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Diagnostic Testing in a Hospital Setting


Provider Administrative Policy

Section
General Information
Policy Date
November 2011
Status/Date
New/November 2011
Provider Type(s)
Physician  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Diagnostic Testing in a Hospital Setting

When billing for diagnostic tests performed in a hospital setting, only the professional component should be billed.  Providers should not bill a technical component or global service for diagnostic tests performed in a hospital.  A hospital setting could be defined as inpatient, outpatient, emergency room or skilled nursing.

When developing this logic into our claims adjudication systems, Blue Cross of Idaho utilized the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) to determine eligibility of a CPT code to be split into professional and technical components.

Within the NPFS, there is a column with the header PC/TC (Professional Component/Technical Component).   Any CPT codes with a value of ‘1’ in that column should only be billed as a professional service when performed in a hospital setting.

1 = Diagnostic Tests for Radiology Services--Identifies codes that describe diagnostic tests.  Examples are pulmonary function tests or therapeutic radiology procedures, e.g., radiation therapy.  These codes have both a professional and technical component.  Modifiers 26 and TC can be used with these codes.  The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense.  The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only.  The total RVUs for codes reported without a modifier include values for physician work, practice expense, and malpractice expense.

To access the NPFS on your own, follow this link:

http://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage

Blue Cross of Idaho will deny payment for any CPT codes that have an indicator of “1” in the PC/TC column of the NPFS and are submitted without modifier 26 appended with a location of inpatient hospital, outpatient hospital or skilled nursing facility.  Providers will have the opportunity to submit a corrected claim for just the professional component of the service by appending a 26 modifier to the CPT.

Line items on FEP claims that deny for this reason will process as a contractual write off with an explanation that the allowable amount is less than submitted charges.

 


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