Advanced Diagnostic Imaging
Section 135(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended section 1834(e) of the Social Security Act. It required the Secretary to designate organizations to accredit suppliers – including, but not limited to, physicians, non-physician practitioners and independent diagnostic testing facilities - that furnish the technical component (TC) of advanced diagnostic imaging services.
MIPPA specifically defines advanced diagnostic imaging procedures as including diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET). The law also authorizes the Secretary to specify other diagnostic imaging services in consultation with physician specialty organizations and other stakeholders. In order to furnish the TC of advanced diagnostic imaging services for Medicare beneficiaries, suppliers must be accredited by January 1, 2012. The effective date of the previously named regulation is January 1, 2012.
CMS approved three national accreditation organizations (AOs) – the American College of Radiology, the Intersocietal Accreditation Commission, and the Joint Commission - to provide accreditation services for suppliers of the TC of advanced diagnostic imaging procedures. The accreditation will apply only to the suppliers of the images, not to the physician's interpretation of the image. Also, this accreditation only applies to those who are paid under the Physician Fee Schedule.
All accreditation organizations have quality standards that address the safety of the equipment as well as the safety of the patients and staff. A provider submitting claims for the TC must be accredited by January 1, 2012 to be reimbursed for the claim if the service is performed on or after that date. Each of these designated AOs submits monthly reports to CMS that list the suppliers who have been or are accredited, as well as the beginning and end date of the accreditation and the respective modalities for which they receive accreditation.
Newly enrolling physicians and non-physician practitioners described above must complete the Internet-based PECOS or the appropriate CMS-855 and check the appropriate boxes for Advanced Diagnostic Imaging (ADI). Contractors shall accept applications from providers and suppliers who are accredited for the new ADI accreditation. The Medicare enrollment contractors shall verify the information sent on the application meets the current enrollment requirements.
The Medicare enrollment contractors shall verify the ADI supplier is listed as one of the accredited individuals/organizations found at www.cms.hhs.gov/Medicareprovidersupenroll and consistent with accreditation information found in section 2 of the CMS-855, and if the application is approved, will enter the information into the Provider Enrollment, Chain and Ownership System (PECOS).
Section 4 of the Form CMS-855B
A. Ambulatory Surgical Centers (ASCs) and Portable X-ray Suppliers
If the applicant’s address or telephone number cannot be verified, the contractor shall contact the applicant for further information. If the supplier states that the facility or its phone number is not yet operational, the contractor shall continue processing the application. However, it shall indicate in its recommendation letter that the address and telephone number of the facility could not be verified.
For purposes of PECOS entry, the contractor can temporarily use the date the certification statement was signed as the effective date.
B. Reassignment of Benefits
Per Pub. 100-04, chapter 1, section 30.2.7, a contractor may permit a reassignment of benefits to any eligible entity regardless of where the service was rendered or whether the entity owned or leased that location. As such, the contractor need not verify the entity’s ownership or leasing arrangement with respect to the reassignment.
C. Ambulance Companies
If an ambulance company will be furnishing all of its services in the same contractor jurisdiction, the supplier should list:
• Each site at which its vehicles are garaged in section 4A. (The site is considered a practice location for enrollment purposes, including with respect to payment of the application fee.)
Each site from which its personnel are dispatched in section 4A. (The site is considered a practice location for enrollment purposes, including with respect to payment of the application fee.)
• Its base of operations – which, for ambulance companies, is their primary headquarters – in section 4E. (The supplier can only have one base of operations.)
If the supplier will be furnishing services in more than one contractor jurisdiction, it shall follow the applicable instructions in section 15.5.18 of this chapter.
D. Out-of-State Practice Locations
If a supplier is adding a practice location in another State that is within the contractor’s jurisdiction, a separate, initial Form CMS-855B enrollment application is not required if the following 5 conditions are met:
• The location is not part of a separate organization (e.g., a separate corporation, partnership),
• The location does not have a separate tax identification number (TIN) and legal business name (LBN),
• The State in which the new location is being added does not require the location to be surveyed,
• The applicable RO does not require the new location or its owner to sign a separate supplier agreement, and
• The location is not an independent diagnostic testing facility (IDTFs are required to separately enroll each site)
Consider the following examples:
1. The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., is enrolled in State X with 3 locations. It wants to add a fourth location in State Y. The new location will be under JGP, Inc. JGP will not be establishing a separate corporation, LBN or TIN for the fourth location. Since there is no State or RO involvement with group practices, all 5 conditions are met. JGP can add the fourth location via a change of information request, rather than an initial application. The change request must include all information relevant to the new location (e.g., licensure, new managing employees). To the extent required, the contractor shall create a separate PECOS enrollment record for the State Y location.
