Anti-Markup Pricing Limitation
Anti-markup applies when a diagnostic service payable under the Medicare Physician Fee Schedule is performed by one physician/supplier and billed by another physician/suppler. The conditions that must exist to establish whether the anti-markup applies are outlined below.
When Anti-Markup Applies
The anti-markup payment limitation will apply (i.e., must mark “yes” in Item 20 of the claim form and provide the acquisition price) in cases where performing physician does not share a practice with the ordering/billing physician/supplier, either under the “substantially all services” or “site of service” test defined below.
Under the anti-markup payment limitation, payment to the billing physician or other supplier for the TC or PC of the diagnostic test may not exceed the lowest of the following amounts:
* The performing supplier’s net charge to the billing physician/supplier.
* The billing physician’s/supplier’s actual charge.
* The fee schedule amount for the test that would be allowed if the performing provider billed directly.
Radiology billing and coding tips. Learn about radiology billing services health care CPT codes and reimbursement. How to do Radiology billing correctly. PET CT scan coding and Guidelines.
Saturday, April 30, 2011
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