Description
Carriers may not pay for the technical component (TC) of radiology services furnished to patients during inpatient stay. Query identifies TC portion of radiology paid to entities other than the inpatient facility. Findings are limited to claim lines billed with modifier TC and claim lines for service codes with TC/PC Indicator "1" and/or “3” for TC component only.
Affected Code(s)
All CPT/HCPCS codes with TC/PC Indicator 1 and/or 3; Type of Service Indicator code 4 and/or 6; CPT/HCPCS modifier TC (technical component) CPT/HCPCS modifier 26 (professional component). Overpaid claims are limited to CPT Codes in the 70000-79999 range
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 Claims Processing Manual, Chapter 13 Radiology Services and Other Diagnostic Procedures, § 20.2.1 Hospital and Skilled Nursing Facility (SNF) Patients
8. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, § 10.7 – Type of Service (TOS)
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
10. AMA CPT Codebook