellaneous
For termination, effective
Pub. L. 113–93, title II, § 220(i),
Pub. L. 113–67, div. B, § 1002,
Pub. L. 111–157, § 5(c),
Pub. L. 111–148, title III, § 3111(a)(2),
Pub. L. 111–148, title III, § 3134(b)(1),
Pub. L. 111–148, title III, § 3002(c)(3), as added by Pub. L. 111–148, title X, § 10327(b),
Pub. L. 110–275, title I, § 131(b)(4)(B),
Pub. L. 110–275, title I, § 131(b)(6),
Pub. L. 110–275, title I, § 138,
Pub. L. 110–173, title I, § 101(a)(2)(C),
Pub. L. 109–432, div. B, title I, § 101(c),
Pub. L. 108–173, title III, § 303(a)(2),
Pub. L. 108–173, title III, § 303(a)(3),
Pub. L. 108–173, title III, § 303(a)(4),
Pub. L. 108–173, title III, § 303(a)(5),
Pub. L. 108–173, title III, § 303(g)(3),
Amendment by section 303 of Pub. L. 108–173, insofar as applicable to payments for drugs or biologicals and drug administration services furnished by physicians, is applicable only to physicians in the specialties of hematology, hematology/oncology, and medical oncology under this subchapter, see section 303(j) of Pub. L. 108–173, set out as a note under section 1395u of this title.
Notwithstanding section 303(j) of Pub. L. 108–173 (see note above), amendment by section 303 of Pub. L. 108–173 also applicable to payments for drugs or biologicals and drug administration services furnished by physicians in specialties other than the specialties of hematology, hematology/oncology, and medical oncology, see section 304 of Pub. L. 108–173, set out as a note under section 1395u of this title.
Pub. L. 108–173, title IV, § 413(c),
Pub. L. 109–171, title V, § 5104(b),
Pub. L. 108–173, title VI, § 601(a)(3),
Pub. L. 108–173, title VI, § 605,
Pub. L. 108–173, title VI, § 606,
Pub. L. 108–173, title VI, § 644,
Pub. L. 108–173, title IX, § 953(a)(2),
Pub. L. 106–554, § 1(a)(6) [title V, § 542],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 211(a)(2)(C)],
Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 212],
Pub. L. 105–33, title IV, § 4105(a)(3),
Pub. L. 105–33, title IV, § 4505(d),
Pub. L. 105–33, title IV, § 4505(f)(2),
Pub. L. 103–432, title I, § 121(a),
Pub. L. 103–432, title I, § 121(b)(3),
Pub. L. 103–432, title I, § 122(c),
Pub. L. 103–432, title I, § 124(a),
For provisions requiring reduction of relative values established under subsec. (c) of this section and amounts determined under subsec. (a)(2)(B)(ii)(I) of this section for 1994 (to be applied for that year and subsequent years) in order to assure that the amendments to this section and section 1395u of this title by section 13515(a) of Pub. L. 103–66 will not result in expenditures under this part that exceed the amount of such expenditures that would have been made if such amendments had not been made, see section 13515(b) of Pub. L. 103–66, set out as a note under section 1395u of this title.
Pub. L. 103–66, title XIII, § 13518(b),
Pub. L. 101–508, title IV, § 4104(c),
Pub. L. 101–508, title IV, § 4105(b)(2),
Pub. L. 101–508, title IV, § 4106(c),
Pub. L. 101–508, title IV, § 4105(d),
Pub. L. 101–508, title IV, § 4115,
Pub. L. 101–508, title IV, § 4117,
Pub. L. 101–239, title VI, § 6102(d),
Pub. L. 101–239, title VI, § 6102(e)(11),