3.0 POLICY
3.1 Frequently,
charges for diagnostic services are split between the professional
(physician) and the technical (equipment) components. Wherever possible,
separate allowable charges are developed for each component. When
a bill is received for the total service, the total allowable charge
is to be used in the processing of the claim.
3.2 Under the
national allowable charge system, the CHAMPUS Maximum Allowable
Charge (CMAC) file provides the contractor with a complete allowable
charge or with separate allowable charges for professional and technical
components.
3.3 For diagnostic procedures that are still priced
using area prevailing allowable charges, the contractor shall establish
professional and technical components from the billed charges for
the service as identified on the claims.
3.4 Clinical diagnostic lab tests
furnished by Critical Access Hospitals (CAHs), are reimbursed under the
reasonable cost method, reference
Chapter 15, Section 1.
3.5 Effective for services provided on or after
January 1, 2017, as required by law, TRICARE adopts Medicare’s reduced
payments for the technical component (and the technical component
of the global fee) of the Physician Fee Schedule (PFS) service for
Computed Tomography (CT) services that do not meet the National
Electrical Manufacturers Association (NEMA) Standard XR-29-2013,
as required by Section 218(8) of the Protecting Access to Medicare
Act (PAMA) of 2014, titled, “Quality Incentives to Promote Patient
Safety and Public Health in Computed Tomography (CT) Diagnostic
Imaging”.
3.5.1 This provision requires that information be
provided and attested to by a supplier and a hospital outpatient
department that indicates whether an applicable CT service was furnished
that was not consistent with the NEMA CT equipment standard.
3.5.2 Claims for the following CT services identified
by CPT codes 70450-70498, 71250-71275, 72125-72133, 72191-72194,
73200-73206, 73700-73706, 74150-74178, 74261-74263, 75571-75574
that are furnished using equipment that does not meet each of the
attributes of the NEMA XR-29-2013 standard, must include modifier CT.
3.5.3 A list of CPT codes subject to the CT modifier
will be maintained in Centers for Medicare and Medicaid Services’
(CMS’) web supporting files for the annual PFS rule.
3.5.4 Effective January 1, 2017, a payment reduction
of 5% applies to the technical component (and the technical component
of the global fee) for CT services furnished using equipment that
is inconsistent with the CT equipment standard and for which payment
is made under the PFS.
3.5.5 Effective January 1, 2018,
and succeeding years, a payment reduction of 15% applies.
3.6 Effective for services provided
on or after January 1, 2017, as required by law, TRICARE adopts Medicare's
reduced payments for the technical component (and the technical
component of the global fee) of the Physician Fee Schedule service
for X-ray imaging services provided using film.
Beginning January 1, 2017, claims
for X-rays using film must include modifier FX. A payment reduction
of 20% applies to the technical component (and the technical component
of the global fee) for X-ray services furnished using film as included
in Section 502(a)(1) of the Consolidated Appropriations Act of 2016
entitled “Medicare Payment Incentive for Transition from Traditional
X-Ray Imaging to Digital Radiography and Other Medicare Imaging
Payment Provision”.