(Medicare Claims Processing Manual)

A physician or other supplier may bill and receive Part B payment for the technical component (TC) or professional component (PC) of diagnostic tests which the physician or other supplier contracts a physician, medical group, or other supplier to perform.  (This claim and payment procedure does not extend to clinical diagnostic laboratory tests.)  The anti -markup rule will apply to the TC or PC of diagnostic tests that have been ordered by the billing physician or other supplier (or by a party financially r elated to the billing physician or other supplier through common ownership or control) if the performing physician or other supplier does not meet the criteria for sharing a practice with the ordering/billing entity.  An example is when the attending physician orders radiology tests from a radiologist and the radiologist purchases the tests from an imaging center with whom the radiologist does not meet the criteria for sharing a practice.  Under the anti -markup payment limitation, the billing physician or other supplier may not mark up the charge for a test from the acquisition price and must accept as full payment for the test (even if assignment is not accepted) the lowest of: the fee schedule amount as if the performing physician or other supplier had billed directly, the billing entitys actual charge, or the performing physician or other suppliers net charge to the billing entity. The billing physician or other supplier must be financially related to the physician or group that ordered the tests through common ownership or control.  If the performing physician or other supplier meets the criteria for sharing a practice with the billing physician or other supplier, then the anti -markup payment limitation will not apply and the lower of the physician fee schedule amount or the billed amount will be paid.  The physician or other supplier that performed the component that is subject to the anti -markup rule must be enrolled in the Medicare program.  No formal reassignment is necessary; however, reassigned services are also subject to the anti -markup payment li mitation.   A.  Radiology Services   Contractors shall apply the anti -markup payment limitation to the TC and PC of radiology diagnostic testing services other than screening mammography procedures.  See Publication 100- 04, chapter 1, 30.2.9 for more information on the anti -markup payment limitation.   B.  Payment to a Physician or Other  Supplier of Diagnostic Tests for Services Subject to the Anti -Markup Payment Limitation   A physician or other supplier that provides diagnostic tests may bill and receive the Part B payment for the TC or PC of diagnostic tests which that physician or other supplier acquires from another physician, medical group, or other supplier.  If the perf orming physician does not meet the requirements for sharing a practice with the ordering/billing physician or other supplier, then the anti -markup payment limitation rules will apply. (See section 30.2.9 of this chapter for more information.)  If the performing physician is deemed to share a practice with the physician or other supplier that ordered the test, then the physician fee schedule amount may be billed and the anti -markup payment limitation will not apply.  In either case, the performing physician or other supplier must be enrolled in the Medicare program.  No formal reassignment is necessary; however, the anti -markup payment limitation will apply to reassigned services.   If the anti -markup rules apply, payment may not exceed the lowest of the following amounts:    The performing physician or other suppliers net charge to the billing physician or other supplier;*   The billing physician or other suppliers actual charges; or    The fee schedule amount allowed for the test if the performing physician or other supplier billed directly.   *The net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the performing physician or supplier by or through the billing entity.  For more information, see Pub. 100- 04, chapter 1, 30.2.9.  The billing physician or other supplier must keep on file the name, address, and NPI of the physician or other supplier who performed the anti -markup service.   C.  Sanctions   Physicians who knowingly and willfully, in repeated cases, bill Medicare beneficiaries amounts beyond those outlined in this chapter are subject to the penalties contained under 1842(j)(2)  of the Act.  Penalties are assigned after post -pay review depending on the severity.   D.  Questionable Business Arrangements   No special charge or payment constraints are imposed on tests performed by a physician or a technician under the physicians supervision.  There are two requirements for all diagnostic tests under 1861(s)(3) of the Act, as implemented by 42 CFR 410.32 and section 10 of chapter13 of this publication and section 80, chapter 15 of Pub. 100- 02BP.  Namely, the test must be ordered by the treating practitioner, and the test must be supervised by a physician.  However, attempts may be made by the medical diagnos tic community to adjust or establish arrangements which continue to allow physicians to profit from other's work or by creating the appearance that the physician has performed or supervised his/her technicians who are employed, contracted, or leased.  Some  of these arrangements may involve cardiac scanning services and mobile ultrasound companies leasing their equipment to physicians for the day the equipment is used, and hiring out their staff to the physicians to meet the supervision requirement.  The bona fides of such arrangements may be suspect and could be an attempt to circumvent the anti -markup payment limitation.  If you have any doubt that a particular arrangement is a valid relationship where the physician is performing or supervising the s ervices, this should be investigated.  The Office of the Inspector General (OIG) has responsibility for investigating violations of 1842(n)  of the Act.   