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Medicare “anti-markup” Limitation on Diagnostic Imaging.

This is reprinted from the American College of Radiology:
http://www.acr.org/Hidden/Economics/FeaturedCategories/
Pubs/coding_source/archives/MarApr2010/Anti-Markup-Limitation-on-Diagnostic-Tests-Expanded.aspx

 

Anti-Markup Limitation on Diagnostic Tests Expanded

The Centers for Medicare and Medicaid Services (CMS) finalized the anti-markup payment limitation by expanding its use to both the technical (TC) and professional (PC) components of diagnostic tests when the physician performing the diagnostic test does not share a practice with the billing physician.

The anti-markup rule prohibits the billing physician or supplier from profiting or marking up diagnostic tests performed by an outside physician or supplier.  The anti-markup limitation does not apply if:

  • the billing and the performing physician share a practice
  • the performing physician furnishes substantially all (at least 75%) of his or her
    professional services through the billing physician
  • the TC or PC is performed or supervised in the office of the billing physician.

The billing physician payment to which the anti-markup payment limitation applies will not exceed the lowest of the following amounts:

  • the performing physician’s net charge
  • the billing physician’s actual charge
  • the physician fee schedule amount for the test when the performing physician bills directly

Global billing is not allowed for those claims to which the anti-markup limitations apply. Therefore, CMS advises physicians to bill both the professional and technical components as separate line items when billing electronically, or on a separate claim form when submitting paper claims (CMS-1500 form.)  In addition, the billing physician must indicate the name, address and national provider identifier number of the performing physician on the claim form.  If the performing physician is enrolled with a different Medicare administrative contractor, the billing physician does not need to report the performing physician’s information on the claim, but should keep a record of this information in case of an audit.

Detailed information on the anti-markup limitation may be obtained from the CMS Web site at www.cms.gov/transmittals/downloads/R1931CP.pdf, and Pub 100-04, Medicare Claims Processing Manual, Section 30.2.9.1.

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