(Medicare Claims Processing Manual)

For services furnished prior to January 1, 1999, A/B MACs (B)  pay separately under the physician fee schedule for the interpretation of an abnormal pap smear furnished to a hospital inpatient by a physician.  They must pay under the clinical laboratory fee schedule for pap smears furnished in all other situations.  This  policy also applies to screening pap smears requiring a physician interpretation.  For services furnished on or after January 1, 1999, A/B MACs (B)  allow separate payment for a physicians interpretation of a pap smear to any patient (i.e., hospital or n on-hospital) as long as:  (1) the laboratorys screening personnel suspect an abnormality; and (2) the physician reviews and interprets the pap smear.   This policy also applies to screening pap smears requiring a physician interpretation and described in the National Coverage Determination Manual and Chapter 18.  These services are reported under codes P3000 or P3001.  Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies.  It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormali ty identified by the technologist. These codes include 85060, 38220, 85097, and 38221.  A/B MACs (B) pay the PC for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory.   For other hematology codes, payment may be made for the PC component if the service is furnished to a patient by a hospital physician or independent laboratory.  In addition, payment may be made for these services furnished to patients by an independent la boratory.   Blood banking services of hematologists and pathologists are paid under the physician fee schedule when analyses are performed on donor and/or patient blood to determine compatible donor units for transfusion where cross matching is difficult or where contamination with transmissible disease of donor is suspected.   The blood banking codes are 86077, 86078, and 86079 and represent professional component only services.   3. Clinical Consultation Services   Clinical consultations are paid under the physician fee schedule only if they:   a. Are requested by the patients attending physician;   b. Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient;   c. Result in a written narrative report included in the patients medical record; and   d. Require the exercise of medical judgment by the consultant physician.  Clinical consultations are professional component services only, i.e., there is no TC service. The clinical consultation codes are 80500 and 80502.  Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met.  Laboratory personnel, including the director, may from time to time cont act attending physicians to report test results or to suggest additional testing or be contacted by attending physicians on similar matters.  These contacts do not constitute clinical consultations.  However, if in the course of such a contact, the attendi ng physician requests a consultation from the pathologist, and if that consultation meets the other criteria and is properly documented, it is paid under the fee schedule.   EXAMPLE:  A pathologist telephones a surgeon about a patients suitability for surgery based on the results of clinical laboratory test results.  During the course of their conversation, the surgeon asks the pathologist whether, based on test results, patient histor y and medical records, the patient is a candidate for surgery.  The surgeons request requires the pathologist to render a medical judgment and provide a consultation.  The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patients medical record that he/she requested a consultation.  This consultation is paid under the fee schedule.   In any case, if the information could ordinarily be furnished by a nonphysician laboratory specialist, the service of the physician is not a consultation payable under the fee schedule.   See the Program Integrity Manual for guidelines for related data analysis to identify inappropriate patterns of billing for consultations.  4. Clinical Laboratory Interpretation Services   Only clinical laboratory interpretation services, which meet the criteria in subsections C.3.a, c, and d, are billable under the physician fee schedule.  These codes have a PC/TC indicator of 6 on the Medicare Physician Fee Schedule database.  These serv ices are reported under the clinical laboratory code with modifier 26.  These services can be paid under the physician fee schedule if they are furnished to a patient by a hospital pathologist or an independent laboratory.  Note that a hospitals standing order policy can be used as a substitute for the individual request by the patients attending physician.  A/B MACs (B) are not allowed to revise CMSs list to accommodate local medical practice.  The CMS periodically reviews this list and adds or deletes clinical laboratory codes as warranted.   D. Global Billing   Billing globally for services that are split into separate PC and TC services is only possible when the PC and TC are furnished by the same physician or supplier entity.  For example, where the PC and the TC of a diagnostic service are provided in the same service location, this is reflected as the address entered into Item 32 on CMS Form 1500, which provides the ZIP Code to pay the right locality/GPCI.  In this case, the physician/entity may bill globally.  