A/B MAC (B) Payment Rules

If a diagnostic test (other than a clinical diagnostic laboratory test) is personally performed or is supervised by a physician, such physician may bill under the normal physician fee schedule rules. This includes situations in which the test is performed or supervised by another physician with whom the billing physician shares a practice, Medicare Benefit Policy, sets forth the various levels of physician supervision required for diagnostic tests. The supervision requirement for physician billing is not met when the test is administered by supplier personnel regardless of whether the test is performed at the physician’s office or at another location.

If a physician bills for a diagnostic test that is subject to the anti-markup payment limitation, the fee schedule amount for the acquired service equals the lower of:

• The performing physician or other supplier’s net charge to the billing physician or other supplier for performing the service;

• The billing physician or other supplier’s actual charge; or

• The fee schedule amount allowed for the jurisdiction where the service was performed.

The lowest figure is the fee schedule amount for purposes of the limiting charge. The billing entity must identify the performing physician or other supplier (including the performing provider’s NPI) and the amount the performing physician or other supplier charged the billing entity (net of any discounts). A physician who accepts assignment is permitted to bill and collect from the beneficiary only the applicable deductible and coinsurance for the acquired test. A physician who does not accept assignment is permitted to bill and collect from the beneficiary only the fee schedule amount (as defined above) for the acquired test. The limiting charge provision is not applicable.

If the physician does not identify who performed the test and provide the other required information, no payment is allowed. The physician may not bill the beneficiary any amount for the test.