Medicare_Carriers_Manual / 15048 / 15048

Why This Topic Matters

Purchased diagnostic test rules affect who can bill, how payment is determined, and whether a claim can be paid at all. The article also highlights compliance risks that can lead to sanctions, exclusion, or criminal penalties, making it important for billing, coding, and compliance review.

Article Sections

1. 15048. Purchased Diagnostic Tests

   Overview of Medicare payment policy for diagnostic tests billed by physicians but performed by outside suppliers. Covers the general framework, billing circumstances, and related compliance considerations.

2. A. General

   Introduces the scope of the rule and the types of diagnostic testing services addressed. Also notes the relationship to physician pathology services and other excluded categories.

3. B. Payment

   Describes how payment is handled when a physician bills for a purchased diagnostic test and what billing information is required. Also addresses beneficiary billing limits and claim payment consequences when required information is missing.

4. C. Sanctions

   Summarizes the enforcement consequences associated with repeated improper billing practices involving beneficiaries. References the applicable Medicare penalty framework.

5. D. Questionable Business Arrangements

   Discusses arrangements that may raise compliance concerns in the context of diagnostic testing services. Covers supervision, ordering, supplier relationships, and referrals in a general way.