Medicare Implements Edits to Prevent Duplicate Claims
Medicare has installed system edits in the common working file that reject claims for the technical component (TC) from radiology and pathology services provided to hospital inpatients. These edits, which were effective on April 1, 2007, were installed to prevent duplicate and improper payments to radiology suppliers, physicians, independent laboratories, and pathology service providers.
The guidance provided by Medicare instructs providers of radiology and pathology services not to bill the technical component of the diagnostic tests. Only a hospital may bill the technical component of radiology services provided by a supplier of radiology services to hospital inpatients.
This policy change was necessitated by the fact that Medicare was paying twice for the TC service, first through the Inpatient Prospective Payment Systems (IPPS) to the hospital and again to the independent radiology service provider who bills the carrier through Part B. As a result, Medicare decided to reject the Part B TC, or globally billed radiology services, with the same service date as a covered hospital inpatient stay. The TC is excluded from coverage unless the tests are performed under an arrangement in which the hospital bills the intermediary.
The Centers for Medicare and Medicaid Services (CMS) did not address how the TC payment is going to be handled if the service is provided within a 24-hour timeframe before admission and before the decision to admit the patient has been made. Furthermore, CMS failed to provide guidance on situations where services are provided in which there is no arrangement with the admitting hospital.
If you have claims denied for the reasons described above, please contact Helen Olkaba at (800) 227 5463, ext. 4132. To help alleviate problems, the ACR would like to learn about radiologists’ experience with this rule.
For further information, please visit www.cms.hhs.gov/Transmittals/downloads/R1221CP.pdf.