Wiki How to Bill imaging services?

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ccarerevcycle

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Question: If a practice owns the PET/CT or CT equipment, how would they bill services? Scenario: If a practice has a radiologist as a vendor to read the scans only, the practice doesn't bill under radiologist nor credentialed... the radiologist is contracted and paid a flat fee for their service only.
How would they bill services? Modifiers? (if applicable)
 
ccarerevcycle said:
What if a practice does not have a radiologist and is paid as a 1099? The radiologist is not credentialed. How do we bill?
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Your practice may bill for the purchased interpretations, but you are subject to the anti-markup rules:

A physician or other supplier may bill for the technical component and/or professional component of a diagnostic test that was ordered by the physician or other supplier (or ordered by a party related to the billing physician or other supplier through common ownership or control), subject to an anti-markup payment limitation, if the diagnostic test is performed by a physician who does not “share a practice” with the billing physician or other supplier. See the Medicare Claims Processing Manual, Chapter 1, Section 30.2.9 linked here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf

You may want to consult the Medicare contractor in the region where your practice is located for billing instructions and additional guidance on the correct way to indicate this on the claim form. For example, here is the guidance from Noridian, which I believe is the contractor for CA where you are. Scroll down to the section titled 'Purchased Professional Component':
 
In order to determine whether the physicians “share a practice,” one of two alternative tests must be met. The first test is called the “substantially all services” test. Under this test, if the performing physician (i.e., the physician supervising the technical component or performing the professional component), furnishes substantially all (i.e., “at least 75 percent”) of his or her professional services through the billing physician, then the providers will be considered to “share a practice” and the anti-markup provisions will not apply.

In this scenario if our ordering provider is on site at least 75% of the time we are not subject to the anti-markup. Would you agree?
 
ccarerevcycle said:
In order to determine whether the physicians “share a practice,” one of two alternative tests must be met. The first test is called the “substantially all services” test. Under this test, if the performing physician (i.e., the physician supervising the technical component or performing the professional component), furnishes substantially all (i.e., “at least 75 percent”) of his or her professional services through the billing physician, then the providers will be considered to “share a practice” and the anti-markup provisions will not apply.

In this scenario if our ordering provider is on site at least 75% of the time we are not subject to the anti-markup. Would you agree?
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No, I wouldn't agree - this has nothing to do with how much time the provider spends on site. They are talking about the relationship between the two providers - i.e. the relationship between the 'billing provider' (which is your provider if you are going to bill for the interpretation) and the 'performing provider' (the provider from whom you are purchasing the service). So as I interpret it, they're saying you would not be subject to the anti-markup rule if the provider who is doing the interpretations for you (the one receiving the 1099) is giving 75% or more of his or her own services to your physician.

But I just have to make a disclaimer here, that this is a legal question and I'm not an attorney and I also don't know your practice arrangement beyond what you've said, so I'm not really the person to rely on for an answer about this. Anti-markup laws are a serious matter and if your practice is entering into a relationship like this and is going to bill for these services, any questions or doubts about this you have are best put to an attorney or compliance specialist to make sure you get this right. I always advise against relying on internet responses about legal questions.
 
thomas7331 said:
No, I wouldn't agree - this has nothing to do with how much time the provider spends on site. They are talking about the relationship between the two providers - i.e. the relationship between the 'billing provider' (which is your provider if you are going to bill for the interpretation) and the 'performing provider' (the provider from whom you are purchasing the service). So as I interpret it, they're saying you would not be subject to the anti-markup rule if the provider who is doing the interpretations for you (the one receiving the 1099) is giving 75% or more of his or her own services to your physician.

But I just have to make a disclaimer here, that this is a legal question and I'm not an attorney and I also don't know your practice arrangement beyond what you've said, so I'm not really the person to rely on for an answer about this. Anti-markup laws are a serious matter and if your practice is entering into a relationship like this and is going to bill for these services, any questions or doubts about this you have are best put to an attorney or compliance specialist to make sure you get this right. I always advise against relying on internet responses about legal questions.
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I completely understand and appreciate the input. This is definitely something we need to inquire and seek legal counsel. I appreciate it.
 
ccarerevcycle said:
I completely understand and appreciate the input. This is definitely something we need to inquire and seek legal counsel. I appreciate it.
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thomas7331 said:
No, I wouldn't agree - this has nothing to do with how much time the provider spends on site. They are talking about the relationship between the two providers - i.e. the relationship between the 'billing provider' (which is your provider if you are going to bill for the interpretation) and the 'performing provider' (the provider from whom you are purchasing the service). So as I interpret it, they're saying you would not be subject to the anti-markup rule if the provider who is doing the interpretations for you (the one receiving the 1099) is giving 75% or more of his or her own services to your physician.

But I just have to make a disclaimer here, that this is a legal question and I'm not an attorney and I also don't know your practice arrangement beyond what you've said, so I'm not really the person to rely on for an answer about this. Anti-markup laws are a serious matter and if your practice is entering into a relationship like this and is going to bill for these services, any questions or doubts about this you have are best put to an attorney or compliance specialist to make sure you get this right. I always advise against relying on internet responses about legal questions.
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Quick question: Thinking with the PC/TC approach, once ready, billing out the claim for PC... Would be credential the radiologists and set them as the billing provider for the professional component?
 
ccarerevcycle said:
Quick question: Thinking with the PC/TC approach, once ready, billing out the claim for PC... Would be credential the radiologists and set them as the billing provider for the professional component?
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Yes, if you credential your contracted radiologists as providers in your own practice, then you can bill for their services just as you would for your other providers.
 
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