CMS Pub. 100-04, ch. 13, § 20.2.1

A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to

hospital patients. Payment for physicians’ radiological services to the hospital, e.g., administrative or

supervisory services, and for provider services needed to produce the radiology service, is made by the

AB MAC (A) to the hospital as a provider service.

AB MACs (A) include the TC of radiology services for hospital inpatients, except Critical Access

Hospitals (CAHs), in the prospective payment system (PPS) payment to hospitals.

Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for beneficiaries

in a hospital inpatient stay. CWF performs reject edits to incoming claims from suppliers of radiology

services.

Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares

the period between the hospital inpatient admission and discharge dates to the line item service date on a

line item TC of a radiology service billed by a supplier. The CWF will generate an unsolicited response

when the line item service date falls within the admission and discharge dates of the hospital inpatient

claim.

Upon receipt of an unsolicited response, the A/B MAC (B) will adjust the TC of the radiology service

and recoup the payment.

For CAHs, payment to the CAH for inpatients is made at 101 percent of reasonable cost.

Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient

Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are

submitted to the AB MAC (A). Effective 4/1/06, type of bill 14X is for non-patient laboratory

specimens and is no longer applicable for radiology services.

As a result of SNF Consolidated Billing (Section 4432(b) of the Balanced Budget Act (BBA) of 1997),

A/B MACs (B) may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF)

inpatients during a Part A covered stay. The SNF must bill radiology services furnished its inpatients in

a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS).

Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service

or by the SNF under arrangements with the supplier. If billed by the SNF, Medicare pays according to

the Medicare Physician Fee Schedule. SNFs submit claims to the AB MAC (A) with type of bill 22X or

23X.