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IDTFs get Claims Processing Manual chapter of their own

Radiology Administrator's Compliance and Reimbursement Insider, July 25, 2008

Previously, the Medicare Claims Processing Manual contained no specific instructions regarding claims processing for IDTFs. To remedy this, CMS directed that information from the Program Integrity Manual, Chapter 10, regarding IDTF claims processing, be excerpted and added to the Medicare Claims Processing Manual. The changes became effective June 16.

However, the new IDTF chapter does not necessarily mean your claims processing process will need to change, says William A. Sarraille, Esq., a partner at Sidley Austin, LLP, in Washington, DC. Let’s examine the claims processing requirements now contained in Chapter 35 of the Medicare Claims Processing Manual, as outlined by CMS.

General coverage and payment policies applicable to IDTFs

Effective for diagnostic procedures performed on or after March 15, 1999, carriers will pay for diagnostic procedures under the Medicare Physician Fee Schedule only when performed by a physician, a group practice of physicians, an approved supplier of portable x-ray services, a nurse practitioner, or a clinical nurse specialist in an IDTF.

Medicare’s definition of an IDTF

An IDTF is a facility that is independent of a hospital and an attending or consulting physician’s office, according to CMS. However, IDTF general coverage and payment policy rules apply when an IDTF furnishes diagnostic procedures in a physician’s office.

Billing issues

CMS states that nothing in Chapter 35 should be construed or interpreted to authorize billing by an IDTF, physician, physician group practice, or any other entity that would otherwise violate the physician self-referral prohibition set forth in the Stark Law.

The supervisory physician for the IDTF, regardless of whether it’s a mobile unit, may not order tests to be performed by the IDTF unless the supervisory physician is the patient’s treating physician and is not otherwise prohibited from referring to the IDTF, CMS states.

CMS defines the supervisory physician—the person who treats the patient for a specific medical problem and uses the imaging test results in its management—as the patient’s treating physician.

If an IDTF wants to bill for an interpretation performed by an independent practitioner off the premises of the IDTF, the IDTF must meet separate legal conditions concerning purchased interpretations.

Transtelephonic and electronic monitoring services

Transtelephonic and electronic monitoring (e.g., 24-hour ambulatory EKG, pacemaker, and cardiac event detection) technicians may perform some of their services without seeing the patient.

These monitoring service entities should be classified as IDTFs and must meet all IDTF requirements. However, CMS currently does not have specific certification standards for their technicians. Technician credentialing requirements remain at carrier discretion, but technicians must work under a supervisory physician.

Final enrollment of a transtelephonic or electronic monitoring service as an IDTF requires a site visit.

For facilities that perform specific procedures, the carrier must make a written determination that the entity has a person available on a 24-hour basis to answer telephone inquiries. Use of an answering service in lieu of the actual person is not acceptable, CMS states.

The person performing the attended monitoring should be listed in Section 3 of Attachment 2 of form CMS-855B. The person’s qualifications are at the carrier’s discretion. The carrier must check that the person is available by attempting to contact the applicant during nonstandard business hours.

Slide preparation facilities and radiation therapy centers

Slide preparation facilities and radiation therapy centers are not IDTFs, CMS states. Slide preparation facilities are entities that provide slide preparation services and other kinds of services payable through the technical component of the surgical pathology service.

Radiation therapy centers do not provide the professional component of surgical pathology services or other kinds of laboratory tests. The services radiation therapy centers provide are recognized by carriers for payment as codes in the surgical pathology code range 88300–88399, with a technical component value under the MPFS.

The services provided by these entities are usually ordered and reviewed by a dermatologist. Slide preparation facilities generally only have one or two people performing this service.

All enrolled slide preparation facilities must enroll separately with their Medicare contractor. Radiation therapy centers provide therapeutic services and, therefore, are not IDTFs.

Radiation therapy centers must enroll separately with their Medicare contractor.

Ordering tests

All procedures performed by the IDTF must be ordered in writing by the physician who is furnishing a consultation or treating a beneficiary for a specific medical problem and who uses the results in its management of the beneficiary’s specific medical problem. The order must specify the diagnosis or other basis for the testing.

The supervising physician for the IDTF may not order tests to be performed by the IDTF unless the IDTF’s supervising physician is the beneficiary’s treating physician, CMS states.

That is, the physician in question had a relationship with the beneficiary prior to the performance of the testing and is treating the beneficiary for a specific medical problem. The IDTF may not add any procedures based on internal protocols without a written order from the treating physician.

Purchased diagnostic tests

A person or supplier who provides diagnostic tests may submit the claim and receive the Part B payment for diagnostic test interpretations purchased from an independent physician or medical group if:

The tests are initiated by a physician or medical group that is independent of the person or entity providing the tests and of the physician or medical group providing the interpretations.

The physician or medical group providing the interpretations does not see the patient.

The purchaser, employee, partner, or owner of the purchaser, performs the technical component of the test. The interpreting physician must be enrolled in the Medicare program. Formal reassignment is not needed.

The purchaser files the name, the provider identification number, and address of the interpreting physician.

The assignment is accepted.

Insider source

William A. Sarraille, Esq., partner, Sidley Austin, LLP, 1501 K Street, NW, Washington, DC 20005, 202/736-8195; wsarraille@sidley.com.

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