Claim Guidelines

The name and NPI of the referring/ordering provider must be in Items 17 and 17b of the CMS-1500 claim form or the EMC equivalent.

An IDTF shall not be allowed to bill for any CPT or HCPCS codes that are solely therapeutic.

Diagnostic tests are made up of both a TC (the supplies, equipment, and technicians) and a PC (the physician’s interpretation of the TC’s results); therefore, professional interpretation may be split and billed separately.

Physician(s) bill for professional component (26)
Facility must bill TC of procedure code for facility fee reimbursement
The IDTF may bill the global code

Note: The IDTF may not bill separately for the TC and PC of a service if both services are performed.

The billing entity must report using the ASC X12 837 professional claim format or on the form CMS-1500 the name, NPI and address of the performing physician or other provider.

The acquisition price of the either the TC or PC of the diagnostic test must also be reported on the claim line item 20 or the electronic equivalent.

The billing provider must report the name, address and NPI of the performing physician or supplier in Item 32a on anti-markup and reference laboratory claims, even if the performing physician or supplier is enrolled in a different MAC (B) jurisdiction.

The point of the actual delivery of service means the POS on the claim form.

When the IDTF performs or administers an entire diagnostic test at the beneficiary’s location, the beneficiary’s location is the POS. When one or more aspects of the diagnostic testing are performed at the IDTF, the IDTF is the POS. (See 42 CFR, Section 410.33(e)[1]).

Physicians working for an IDTF do not order diagnostic tests because such tests are generally ordered by the patient’s treating physician.

If a physician working for an IDTF does not order a diagnostic test, the test is not subject to the anti-markup payment limitation.

If a physician working for an IDTF (or a physician financially related to the IDTF through common ownership or control) orders a diagnostic test payable under the MPFS, the anti-markup payment limitation may apply (depending on whether the performing physician or other supplier meets the “sharing a practice” requirements). For additional information, see CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.2.9.

If a physician working for an IDTF (or a physician financially related to the IDTF through common ownership or control) orders and the IDTF bills for a diagnostic test that is performed by another provider, the performing physician or other provider must be enrolled in the Medicare program. No formal reassignment is necessary; however, reassigned diagnostic testing services may also be subject to the anti-markup payment limitation.

Claim Guidelines

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