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”.