decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 6 (June)
Watch PC-TC billing under new CMS anti-markup rules
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Article Overview
This article covers CMS’s updated anti-markup framework for diagnostic test billing and how it may affect practices that purchase professional or technical components from outside providers. It discusses the timing of the policy change, the kinds of billing arrangements that may be affected, and the general tests CMS uses to determine whether the anti-markup limits apply. The piece is relevant to ophthalmology, optometry, and other physician practices that interpret or furnish diagnostic testing services and need to understand the compliance impact of the revised Medicare guidance.
Why This Topic Matters
Practices that bill Medicare for diagnostic tests need to understand whether their billing arrangements fall within CMS’s anti-markup rules, because the policy can affect reimbursement structure and contractual relationships with outside interpreters or testing providers.
Article Sections
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Policy update and compliance timeline
Introduces the CMS policy change, the revised effective and implementation timing, and the need for practices to review existing billing arrangements.
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Billing impact for ophthalmology practices
Summarizes how the policy may affect common diagnostic test billing patterns in ophthalmology and related settings, including arrangements involving outside interpretation or testing services.
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Official resources
Lists the external CMS and Federal Register references associated with the guidance discussed in the article.
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Two tests check whether Medicare's anti-markup rules apply to your dx tests
Outlines the two CMS tests described in the article for determining whether anti-markup rules apply to diagnostic test billing arrangements.
What You Will Learn
- How CMS’s anti-markup policy change affects diagnostic test billing arrangements
- Which general types of billing relationships may require review
- What broad categories of CMS tests are used to assess applicability
- Where the article points readers for supporting federal guidance
Who Should Read This
- Ophthalmology practices
- Optometry practices
- Physician billing staff
- Medical coders
- Practice administrators
- Compliance personnel
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