Medicare covers imaging services that are performed or supervised by a
physician who is certified or eligible to be certified by the American
Board of Radiology or for whom radiology services account for at least
50 percent of the total amount of charges made under Medicare.
Medicare generally covers : x-rays, including portable x-rays, including
portable x-rays, fluoroscopy and mammography; CT, including portable
CT, CT angiography (CTA) and CT- guided procedures; MRI, including MR
angiography (MRS) and MRI, including MR angiography (MRA) and MRI-
guided procedures; ultrasound (US), including diagnostic grey-scale and
vascular Doppler imaging, and US-guided procedures; nuclear medicine
diagnostic imaging and procedures, including radionuclide’s and PET for
certain conditions; radiation oncology; and bone density (DEXA) scans.
Coverage may be limited to certain indications.
Billing and Payment on Medicare Professional Claims
Imaging services are billed under Medicare Part B to Medicare Carriers
and A/B Medicare Administrative Contractors (A/B MACs) using acceptable
Healthcare Common Procedure Coding System (HCPCS) codes for imaging and
other diagnostic services taken primarily from the Current Procedural
Terminology (Procedure code ) 4 portion of HCPCS and the supporting ICD diagnosis
Imaging services are generally paid based on the lower of the charge or
the Medicare Physician Fee Schedule (MPFS) amount. Deductible and
coinsurance apply, and coinsurance is based on the allowed amount.
Payment Conditions for Imaging Services
Generally, imaging services are split into technical and professional
components (the TC and PC), each separately billable to the local
Medicare contractor. Medicare pays under the MPFS for the TC of imaging
services furnished to Medicare beneficiaries who are not patients of any
hospital, and who receive services in a physician’s office, a
freestanding imaging or radiation oncology center, ambulatory surgical
center (ASC) or other setting that is not part of a hospital.
When imaging services are furnished in a leased hospital radiology
department to a beneficiary who is neither an inpatient nor an
outpatient of any hospital, both the PC and the TC of the services are
payable under the MPFS by the carrier or A/B MAC.
Definitions of Professional and Technical Components and Billing Codes
The PC of a service is for physician work interpreting a diagnostic test
or performing a procedure, and includes indirect practice and
malpractice expenses related to that work. Modifier 26 is used with the
billing code to indicate that the PC is being billed.
The TC is for all non-physician work, and includes administrative,
personnel and capital (equipment and facility) cost, and related
malpractice expenses. Modifier TC is used with the billing code to
indicate that the TC is being billed.
PC and TC do not apply to physician services that cannot be distinctly
split into professional and technical components. Modifier PC and TC may
not be used with these billing codes. For example: A diagnostic service
or test that cannot be distinctly split between TC and PC is considered
to be a global test or service. Examples of global tests/services are
raditaion treatment delivery (Procedure codes 77401-77416).
Anti-Markup Payment Limitations for Professional and Technical Components
Medicare payment rules for certain diagnostic tests (other than clinical
diagnostic laboratory tests) ordered by a billing physician or other
supplier (or by a party related to the billing physisican or other
supplier through commin ownership or contril) limit the amount of
payment where the physician performing or supervising the diagnostic
test does not share a practice with the billing/ordering physisican or
other supplier. Pursuant to this “anti-markup” rule, Medicare payment
must not exceed the lowest of:
The performing/supervising physician’s net charge to the billing physician or other supplier;
The billing physician or other supplier’s actual charge;
The fee schedule amount for the test that would be allowed if the performing/supervising physician billed directly
Both the TC and PC of certain diagnostic tests (other than clinical
diagnostic laboratory tests) are subject to the anti-markup payment
limitation. Examples of services subject to the anti-markup payment
limitations include: x-rays, EKGs, EEGs, cardiac monitoring, and