CMS Place-of-service Instructions Continue to Confound Providers

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon

Paul W. PittsThomas W. GreesonOn October 11, 2012, CMS published yet another version of its guidance on place-of-service codes for the professional and technical components of diagnostic tests. The guidance was first issued as transmittal 2561 on September 28, but that was rescinded and replaced (due to preimplementation contact-information changes) by transmittal 2563. 1 It revises the instructions set forth in chapter 13 of the CMS manual system for Medicare claims processing.

This transmittal is the latest in a series of transmittals that began surfacing in 2009 addressing the place-of-service codes, including transmittal 1823, which was to have gone into effect January 4, 2010, and transmittal 2435, which was issued March 29, 2012 but subsequently delayed until October 1. Unless this new release is delayed, the latest guidance will become effective on April 1, 2013.

Despite the many delays, there are really no significant changes, in the latest transmittal, over the prior iterations—only minor clarifications. We expect that CMS intends for this transmittal to reflect its final instructions on the place-of-service codes. Given the importance of these instructions, and lingering confusion on aspects of the place-of-service codes, it is worth reviewing how the location of imaging services should be reflected on the claim form.

Summary of Instructions

First and foremost, the place of service for the professional component/interpretation service is the location where the technical component was provided to the patient. If, however, one is billing separately for the professional interpretation with a -26 modifier, the claim must report the address and zip code of the interpreting physician on line 32 of the CMS-1500 form (or its electronic equivalent).

Second, the payment-jurisdiction rules remain in place. Claims for interpretation services should be billed to the Medicare administrative contractor (MAC) responsible for the jurisdiction where the service was furnished (unless the interpretation was performed in an unusual and infrequent location, in which case the claim is to be adjudicated where the physician most commonly practices). The payment-jurisdiction rule is particularly relevant when the professional component is routinely performed in a different state (or MAC jurisdiction) from where the technical component is performed. This is most often the case in teleradiology and in urban areas that cross or border state lines.

Third, CMS has clarified that global billing is permitted only when the interpreting physician and the physician or supplier furnishing the technical component are the same and the professional component and technical component are performed in the same Medicare Physician Fee Schedule (MPFS) payment locality. If these conditions are not met, the technical component and professional component must be billed separately.

It appears, to the authors, that a radiology group might bill the technical component and the professional component globally if the test is interpreted by a radiologist employed by the group and the technical component and the professional component are furnished in the same MPFS payment locality. We base that view on the phrase “furnished by the same physician or supplier entity”1 in the transmittal.

Remaining Questions

Thus, when the interpreting physician is an employee of the radiology group, and the group furnished both the technical and professional components in the same MPFS payment locality, the radiology group can bill globally, we believe. What remains unclear is whether a radiology group can bill globally if the interpreting physician is an independent contractor reassigning billing rights to the group (rather than an employee) and the group furnished both the technical and professional components in the same MPFS payment locality.

Transmittal 2563 doesn’t provide further guidance on what constitutes a supplier entity, for purposes of global billing. Arguably, a radiology group should be permitted to bill globally when its employed and contracted radiologists perform the technical component and professional component and reassign their right to bill for the services to the group, which constitutes a single supplier entity. Otherwise, it appears that any claim for professional-component services only submitted by a radiology group for a radiologist who is not employed by the group would have to be split for billing.

Given the language in the transmittal, CMS doesn’t seem to