Midlevel providers (MLPs) who obtain their own provider numbers may be reimbursed by Medicare (or the group employing them may be) for any diagnostic testing they perform that is within the scope of their licensure under state law as long as a physician would be reimbursed by Medicare if he or she performed the same service.
Full Answer
Can I bill Medicare for diagnostic testing?
Diagnostic laboratory tests. Medicare Part B (Medical Insurance) Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. covers medically necessary clinical diagnostic laboratory tests, when your doctor or provider orders them.
Can I claim for MRI services provided with ineligible MRI equipment?
diagnostic services, in order to be covered these services must be related to a patient’s illness or injury (or symptom or complaint) and ordered by a physician. A small number of laboratory tests can be covered as a preventive screening service. See the Medicare Benefit Policy Manual, Chapter 15, for detailed coverage requirements.
What tests are covered by Medicare?
You and your patients can only claim Medicare benefits for diagnostic imaging or radiation oncology services if the practice: has registered for an LSPN is accredited to provide diagnostic imaging services. Practices that only provide radiation oncology services don’t need to be accredited. Registering for an LSPN
Can a doctor claim Medicare if they are not accredited?
Medicare Claims Processing Manual . Chapter 13 - Radiology Services and Other Diagnostic Procedures . Table of Contents (Rev. 11021, 10-01-21) Transmittals for Chapter 13. 10 - ICD Coding for Diagnostic Tests 10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures 20 - Payment Conditions for Radiology Services
How is Medicare payment based on locality?
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. Global Service Code
Who must pay for TC of radiology services?
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 physician’s office, a freestanding imaging or radiation oncology center, or other setting that is not part of a hospital.
What is the SNF code for contrast material?
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 available code.
How much iodine is in a low osmolar contrast material?
Supply of low osmolar contrast material (100-199 mgs of iodine); Supply of low osmolar contrast material (200-299 mgs of iodine); or Supply of low osmolar contrast material (300-399 mgs of iodine).
What is CPT code 79900?
In addition, CPT code 79900 is separately payable in connection with certain clinical brachytherapy procedures. (See §70.4 for brachytherapy procedures).
Is contrast media included in PE RVUs?
With the implementation for calendar year 2007 of a bottom-up methodology, which utilizes the direct inputs to determine the practice expense (PE) relative value units (RVUs), the cost of the contrast media is not included in the PE RVUs. Therefore, a separate payment for the contrast media used in various imaging procedures is paid. In addition to the CPT code representing the imaging procedure, separately bill the appropriate HCPCS “Q” code (Q9945 – Q9954; Q9958-Q9964) for the contrast medium utilized in performing the service.
What is the ASC X12 837?
Claims for PET scan services must be billed using the ASC X12 837 professional claim format or on Form-CMS 1500 with the appropriate HCPCS or CPT code and diagnosis codes to the A/B MAC (B). Effective for claims received on or after July 1, 2001, PET modifiers were discontinued and are no longer a claims processing requirement for PET scan claims. Therefore, July 1, 2001, and after the MSN messages regarding the use of PET modifiers can be discontinued. The type of service (TOS) for the new PET scan procedure codes is TOS 4, Diagnostic Radiology. Payment is based on the Medicare Physician Fee Schedule.
What are the Medicare reimbursement rules?
The basic Medicare reimbursement rules impose strict requirements on who may bill for a service performed by another. These rules are referred to as the “reassignment rules” because the clinician who accepts assignment of the claim reassigns it to another entity. They also implicate diagnostic testing arrangements.
Why is diagnostic testing important?
Medicare controls how it must be provided, obtained and billed to avoid false claims liability, Stark violations and breach of the reassignment rules. You should carefully review your organization, employment and compensation arrangements to avoid pitfalls in this confusing arena.
What is direct supervision?
Direct supervision, which requires a physician in the group (not necessarily the attending or ordering physician) on the premises in the office suite; Personal supervision, which requires a physician in the room with the patient when the service is being provided. The physician need not be the attending or ordering physician.
Is diagnostic testing a Medicare benefit?
In the 2003 Medicare Fee Schedule, the regulators stated their position that diagnostic testing is not a physician service but rather a separate Medicare benefit subject to its own rules, even when performed in a physician practice. 1 Diagnostic testing performed by ancillary personnel (e.g., technicians, nurses and medical assistants) must meet a separate set of physician supervision requirements. 2 (Most other services rendered by clinical staff in physician offices must meet the criteria for “incident to” billing. See “The Ins and Outs of ‘Incident-To’ Reimbursement,” FPM, November/December 2001, page 23 .) One of the following levels of supervision must be met for a diagnostic testing service to be reimbursable, even if it’s billed “incident to” a physician. The CPT code will specify the level of supervision that the service requires:
What is a local coverage determination?
What’s a "Local Coverage Determination" (LCD)? LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC’s jurisdiction (region) in accordance with section 1862 (a) (1) (A) of the Social Security Act. MACs are Medicare contractors that develop LCDs and process Medicare claims.
What is MAC in Medicare?
MACs are Medicare contractors that develop LCDs and process Medicare claims. The MAC’s decision is based on whether the service or item is considered reasonable and necessary.
What is Medicare Part B?
Medicare Part B (Medical Insurance) Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. , or both. You need the item (s) or service (s) determined not covered by the LCD.
What is the loop for 837P 2400?
1. Complete the 837P 2400 loop (Purchased service information ), segments PS101 (Purchased service provider identifier) indicating the NPI of the entity who actually rendered the service and PS102 (Purchased service charge amount) indicating the amount you paid to the performing entity for the service.
Can you claim a TC from a separate entity?
A: If you purchased the technical component (TC) or interpretation (PC) of certain diagnostic tests from a separate entity that does not share a practice location with the billing provider , submit a separate claim for the anti-markup (purchased) service.
Where is the ICN number on a 277CA claim?
The ICN / DCN number must be obtained on the 277CA claims acknowledgement report after submitting the electronic claim. The ICN / DCN is located in the 2200D REF segment. If you do not normally receive the 277CA or do not know how to retrieve it with your software, please contact your software vendor.
Can PC-ACE send medical documents?
Ability | PC-ACE Users can send medical documentation by completing the appropriate sections of the claim form screen and using the Medicare Fax Cover Sheet for Submitting Unsolicited Paperwork (PWK) Segments.
