(A) For independent diagnostic testing facility services to be covered:
(1) The service must be medically necessary as defined in rule 5101:3-1-01 of the Administrative Code; and
(2) The service must be requested in writing by a the treating physician or non-physician practitioner in accordance with state law.
(a) The service may be performed upon the verbal order of a the treating physician but the independent diagnostic testing facility must obtain an order that is written, dated, and signed by the treating physician before the service is billed to the department.
(b) The treating physician's order must specify the procedures to be performed and the reason for the service.
(c) A copy of the written, dated, and signed treating physician's order must be kept on file for six years.
(d) The independent diagnostic testing facility may not add any procedures based on internal protocols without a written order by the treating physician.
(B) An independent diagnostic test facility may not perform or bill for CLIA tests. An entity that owns both an independent diagnostic testing facility and an independent laboratory should enroll and bill separately to Ohio medicaid.
(C) Services are reimbursable directly to a independent diagnostic testing facility only if the services were rendered to a nonhospital patient and the independent diagnostic testing facility provided all services (professional and technical) associated with the total procedure as the procedure is defined in the CPT with the following exceptions:
(1) When separate CPT codes itemize a service by its professional and technical components, the independent diagnostic testing facility may bill and be reimbursed for the components of the procedure it actually performed.
(2) When the service provided is an echocardiography or a radiology procedure, the independent diagnostic testing facility may provide, bill and be reimbursed for either the total procedure or for the technical component of the procedure.
(a) To bill for the technical component of an echocardiography or a radiology procedure, the independent diagnostic testing facility must bill the CPT code followed by the modifier TC (e.g., 93307TC).
(b) To bill for the total procedure, the independent diagnostic testing facility must bill the CPT code without a modifier.
(D) When an independent diagnostic testing facility provides services for a hospital inpatient, a hospital outpatient, or a hospital emergency room patient, the hospital must bill and be reimbursed for the technical services associated with the procedure and the physician who provided the professional services associated with the procedure must bill for the professional component. The independent diagnostic testing must make separate arrangements to receive payment from the hospital for the services rendered to a hospital patient.
R.C. 119.032 review dates: 03/09/2006 and 05/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 2/17/91, 8/1/01