Desk and Site Reviews
All new IDTF applications shall receive (1) a thorough desk review, and (2) a mandatory site review prior to the contractor’s enrollment of the applicant and issuance of a billing number. The general purpose of both reviews is to determine whether the information listed on Attachment 2 of the CMS-855B is correct, verifiable, and in accordance with IDTF regulatory and manual requirements.
Site Visits for Mobile Units and Electronic Monitoring Services
Mobile units are required to list their geographic service area. They can be site visited by the following methods: 1) The mobile unit may visit the office of the site reviewer, or 2) The site reviewer can obtain an advance schedule of the locations the IDTF will be visiting and conduct the site visit at one of those locations.
Transtelephonic and electronic monitoring services (e.g., 24-hour ambulatory EKG monitoring; pacemaker monitoring and cardiac event detection) should be classified as IDTFs and must meet all IDTF requirements. These entities require a supervisory physician who performs general supervision. Final enrollment of a transtelephonic or electronic monitoring service, such as an IDTF, requires a site visit.
An Independent Diagnostic Testing Facility (IDTF) is not restricted to billing only the technical component of diagnostic services. In certain situations, an IDTF can bill for both the technical component of the diagnostic test and interpretative services. This approach is referred to as billing “globally”. The interpretative services must be performed by a licensed practitioner who is allowed to perform the service.
When enrolling or updating information, the IDTF shall list all physicians for whose diagnostic test interpretations it will bill. This includes physicians who are providing purchased interpretations to the IDTF (in accordance with CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.2), as well as physicians who are reassigning their benefits to the IDTF. The contractor will ensure and document the following:
All physicians listed are enrolled in Medicare.
All interpreting physicians who are reassigning their benefits to the IDTF have the right to do so. All required CMS-855R forms have been submitted.
The interpreting physicians listed are qualified to interpret the types of tests (codes) listed. In accordance with this CMS requirement (CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 10, Section 4.19.3), the contractor requires that the interpreting physician for a test billed by the IDTF meet the same qualification requirements as the supervising physician for that IDTF test as listed in the ‘Credentialing Matrix’.
Note: The applicant cannot bill globally for interpreting physicians not listed.
If an interpreting physician has been recently added or changed, the new interpreting physician must have met all of the interpreting physician requirements at the time any tests were performed.
If an IDTF wants to bill for an interpretation performed by an independent practitioner off the premises of the IDTF, it must meet all instructions identified in the CMS Manual System, Pub. 100-04, Medical Claims Processing Manual, Chapter 1, concerning purchased interpretations. In this scenario, there is no reassignment of benefits because the purchaser of the test is also considered the supplier of the test.
When the technical component of a test is performed by the IDTF and the interpreting practitioner is the practitioner who ordered the test, the IDTF cannot bill for the interpretation. The interpreting practitioner must bill the interpretation since the IDTF cannot bill the interpretation when the interpreting physician is the referring physician.
Purchased Diagnostic Tests and Jurisdictional Pricing
Services that are reimbursed under the Medicare Physician Fee Schedule (MPFS) are reimbursed by the payment locality where the service is furnished and by the zip code. Contractors must use the zip code of the location where the service was rendered to determine contractor jurisdiction over the claim and the correct payment locality.
When a physician, practitioner, or supplier furnishes services in payment localities that cover more than one contractor’s service area (e.g., the provider has separate office in multiple localities and/or multiple contractors), separate claims must be submitted to the appropriate contractor for processing.
Providers may not submit a global billing code on paper or electronic claims when one component of the service has been purchased. Only one service facility location (name, address and zip code) can be indicated in item 32 on the CMS-1500 form. Claims received with global services will be returned as unprocessable.
Suppliers (including laboratories, physicians and independent diagnostic testing facilities [IDTFs]) must bill their local contractor for all purchased diagnostic tests/interpretations, regardless of the location where the purchased service was rendered.
Purchased Technical Components
A physician may bill for the technical component of a diagnostic test that he/she purchased from another physician, medical group or supplier. However, in order to purchase a diagnostic test from another physician, medical group, or supplier, the purchaser must perform the interpretation (professional component). Additionally, the physician or supplier that furnished the technical component must be enrolled in the Medicare program.
A person or entity that provides diagnostic tests may submit the claim, and (if assignment is accepted) receive the Part B payment, for diagnostic test interpretations which that person or entity purchases from an independent physician or medical group if:
The tests are initiated by a physician or medical group which is independent of the person or entity providing the tests and of the physician or medical group providing the interpretations;
The physician or medical group providing the interpretations does not see the patient; and
The purchaser (or employee, partner, or owner of the purchaser) performs the technical component of the test. The interpreting physician must be enrolled in the Medicare program. No formal reassignment is necessary.
The purchaser must keep on file the name, the provider identification number and address of the interpreting physician.
Note: This does not remove the requirement that when an entity either purchases an interpretation or a test, they must perform the other component in order to be paid for the purchased component.
In order to price claims correctly and apply purchase price limitations, global billing is not acceptable for claims received on the Form CMS-1500 or on the ANSI X12N 837 electronic format. Each component must be billed as a separate line item (or on a separate claim).
Suppliers (including laboratories, physicians, and IDTFs) must submit claims for all purchased diagnostic tests/interpretations to their local contractor, regardless of the location where the purchased service was furnished.
Physician Supervision of Diagnostic Procedures
01 = Procedure must be performed under the general supervision of a physician.
02 = Procedure must be performed under the direct supervision of a physician.
03 = Procedure must be performed under the personal supervision of a physician.
04 = Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist. Otherwise the procedure must be performed under the general supervision of a physician.
05 = Not subject to supervision when furnished personally by a qualified audiologist, physician, or non-physician practitioner. Direct supervision by a physician is required for those parts of the test that may be furnished by a qualified technician when appropriate to the circumstances of the test.
06 = Procedure must be personally performed by a physician or a Physical Therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiological clinical specialist and is permitted to provide the procedure under State law. Procedure may also be performed by a PT with ABPTS certification without physician supervision.
21 = Procedure may be performed by a technician with certification under general supervision of a physician. Otherwise the procedure must be performed under direct supervision of a physician. Procedure may also be performed by a PT with ABPTS certification without physician supervision.
22 = May be performed by a technician with on-line real-time contact with a physician.
66 = May be personally performed by a physician or by a PT with ABPTS certification and certification in this specific procedure.
6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.
77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC & PC), or by a technician with certification under general supervision of a physician (TC only; PC always physician).
7A = Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.
09 = Concept does not apply.