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CMS further clarifies billing for diagnostic tests subject to the anti-markup rule
The Centers for Medicare and Medicaid Services (CMS) released instructions to its contractors, effective March 15, for handling tests subject to the anti-markup rule. The anti-markup rule places limits on reimbursement for diagnostic tests (excluding clinical diagnostic lab tests) when the performing physician does not share a practice with the billing entity. It applies when a test is ordered and billed by the same or a related entity. The anti-markup rule became effective on Jan. 1, 2009, and replaces the “purchased diagnostic test rule.”
This transmittal is one of a series that clarify billing for tests subject to the new rule. (See, for example, CMS instructs contractors on ambiguous anti-markup claims and CMS releases instructions to contractors on implementing new anti-markup rule). It also phases out the term “purchased diagnostic test” in favor of the term “anti-markup test” in the CMS manuals.
Highlights from this transmittal 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.
Read the MLN Matters article.
Read CMS’s transmittal to its contractors.
