Medicare Radiology payment when Anti-Markup Does Not Apply

When Anti-Markup Does Not Apply
The anti-markup payment limitation will not apply if the performing physician “shares a practice” with the ordering/billing physician or other supplier. There are two alternatives for determining whether a performing/supervising physician shares a practice with the ordering/billing physician or other supplier. The two alternatives are:

Alternative One – Substantially all services requirement:

If the performing physician (that is, the physician who supervises the TC or performs the PC) furnishes substantially all (at least 75 percent) of his professional services through the billing physician/supplier, none of the physician’s diagnostic testing services will be subject to the anti-markup payment limitation (i.e., would not mark any services as purchased).

This scenario establishes the “shares a practice” criteria based on Alternative One.

Note: If the performing physician does not meet the “substantially all services” requirement, a “site of service” (Alternative Two) analysis may be applied on a test-by-test basis to determine whether the anti-markup payment limitation applies.


Alternative Two – Site of service test:
Only TCs conducted and supervised and PCs performed in the “office of the billing physician or other supplier” by a physician owner, employee or independent contractor of the billing physician or other supplier will avoid application of the anti-markup limitation.

The “office of the billing physician or other supplier” is any medical office space, regardless of the number of locations, in which the ordering physician regularly furnishes patient care. This includes space where the billing physician or other supplier furnishes diagnostic testing if the space is located in the “same building” (as defined in 42 CFR 411.351) in which the ordering physician regularly furnishes patient care.

If the billing physician or other supplier is a physician organization (as defined in 42 CFR 411.351), the “office of the billing physician or other supplier” is space in which the ordering physician provides substantially the full range of patient care services that the ordering physician generally provides. With respect to the TC, the performing supplier is the physician that supervised the TC and, with the respect to the PC, the performing supplier is the physician that performed the PC. Thus if the “site of service” requirements are met, the anti-markup payment limitation will not apply.

Note: Providers may not submit a total component code when one component of the service is subject to the anti-markup limitation. It must be split-billed due to jurisdiction pricing.
http://www.cms.gov/MLNMattersArticles/downloads/MM6371.pdf