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Wiki Anti-markup rule question
- Thread starter ramzeee68
- Start date
SharonCollachi
Guest
I'm not understanding your question. This is about Medicare but you don't want the information from Medicare??
I have the info from Medicare but I’m being told that because of the MACs Physician Supervision Indicator of “9” that a service being purchased from a vendor does not qualify for anti-markup. I’m not sure where my boss is getting that from. Not sure if that helps. This is a link my supervisor directed me to https://med.noridianmedicare.com/we...mpfs/2020-mpfs-indicator-list-and-descriptors and I'm not sure what this has to do with Anti-markup. I was hoping someone other than her could explain to me.
Last edited:
SharonCollachi
Guest
I'm not sure where your boss is getting it from either. I have found nothing regarding supervision on a specific code having an effect on anti-markup. Medicare is very clear (CR 6733) on determining anti-markup exceptions:
The anti-markup payment limitation will not apply:
•If the physician or other supplier does not order the diagnostic test; or
•If the performing/supervising physician is deemed to “share a practice” with the billing physician or other supplier.
There are two alternative methods for determining whether the performing/supervising physician is deemed to “share a practice.” Those alternatives are:
Alternative one, “substantially all services” test:
•If the performing physician (the physician who supervises or conducts the TC, performs the PC, or both) furnishes substantially all (at least 75 percent) of his or her professional services through the billing physician or other supplier, the anti-markup payment limitation will not apply.
Alternative two, “site of service/same building” test:
•If the TC or the PC is supervised/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, the anti-markup payment limitation will not apply.
•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 services, if the space is located in the “same building”in which the ordering physician regularly furnishes patient care.
•If the billing physician or other supplier is a physician organization, the “office of the billing physician or other supplier” is space in which the ordering physician provides substantially the full range of patient care services that the ordering physician provides generally. With respect to the TC, the performing physician is the physician who conducted and/or supervised the TC, and with respect to the PC, the performing physician is the physician who personally performed the PC.
The anti-markup payment limitation will not apply:
•If the physician or other supplier does not order the diagnostic test; or
•If the performing/supervising physician is deemed to “share a practice” with the billing physician or other supplier.
There are two alternative methods for determining whether the performing/supervising physician is deemed to “share a practice.” Those alternatives are:
Alternative one, “substantially all services” test:
•If the performing physician (the physician who supervises or conducts the TC, performs the PC, or both) furnishes substantially all (at least 75 percent) of his or her professional services through the billing physician or other supplier, the anti-markup payment limitation will not apply.
Alternative two, “site of service/same building” test:
•If the TC or the PC is supervised/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, the anti-markup payment limitation will not apply.
•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 services, if the space is located in the “same building”in which the ordering physician regularly furnishes patient care.
•If the billing physician or other supplier is a physician organization, the “office of the billing physician or other supplier” is space in which the ordering physician provides substantially the full range of patient care services that the ordering physician provides generally. With respect to the TC, the performing physician is the physician who conducted and/or supervised the TC, and with respect to the PC, the performing physician is the physician who personally performed the PC.
Thank you Sharon, that is all I can find too. She gave me information from Palmetto GBA's website that shows the CPT code having an "anti-markup" code of 9 but we don't bill to Palmetto, we bill to Noridian. Thank you for helping me with this, I thought I was going insane!
SharonCollachi
Guest
Okay, I know what she's talking about, but she is interpreting it incorrectly. There are supervision codes, which indicate the level of supervision required for furnishing the technical component of diagnostic tests for a Medicare patient who is not a hospital inpatient. The code of 9 means "concept does not apply". This means the concept of SUPERVISION does not apply, not the ANTI-MARKUP concept. For instances, the code 22 means "the procedure may be performed by a technician with online real-time contact with physician."
Here is a table of the codes.
Here is a table of the codes.