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January 25, 2018


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Medical Coding News Archives

CMS Publishes Rule Delaying Anti-Markup Provisions

 
January 8, 2008:
On January 3rd, 2008, the Centers for Medicare and Medicaid Services (CMS) published a final rule that delays until January 1, 2009, the revised criteria of the anti markup provisions in section 414.50 of the Code of Federal Regulations (CFR).

In summary, the physician may not mark up the costs of purchased technical or professional component of a diagnostic test. In detail, the revised criteria state that if a physician or other supplier bills for the technical or professional component of a diagnostic test ordered by the physician or other supplier (or ordered by a party related to the physician or other supplier through common ownership or control) and the diagnostic test (except anatomical pathology) is either purchased from an outside supplier or performed at a site other than the office of the billing physician or other supplier, payment to the billing physician or other supplier (less applicable deductibles and coinsurance paid by the beneficiary or on his or her behalf) for the technical component or professional component of the diagnostic test may not exceed the lowest of the following amounts:
  • The performing supplier`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 supplier billed directly
After the rule was published CMS received a number of comments stating that the rule’s provisions were unclear, particularly those defining whether certain types of space arrangements meet the definition of the “office of the billing physician or other supplier.” Additionally some physician groups allege that if they are limited to billing Medicare for the amount of the net charge imposed by the performing supplier, they will not be able to realize a profit, recoup their overhead costs, and continue to provide diagnostic testing services to the same extent that they currently do.

The agency wishes to review the comments more thoroughly and determine if any additional revisions are necessary. It therefore is delaying implementing the new site restrictions.

Deborah C. Hall
Clinical/Technical Editor

 

 
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