Claims Processing

10.2 - Claims Processing (Rev. 4473, Issued: 12-6-19; Effective: 3-9-20; Implementation: 3-9-20) A. Billing Issues Nothing in this document or in the Medicare Enrollment Application, (CMS-855B) or the Internet-based Provider Enrollment, Chain and Ownership System shall be construed or interpreted to authorize billing by an IDTF, physician, physician group practice, or any other entity that would otherwise violate the physician self-referral prohibition set forth in §1877 of the Social Security Act and related regulations. A/B MACs (Part B) must deny claims submitted in violation of §1877 and demand refunds of any payments that have been made in violation of §1877. Consistent with 42 CFR 410.32(a), the supervisory physician for the IDTF, whether or not for a mobile unit, may not order tests to be performed by the IDTF, unless the supervisory physician is the patient’s treating physician and is not otherwise prohibited from referring to the IDTF. The supervisory physician is the patient’s treating physician if he or she furnishes a consultation or treats the patient for a specific medical problem and uses the test results in the management of the patient’s medical problem. If an IDTF wants to bill for an interpretation performed by a physician who does not share a practice with the IDTF, the IDTF must meet certain conditions concerning the anti-markup payment limitation. If a physician working for an IDTF (or a party related to the IDTF through common ownership or control as described in 42 CFR §413.17) does not order the technical component or professional component of a diagnostic test (excluding clinical diagnostic laboratory tests), it would not be subject to the anti-markup payment limitation. (See Pub. 100-04, chapter 1, §30.2.9) B. Transtelephonic and Electronic Monitoring Services Transtelephonic and electronic monitoring services (e.g., 24 hour ambulatory EKG monitoring, pacemaker monitoring and cardiac event detection) may perform some of their services without actually seeing the patient. Most but not all of these billing codes are 93012 ,93014, 93040, 93224, 93225, 93226, 93232, 93230, 93231, 93233, 93236, 93270, 93271, 93731, 93733, 93736, 95953, 95956, These monitoring service entities should be classified as IDTFs and must meet all IDTF requirements. We currently do not have specific certification standards for their technicians; technician credentialing requirements for them are at A/B MAC (Part B) discretion. They do require a supervisory physician who performs General Supervision. Final enrollment of a transtelephonic or electronic monitoring service as an IDTF requires a site visit. For any entity that lists and will bill codes 93012, 93014, 93268, 93270, 93271, 93272, the A/B MAC (Part B) must make a written determination that the entity actually has a person available on a 24 hour basis to answer telephone inquiries. Use of an answering service in lieu of the actual person is not acceptable. The person performing the attended monitoring should be listed in Section 3 of Attachment 2 of Form CMS-855B. The qualifications of the person are at the A/B MAC (Part B)’s discretion. The A/B MAC (Part B) shall check that the person is available by attempting to contact the applicant during non-standard business hours. In Particular, at least one of the contact calls should be made between midnight and 6:00 AM. If the applicant does not meet the availability standard they should receive a denial. C. Slide Preparation Facilities and Radiation Therapy Centers Slide Preparation Facilities and Radiation Therapy Centers are not IDTFs. Slide preparation facilities are entities that provide slide preparation services and other kinds of services that are payable through the technical component of the surgical pathology service. These entities do not provide the professional component of surgical pathology services or other kinds of laboratory tests. The services that they provide are recognized by A/B MACs (Part B) for payment, as codes in the surgical pathology code range (88300) to (88399) with a technical component value under the physician fee schedule. The services provided by these entities are usually ordered by and reviewed by a dermatologist. Slide preparation facilities generally only have one or two people performing this service. All enrolled Slide Preparation Facilities must enroll separately with their Medicare contractor. Radiation therapy centers provide therapeutic services and therefore are not IDTFs. Radiation therapy centers must enroll separately with their Medicare contractor.