CMS Pub. 100-04, ch. 13, § 20.3.2

A physician or other supplier may bill and receive Part B payment for the technical component (TC) or

professional component (PC) of diagnostic tests which the physician or other supplier contracts a

physician, medical group, or other supplier to perform. (This claim and payment procedure does not

extend to clinical diagnostic laboratory tests.) The anti-markup rule will apply to the TC or PC of

diagnostic tests that have been ordered by the billing physician or other supplier (or by a party

financially related to the billing physician or other supplier through common ownership or control) if the

performing physician or other supplier does not meet the criteria for “sharing a practice” with the

ordering/billing entity. An example is when the attending physician orders radiology tests from a

radiologist and the radiologist purchases the tests from an imaging center with whom the radiologist

does not meet the criteria for “sharing a practice.” Under the anti-markup payment limitation, the billing

physician or other supplier may not mark up the charge for a test from the acquisition price and must

accept as full payment for the test (even if assignment is not accepted) the lowest of: the fee schedule

amount as if the performing physician or other supplier had billed directly, the billing entity’s actual

charge, or the performing physician or other supplier’s net charge to the billing entity. The billing

physician or other supplier must be financially related to the physician or group that ordered the tests

through common ownership or control.

If the performing physician or other supplier meets the criteria for “sharing a practice” with the billing

physician or other supplier, then the anti-markup payment limitation will not apply and the lower of the

physician fee schedule amount or the billed amount will be paid.

The physician or other supplier that performed the component that is subject to the anti-markup rule

must be enrolled in the Medicare program. No formal reassignment is necessary; however, reassigned

services are also subject to the anti-markup payment limitation.

A. Radiology Services

Contractors shall apply the anti-markup payment limitation to the TC and PC of radiology diagnostic

testing services other than screening mammography procedures. See Publication 100-04, chapter 1,

§30.2.9 for more information on the anti-markup payment limitation.

B. Payment to a Physician or Other Supplier of Diagnostic Tests for Services Subject to the Anti-Markup Payment Limitation

A physician or other supplier that provides diagnostic tests may bill and receive the Part B payment for

the TC or PC of diagnostic tests which that physician or other supplier acquires from another physician,

medical group, or other supplier. If the performing physician does not meet the requirements for sharing

a practice with the ordering/billing physician or other supplier, then the anti-markup payment limitation

rules will apply. (See section 30.2.9 of this chapter for more information.) If the performing physician is

deemed to share a practice with the physician or other supplier that ordered the test, then the physician

fee schedule amount may be billed and the anti-markup payment limitation will not apply. In either

case, the performing physician or other supplier must be enrolled in the Medicare program. No formal

reassignment is necessary; however, the anti-markup payment limitation will apply to reassigned

services.

If the anti-markup rules apply, payment may not exceed the lowest of the following amounts:

• The performing physician or other supplier’s net charge to the billing physician or other

supplier;*

• The billing physician or other supplier’s actual charges; or

• The fee schedule amount allowed for the test if the performing physician or other supplier billed

directly.

*The net charge must be determined without regard to any charge that is intended to reflect the cost of

equipment or space leased to the performing physician or supplier by or through the billing entity. For

more information, see Pub. 100-04, chapter 1, §30.2.9.

The billing physician or other supplier must keep on file the name, address, and NPI of the physician or

other supplier who performed the anti-markup service.

C. Sanctions

Physicians who knowingly and willfully, in repeated cases, bill Medicare beneficiaries amounts beyond

those outlined in this chapter are subject to the penalties contained under §1842(j)(2) of the Act.

Penalties are assigned after post-pay review depending on the severity.

D. Questionable Business Arrangements

No special charge or payment constraints are imposed on tests performed by a physician or a technician

under the physician’s supervision. There are two requirements for all diagnostic tests under §1861(s)(3)

of the Act, as implemented by 42 CFR §410.32 and section 10 of chapter13 of this publication and

section 80, chapter 15 of Pub. 100-02BP. Namely, the test must be ordered by the treating practitioner,

and the test must be supervised by a physician. However, attempts may be made by the medical

diagnostic community to adjust or establish arrangements which continue to allow physicians to profit

from other's work or by creating the appearance that the physician has performed or supervised his/her

technicians who are employed, contracted, or leased. Some of these arrangements may involve cardiac

scanning services and mobile ultrasound companies leasing their equipment to physicians for the day the

equipment is used, and hiring out their staff to the physicians to meet the supervision requirement.

The bona fides of such arrangements may be suspect and could be an attempt to circumvent the anti-markup payment limitation. If you have any doubt that a particular arrangement is a valid relationship

where the physician is performing or supervising the services, this should be investigated. The Office of

the Inspector General (OIG) has responsibility for investigating violations of §1842(n) of the Act.

Another arrangement to circumvent the anti-markup payment limitation is for the ordering physician to

reassign his/her payment for the interpretation of the test to the supplier. The supplier, in turn, bills for

both the test and the interpretation and pays the ordering physician a fee for the interpretation. This

arrangement violates §1842(b)(6) of the Act, which prohibits Medicare from paying benefits due the

person that furnished the service to any other person, subject to limited exceptions discussed in Pub.

100-04, chapter 1, §30.2.2. Also, this arrangement could constitute a violation of §1128 B (b) of the

Act, which prohibits remuneration for referrals (i.e., kickbacks).

Violations of §1128B (b) of the Act may subject the physician or supplier to criminal penalties or

exclusion from the Medicare and Medicaid programs. Illegal remuneration for referrals can be found

even when the ordering physician performs some service for the remuneration.