Many of the diagnostic services, including radiology services, provided by physicians/practitioners contain both a technical component (TC) and a professional component (PC). Often, the PC and TC of diagnostic services are furnished in different settings. As a general policy, the POS code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service.
A. Interpretation Provided Telephonically by Wireless Remote
Teleradiology services (radiology services that do not require a face-to-face encounter with the patient furnished through the use of a telecommunications system) are discussed in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 30. The interpretation of an x-ray, electrocardiogram, electroencephalogram and tissue samples are listed as examples of these services.
In cases where the face-to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the POS code assigned by the physician /practitioner shall be the setting in which the beneficiary received the TC service. The POS code for a teleradiology interpretation is generally the place where the beneficiary received the TC, or face-to-face encounter. The POS code representing the setting where the beneficiary received the TC is entered in item 24B on the paper claim Form CMS 1500 (or its electronic equivalent). In cases
where it is unclear which POS code applies, the Medicare contractor can provide guidance.
For example: A beneficiary receives an MRI at an outpatient hospital near his/her home. The outpatient hospital submits a claim that would correspond to the TC portion of the MRI. The physician furnishes the PC portion of the beneficiary’s MRI from his/her office location – POS code 22(Outpatient Hospital) shall be used on the physician’s claim to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.
B. Interpretation Provided Outside of the United States
Generally, Medicare will not pay for health care or supplies that are performed outside the United States (U.S.). The term “outside the U.S.” means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. See Pub. 100-02, chapter 16, section 60, for exceptions to the “outside the U.S.” exclusions.
C. Interpretation Provided Under Arrangement – To A Hospital
Separate TC and PC
If a diagnostic test which has a separate TC and PC is provided under arrangement to a hospital, the physician who reads the test can bill and be paid for the professional component. Both the technical and professional components of the test are also subject to the physician self-referral prohibition.
The appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the TC service. If the interpretation is performed in the physician’s office and the patient received the TC service in the provider-based outpatient hospital setting, the physician assigns POS code 22, for outpatient hospital, on the claim for the interpretation or PC.
When a physician performs a diagnostic test under arrangement to a hospital and the test and the interpretation are not separately billable, the interpretation cannot be billed by the physician. In this scenario, the hospital is the only entity that can bill for the diagnostic test which encompasses the interpretation. There is no POS code for the interpretation since a physician claim is not generated.
D. Global Billing
Billing globally for services that are split into PC and TC components is only possible when the TC and the physician who provides the PC of the diagnostic service are furnished by the same physician or supplier entity and the PC and TC components are furnished within the same Medicare physician fee schedule payment locality. Merely applying the same POS code to the PC as that of the TC (as described in “A” above) does not permit global billing for any diagnostic procedure.
E. Determination of Payment Locality
Under the Medicare physician fee schedule (MPFS), payment amounts are based on the relative resources required to provide services and vary among payment localities as resource costs vary geographically as measured by the geographic practice cost indices (GPCIs). 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 in Item 32 on the paper claim Form CMS 1500 (or its electronic equivalent).
Global Service Code
If the global diagnostic service code is billed, the biller (either the entity that took the test, physician who interpreted the test, or separate billing agent) must report the address and ZIP code of where the test was furnished on the bill for the global diagnostic service code. In other words, when the global diagnostic service code is billed, for example, chest x-ray as described by HCPCS code 71010 (no modifier TC and no modifier -26), the locality is determined by the ZIP code applicable to the testing facility, i.e. where the TC of the chest x-ray was furnished. The testing facility (or its billing agent) enters the address and ZIP code of the setting/location where the test took place. This practice location is entered in Item 32 on the paper claim Form CMS 1500 (or its electronic equivalent). As explained in D above, in order to bill for a global diagnostic service code, the same physician or supplier entity must furnish both the TC and the PC of the diagnostic service and the TC and PC must be furnished within the same MPFS payment locality.
Separate Billing of Professional Interpretation
If the same physician or other supplier entity does not furnish both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different payment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician.
When the physician’s interpretation of a diagnostic test is billed separately from the technical component, as identified by modifier -26, the interpreting physician (or his or her billing agent) must report the address and ZIP code of the interpreting physician’s location on the claim form. If the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional interpretation is determined based on the Medicare enrolled location where the interpreting physician most commonly practices. The address and ZIP code of this practice location is entered in Item 32 on the paper claim Form CMS 1500 (or its electronic equivalent).