Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare Guidance Says A/B MACs (B) may not pay for the technical component (TC) of radiology services 
furnished to hospital patients. Payment for physicians radiological services to the hospital, e.g., administrative 
or supervisory services, and for provider services needed to produce the radiology service, is made by the AB 
MAC (A) to the hospital as a provider service. Hospital bundling rules exclude payment to suppliers of the TC 
of a radiology service for beneficiaries in a hospital inpatient stay. CWF performs reject edits to incoming 
claims from suppliers of radiology services. Upon receipt of a hospital inpatient claim at the CWF, CWF 
searches paid claim history and compares the period between the hospital inpatient admission and discharge 
dates to the line item service date on a line item TC of a radiology service billed by a supplier. The CWF will 
generate an unsolicited response when the line item service date falls within the admission and discharge dates 
of the hospital inpatient claim. 
 
Many of the diagnostic services, including radiology services, provided by physicians/practitioners contain 
both a technical component (TC) and a professional component (PC). Often, the PC and TC of diagnostic 
services are furnished in different settings. As a general policy, the Place of Service (POS) code assigned by 
the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary 
received the TC service. 
Determination of Payment Locality Under the Medicare physician fee schedule (MPFS), payment amounts are 
based on the relative resources required to provide services and vary among payment localities as resource 
costs vary geographically as measured by the geographic practice cost indices (GPCIs). The payment locality is 
determined based on the location where a specific service code was furnished. For purposes of determining the 
appropriate payment locality, CMS requires that the address, including the ZIP code for each service code be 
included on the claim form in order to determine the appropriate payment locality. The location in which the 
service code was furnished is entered on the ASC X12 837 professional claim format or in Item 32 on the paper 
claim Form CMS 1500. 
Separate Billing of Professional Interpretation If the same physician or other supplier entity does not furnish 
both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both 
the TC and PC but the professional interpretation was furnished in a different payment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier -
26 by the interpreting physician. You can find this information in the Medicare Claims Processing Manual, 
Chapter 13  Radiology Services and Other Diagnostic Procedures, Section 150  Place of Service (POS) 
Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of 
Diagnostic Tests. 
 
The rules say 1 = Diagnostic tests or radiology services: This indicator identifies codes that describe diagnostic 
tests, e.g., pulmonary function tests, or therapeutic radiology procedures, e.g., radiation therapy. These codes 
generally have both a professional and technical component. Modifiers 26 and TC can be used with these 
codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice 
expense, and malpractice expense. The total RVUs for codes reported with a TC modifier include values 
for practice expense and malpractice expense only. The total RVUs for codes reported without a modifier 
equals the sum of RVUs for both the professional and technical component. You can find Medicare guidance in 
the Medicare Claims Processing Manual, Chapter 23  Fee Schedule Administration and Coding Requirements, 
Section 50.6 Physician Fee Schedule Payment Policy Indicator File Record Layout. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.