AMA Clinical Examples in Radiology - 2007 Bulletin 2
Pricing Rules Implemented by CMS for Purchased Diagnostic Service Claims Outside Local Carrier's Jurisdiction
Pricing Rules Implemented by CMS for Purchased Diagnostic Service Claims Outside Local Carrier's Jurisdiction The Centers for Medicare and Medicaid Services (CMS) instructed carriers and Medicare administrative contractors that effective October 1, 2007, all purchased diagnostic service payments should be based on the zip code of the location where the services are rendered (Transmittal 1250 [CR 5543]). All purchased diagnostic services are based on the Medicare Physician Fee Schedule and are subject to the jurisdiction rule. Carriers pay the local rate for claims of purchased diagnostic services dated on or after October 1, 2007. CR 5543 replaced the temporary...
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Article Overview
This article covers CMS guidance for pricing purchased diagnostic service claims under Medicare, including updates tied to contractor jurisdiction and the location where services are rendered. It is aimed at coding and billing professionals who need to understand the scope of the CMS change, the manual updates referenced, and the general claims-processing context involved.
Why This Topic Matters
It matters because purchased diagnostic service claims can be priced differently depending on where the service is rendered and which Medicare contractor has jurisdiction, affecting claim payment and processing consistency.
Article Sections
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CMS pricing guidance for purchased diagnostic services
Overview of the CMS instruction affecting payment treatment for purchased diagnostic services under Medicare. The section frames the policy change and its general billing context.
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Implementation details and manual updates
Discussion of the operational changes referenced by CMS and the related Medicare Claims Processing Manual updates. This section also addresses contractor pricing procedures and the handling of claims outside a local jurisdiction.
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Reference to CMS resources
Brief pointer to CMS educational materials and related online resources. This section serves as a citation and access reference rather than substantive coding guidance.
What You Will Learn
- The general CMS policy context for purchased diagnostic service claims
- How jurisdiction and service location factor into Medicare pricing guidance
- Which CMS manual references and contractor processes are discussed
- What type of claims are addressed in the article
Who Should Read This
- Medical coders
- Billing specialists
- Revenue cycle staff
- Medicare claims processors
- Radiology billing professionals
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