(Medicare Claims Processing Manual)

Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are submitted to the AB MAC (A).  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for radiology services.   As a result of SNF Consolidated Billing (Section 4432(b) of the Balanced Budget Act (BBA) of 1997), A/B MACs (B) may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay.  The SNF must  bill radiology services furnished its inpatients in a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS).   Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service or by the SNF under arrangements with the supplier.  If billed by the SNF, Medicare pays according to the Medicare Physician Fee Schedule.  SNFs submit  claims to the AB MAC (A) with type of bill 22X or 23X.  20.2.2 - Services Not Furnished in Hospitals  (Rev. 1, 10- 01-03)  A/B MACs (B) must pay under the fee schedule for the TC of radiology services furnished to beneficiaries who are not patients of any hospital, and who receive services in a physicians office, a freestanding imaging or radiation oncology center, or other s etting that is not part of a hospital.   20.2.3 - Services Furnished in Leased Departments  (Rev. 1, 10- 01-03)  In the case of procedures furnished in a leased hospital radiology department to a beneficiary who is neither an inpatient nor an outpatient of any hospital, e.g., the patient is referred by an outside physician and is not registered as a hospital outpatie nt, both the PC and the TC of the services are payable under the fee schedule by the A/B MAC (B).   20.2.4  Services That Do Not Meet the National Electrical Manufacturers Association (NEMA) Standard XR -29-2013 (Rev.  3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)  Section 218(a) of the Protecting Access to Medicare Act of 2014 (PAMA) is titled Quality Incentives To Promote Patient Safety and Public Health in Computed Tomography Diagnostic Imaging.  It amends the Social Security Act (SSA) by reducing payment for the technical component (and the technical component of the global fee) of the Physician Fee Schedule service (5 percent in 2016 and 15 percent in 2017 and subsequent years) for computed tomography (CT) services identified by CPT codes 70450 -70498, 71250 -71275, 72125 -72133, 72191 -72194, 73200 -73206, 73700 -73706, 74150 -74178, 74261- 74263, and 75571 -75574 furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard  XR-29-2013, entitled Standard Attributes on CT Equipment Related to Dose Optimization and Management.  The statutory provision requires that information be provided and attested to by a supplier and a hospital outpatient department that indicates whether an applicable CT service was furnished that was not consistent with the NEMA CT equipment standard, and that such information may be included on a claim and may be a modifier.  The statutory provision also provides that such information shall be verified, as appropriate, as part of the periodic accreditation of suppliers under SSA section 1834(e) and hospita ls under SSA section 1865(a).  Any reduced expenditures resulting from this provision are not budget neutral.  To implement this provision, CMS created modifier CT (Computed tomography services furnished using equipment that does not meet each of the att ributes of the National Electrical Manufacturers Association (NEMA) XR -29-2013 standard).  Beginning in 2016, claims for CT scans described by above -listed CPT codes (and any successor codes) that are furnished on non -NEMA Standard XR -29-2013- compliant CT scans must include modifier CT that will result in the applicable payment reduction.   A list of codes subject to the CT modifier will be maintained in the web supporting files for the annual rule.  Beginning January 1, 2016, a payment reduction of 5 percent applies to the technical component (and the technical component of the global fee) for Computed Tomography (CT) services furnished using equipment that is inconsistent with the CT equipment standard and for which payment is m ade under the physician fee schedule.  This payment reduction becomes 15 percent beginning January 1, 2017, and after.  20.2.5 - Special Rule to Incentivize Transition from Traditional X- Ray Imaging to Digital Radiography  (Rev. 3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)  Section 502(a)(1) of the  Consolidated Appropriations  Act of 2016 is titled "Medicare Payment Incentive for the Transition from Traditional X -Ray Imaging to Digital Radiography and Other Medicare Imaging Payment Provision."   It amends the Social Security Act (SSA) by reducing the  payment amounts under the Physician Fee Schedule by 20 percent for the technical component (and the technical component of the global fee) of  imaging services that are X -rays taken using film, effective January 1, 2017, and after.    Modifier FX (X ray taken using film) was created to implement this provision.   Beginning January 1, 2017, claims for  X-rays using film must include modifier FX, which will result in the applicable payment reduction.   