decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 4 (April)
New dx test rules: Check your payment arrangements
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Article Overview
This article covers Medicare’s revised anti-markup rules for diagnostic tests that have professional and technical components, with a focus on how primary care practices should review existing billing and contracting arrangements. It is aimed at physicians, practice managers, and coding/billing staff who handle diagnostic test payment issues. The discussion includes the timing of Medicare’s policy update, the types of arrangements that may be affected, and the general factors Medicare uses to determine whether the rule applies.
Why This Topic Matters
Practices that purchase diagnostic test components and bill Medicare for them may need to reassess their workflow, contracts, and billing setup to avoid payment problems and compliance risk under the updated policy.
Article Sections
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Background on diagnostic test components and Medicare billing
Introduces the difference between professional and technical components of diagnostic tests and explains why fee schedule structure matters for payment review.
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Effective dates and compliance steps
Summarizes the timing of the Medicare update and the broad actions practices are expected to take before the change becomes operational.
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Common billing arrangements for purchased services
Describes typical practice relationships with outside specialists or vendors and how those arrangements may affect billing workflows.
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Example involving echocardiography
Uses a diagnostic test example to illustrate the kinds of payment and billing arrangements discussed in the article.
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Two factors that determine whether anti-markup rules apply
Presents the general Medicare questions used to evaluate whether the anti-markup rule applies to purchased diagnostic services.
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Bottom line and practical options
Summarizes the broad compliance approaches discussed for practices that want to avoid the anti-markup limitation.
What You Will Learn
- How Medicare’s anti-markup policy relates to diagnostic tests with separate components
- What types of practice arrangements may be affected by the policy
- Which general factors Medicare uses to evaluate whether the rule applies
- How the article frames common response options for affected practices
Who Should Read This
- Primary care physicians
- Practice managers
- Medical coders
- Billing staff
- Compliance staff
Codes Discussed
Modifiers Discussed
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