However, if the PC and the TC are each provided in different service locations (enrolled practice locations), the PC and the TC must be separately billed.   Merely applying the same place of service (POS) code to the PC and the TC does not permit global billing for any diagnostic procedure.  70 - Payment Conditions for Radiology Services  (Rev. 1, 10-01-03) B3-15022 See chapter 13, for claims processing instructions for radiology. 80 - Services of Physicians Furnished in Providers or to Patients of Providers  (Rev. 1, 10-01-03) B3-15014  This section sets forth special conditions that govern payments for services that physicians furnish in, or to patients of, providers of services including hospitals, SNFs, or Comprehensive Outpatient Rehabilitation Facilities ( CORFs).  If physicians are compensated for their services by a provider or another entity, the compensation they receive must be allocated among the various types of services they furnish. The A/B MAC (A) pays for services that physicians furnish to the provider.  Physician services to the provider include, but are not limited to, standby surgical services.  Payment for physicians services to individual patients that meet the conditions in subsection A is made under the physicians fee schedule.  However:  Payment for physicians services furnished in teaching settings is subject to the additional conditions in 100;  Payment for physicians services furnished to ESRD patients is subject to additional requirements in Chapter 8, and  The A/B MAC (A) pays for the services of residents, as well as for physicians who are licensed to practice only in the provider setting, as provider services.  (See 100.2)  A. Conditions for Physician Fee Schedule Payment for Physicians Services to Patients in Providers   1. General  A/B MACs (B) pay for physicians services to patients of providers on a fee schedule basis only if the following requirements are met:   The services are personally furnished for an individual patient by a physician;  The services contribute directly to the diagnosis or treatment or an individual patient;  The services ordinarily require performance by a physician; and  In the case of anesthesiology, radiology, or pathology/laboratory services, certain additional requirements in 50, 60, and 70 are met.  2. Services of Physicians to Patients in Providers  If a physician furnishes services to a patient in a hospital or SNF that do not meet the requirements in 80.A.1 , above, but are related to patient care, the services may be covered as provider services and paid by the A/B MAC (A) within the applicable Prospective Payment System (PPS) rate.  3. Effect of Billing Charges for Physician Services to Provider  If services furnished by a physician to a provider may be paid by the A/B MAC (A), neither the provider nor the physician may seek fee schedule payments from the A/B MAC (B), the beneficiary, or another insurer.  A/B MACs (B) must report any situation in which this happens to the RO unless it is clearly an isolated case of billing error.  4. Effect of Assumption of Operating Costs  If a physician or an entity enters into an agreement (such as a lease or concession) with a provider under which the physician (or entity) assumes some or all of the operating costs of the provider department:  A/B MACs (B) make fee schedule payments only for physicians services to individual patients;  The physician (or other entity) must make its books and records available to the provider and the A/B MAC (A), as necessary, to verify the nature and extent of the costs of the services furnished by the physician (or other entity); and  The lessees costs associated with producing these services, including overhead, supplies, equipment, and the costs of employing nonphysician personnel are payable by the A/B MAC (A) as provider services.  80.1 - Coverage of Physicians Services Provided in Comprehensive Outpatient Rehabilitation Facility  (Rev. 1, 10-01-03) B3-2220  Rehabilitation services furnished by comprehensive outpatient rehabilitation facilities (CORFs) are covered by Medicare Part B.   Under 1832(a)(2)(E), and 1861(cc)(2) (go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm and select the applicable title) and related provisions of the Act, a CORF is recognized as a provider of services on the basis of its reasonable costs.  Except for diagnostic and therapeutic services provided by physicians to individual patients, payment is made to the CORF by A/B MACs (A) (acting in the role of the A/B MAC (B).)  Physicians diagnostic and therapeutic services furnished to a CORF patient are not considered CORF physicians services.  Instead they are services that the physician must bill to the A/B MAC (B).  If covered services, payment is made according to the Medicare Physician Fee Schedule.  When physicians diagnostic and therapeutic services are furnished in a CORF, the claim must be annotated to show the CORF as the place of treatment.  Services considered administrative services provided by the physician associated with the CORF are considered CORF services reimbursable to the CORF by the A/B MACs (A).  Administrative services include consultation with and medical supervision of nonphysi cian staff, establishing and reviewing the plan of treatment, and other medical and facility administration activities.  80.2 - Rural Health Clinic and Federally Qualified Health Center Services  (Rev. 1, 10-01-03) B3-2260-2260.3