The teleradiology market is exploding. The global market was valued at $1.99 billion in 2016 and it is estimated to reach $8.2 billion by 2024, according to a report by Grand View Research, Inc. North America comprised 40% of the overall market in 2015, according to the report. Teleradiology enables rapid diagnoses and allows specialists to provide second opinions, regardless of the geographic location in the United States.
As more and more radiology providers incorporate teleradiology into their practices, it is crucial that these providers, and the medical groups with which they contract, are aware of Medicare’s billing requirements for teleradiology services.
The anti-markup rule, at 42 CFR 414.50, limits the amount a medical practice can charge Medicare for the technical component (“TC”) and professional component (“PC”) of a diagnostic test, when the diagnostic tests are ordered by a physician in that practice but the TC and the PC are not performed by that ordering physician.
While many are aware of the payment limitations created by the anti-markup rule, the billing requirements with respect to anti-markup claims seem to be less discussed or understood.
In situations where the anti-markup rule applies, global billing is not allowed by the billing entity. If the billing entity performs only the TC or the PC and wants to bill for both components, the TC and the PC must be reported as separate line items if billing electronically (ANSI X12 837) or on separate claims if billing on paper (Form CMS-1500). (See Medicare Claims Processing Manual Section 30.2.9, entitled “Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation – Claims Submitted to A/B MACs (B)”).
Unlike with reassigned claims not subject to the anti-markup rule (addressed below), the billing entity is not required to enroll in the B/MAC where the read is performed in order to bill for anti-markup rule claims. The B/MACs must accept and process claims for services subject to the anti-markup payment limitation when billed by the billing entity in the billing entity’s B/MAC’s jurisdiction, regardless of the location where the read was furnished. However, the billing entity must report the name, address, zip code and NPI of the physician performing the read in Item 32a of the CMS-1500 claim form or the corresponding loop and segment of the ANSI X12 837 professional electronic clam transaction. (See Medicare Claims Processing Manual Section 30.2.9, entitled “Payment to Physician or Other Supplier for Diagnostic Test Subject to the Anti-Markup Payment Limitation – Claims Submitted to A/B MACs (B)”).
Also, directly below is a summary of teleradiology billing procedures with respect to reassigned claims not subject to the anti-markup rule.
In situations where the anti-markup rule does not apply, if the performing physician is reassigning payment for a read to another entity and such read is not performed in the same Medicare Payment Fee Schedule (“MPFS”) locale, the billing entity must submit the claim for the read to the B/MAC that has jurisdiction over the geographic area where the read was performed. The physician performing the read and the billing entity must be credentialed in the B/MAC where the read was performed.
When enrolling with the B/MAC where the read was performed, the home address of the physician performing the read can be listed as the “practice location.” The billing entity must identify the teleradiologist’s home address in the other MAC jurisdiction as the billing entity’s “practice location” on its Form CMS-855B (per #3 on CMS Transmittal 503, “Inter-Jurisdictional Reassignments”).
See the following for more information:
– See Sections 10.1.1.2, called “Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation”, and 10.1.1.3, called “Payment Jurisdiction for Reassigned Services”, in the Medicare Claims Processing Manual;
– See Section 15.20.1, called “Inter-Jurisdictional Reassignments” in CMS Transmittal 503; and
– See Section 30.2.9, called “Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation – Claims Submitted to A/B MACs (B)”, in the Medicare Claims Processing Manual.
For more information or questions about Medicare billing requirements or other health law issues, get in touch with one of our experienced health law attorneys.