Jul
7
Written by:
cancermd
7/7/2009
Under the model, there is an important issue about anti-markup.
Under the 2009 CMS new rule, the anti-markup payment restrictions will apply if a physician who orders a diagnostic test also bills for the test and either the technical component (TC) or professional component (PC) of the test is performed by a physician who does not “share a practice” with the billing physician.
To that end, CMS has designed two alternative means of assessing the extent to which the physicians can be said to “share a practice” :
· the first alternative is to focus on WHO performs the test (the “substantially all” test), and
· the second one is to focus on WHERE the test is being performed (the “site-of-service” test).
Physicians providing billing for diagnostic testing services will NOT be subject to the payment limitations of the Anti-Markup Rule IF either of the two alternatives detailed below apply.
Alternative 1: The “Substantially All” Test
Under this test, CMS has indicated that the performing physician (the physician who supervises the TC or performs the PC) may be said to “share a practice” with the billing physician if he/she performs “substantially all” of his/her professional services for the billing physician or supplier. For the purpose of applying this test, CMS has defined “substantially all” to require that the performing physician provides at least 75% of his services for the billing physician or supplier, and the 75% must be calculated based upon a 12 month period that includes the month during which the service is provided. The 12 month period can be applied retrospectively (the preceding 12 months) or prospectively (the following 12 months).
Alternative 2: The “Site-of-Service” Test
If the “substantially all” test is NOT met, then the ordering/billing physician may avoid the anti-markup payment limitation by satisfying the “site-of-service” test. Under this approach, the performing physician may be said to “share a practice” with the billing physician if the TC is conducted and supervised and the PC is performed in the “office of the billing physician”. For the purpose of applying this test, the “office of the billing physician is defined as any medical office space (regardless of the number of locations), in which the ordering physician regularly furnishes patient care, and includes space where the billing physician furnishes diagnostic testing, as long as it is in the “same building” in which the ordering physician regularly furnishes patient care. The “same building” is further defined as the space in which the ordering physician performs “substantially all” of the patient care services that the ordering physician provides generally.
Usually, most GI practice groups take the alternative of “site-of-service” test, that is, setting up a specific office space for a pathologist to read slides on-site. In New York, however, the pathologist must be employed as a W-2 employee by the group.
Reference
"POD Labs and In-Office Histology Labs in the Cross-Hairs" John Outlaw, PSA, LLC
www.pathologyoutlines.com/management/psa200904.html