Radiology claim when service in inpatient or outpatient hospital setup

Services Provided in Inpatient or Outpatient Hospital

As a reminder, carriers must pay under the fee schedule for the TC of radiology services furnished to beneficiaries who are not patients of any hospital and who receive services in a physician’s office; a freestanding imaging or radiation oncology center; or other setting that is not part of a hospital.
However, carriers may not pay for the TC of radiology services furnished to hospital patients.

Payment for physicians’ radiological services to the hospital (e.g., administrative or supervisory services and for provider services needed to produce the radiology service) is made by the Fiscal Intermediary (FI) as a provider service.

FIs include the TC of radiology services for hospital inpatients except Critical Access Hospitals (CAHs) in the Prospective Payment System (PPS) payment to hospitals.

For CAHs, payment is made by the FI based on reasonable cost.

Radiology and other diagnostic services furnished to hospital outpatients are paid under the OPPS to the hospital.

As a result of Skilled Nursing Facility (SNF) Consolidated Billing (CB) (Section 4432(b) of the Balanced Budget Act (BBA) of 1997), carriers may not pay for the TC of radiology services furnished to SNF inpatients during a Part A-covered stay. The SNF must bill radiology services furnished its inpatients in a Part A-covered stay and payment is included in the SNF PPS.

Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service or by the SNF under arrangements with the supplier. If billed by the SNF, FIs pay according to the Medicare Physician Fee Schedule.

Some hospitals do not always have the necessary equipment to perform radiological tests for their patients and will request an outside entity to come perform the TC of those tests. These may be paid “under arrangement.”