20.2.5.1 - Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs), and Medicare Summary Notice (MSN)  (Rev. 3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)  Contractors shall use the following messages when adjusting x- ray radiograph claim lines that have been reported with the FX modifier:  CARC 237  Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)   RARC N775 - Payment adjusted based on x -ray radiograph on film.   MSN 30.1 -  The approved amount is based on a special payment method.   20.2.6 - Special Rule to Incentivize Transition from X-rays taken using Computed Radiography to Digital Radiography (Rev.  3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)  1848 (b)(9) of the Social Security Act provides that payments for imaging services that are X -rays taken using computed radiography (including the X -ray component of a packaged service) furnished during CY 2018, 2019, 2020, 2021, or 2022, that would  other wise be made under the PFS (without application of subparagraph (B)(i)  and before application of any other adjustment), be reduced by 7 percent, and similarly, if such X -ray services are furnished during CY 2023 or a subsequent year, by 10 percent.   Computed radiography technology is defined for purposes of this paragraph as cassette -based imaging which utilizes an imaging plate to create the image involved.   Modifier FY was created to implement this provision.   Beginning January 1, 2018, claims for  computed radiography must include modifier FY, which will result in the applicable payment reduction.   20.3  Anti -Markup Payment Limitation  (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)  Section 1842(n) (1) of the Social Security Act (the Act) establishes payment rules for certain diagnostic tests (other than clinical diagnostic laboratory tests) where the physician performing or supervising the test does not share a practice with the billing physician or  other supplier.  Examples of tests covered under this rule include, but are not limited to: x- rays, EKGs, EEGs, cardiac monitoring, and ultrasound services furnished on or after January 1, 1994.  (Note that screening mammography services are covered under  another provision of the Act and are not subject to the anti -markup payment limitation.)  The anti -markup payment limitation applies to the technical component or TC of certain diagnostic tests that are payable on the Medicare Physician Fee Schedule (MP FS).  Effective January 1, 2009, the anti -markup payment limitation also applies to the professional component or (PC) of diagnostic tests (other than clinical diagnostic tests). The anti- markup payment limitation only applies when a physician (or other supplier) orders and bills for a diagnostic test in which the TC or PC is performed by a physician who does not share a practice with the ordering/billing physician (or other supplier).  For more information on the anti -markup payment limitation, see cha pter 1, 30.2.9.  20.3.1  A/B MAC (B) Payment Rules (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)  If a diagnostic test (other than a clinical diagnostic laboratory test) is personally performed or is supervised by a physician, such physician may bill under the normal physician fee schedule rules.  This includes situations in which the test is performed or supervised by another physician with whom the billing physician shares a practice (see Pub. 100- 04, chapter 1, 30.2.9).  Section 80, chapter 15, of Pub. 100-02, Medicare Benefit Policy, sets forth the various levels of physician supervision required f or diagnostic tests.  The supervision requirement for physician billing is not  met when the test is administered by supplier personnel regardless of whether the test is performed at the physician's office or at another location.   If a physician bills for a diagnostic test that is subject to the anti- markup payment limitation, the fee schedule amount for the acquired service equals the lower of:    The performing physician or other suppliers net charge to the billing physician or other supplier for performing the service;    The billing physician or other suppliers actual charge; or    The fee schedule amount allowed for the jurisdiction where the service was performed.   The lowest figure is the fee schedule amount for purposes of the limiting charge.  (See chapter 1, 30.3.12.1 of this publication)  The billing entity must identify the performing physician or other supplier (including the performing providers NPI) and the amount the performing physician or other supplier charged the billing entity (net of any discounts).  A physician who accepts assignment is permitted to bill and collect from the beneficiary only the applicable deductible and coinsurance for the acquired  test.  A physician who does not accept assignment is permitted to bill and collect from the beneficiary only the fee schedule amount (as defined above) for the acquired test.  The limiting charge provision is not applicable.  If the physician does not identify who performed the test and provide the other required information, no payment is allowed.  The physician may not bill the beneficiary any amount for the test.   20.3.2 - Billing for Services  (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)  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.