Another arrangement to circumvent the anti -markup payment limitation is for the ordering physician to reassign his/her payment for the interpretation of the test to the supplier.  The supplier, in turn, bills for both the test and the interpretation and pa ys the ordering physician a fee for the interpretation.  This arrangement violates 1842(b)(6) of the Act, which prohibits Medicare from paying benefits due the person that furnished the service to any other person, subject to limited exceptions discussed in Pub. 100-04, chapter 1, 30.2.2.  Also, this arrangement could constitute a violation of 1128 B (b) of the Act, which prohibits remuneration for referrals (i.e., kickbacks).   Violations of 1128B (b) of the Act may subject the physician or supplier to criminal penalties or exclusion from the Medicare and Medicaid programs.  Illegal remuneration for referrals can be found even when the ordering physician performs some service for the remuneration.  30 - Computerized Axial Tomography (CT) Procedures  (Rev. 1, 10- 01-03)  A/B MACs (B) do not reduce or deny payment for medically necessary multiple CT scans of different areas of the body that are performed on the same day.  The TC RVUs for CT procedures that specify with contrast include payment for high osmolar contrast media.  When separate payment is made for low osmolar contrast media under the conditions set forth in 30.1.1, reduce payment for the contrast media as set forth in 30.1.2.  30.1 - Low Osmolar Contrast Media (LOCM) (HCPCS Codes Q9945 -Q9951)  (Rev. 627, Issued: 07- 29-05, Effective: 01 -01-05, Implementation: 10- 31-05)  HCPCS codes A4644- A4646 have been replaced with Q9945- Q0051.   30.1.1 - Payment Criteria  (Rev. 627, Issued: 07- 29-05, Effective: 01 -01-05, Implementation: 10 -31-05)  A/B MACs (B) make separate payments for LOCM (HCPCS codes Q9945 -Q9951) in the case of all medically necessary intrathecal radiologic procedures furnished to nonhospital patients.  Effective January 1, 2005 in the case of intraarterial and intravenous radiologic procedures, the five restrictive criteria (a history of previous adverse reaction to contrast material, with the exception of a sensation of heat, flushing, or a single episode of nausea or vomiting; a history of asthma or allergy; significant cardia c dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension; generalized severe debilitation; or sickle cell disease) for the payment of LOCM are eliminated.   30.1.2 - Payment Level (Rev. 627, Issued: 07- 29-05, Effective: 01 -01-05, Implementation: 10- 31-05)  Determine payment in the same manner as for a drug furnished incident to a physicians service.   The payment methodology for LOCM for the period of January 1, 2005 through March 31, 2005 is made in accordance with the established payment for calendar year 2004 using codes A4644- A4646.   Effective April 1, 2005, the method of payment for LOCM is the average sales price (ASP) plus six percent in accordance with the standard methodology for drug pricing established by the Medicare Modernization Act (MMA0 for other than hospital outpatient cl aims.  Payments for the new Q codes can be found in the respective quarterly Medicare Part B drug pricing files that are posted on the CMS Web site.  30.1.3 - SNF Billing and A/B MAC (A) Payment for Contrast Material Other Than Low Osmolar Contrast Material (LOCM) (Radiology)  (Rev. 1, 10- 01-03)  When a radiology procedure is provided with contrast material, a SNF should bill using the CPT -4 code that indicates with contrast material.  If the coding does not distinguish between with and without contrast material, the SNF should use the availa ble code.   Contrast material other than LOCM may be billed separately in addition to the radiology procedure, or it may be billed as part of the amount for the radiology procedure.  If the SNF bills separately for the contrast material and the charge for the procedur e includes a charge for contrast material, the SNF must adjust the charge for the procedure to exclude any amount for the contrast material.  Regardless of the billing method used, charges are subject to the fee schedule.   When billing separately for this contrast material, the SNF should use revenue code 0255 (drugs incident to radiology and subject to the payment limit) and report the charge on the same bill as the radiology procedure.  The A/B MAC (A)  will not accept late charge bills for this service.   30.1.3.1 - A/B MAC (A) Payment for Low Osmolar Contrast Material (LOCM) (Radiology)  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  The LOCM is paid on a reasonable cost basis when rendered by a SNF to its Part B patients (in addition to payment for the radiology procedure) when it is used in one of the situations listed below.  The following HCPCS are used when billing for LOCM.  HCPCS Code  Description (January 1. 1994, and later)  A4644  Supply of low osmolar contrast material (100 -199 mgs of iodine);  A4645  Supply of low osmolar contrast material (200 -299 mgs of iodine); or  A4646  Supply of low osmolar contrast material (300 -399 mgs of iodine).   When billing for LOCM, SNFs use revenue code 0636.  If the SNF charge for the radiology procedure includes a charge for contrast material, the SNF must adjust the charge for the radiology procedure to exclude any amount for the contrast material.   NOTE:  LOCM is never billed with revenue code 0255 or as part of the radiology procedure.   The A/B MAC (A) will edit for the intrathecal procedure codes and the following codes to determine if payment for LOCM is to be made.  If an intrathecal procedure code is not present, or one of the ICD codes is not present to indicate that a required medic al condition is met, the A/B MAC (A) will deny payment for LOCM.  In these instances, LOCM is not covered and should not be billed to Medicare.  When LOCM Is Separately Billable and Related Coding Requirements    In all intrathecal injections.  HCPCS codes that indicate intrathecal injections are: