Jurisdiction 5 (J5) Post-implementation Ask-the-Contractor Teleconferences (ACTs): Question and Answer Follow Up - Part B
Coverage of the Technical Component of Radiology and Diagnostic Tests to Hospital Patients
The Medicare Physician Fee Schedule does not allow payment for the technical component of radiology or diagnostic procedures provided by physicians to hospital patients. This applies to services provided in place of service (POS) 21 or 22.
Medicare can pay for both the professional and technical components of services provided in a leased hospital department to patients who are neither an inpatient nor an outpatient of any hospital.
Check the Medicare Physician Fee Schedule Database (MPFSDB) to determine if the procedure is subject to this payment restriction. The PC/TC indicator identifies codes that have both a technical and professional component.
You can access the MPFSDB, also known as the relative value file, on the CMS Website at the first address listed below. For assistance on how to read and interpret these files please review our Computer Based Training (CBT) titled Medicare Physician Fee Schedule Database available on our Website at the second address listed below:
http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage 
http://www.wpsmedicare.com/mac/education/b_cbt.shtml
Repeat Procedures
To avoid claim denials when billing for multiple procedures that cannot be quantity billed, indicate the total number of services provided in item 19 of the Form CMS-1500 claim form. Electronic claim submitters enter this information in Loop 2400 MEA segment.
You may also want to review the Modifier 76 fact sheet on our Website at the address below:
http://www.wpsmedicare.com/mac/education/76.pdf
Medical Necessity Denials
A medical necessity denial indicates that the information submitted on the claim does not meet Medicare's requirement for coverage. If the patient's medical record contains information that was not previously submitted, you may request a redetermination with the additional documentation, request a reopening to add the omitted diagnosis or resubmit the claim.
Development Letters
When WPS Medicare requires additional information to process a claim, we notify providers by sending a development letter. The letter identifies the information we need, the date of service and the patient.
Please be aware that by not responding promptly, we will make a decision based on the information present on the claim. Providers have up to 45 days to return the information to us; however, we encourage you to respond sooner. The longer you wait, the greater the chance of the response not getting into our office, processed, and worked within the 45-day time limit.
Modifier 51
It is not necessary for providers to append modifier 51 to procedures when billing for multiple surgeries as the Multi-Carrier System (MCS) has the ability to apply this modifier.
For additional information, please review the Modifier 51 fact sheet located on our Website at the address listed below:
http://www.wpsmedicare.com/mac/education/51.pdf 
Therapy Personnel Qualifications and Policies
CMS released Change Request (CR) 5921 "Therapy Personnel Qualifications and Policies," effective January 1, 2008. The information in this document indicates that contractors shall not require recertification every 30 calendar days during treatment. However, WPS Medicare's policy states that recertification is every 30 days.
WPS Medicare has corrected the policy to indicate the correct language as stated in CR 5921.
Page Last Updated: Wednesday, 23-Jul-2008 11:49:55 CDT
