Independent Labs

CMS Clarifies IDTF Billing, Coding and Coverage Rules

In September, the Centers for Medicare & Medicaid Services (CMS) issued new guidance making some important clarifications on Independent Diagnostic Testing Facility (IDTF) billing requirements. Here’s a look at the seven things lab managers need to be aware of to ensure proper billing and coding IDTF services.

Which Labs IDTF Billing Rules Affect

The new guidelines apply to you if your lab or facility is an IDTF, i.e., a facility that’s independent of both an attending or consulting physician’s office and of a hospital. IDTFs may be either a fixed location or a mobile entity. Other than hospital-based and mobile IDTFs, a fixed-base IDTF doesn’t:

  • Share a practice location with another Medicare-enrolled individual or organization;
  • Lease or sublease its operations or practice location to another Medicare-enrolled individual or organization; or
  • Share diagnostic testing equipment used in the initial diagnostic test with another Medicare-enrolled individual or organization.

The IDTF Billing Clarifications

When an IDTF provides diagnostic procedures in a physician’s office, IDTF general coverage and payment policy rules apply. Medicare reimburses diagnostic procedures performed by IDTFs at the Medicare Physician Fee Schedule (MPFS) rate. The IDTF billing clarifications are contained in the Medicare Learning Network (MLN) Booklet that CMS issued in September. There are seven points of clarification:

  1. Reimbursement of Nurse Practitioner Supervised Tests

CMS reminded providers that it’s issued waivers on certain billing rules to make it easier for Medicare patients to access lab and other diagnostic tests during the COVID-19 Public Health Emergency (PHE), including allowing nurse practitioners, clinical nurse specialists, physician assistants and certified nurse-midwives to provide the required level of supervision for reimbursement under the MPFS.

  1. Billing & Coding of Transtelephonic & Electronic Monitoring Services

The Booklet lists important coding clarification you need to be aware of if your IDTF provides 24-hour EKG monitoring or other transtelephonic and electronic monitoring services without actually seeing a patient. Most, but not all of the current billing codes for these services are 93040, 93224, 93225, 93226, 93270 and 93271. CMS doesn’t currently have specific certification standards for IDTF technicians.

If an entity lists and bills codes 93268, 93270, 93271, or 93272, the Booklet explains, the Medicare Administrative Contractor (MAC) must make a written determination that the entity has a person available on a 24-hour basis to answer telephone inquiries. Use of an answering service instead of the actual person isn’t acceptable.

Billing Instruction: List the person performing the attended monitoring in Section D of Attachment 2 of Form CMS-855B

  1. Global Billing

According to the Booklet, global billing is acceptable when the same entity performs both the TC and Modifier 26 and that entity provides both the TC and Modifier 26 within the same MPFS payment locality. It’s okay to provide the TC and Modifier 26 in different locations as long as you furnish them within the same MPFS payment locality.

Note: As with all services payable under the MPFS, CMS uses ZIP Code to determine the appropriate payment locality and corresponding fee used to price the service that’s subject to the anti-markup payment limitation. When a ZIP Code crosses county lines, agency uses the dominant locality to determine the corresponding fee.

Billing Instruction: If you bill with the global diagnostic test code, report the name, address, and National Provider Identifier (NPI) of the location where you provided the TC in Items 32 and 32a (or the 837P electronic claim equivalent).

  1. Separate TC & PC Billing—Non-Global Billing

 Billing Instruction: When you bill the TC and Modifier 26 separately (not billed globally), report the name, address and NPI of the location where you performed each component. If the billing provider has an enrolled practice location at the address where the service took place, the billing provider or supplier may report their own name, address and NPI in Items 32 and 32a (or the 837P electronic claim equivalent).

The NPI in Item 32a must correspond to the entity identified in Item 32 (no matter if it’s the group, hospital, IDTF, or individual physician), the Booklet explains. The only exception for Medicare claims is when a provider performs a service out of jurisdiction and is subject to the anti-markup or a reference lab service.

  1. IDTFs & Opioid Treatment Programs (OTPs)

CMS clarifies that for an IDTF to be eligible to enroll as an OTP service provider with Medicare, its program must have current, valid, and full certification by the Substance Abuse and Mental Health Services Administration (SAMHSA), and meet all of SAMHSA’s criteria, including but not limited to:

  • Drug Enforcement Administration (DEA) registration;
  • State licensure; and
  • Accreditation
  1. Coverage of SNF Residents Requiring Transportation for IDTF Service

In 2018, CMS revised both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to clarify that Part B may cover a medically necessary ambulance transport from an SNF to the nearest supplier of medically necessary services not available at the SNF where the patient is the resident, including the return trip (including an IDTF). In the Booklet, CMS clarifies that this applies to patients in an SNF stay uncovered by Part A, but who have Part B benefits.

For SNF residents receiving Part A benefits, such ambulance trips to IDTFs for medically necessary services are subject to SNF consolidated billing.

  1. Billing of IDTF Mammography Services

Under (Chapter 18, Section of) the Medicare Claims Processing Manual, if an IDTF furnishes any type of mammography service (screening or diagnostic), it must have an FDA certification to perform such services. However, if you only perform diagnostic mammography services, you shouldn’t enroll as an IDTF. Medicare does pay for screening mammographies (including those that are self-referred) when an IDTF performs them at the IDTF facility.



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