Payment Requirements

40.1.4 – Payment Requirements (Rev. 3227, Issued: 04-02-15, Effective; ASC-X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: June 11, 2013, ICD-10: Upon Implementation of ICD-10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors: May 19, 2014 - MAC Non-Shared System Edits; July 7, 2014 - CWF development/testing, FISS requirement development; October 6, 2014 - CWF, FISS, MCS Shared System Edits), ICD-10: Upon Implementation of ICD-10) For claims with dates of service on and after February 24, 2011, the following diagnosis code and modifier shall be reported on MRI claims for beneficiaries with implanted PMs, that are outside FDA- approved labeling for use in an MRI environment (in a Medicare-approved clinical study): • Appropriate MRI code • Q0 modifier • Condition code 30 (for institutional claims) • If ICD-9-CM is applicable o ICD-9 code V70.7- Examination of participant in clinical trial (for institutional claims) o ICD-9 code V45.02 (automatic implantable cardiac defibrillator) or o ICD-9 code V45.01 (cardiac pacemaker) • If ICD-10-CM is applicable • Z00.6 - Encounter for examination for normal comparison and control in clinical research program • Z95.810 - Presence of automatic (implantable) cardiac defibrillator or • Z95.0 - Presence of cardiac pacemaker For claims with dates of services on and after July 7, 2011, the following codes shall be reported on MRI claims for beneficiaries with implanted PMs that have FDA-approved labeling for use in an MRI environment: • Appropriate MRI code • KX modifier • If ICD-9-CM is applicable o ICD-9 code V45.01 (cardiac pacemaker) • If ICD-10-CM is applicable o ICD-10 code Z95.0 (cardiac pacemaker) Payment is as follows: • Professional claims (practitioners and suppliers) - based on the Medicare Physician Fee Schedule (MPFS) • Inpatient (11x) - Prospective payment system (PPS), based on the diagnosis-related group • Hospital outpatient departments (13x) - Outpatient PPS, based on the ambulatory payment classification • Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) (71x/77x) - All- inclusive rate, professional component only, based on the visit furnished to the RHC/FQHC beneficiary to receive the MRI. The technical component is outside the scope of the RHC/FQHC benefit. Therefore the provider of the technical service bills their A/B MAC (B) on the ASC X12 837 professional claim format or hardcopy Form CMS-1500 and payment is made under the MPFS. • Critical access hospitals (CAHs) (85x) – o For CAHs that elected the optional method of payment for outpatient services, the payment for technical services would be the same as the CAHs that did not elect the optional method - Reasonable cost. o The A/B MAC (A) pays the professional component at 115% of the MPFS. Deductible and coinsurance apply.