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  • 1.  PET Reimbursment from Medicare Question

    Posted 05-30-2018 10:41
    ​​​Good Morning,

                We are a free standing facility that bills out with a office POS globally to Medicare, looking at the reimbursement we are receiving they are using the OPPS Cap Facility Reimbursement.  If we are not an outpatient hospital shouldn't they pay the global reimbursement?

    Per Medicare "Amounts for which providers [performing the service in a facility setting] would be reimbursed when the Outpatient Prospective Payment System (OPPS) Cap on the Technical Component (TC) of Imaging Procedures applies. (Check the "Imaging Cap Indicator" below) Place of service codes which identify a facility setting: 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56, 61".

    We do not bill out with these POS so the CAP shouldn't apply correct?

    Any clarification or insight would be appreciated, thank you.




    ------------------------------
    Diane Ramirez
    Business Office Manager
    Radiology and Imaging of South Texas LLP
    Corpus Christi TX
    361-853-4503
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  • 2.  RE: PET Reimbursment from Medicare Question

    Posted 05-30-2018 10:46

    I found this – this helped clarified my question.

     

    Thank you

     

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1171CP.pdf

     

    Diane Ramirez

    Business Manager

    3226 Reid Drive

    Corpus Christi, TX 78404

    361-853-4503 ext 1006

    361-389-8014 - Cell Phone

     

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  • 3.  RE: PET Reimbursment from Medicare Question

    Posted 05-30-2018 11:03

    Diane,

    The Imaging Cap applies.  The Imaging Cap is applied to the Technical Component of all affected codes in the Non-Facility (outpatient imaging – office and IDTF) settings versus "Facility" meaning Hospital.  Remember the Global / Technical Components of the Medicare Physician Fee Schedule (MPFS) are paid at the "lower of" the MPFS or OPPS for "Advanced Imaging" – meaning CT. CTA, MRI. MRA, PET, PET/CT and certain other CPT Codes listed for the "Imaging Cap" applied.

     

    It is important also to obtain the affected CPT Codes, GPCI Adjusted, with the Imaging Cap Applied and examine the PC, TC and Global carefully.  When the "Imaging Cap" is applied, you will also notice the % PC to Global payments (not RVU's) is higher than without the "Imaging Cap Applied".  So if you are paying the PC to the Group as a % Global, be sure you are calculating the PC as % Global accurately – with the Imaging Cap Applied to the "Global" – really the TC.

     

    Douglas G. Smith, FRBMA

    President & CEO

    Phase 4 Radiology Business Strategies, LLC

    509 Crested Hawk Ridge

    Canton, Ga 30114

    Office: 770-213-4605 Cell: 847-772-5168

    Website: www.phase4rbs.com

     

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  • 4.  RE: PET Reimbursment from Medicare Question

    Posted 05-30-2018 11:37

    Thank you Douglas.

     

    Diane Ramirez

    Business Manager

    3226 Reid Drive

    Corpus Christi, TX 78404

    361-853-4503 ext 1006

    361-389-8014 - Cell Phone

     

    logo

     

    PRIVILEGED AND CONFIDENTIAL:  This document and the information contained herein are confidential and protected from disclosure pursuant to federal law.  This message is intended only for the use of the Addressee(s) and may contain information that is PRIVILEGED and CONFIDENTIAL. If you are not the intended recipient, you are hereby notified that the use, dissemination, or copying of this information is strictly prohibited.  If you have received this communication in error, please erase all copies of the message and its attachments and notify the sender immediately.

     

     

     




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