0123-Technical Component of Diagnostic Procedures during Inpatient: Unbundling

Dynamic List Information
Dynamic List Data
Issue Name
0123-Technical Component of Diagnostic Procedures during Inpatient: Unbundling
Review Type
Automated
Provider Type
Professional Services
MAC Jurisdiction
All A/B MACs
Date
2018-11-06
RAC Type
Approved

Description

When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable to the Part B provider. The technical component is performed by the facility while a patient is in a covered Part A Inpatient Stay.

Affected Codes

CPT Code Range 10000-99999 (Excluding CPT Codes 70000-89999) with PC/TC Indicators of 1 and 3

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.929- Post-Payment Review
4.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
5.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 CFR §405.986- Good Cause for Reopening  
7.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8.    Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Record Layout and Field Descriptions (Effective 10/19/2020)
9.    Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §30- Services Paid Under the Medicare Physician’s Fee Schedule
10.     Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §30.1-Provider-Based Physician Services    
11.    Physician Fee Schedule, https://www.cms.gov/medicare/physician-fee-schedule/search     
AMA CPT Codebook