The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS

DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents. CPT only copyright 2009 American Medical Association.Edit to Deny Payment to Physicians and Other Suppliers for theTechnical Component (TC) of Pathology Services Furnished on SameDate as Inpatient and Outpatient Services and Implements NewMessagesMLN Matters Number: MM7061Related Change Request (CR) #: 7061Related CR Release Date: October 29, 2010Effective Date: April 1, 2011Related CR Transmittal #: R795OTNImplementation Date: April 4, 2011Provider Types AffectedThis article is for physicians, providers, and suppliers billing Medicare contractors (carriers and Part A/BMedicare administrative contractors [A/B MACs]) for services provided to Medicare beneficiaries.What You Need to KnowChange Request (CR) 7061, from which this article is taken, instructs your carriers and A/B MACs tomodify previously implemented edits that prevent payments to physicians, practitioners, independentdiagnostic testing facilities (IDTFs) and independent laboratories for the technical component (TC)portion of the radiology and pathology services furnished to an inpatient or outpatient of a hospital. TheCR also revises certain claim adjustment reason code (CARC), remittance advice remark code (RARC),and Medicare Summary Notice messages for both radiology and pathology because the current codeslisted are obsolete. Make sure your billing staff is aware of these changes.BackgroundCR7061 amends CR5347, issued on April 18, 2007, (see the related MLN Matters ® article athttp://www.cms.gov/MLNMattersArticles/downloads/MM5347.pdf), which implemented edits toprevent payments to physicians, practitioners, IDTFs and independent laboratories for the TC portion ofthe radiology and pathology services furnished to a hospital inpatient or outpatient. Payment for the TCof physician pathology services provided to a hospital inpatient or outpatient is included in the bundledpayment to the hospital. The only exception to this policy is that independent laboratories may bill for theTC of pathology services to an inpatient or outpatient of a hospital according to Section 3104 of theAffordable Care Act.CR7061 also implements an edit to prevent payments for the TC of pathology services billed by any entityother than an independent laboratory for dates of service coincident with hospital inpatient andoutpatient services.The Centers for Medicare & Medicaid Services (CMS) will provide your contractors with a file containingphysician pathology Healthcare Common Procedure Coding System (HCPCS) codes that are subject tothe edit. In addition, CMS will make updates to the file to add and/or delete codes, as needed, inconjunction with the Medicare Physician Fee Schedule Database (MPFSDB) quarterly updates.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 83 MMR 2011-01, January 2011