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 National Correct Coding Initiative Policy Manual, Chapter I General Correct Coding 
Policies, A. Introduction: Physicians must report services correctly. This manual discusses general coding 
principles in Chapter I, and principles more relevant to other specific groups of HCPCS/CPT codes in the other 
chapters. There are certain types of improper coding that physicians must avoid. Medicare Claims Processing 
Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures; Section 20.2.1 - Hospital and 
Skilled Nursing Facility (SNF) Patients, Section 150  Place of Service (POS) Instructions for the Professional 
Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests: 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. Interpretation Provided Under Arrangement - To A Hospital Separate TC and PC If a 
diagnostic test which has a separate TC and PC is provided under arrangement to a hospital, the physician who 
reads the test can bill and be paid for the professional component. Both the technical and professional 
components of the test are also subject to the physician self-referral prohibition. The appropriate POS code for 
the interpretation (or PC) is the setting where the beneficiary received the TC service. If the interpretation is 
performed in the physicians office and the patient received the TC service in the provider-based outpatient 
hospital setting, the physician assigns POS code 22, for On Campus-Outpatient Hospital, or POS 19, for Off Campus [1] Outpatient Hospital, on the claim for the interpretation or PC. 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. Medicare Claims Processing Manual, Chapter 23  Fee 
Schedule Administration and Coding Requirements, Section 50.6  Physician Fee Schedule Payment Policy 
Indicator File Record Layout: 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. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.