Complete Story
03/18/2010Reimbursement Update - Recent Medicare Changes/ClarificationsBy, Joy Newby, LPN, CPC, Newby Consulting, Inc.
The "Temporary Extension Act of 2010" Extends the Zero Percent Medicare Physician Fee Schedule Update - CMS Releases Claims for Processing
http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21827
On March 2, 2010, President Obama signed into law the "Temporary Extension Act of 2010." Among other things, this law extends through March 31, 2010, the zero percent update to the Medicare physician fee schedule that was in effect for claims with dates of service January 1, 2010, through February 28, 2010.
Consequently, effective immediately, claims with dates of service March 1 and later which were being held by Medicare contractors will be released for processing and payment. Please keep in mind that the statutory payment floors still apply and, therefore, clean electronic claims cannot be paid before 14 calendar days after the date they are received by Medicare contractors (29 calendar days for clean paper claims).
Please watch your Listserv and contractor's Web site for more information about the new legislation. Posted 03/04/2010
CMS Cancels Change Request 6375 Place of Service and Date of Service Instructions for the Interpretation Professional Component and Technical Component of Diagnostic Tests
http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21623
Good news for ophthalmology, CMS has rescinded Change Request (CR) 6375, Transmittal 1873, dated December 11, 2009, and will replace it with another CR in the future, pending further policy clarification on date of service and place of service reporting for the interpretation of diagnostic tests. The revised CR will address the full spectrum of clinical scenarios.
The accompanying Medicare Learning Network (MLN) Matters article, MM6375, is also rescinded. Another MLN Matters article will be issued when the new CR is released. Posted 02/10/2010
Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation
http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21458
Section 1842(n)(1) of the Social Security Act requires CMS to impose a payment limitation on certain diagnostic tests where the physician performing or supervising the test does not share a practice with the billing physician or other supplier. Such a test was formerly referred to as a "purchased diagnostic test". In the CY 2009 MPFS final rule (73 Federal Register 69799, November 19, 2008), CMS finalized changes to 42 CFR section 414.50 to include alternative methods to determine when not to apply anti-markup rules.
When the anti-markup provision applies, it is applicable to the professional component as well as the technical component of a diagnostic test that is billed by a physician or other supplier that did not perform the test.
The anti-markup payment limitation applies when:
- A diagnostic test, payable under the Medicare physician fee schedule (MPFS), is performed by a physician who does not meet the requirements, described in 42 CFR section 414.50 and in the revised §30.2.9 of the Medicare Claims Processing Manual for "sharing a practice" with the billing physician or other supplier.
When the anti-markup payment limitation applies, payment to the billing physician or other supplier (less any applicable deductibles or coinsurance) for the technical component (-TC) or professional component (PC; modifier -26) of the diagnostic test may not exceed the lowest of the following amounts:
1. The performing supplier's net charge to the billing physician or other supplier
2. The billing physician or other supplier's actual charge
3. The MPFS amount for the test that would be allowed if the performing supplier had billed directly
The net charge must be determined without regard to any charge that reflects the cost of equipment or space leased to the performing physician.
The anti-markup payment limitation will not apply:
- If the physician or other supplier does not order the diagnostic test; or
- If the performing/supervising physician is deemed to "share a practice" with the billing physician or other supplier. There are two alternative methods for determining whether the performing/supervising physician is deemed to "share a practice." Those alternatives are
Alternative one, "substantially all services" test:
Ø If the performing physician (the physician who supervises or conducts the TC, performs the PC, or both) furnishes substantially all (at least 75 percent) of his or her professional services through the billing physician or other supplier, the anti-markup payment limitation will not apply.
Alternative two, "site of service/same building" test:
Ø If the TC or the PC is supervised/performed in the "office of the billing physician or other supplier" by a physician owner, employee, or independent contractor of the billing physician or other supplier, the anti-markup payment limitation will not apply.
Ø The "office of the billing physician or other supplier" is any medical office space, regardless of the number of locations, in which the ordering physician regularly furnishes patient care. This includes space where the billing physician or other supplier furnishes diagnostic testing services, if the space is located in the "same building" in which the ordering physician regularly furnishes patient care.
Ø If the billing physician or other supplier is a physician organization, the "office of the billing physician or other supplier" is space in which the ordering physician provides substantially the full range of patient care services that the ordering physician provides generally. With respect to the TC, the performing physician is the physician who conducted and/or supervised the TC, and with respect to the PC, the performing physician is the physician who personally performed the PC.
Key Billing Points of Change Request 6733
- The anti-markup payment limitation will apply if the performing physician does not "share a practice" with the billing physician or other supplier who ordered the test.
- If the anti-markup payment limitation applies, the billing physician or other supplier will be paid for the -TC or PC (-26) of the diagnostic test (less any applicable deductibles or coinsurance) the lower of:
1) the performing physician's net charge to the billing physician or other supplier;
2) the billing physician or other supplier's actual charge; or
3) the MPFS amount for the test that would be allowed if the performing physician had billed directly.
- The anti-markup payment limitation will not apply if the performing/supervising physician "shares a practice" with the billing physician or other supplier.
- If the performing physician (the physician who supervises or conducts the -TC, performs the -PC [-26], or both) furnishes substantially all (at least 75 percent) of his or her professional services through the billing physician or other supplier, the anti-markup payment limitation will not apply.
- If the -TC or PC (-26) is supervised/performed in the "office of the billing physician or other supplier" or in the "same building" by a physician owner, employee, or independent contractor of the billing physician or other supplier, the anti-markup payment limitation will not apply.
- The billing physician or other supplier must keep on file the name, the National Provider Identifier, and address of the performing physician. The physician or other supplier furnishing the -TC or PC (-26) of the diagnostic test must be enrolled in the Medicare program. No formal reassignment is necessary.
Note: When billing for the -TC or PC (-26) of a diagnostic test (other than a clinical diagnostic laboratory test) that is performed by another physician, the billing entity must indicate the name, address and NPI of the performing physician in Item 32 of the CMS-1500 claim form. However, if the performing physician is enrolled with a different Medicare contractor, the NPI of the performing physician is not reported on the CMS-1500 claim form. In this instance, the billing entity must submit its own NPI with the name, address, and ZIP code of the performing physician in Item 32 of the CMS-1500, or electronic equivalent, claim form. The billing supplier should maintain a record of the performing physician's NPI in the clinical record for auditing purposes.
- If the billing physician or other supplier performs only the -TC or the -PC (-26) and wants to bill for both components of the diagnostic test, the TC and PC must be reported as separate line items if billing electronically (ANSI X12 837) or on separate claims if billing on paper (CMS-1500). Global billing is not allowed unless the billing physician or other supplier performs both components.
Additional Information
New Health Privacy and Security Requirements
The American Medical Association has published an excellent summary of the new HIPAA requirements. The American Recovery and Reinvestment Act (ARRA) signed into law on February 17, 2009 extends HIPAA requirements for patient health information privacy and security protections. The new requirements effect covered entities (including physician) and their business associates.
The AMA's summary can be found on the AMA's website at http://www.ama-assn.org/ama1/pub/upload/mm/368/hipaa-guidance.pdf
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