Revision to CMS Manual Related to Anatomic Pathology Raises Additional Global Billing Issues

by Baker Donelson
Contact

The Centers for Medicare & Medicaid Services (CMS) recently amended Medicare Claims Processing Manual (MCPM) provisions related to payment for anatomic pathology services [PDF] to specifically address submission of such claims on a global basis. While these changes may have clarified application of global billing principles to anatomic pathology, they may have contributed to the continuing uncertainty regarding global billing requirements generally.

Global Billing for Diagnostic Services

Principles governing global billing for diagnostic services such as radiology and anatomic pathology have been misunderstood frequently. This may result, in part, from the lack of a universally known and accepted definition of the term. In the strict sense, a global bill includes a claim for payment for a single service that reflects both its technical component (TC) and professional component (PC). Global billing does not occur when the billing entity submits separate paper claims for the TC and PC of a diagnostic service on a CMS-1500 form; nor is a single electronic claim, with separate line item charges for the TC and PC, considered a global bill.

Total Medicare payments should be the same whether a diagnostic service is billed globally or separate claims for its TC and PC are submitted (although in a recently filed qui tam action against a clinical laboratory, it was alleged that the laboratory’s practice of billing separate TC and PC charges constituted “unbundling” resulting in overbilling Medicare). The advantage of global billing is potential convenience for both the billing entity and the patient who will receive one bill or explanation of benefit (EOB) for what he or she perceives as a single diagnostic service, rather than separate bills or EOBs for the service’s TC and PC. Additionally, when submitted to a private insurer, a global bill may prevent the patient from being responsible for separate copayments for the TC and PC. For this reason, entities that are able to bill on a global basis may have a significant marketing advantage over those that are required to bill for the TC and PC separately.

The disadvantage of a global bill is that such a claim is not literally accurate unless precisely the same information applies to both the TC and PC. Similarly, a global bill may not include all of the information required to determine the proper payment amount, particularly as to the Medicare payment locality in which each particular test component was performed. Therefore, in some cases, a global bill could prevent the Medicare contractor from making correct payment determinations. For that reason, global bills are not permissible when either the TC or PC is subject to Medicare anti-markup limitations; a global bill that does not include a separate payment claim for each service component would not allow the Medicare contractor to determine the proper payment for the TC or PC subject to the payment limitations. See MCPM, Ch. 1, General Billing Requirements, § 30.2.9.

Radiology and Other Diagnostic Procedures

The MCPM states that radiology services and other diagnostic procedures can be billed on a global basis “when the TC and the physician who provides the PC… are furnished by the same physician or supplier entity and the PC and TC components are furnished within the same Medicare physician fee schedule payment locality.” MCPM, Ch. 13, Radiology Services and Other Diagnostic Procedures, § 150(D). The provision indicates that the mere fact that the TC and PC have the same place of service (POS) code – which reflects the setting in which the service was performed, rather than the specific location – does not permit the procedure to be billed globally. In a related FAQ issued on April 25, 2013, CMS clarified that in order for a global diagnostic service code to be billed, the same physician or supplier entity must furnish both the TC and PC, and they must have been furnished within the same Medicare physician fee schedule (MPFS) payment locality www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQs-CR7631-4-25-13.pdf. According to CMS, “[t]he TC and PC may be furnished in different locations as long as they are furnished within the same MPFS payment locality.”

Pathology Services

As a result of the recent issuance of CMS Transmittal 2714, CR 8013 (May 24, 2013), the MCPM states that global billing of pathology services is permissible only “when the PC and TC are furnished by the same physician or supplier entity.” MCPM, Ch. 12, Physicians/Non-Physician Practitioners, § 60(D). This is consistent with the radiology provision. But the revised MCPM provision goes on to state: “For example, where the PC and the TC… are provided in the same service location, this is reflected as the address entered into Item 32 on CMS Form 1500, which provides the ZIP Code to pay the right locality/GPCI.” CMS states that “[i]n this case, the physician/entity may bill globally.” By contrast, according to CMS, “if the PC and the TC are each provided in different service locations (enrolled practice locations), the PC and the TC must be separately billed.”

Thus, it appears that, in addition to being furnished by the same entity and in the same Medicare payment locality as provided for in the radiology provisions, the TC and PC of a pathology service must be performed at the same location in order to be billed globally. This requirement would appear unnecessary. After all, what difference should it make that the pathologist performed the interpretation across the street from the facility in which the slide was prepared (unless the road served as the border for two Medicare payment localities)? However, CMS has indicated that, in that scenario, separate claims for the TC and PC of the service are required, even if the pathologist interpreting the slide and the laboratory technician who prepared it were employed by the same entity.

Questions Remaining

The provision addressing the circumstances under which radiology services may be billed on a global basis does not include references to “service location,” “address,” or “enrolled practice location.” As a result, radiology services are not subject to the “same location” requirement as are pathology services. But why are the requirements for billing pathology services globally more stringent than those that apply to radiology? Hopefully, CMS will address this issue in the future. Meanwhile, I keep thinking of the camel – the horse designed by committee – and wonder whether too many people have been involved in preparing these Medicare instructions.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Baker Donelson | Attorney Advertising

Written by:

Baker Donelson
Contact
more
less

Baker Donelson on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Privacy Policy (Updated: October 8, 2015):
hide

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.

Security

JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at info@jdsupra.com. In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at: info@jdsupra.com.

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.
Feedback? Tell us what you think of the new jdsupra.com!