Although place-of-service rules haven’t changed in a while, a brand-new year is a perfect time to brush up on the basics that impact collections regardless of the season.
CMS last updated place-of-service (POS) rules in 2013, but there are still compliance and billing pitfalls to be wary of especially as technology continues to change the landscape of the healthcare industry.
Remembering the basics of POS requirements can help protect revenue as radiology practices, and the industry, expand and evolve with teleradiology and remote-reading physicians.
Medicare requires two pieces of location information for radiologic service claims to be billed/paid. One is a POS code that identifies where a patient received a face-to-face encounter, otherwise known as the technical component (TC). The other is the physical address and zip code of where the professional component (PC) was furnished, which is where the radiologist does the interpretation.
When billing the TC and the PC separately, the Relative Value Unit (RVU) for the procedure code (CPT code) is split with different weights. RVUs are then multiplied by a Geographic Practice Cost Index (GPCI) and the CMS Medicare Physician Fee Schedule conversion factor to calculate the total payout for a claim.
For both the TC and PC to be billed together, or to bill Globally, CMS requires the radiologic service to be furnished by the same physician or supplier entity within the same payment locality.
With more groups performing services across state lines, using teleradiologists or employing doctors who read from remote locations, it is important to remember the location related rules when billing Medicare.
When the TC and PC components are performed in two different Medicare localities, CMS requires that they be billed separately with the appropriate modifiers. For example, if a diagnostic test is performed in Florida but the radiologist interprets it in Indiana, the TC should be billed to the appropriate Florida MAC (Medicare Administrative Contractor) and the PC should be billed to the appropriate Indiana MAC.
Several states have multiple MACs so it’s important to ensure that both components are being billed to the correct locality.
At Advocate, we work closely with our clients to ensure this is handled properly. Key to that success is good, open, frequent, communication as practices make (or consider) changes to how they perform their services.
As always, ADVOCATE will continue to keep you up to date on all regulatory issues impacting radiology.
Manager of Regulatory Affairs