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In
this issue
·
Quarterly CCI edits posted
MGMA
asks CMS to delay instruction on place and date of service for diagnostic tests
The
Centers for Medicare & Medicaid Services (CMS) has released
instructions to its contractors on processing claims for diagnostic tests.
Transmittal 1823 relates to the place of service (POS) and date of service
(DOS) for the professional component or interpretation (PC) and technical
component (TC) of diagnostic tests, including tests subject to the new
anti-markup rule.
The new
anti-markup rule is a payment limitation that took effect on Jan. 1, 2009,
and was formerly known as the purchased diagnostic test rule. (See Dec.
15, 2008, Washington Connexion). It prohibits an ordering and
billing entity, such as a physician or group practice, from marking up
either the PC or the TC of a test ordered by the billing entity but
performed by a physician who does not “share a practice” with that entity.
The rule is complex and has resulted in confusion among healthcare providers.
CMS has also had to clarify the rule and its application to its
contractors.
In Transmittal
1823, CMS generally instructs its contractors on the application of the
anti-markup rule and the POS for such services. It also includes specific
instructions on the POS and DOS for diagnostic tests in general. CMS
clarifies that only one POS (other than “home”) may be submitted on the
CMS-1500 and provides guidance on using POS codes for “office,” “ambulatory
surgery center,” “hospital outpatient,” “temporary lodging” and “other.”
CMS will
now require the actual POS and DOS of the PC to be included on the claim,
even when they differ from the date and location of the TC. Payment for the
PC will be based on the ZIP code of the location where the interpretation
is actually performed. This change will affect situations where the TC of a
service was performed one day but the PC was performed on a different day
or in a different location (for example, when interpretations are done
through teleradiology). Note that special rules apply for the DOS of the TC
of clinical laboratory and pathology specimens.
The
Medical Group Management Association (MGMA), the Radiology Business
Management Association and others asked CMS in a letter
to delay implementing this instruction to allow time to address serious
concerns about the policy. MGMA is concerned that healthcare providers,
patients reading their explanation of benefits and secondary payers that
use the date of the TC as the date a test was performed may become confused
about the actual test date. Similarly, having separate locations for the PC
and TC may also result in confusion and even payment by two separate
Medicare Administrative Contractors for one diagnostic test.
This new
policy is set to take effect on Jan. 4. MGMA will advocate on this issue
and provide updates as they become available.
Read Transmittal
1823.
Read MGMA’s
letter to CMS.
CMS instructs contractors on ambiguous anti-markup
claims
In
Transmittal 1842, which is set to take effect on April 1, 2010, the Centers
for Medicare & Medicaid Services (CMS) instructs its contractors on how
to address billing ambiguities associated with Item 20 on the CMS-1500 (or
its electronic equivalent). Item 20 is where billing entities indicate
whether the service being billed is subject to the anti-markup rule (see
summary above); it was previously used primarily for “purchased diagnostic
tests.”
The
following policies will apply to Item 20 or its electronic equivalent for
both the technical and professional components:
- If a “Yes” or
“No” is not indicated in Item 20 and the associated dollar amount is
missing, contractors will assume the service is not subject to the
anti-markup payment limitation and will process the claim accordingly.
- If a “Yes”
or “No” is not indicated in Item 20 and the associated dollar amount
is present, contractors will return the claim as unprocessable.
- If the “Yes”
box is marked in Item 20 and the associated dollar amount is missing,
contractors will return the claim as unprocessable.
- If the “No”
box is marked in Item 20 and the associated dollar amount is present,
contractors will return the claim as unprocessable.
Read the
MLN
Matters article on this issue.
Read CMS’
instructions to its contractors in Transmittal 1842.
Quarterly
CCI edits posted
The
Centers for Medicare & Medicaid Services (CMS) recently posted the
Correct Coding Initiative (CCI) edits that take effect Jan. 1. In the
agency’s words, the purpose of the CCI is “to promote national correct
coding methodologies and to control improper coding leading to
inappropriate payment in Part B claims.”
Read a
CMS CCI
educational article.
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