2. The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., is enrolled in State X with 3 locations. It wants to add a fourth location in
Section 135(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended section 1834(e) of the Social Security Act. It required the Secretary to designate organizations to accredit suppliers – including, but not limited to, physicians, non-physician practitioners and independent diagnostic testing facilities - that furnish the technical component (TC) of advanced diagnostic imaging services.
MIPPA specifically defines advanced diagnostic imaging procedures as including diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET). The law also authorizes the Secretary to specify other diagnostic imaging services in consultation with physician specialty organizations and other stakeholders. In order to furnish the TC of advanced diagnostic imaging services for Medicare beneficiaries, suppliers must be accredited by January 1, 2012. The effective date of the previously named regulation is January 1, 2012.
CMS approved three national accreditation organizations (AOs) – the American College of Radiology, the Intersocietal Accreditation Commission, and the Joint Commission - to provide accreditation services for suppliers of the TC of advanced diagnostic imaging procedures. The accreditation will apply only to the suppliers of the images, not to the physician's interpretation of the image. Also, this accreditation only applies to those who are paid under the Physician Fee Schedule.
All accreditation organizations have quality standards that address the safety of the equipment as well as the safety of the patients and staff. A provider submitting claims for the TC must be accredited by January 1, 2012 to be reimbursed for the claim if the service is performed on or after that date. Each of these designated AOs submits monthly reports to CMS that list the suppliers who have been or are accredited, as well as the beginning and end date of the accreditation and the respective modalities for which they receive accreditation.
Newly enrolling physicians and non-physician practitioners described above must complete the Internet-based PECOS or the appropriate CMS-855 and check the appropriate boxes for Advanced Diagnostic Imaging (ADI). Contractors shall accept applications from providers and suppliers who are accredited for the new ADI accreditation. The Medicare enrollment contractors shall verify the information sent on the application meets the current enrollment requirements.
The Medicare enrollment contractors shall verify the ADI supplier is listed as one of the accredited individuals/organizations found at www.cms.hhs.gov/Medicareprovidersupenroll and consistent with accreditation information found in section 2 of the CMS-855, and if the application is approved, will enter the information into the Provider Enrollment, Chain and Ownership System (PECOS).
Section 4 of the Form CMS-855B
A. Ambulatory Surgical Centers (ASCs) and Portable X-ray Suppliers
If the applicant’s address or telephone number cannot be verified, the contractor shall contact the applicant for further information. If the supplier states that the facility or its phone number is not yet operational, the contractor shall continue processing the application. However, it shall indicate in its recommendation letter that the address and telephone number of the facility could not be verified.
For purposes of PECOS entry, the contractor can temporarily use the date the certification statement was signed as the effective date.
B. Reassignment of Benefits
Per Pub. 100-04, chapter 1, section 30.2.7, a contractor may permit a reassignment of benefits to any eligible entity regardless of where the service was rendered or whether the entity owned or leased that location. As such, the contractor need not verify the entity’s ownership or leasing arrangement with respect to the reassignment.
C. Ambulance Companies
If an ambulance company will be furnishing all of its services in the same contractor jurisdiction, the supplier should list:
• Each site at which its vehicles are garaged in section 4A. (The site is considered a practice location for enrollment purposes, including with respect to payment of the application fee.)
Each site from which its personnel are dispatched in section 4A. (The site is considered a practice location for enrollment purposes, including with respect to payment of the application fee.)
• Its base of operations – which, for ambulance companies, is their primary headquarters – in section 4E. (The supplier can only have one base of operations.)
If the supplier will be furnishing services in more than one contractor jurisdiction, it shall follow the applicable instructions in section 15.5.18 of this chapter.
D. Out-of-State Practice Locations
If a supplier is adding a practice location in another State that is within the contractor’s jurisdiction, a separate, initial Form CMS-855B enrollment application is not required if the following 5 conditions are met:
• The location is not part of a separate organization (e.g., a separate corporation, partnership),
• The location does not have a separate tax identification number (TIN) and legal business name (LBN),
• The State in which the new location is being added does not require the location to be surveyed,
• The applicable RO does not require the new location or its owner to sign a separate supplier agreement, and
• The location is not an independent diagnostic testing facility (IDTFs are required to separately enroll each site)
Consider the following examples:
1. The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., is enrolled in State X with 3 locations. It wants to add a fourth location in State Y. The new location will be under JGP, Inc. JGP will not be establishing a separate corporation, LBN or TIN for the fourth location. Since there is no State or RO involvement with group practices, all 5 conditions are met. JGP can add the fourth location via a change of information request, rather than an initial application. The change request must include all information relevant to the new location (e.g., licensure, new managing employees). To the extent required, the contractor shall create a separate PECOS enrollment record for the State Y location.
2. The contractor’s jurisdiction consists of States X, Y and Z. Jones Group Practice (JGP), Inc., is enrolled in State X with 3 locations. It wants to add a fourth location in
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