Medicare covers diagnostic and radiology services, but these services must be completed or supervised by a certified radiology physician. Both radiology and other diagnostic health services go under a patient’s Medicare Part B coverage. Radiology services are typically under a fee schedule. This means the payment is either the lower billing charge or the Medicare Physician Fee Schedule dollar amount. Both coinsurance and deductibles apply; a patient’s coinsurance determines their amount.
Basic Medicare Payment Conditions for Radiology Services
Professional Component (PC)
- Medicare part B pay for the PC of radiology services furnished by a physician to an individual patient in all settings under the fee schedule for physician services regardless of the specialty of the physician who performs the service.
- For services furnished to hospital patients, Medicare part B pays only if the services meet the conditions for fee schedule payment and are identifiable, direct, and discrete diagnostic or therapeutic services to an individual patient, such as an interpretation of diagnostic procedures and the PC of therapeutic procedures. The interpretation of a diagnostic procedure includes a written report.
Technical Component (TC)
- Medicare part B may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians’ radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service.
- Medicare part B includes the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in the prospective payment system (PPS) payment to hospitals.
- Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay. CWF performs reject edits to incoming claims from suppliers of radiology services.
- Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares the period between the hospital inpatient admission and discharge dates to the line item service date on a line item TC of a radiology service billed by a supplier. The CWF will generate an unsolicited response when the line item service date falls within the admission and discharge dates of the hospital inpatient claim.
- Upon receipt of an unsolicited response, the A/B MAC (B) will adjust the TC of the radiology service and recoup the payment
- For CAHs, payment to the CAH for inpatients is made at 101 percent of reasonable cost.
- Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are submitted to the AB MAC (A). Effective 4/1/06, the type of bill 14X is for non-patient laboratory specimens and is no longer applicable for it.
- As a result of SNF Consolidated Billing (Section 4432(b) of the Balanced Budget Act (BBA) of 1997), A/B MACs (B) may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay. The SNF must bill services furnished to its inpatients in a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS).
- Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service or by the SNF under arrangements with the supplier. If billed by the SNF, Medicare pays according to the Medicare Physician Fee Schedule. SNFs submit claims to the AB MAC (A) with a type of bill 22X or 23X.
We shared an excerpt from Medicare Claims Processing Manual Chapter 13 to discuss Medicare payment conditions. For detailed coverage and other payment conditions, you can refer CMS link. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We can assist you in Medicare billing for receiving accurate reimbursements for delivered services. To know more about our Medicare billing services, contact us at firstname.lastname@example.org/ 888-357-3226