Thursday, September 24, 2015

Medicare Coverage of Imaging Services

Medicare covers imaging services that are performed or supervised by a physician who is certified or eligible to be certified by the American Board of Radiology or for whom radiology services account for at least 50 percent of the total amount of charges made under Medicare.

Medicare generally covers : x-rays, including portable x-rays, including portable x-rays, fluoroscopy and mammography; CT, including portable CT, CT angiography (CTA) and CT- guided procedures; MRI, including MR angiography (MRS) and MRI, including MR angiography (MRA) and MRI- guided procedures; ultrasound (US), including diagnostic grey-scale and vascular Doppler imaging, and US-guided procedures; nuclear medicine diagnostic imaging and procedures, including radionuclide’s and PET for certain conditions; radiation oncology; and bone density (DEXA) scans. Coverage may be limited to certain indications.

Billing and Payment on Medicare Professional Claims

Imaging services are billed under Medicare Part B to Medicare Carriers and A/B Medicare Administrative Contractors (A/B MACs) using acceptable Healthcare Common Procedure Coding System (HCPCS) codes for imaging and other diagnostic services taken primarily from the Current Procedural Terminology (Procedure code ) 4 portion of HCPCS and the supporting ICD diagnosis codes.
Imaging services are generally paid based on the lower of the charge or the Medicare Physician Fee Schedule (MPFS) amount. Deductible and coinsurance apply, and coinsurance is based on the allowed amount.

Payment Conditions for Imaging Services
Generally, imaging services are split into technical and professional components (the TC and PC), each separately billable to the local Medicare contractor. Medicare pays under the MPFS for the TC of imaging services furnished to Medicare beneficiaries who are not patients of any hospital, and who receive services in a physician's office, a freestanding imaging or radiation oncology center, ambulatory surgical center (ASC) or other setting that is not part of a hospital.

When imaging services are furnished in a leased hospital radiology department to a beneficiary who is neither an inpatient nor an outpatient of any hospital, both the PC and the TC of the services are payable under the MPFS by the carrier or A/B MAC.

Definitions of Professional and Technical Components and Billing Codes

The PC of a service is for physician work interpreting a diagnostic test or performing a procedure, and includes indirect practice and malpractice expenses related to that work. Modifier 26 is used with the billing code to indicate that the PC is being billed.

The TC is for all non-physician work, and includes administrative, personnel and capital (equipment and facility) cost, and related malpractice expenses. Modifier TC is used with the billing code to indicate that the TC is being billed.

PC and TC do not apply to physician services that cannot be distinctly split into professional and technical components. Modifier PC and TC may not be used with these billing codes. For example: A diagnostic service or test that cannot be distinctly split between TC and PC is considered to be a global test or service. Examples of global tests/services are raditaion treatment delivery (Procedure codes 77401-77416).

Anti-Markup Payment Limitations for Professional and Technical Components

Medicare payment rules for certain diagnostic tests (other than clinical diagnostic laboratory tests) ordered by a billing physician or other supplier (or by a party related to the billing physisican or other supplier through commin ownership or contril) limit the amount of payment where the physician performing or supervising the diagnostic test does not share a practice with the billing/ordering physisican or other supplier. Pursuant to this "anti-markup" rule, Medicare payment must not exceed the lowest of:

The performing/supervising physician's net charge to the billing physician or other supplier;
The billing physician or other supplier's actual charge;
The fee schedule amount for the test that would be allowed if the performing/supervising physician billed directly

Both the TC and PC of certain diagnostic tests (other than clinical diagnostic laboratory tests) are subject to the anti-markup payment limitation. Examples of services subject to the anti-markup payment limitations include: x-rays, EKGs, EEGs, cardiac monitoring, and ultrasound services.

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