Optum360 coding books logo
Optum360Coding.com
    Contact Us   (7 a.m.–7 p.m. CST)
  Home > Coding Central Articles > Coding Central Articles  
Coding Central
Coding Central Home
Inside Track to ICD-10
Coding Central Articles
Code This!
Case Studies
Chargemaster Corner

Articles for:
January 25, 2018


Four Tests Added to List of CLIA Waived Tests

In early January, the Centers for Medicare and Medicaid Services (CMS) announced new waived tests... Learn More


New and Revised Vaccine Codes Added to 2018 CPT Code Book

The American Medical Association (AMA) added and revised several vaccine CPT codes for its 201... Learn More


OIG Recommends Measures for Curbing Opioid Misuse and Fraud

Office of Inspector General testimony before the House Committee on Ways and Means in January ... Learn More


View Article Archive

Subscribe:
To subscribe, paste this link into your preferred feedreader, or click on one of the buttons below:
 

Medical Coding News Archives

Anti-Markup Payment Limitations Outlined

 
February 24, 2009:

The Centers for Medicare and Medicaid has issued instructions to contractors outlining when anti-markup payment limitations apply to diagnostic services. These guidelines are effective July 1, 2009.  

Basically, anti-markup guidelines apply when a diagnostic service payable under the Medicare physician fee schedule (MPFS) is performed by one physician/supplier and billed by another physician/supplier. These limitations apply when a physician does not share a practice with the billing physician or other supplier, either under the “substantially all services” or “site-of-service” test defined below. This new anti-markup provision does not apply to independent laboratories.

Payment to the billing physician or other supplier (less the applicable deductibles and coinsurance paid by or on behalf of the beneficiary) for the TC or PC of the diagnostic test are not to 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

Contractors determine the net charge without consideration to any charge that reflects the cost of equipment or space leased to the performing supplier by the billing physician or other supplier.

When anti-markup does not apply:
The anti-markup payment limitation does not apply if the performing physician “shares a practice” with the billing physician or other supplier. There are two alternatives that may be used when determining whether a performing/supervising physician shares a practice with the billing physician or other supplier:

  • Under the first alternative, if the performing provider (that is, the physician who supervises the technical component or performs the professional component, or both) furnishes substantially all (at least 75 percent) of his or her professional services through the billing physician or other supplier, none of the physician’s diagnostic testing services are subject to the anti-markup payment limitation.
  • The second alternative is the “site-of-service” test. Only TCs conducted and supervised and PCs performed in the “office of the billing physician or other supplier” by a physician owner, employee, or independent contractor of the billing physician or other supplier are not subject to the anti-markup payment limitation.

The “office of the billing physician or other supplier” is any medical office space, regardless of the number of locations, in which the ordering physician regularly furnishes patient care. This includes space where the billing physician or other supplier furnishes diagnostic testing, if the space is in the “same building” in which the ordering physician regularly furnishes patient care.

When billing for the technical component of a diagnostic test, the performing supplier is the physician that supervised the TC. Likewise, when billing the professional component of the diagnostic test, the performing supplier is the physician who performed the PC.

Deborah C. Hall
Clinical/Technical Editor

 

 
Sign in to
Your Account
USERNAME
Forgot your username?
PASSWORD
Forgot your password?
Don't have an account?
It's easy to create one.
Promo code

Have a promotional source code? Enter it here:


What is this?

Code This!

Test your coding knowledge!

/VIEW MORE