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CMS-1403-FC
Group A orders the TC and PC of a diagnostic test.
Laboratory B performs TC and contracts with Physician C to
perform the PC, and Laboratory B bills for the TC and the
PC. In this example, the anti-markup provisions would not
apply to the TC or the PC billed by Laboratory B. However,
if the interpreting pathologist decides to order additional
tests that are then performed and/or interpreted by another
pathologist, the anti-markup payment limitation potentially
would apply if the ordering pathologist wishes to bill for
the additional interpretations performed by the different
pathologist. Whether the anti-markup payment limitation in
fact would apply would depend on whether the arrangement
between the ordering/billing pathologist and the
pathologist performing or supervising the TC/performing the
PC satisfies the requirements of Alternative 1 (and, if
not, whether it satisfies, on a case-by-case basis, the
requirements of Alternative 2).
Comment: Some commenters offered support for
Alternative 1. The commenters believed that this
alternative has greater potential to limit self-referral
arrangements by requiring that a physician practice should
not be able to mark up anatomic pathology tests unless the
physician who performs and supervises the pathology
services is dedicated solely to that physician practice.
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