Texas Medicaid's version of the ordering, referring and prescribing rules (what Medicare implemented back in i believe 2014) is set to go into effect.
We have been corresponding with Texas Medicaid on a number of issues but one specific issue related to whether these edits would be applied to the professional component of radiology services.
As you may recall, Medicare specifically excluded the professional component so it only seemed reasonable that Medicaid would too.
Well that apparently would make too much sense and here is the response from CMS, to Texas Medicaid, after we had been pressing the issue with Texas Medicaid: this will truly take an attorney to decipher:
Below for your reference is CMS' response:
"I know we've discussed this a few times over the past month and I have been working to develop and clarify for you as to why this requirement is applied differently in Medicare than it is in Medicaid. I want to thank you for your patience.
As we've responded earlier, Medicaid is not able to apply the ORP requirement in the same way that Medicare has (paying for the professional component for lab and imaging services when the ORP is not enrolled). I understand the reason for this difference may not be clear when looking at the regulatory language you cite below. However, the statutory authority under which these regulations were implemented is different. The Medicaid requirement is a general requirement that ALL ordering and referring physicians or other professionals must be enrolled (6401(b) of the ACA, adding a new requirement at 1902(kk)(7), and then more recently 5005(b) of the 21st Century Cures Act, adding a new 1902(a)(78)). In contrast, the Medicare requirement is based on different statutory language, and is limited to certain services rather than applying to all services. It applies to the ordering/referral of DME (6405(a) of the ACA), Home Health services (6405(b)), and "other items or services" as specified by the Secretary (6405(c)).
By regulation (CMS-6010), CMS included additional services within the ORP requirement as permitted by 6405(c) – among them, imaging services. And in the preamble to the final rule, there's a "clarification" that the requirement only applies to the technical component of such services.
Comment: Several commenters questioned what is meant by "imaging services" and "imaging suppliers." Commenters questioned if the term applies only to the technical component of imaging services (or global services) or if it also applies to the professional component. They also requested clarification on whether claims for imaging services provided in the hospital outpatient setting would be affected, if independent diagnostic testing facilities (IDTFs) and portable x-ray suppliers are considered "imaging suppliers", and if "services" apply to claims for routine x-rays performed in a physician's own office.
Response: The IFC and this final rule specifically refer to the technical components of imaging services that are: (1) Ordered by physicians and, where permitted, other eligible professionals; (2) furnished by IDTFs, mammography centers, portable X-ray facilities, and radiation therapy centers that are enrolled in Medicare via the CMS-855B; and (3) billed by these Part B suppliers to the Part B claims system (MCS) on an X12N 837P or a paper form CMS-1500.
77 Fed. Reg. 25284, 25291 (Apr. 27, 2012)
However, because the statutory basis for the Medicaid requirement is different – expressly applying to all ordered and referred services, States do not have the ability to reimburse for the professional component when the ORP is not enrolled."
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Douglas Kraus CPA
Chief Financial Officer
South Texas Radiology Group, PA
San Antonio TX
(210) 616-7700
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