New CMS Rules Complicate Supervision and Interpretation

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Tom GreesonRecently altered CMS rules governing diagnostic-imaging supervision and interpretation agreements have created what one knowledgeable observer calls a horrible mess. Health-care attorney Tom Greeson, a partner in the law firm Reed Smith LLP of Falls Church, Virginia, expresses concern that regulatory changes that took effect earlier this year might cause confusion among imaging centers and radiology groups that provide interpretation services across state lines. For starters, “CMS has changed the rules dramatically by eliminating the concept of purchased interpretations,” according to Greeson, whose practice focuses on Medicare reimbursement and on legislative and regulatory issues. Purchased interpretations, he indicates, have been superseded by antimarkup tests and so-called reassigned professional services. No longer can a claim for an interpretation be submitted to the imaging center’s local carrier when the physician who orders the exam is totally independent of the physician performing the test and the one interpreting it, and the interpreting physician is located in another state, Greeson explains. Now, trouble arises when claims for reassigned professional services are sent to the wrong Medicare administrative contractor (MAC). Greeson reports that the correct destination must be the MAC that has jurisdiction over the locality where the interpretation was performed—which might or might not be the same as the one where the technical-component supplier is located. Not so long ago, CMS rules were more favorable to imaging centers and radiology groups purchasing their interpretations from independent contractors (typically via teleradiology) across state lines. “You could bill through the MAC in the same state where the imaging center was located,” Greeson says. States of Confusion Under the new rules, to be paid, an imaging center or radiology group must first jump through a flaming hoop or two. “For example, if the imaging center in state A wants to bill for interpretation services supplied to it by radiologists located in states B and C, the imaging center now must enroll as an admitted supplier in state B and again in state C,” Greeson explains. “It must submit a CMS-855B enrollment application to the Medicare carrier in each state in order to submit claims. Trust me, it’s a hassle to do this because CMS has made it almost impossible to enroll with Medicare carriers in the other states if the IDTF or radiology group doesn’t have a physical location in those jurisdictions.” In short, he says, “CMS is saying you must bill in the other state, but then it turns around and says, ‘Good luck trying to get authorization to do so.’ Clearly, CMS has created a horrible mess here with its claims-processing instructions.” The reason behind this requirement to bill in the state where the interpretation is actually performed has to do with the reliance of CMS on geographical practice-cost indices. CMS, Greeson says, applies this calculation to every Medicare claim in order to ensure that services are priced accurately. Greeson believes, however, there is a fix that CMS could adopt and implement with relative simplicity: zip-code billing. “CMS, in the past, permitted imaging centers to submit claims locally for out-of-Medicare-locality services,” he says. Under this rubric, he adds, “The IDTF needed only to identify, on the claim form, the interpreting physician’s zip code in order to cull the information required for those geographical practice-cost indices. It would be helpful if CMS applied this zip-code billing concept to reassigned professional services so that it can easily and quickly adjudicate interpretations performed across state lines. Something so basic as this would go a long way toward alleviating the problems the recent rules changes have introduced.” Zipping Along The narrow range of situations in which the zip-code identification method currently holds sway is defined by Stark antimarkup test rules. Tests in compliance with the rules are those studies performed at the behest of a referring physician’s office by a second physician, who does not share a practice with the ordering physician. The rules deem the second physician (labeled the performing supplier) to be sharing a practice with the ordering physician if both work from offices in the same building or if the interpreting physician performed at least 75% of his or her studies for the same ordering physician group, Greeson says. If the referrer and performing supplier are found not to share a practice, the rule now is that payment to the billing physician will be the lowest of the following: the performing supplier’s net charge to the billing physician; the billing physician’s actual charge; or the MPFS amount that would be allowed if billed by the performing supplier. Greeson believes that IDTF operators and radiology groups should reach out to CMS and advocate that zip-code billing be extended to cover interpretation services performed out of state. Greeson discloses that he is participating in efforts to persuade the agency along those very lines. Meanwhile, Greeson advises radiology groups to exercise a heightened degree of caution when entering into supervision and interpretation agreements with referring-physician groups. “An issue to be alert to is that some referring physician practices may try to ascribe a radiologist’s services to an overreading in order to sidestep compliance with the antimarkup rules,” he says. “It’s entirely possible that a primary-care or self-referring physician group will pretend that it has performed a reading and made a note in the chart in order to avoid antimarkup payment restrictions—thus becoming able to bill globally for both the technical component and the professional component, even if it did not perform the interpretation service at all.” Greeson continues, “In actuality, the interpretation it is relying on is that of the radiologist. Billing in this fashion could (arguably) be considered a false claim because it did not, in fact, perform the interpretation.” He adds, “The radiologist, by getting involved in this type of dealing, is thus potentially facilitating the filing of false claims—and so he or she may end up in trouble for it. My advice for anyone involved in an overread arrangement is to make sure you’re performing a genuine overread—that you’re giving a genuine secondary opinion to a previous interpretation that had actually been performed.” In closing, Greeson recommends implementing stringent internal policies and procedures to ensure that every secondary interpretation is valid and will pass muster with CMS inspectors. Rich Smith is a contributing writer for