BILLING AND PAYMENT ON MEDICARE INSTITUTIONAL CLAIMS

Services Furnished in Hospitals to Inpatients

Imaging services provided under arrangement are billed under Part A to Medicare Fiscal Intermediaries (FIs) and A/B MACs, using revenue codes.

Payment for physician's imaging services to the hospital, for example, administrative or supervisory services, and for provider services needed to produce the imaging service, ar made by the FI or A/B MAC to the hospital as a provider service.

FIs and A/B MACs include the TC of imaging services for hospital inpatients in the Inpatient Prospective Payment System (IPPS) payment to hospitals, except that payment to Critial Access Hospitals (CAHs) for inpatients is made at 101 percent of reasonable cost. Carriers may not pay for the TC of imaging services furnished to hospital patients.

The PC of imaging services performed by physicians for hospital inpatients may be separately billed by the physician and paid by the carrier or A/B MAC.

Services Furnished in Hospitals to Outpatients
Imaging services provided either directly or under arrangement are billed under Part B to Medicare FIs and A/B MACs, using revenue codes, HCPCS code, line item dates of service, units, and applicable HCPCS modifiers. Charges must be reported by HCPCS code.

Imaging services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital, except that payment to CAHs for outpatients is made at 101 percent of reasonable cost.

Mammograms furnished to inpatients or outpatients are paid under the MPFS to the hospital.

The PC of imaging services performed by physicians for hospital outpatients may be separately billed by the physician and paid by the local carrier or A/B MAC.

Services Furnished in Method II CAH Hospitals

In addition to the TC mentioned above, the PC of imaging services are billed under Part B to Medicare FIs and A/B MACs, using revenue codes series 0960 thru 0989, HCPCS code, line item date of service, units, and applicable HCPCS modifiers. Charges must be reported by HCPCS code.

The PC of imaging services furnished to CAH patients is made at 115 percent of the MPFS.

Services Furnished in Skilled Nursing Facilities (SNF)
Payment for a SNF bill for imaging services furnished to its residents in a Part A covered stay is include in the SNF Prospective Payment System. However, certain types of ADI, such as MRI and CT, are separately payable under Part B when performed in the outpatient hospital setting.

Imaging services furnished on an ambulatory basis to residents of SMFs may be billed by the supplier performing he service or by the SNF under arrangements with the supplier.

The PC of imaging services performed by physicians for SNF residents, on either an inpatient or ambulatory basis, may be separately billed and paid.

Mammograms furnished to SNF residents are paid under the MPFS to the SNF.

Services Furnished by Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)
Independent and provider-based RHCs and FQHCs bill for the PC using revenue codes 52x. RHCs are not required to submit HCPCS codes for imaging services. However, FQ?HCs are required to submit HCPCS codes.

The TC is outside the scope of the RHC/FQHC benefit. Technical services/components associated with professional services/components performed by independent RHCs or FQHC are billed to the carrier and A/B MAC.

Technical services/components associated with professional services/components performed by provider-based RHCs or FQHCs are billed to the FI and A/B MAC on the base-provider type of bill.