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Outside Lab

Kristene Posted Tue 15th of May, 2012 19:20:49 PM

I was hoping for some assistance….

I understand Medicare requires participating providers to indicate on the claim form in Box 20 that the service was purchased from an outside lab and what that amount is. My question is regarding our charge amount that we report in Box 24-F, can this fee exceed that which is reported in Box 20 or does it have to equal or be of lesser value? I’ve read some correspondence where CMS clarifies the Anti-Markup Rule for diagnostic tests but I still don’t see any reference to a limit on what we can charge. Article states that Medicare pays the lower of: supplier’s charge to physicians, billing physician’s actual charge or the Medicare fee schedule. And if it does have to be equal (or lesser) then how does this come in to play when you are billing a commercial carrier as we can’t have two separate fee schedules. I hope I have provided enough information but if not please let me know.

SuperCoder Answered Thu 17th of May, 2012 11:46:55 AM

We are discussing this with our Path-Lab coding expert. Kindly bear with us. We would get back to you as soon as possible with a plausible solution.

Kristene Posted Wed 23rd of May, 2012 20:38:29 PM

Just checking in to see if you’ve received any response back on this yet?

SuperCoder Answered Wed 23rd of May, 2012 20:45:12 PM

Hi Stephanie, we apologize. Still in the process of finding the solution for you.Thanks

SuperCoder Answered Fri 25th of May, 2012 17:32:46 PM

We are really sorry – We've tried to research this and contacted a source but couldn’t get a straight answer. This is really a legal question because it has to do with billing Medicare and the amounts that can be billed. We've sent this off to one more source whom we really hope can answer, but we don’t have an answer yet. Thanks

SuperCoder Answered Fri 25th of May, 2012 19:43:44 PM

Hi Stephaine, We heard back from our source, and this is what said:

CMS is emphatic that there is no longer a “purchased diagnostic test” rule. Instead, there’s an “anti-markup rule” that has to be taken into account. Basically, a physician must check box 20 ‘yes’ and enter a dollar amount only if the anti-markup rule applies to a particular claim. Most of the time when a pathologist purchases the TC from a hospital, he or she supervises the histology technologists, and that’s one of the exceptions to the anti-markup rule. So the pathologist bills the global charge and doesn’t have to declare that the TC was purchased from the hospital.

Dermatologists often buy the TC from hospitals or independent labs, but they don’t supervise the histology technologists (nor do they meet the second exception to the anti-markup rule), so they have to declare that the TC was purchased and report the amount paid to the supplier in box 20. They have to split the PC and TC into two lines, and the charge for the TC must be no more than is reported in box 20 as the purchase price. (Hence the term “anti-markup”.) This doesn’t violate any pricing rule, because the physician is following federal regulations.

The preceding obviously isn’t a comprehensive description of the anti-markup rule, but it covers the basics and the most frequently encountered situations.

A big thanks to our Path-Lab Coding Expert.

Kristene Posted Tue 29th of May, 2012 19:48:49 PM

Much thanks for the response and all your time and help!!!!

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