National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Laboratory and Radiology: Adjustment to Medicare System Common Working File (CWF) Duplicate Claim Edit for the Technical Component (TC) of Radiology and Pathology Laboratory Services Provided to Hospital Patients  

Provider Types Affected
Radiology suppliers, clinical diagnostic laboratories, and other providers billing Medicare carriers or Part A/B Medicare Administrative Contractors (A/B MAC) for the TC of radiology and pathology services provided to Medicare fee-for-service hospital inpatients

Provider Action Needed
Impact to You
Previously the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 5347 that established duplicate claims edits, which included consideration of the admission and discharge dates of a hospital stay in identifying duplicate claims for radiology and pathology services.

What You Need to Know
Effective with implementation of CR5675 on October 1, 2007, claims with dates of service on or after April 1, 2007, will be paid that provide radiology and pathology services to Medicare beneficiaries on the day of admission and the day of discharge during an inpatient hospital stay. 

What You Need to Do
Make certain that your billing staffs are aware of these changes.  

Background
This CR is being implemented to avoid denying claims that were legitimately provided to beneficiaries on the admission and discharge dates. The general rule is that the technical component (TC) of radiology services provided during an inpatient stay may be billed only by the admitting hospital. Radiology suppliers that render services to beneficiaries in an inpatient stay may not bill the Medicare carrier for the technical portion of the service.

Also, the TC of physician pathology services provided to a hospital inpatient may be billed only by the admitting hospital. Independent laboratories have been instructed that they may not bill for these services after December 31, 2007 per CR 5468 (Transmittal 1148, issued Jan 5, 2007). The exception is that imaging and pathology services performed on the admission date and discharge date by entities other than the admitting hospital are separately payable.

Also, note that carriers and A/B MACs will not reprocess claims already processed, but they will adjust previously processed claims if affected providers bring such claims to the attention of their carrier or A/B MAC.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5675) issued to your Medicare carrier or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1295CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier or A/B MAC, at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

CR 5347 implemented a process to prevent payments of the TC of radiology services furnished to an inpatient of a hospital by any entity other than the admitting hospital. This CR may be reviewed by clicking on http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5347.pdf on the CMS Web site.

MLN Matters Number: MM5675
Related Change Request (CR) #: 5675
Related CR Release Date: July 13, 2007
Effective Date: April 1, 2007
Related CR Transmittal #: R1295CP
Implementation Date: October 1, 2007

National Provider Identifier (NPI) News – During this testing and implementation phase for the NPI, providers should pay close attention to information from health plans and clearinghouses to understand how claims are being processed and what providers should be doing to assure no disruption in payment. Providers should also ensure that the information they are submitting on a claim is what is being transmitted to each health plan by the billing vendors or clearinghouses who may be submitting the claims on their behalf. Additional information can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.