Practice Management

This is correct from our research as well.  The location where the radiologist is reading dictates the payment rather than where the patient is seen.  The Medicare transmittal that I still have is 2613 for change request 7631 published Dec 14, 2012 and it was effective April 1, 2013.

Mindy Smith

Billing Manager

Management Data Systems

3114 Lake St

Lake Charles, LA 70601

337-437-7681

866-437-7681

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I believe that is correct.

Yes – I believe Box 32 on the 1500 form (or equivalent) has to be the address and zip code of the physical location of the reading radiologist.

Thanks!

Sharon,

That is correct. The professional billing depends on where the physician is sitting when doing the interpretation. I have added a few links for additional information on this subject.

The official instruction, CR7631 issued regarding this change may be viewed at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Physician-Transmittals-Items/Phys-CR7631-R2613CP.html  on the CMS website.

FAQs from CR 7631: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQs-CR7631-4-25-13.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7631.pdf

Excerpt from:

MLN Matters number MM7631 - Related Change Request Number 7631

Effective: April 1, 2013

Separate Billing of Professional Interpretation
If the same physician or other supplier entity does not furnish both the TC and PC of the
diagnostic service, or if the same physician or other supplier entity furnishes both the TC
and PC but the professional interpretation was furnished in a different payment locality from
where the TC was furnished, the professional interpretation of a diagnostic test must be
separately billed with modifier -26 by the interpreting physician.
When the physician's interpretation of a diagnostic test is billed separately from the
technical component, as identified by modifier -26, the interpreting physician (or his or her
billing agent) must report the address and ZIP code of the interpreting physician's location
on the claim form. If the professional interpretation was furnished at an unusual and
infrequent location for example, a hotel, the locality of the professional interpretation is
determined based on the Medicare enrolled location where the interpreting physician most
commonly practices. The address and ZIP code of this practice location is entered in Item 32
on the paper claim Form CMS 1500 (or its electronic equivalent).

Sharon,

This change was made to ensure that Medicare is paying the rate that is in effect at the place of service for the PC when it is different from the place where the TC was performed.  It also requires that the practice be enrolled with the MAC that is responsible for the PC place of service-which means enrolling in multiple MACs based on where the radiologist is sitting when they read.

There is an exception for Global billing which is billed to the MAC where the TC was performed. 

I know you are probably saying and incredulous..."REALLY?"  We all felt that way when this came about but after much work on the part of the RBMA and others, it was determined that this is the way it must be done.  I hope this helps. 

After further research, that is not the case.  Per MM7631, the following is true for global bills: 

Clarifications Regarding Global Services
When a physician performs a diagnostic test under arrangement to a hospital and the test
and the interpretation are not separately billable, the interpretation cannot be billed by the
physician. In this scenario, the hospital is the only entity that can bill for the diagnostic test
which encompasses the interpretation. There is no POS code for the interpretation since a
physician claim is not generated.

Billing globally for services that are split into PC and TC components is only possible when
the TC and the physician who provides the PC of the diagnostic service are furnished by the
same physician or supplier entity and the PC and TC components are furnished within the
same MPFS payment locality. Merely applying the same POS code to the PC as that of the
TC does not permit global billing for any diagnostic procedure.

Clarification Regarding Determination of Payment Locality
Under the MPFS, payment amounts are based on the relative resources required to provide
services and vary among payment localities as resource costs vary geographically as
measured by the geographic practice cost indices (GPCIs). The payment locality is
determined based on the location where a specific service code was furnished. For purposes
of determining the appropriate payment locality, CMS requires that the address, including
the ZIP code for each service code be included on the claim form in order to determine the
appropriate payment locality. The location in which the service code was furnished is
entered in Item 32 on the paper claim Form CMS 1500 (or its electronic equivalent).

Global Service Code
If the global diagnostic service code is billed, the biller (either the entity that took the test,
physician who interpreted the test, or separate billing agent) must report the address and ZIP
code of where the test was furnished on the bill for the global diagnostic service code. In
other words, when the global diagnostic service code is billed, for example, chest x-ray as
described by HCPCS code 71010 (no modifier TC and no modifier -26), the locality is
determined by the ZIP code applicable to the testing facility, i.e. where the TC of the chest
x-ray was furnished. The testing facility (or its billing agent) enters the address and ZIP
code of the setting/location where the test took place. This practice location is entered in
Item 32 on the paper claim Form CMS 1500 (or its electronic equivalent). As explained
above, in order to bill for a global diagnostic service code, the same physician or supplier
entity must furnish both the TC and the PC of the diagnostic service and the TC and PC
must be furnished within the same MPFS payment locality

I recommend you read the entire MM7631 to completely understand but my read is that both services must be furnished in the same payment locality.  If they are, then the TC location governs the payment of the Global. 

I hope this helps, Wendy