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”.