Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation

The Centers for Medicare & Medicaid Services (CMS) is revising the section of the Medicare Claims Processing Manual to implement changes to 42 CFR section 414.50 that were made in the CY 2009 PFS final rule. These changes include two alternative methods for determining when not to apply the anti-markup payment limitation. The MLN Matters article can be found at:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6733.pdf

Highlights include: 

• When billing for the technical component (TC) or professional component (PC) 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 National Provider Identifier (NPI) of the performing physician in Item 32 of the CMS-1500 claim form.

• However, if the performing physician is enrolled with a different Part B Medicare Administrative 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 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.

About the Author

Reed Tinsley CPA

This article is written by Reed Tinsley, a Houston, TX-based CPA with over 30 years of experience advising physicians and medical practices across Texas and the United States. Reed holds certifications as a Certified Valuation Analyst (CVA), Certified Healthcare Business Consultant (CHBC), and Certified Financial Planner (CFP), specializing exclusively in the healthcare sector. He is a published author, nationally recognized speaker, and trusted advisor to physicians on accounting & tax, practice management, and financial planning. Schedule a Free Consultation.