HI 00610.070 Radiological and Pathological Services to Hospital Inpatients

A. Inpatient status

100 percent reimbursement for services furnished by physicians in the fields of radiology and pathology applies where the beneficiary is an inpatient of a qualified hospital during a medically necessary stay at the time the services are rendered. For the purposes of this provision, the beneficiary's inpatient status is maintained after Part A coverage is exhausted as long as the individual continues to require a hospital level of care. However, where the beneficiary's hospital stay is not medically necessary, the individual is not considered to be an inpatient for purposes of the 100 percent reimbursement provision. Thus, reimbursement for otherwise covered physician's services in this situation would be subject to the Part B deductible and coinsurance. The intermediary determines whether payment for the radiology and pathology services will be at the 100 percent rate or whether Part B deductibles and coinsurance apply. Expenses incurred under this provision will not count toward the Part B deductible.

Under the Omnibus Reconciliation Act of 1980, the Medicare Part B program pays 100 percent of the reasonable charges for such services only if the physician has in effect an agreement to accept Medicare Part B assignment for all such services he furnishes to hospital inpatients. If he does not have such an agreement in effect, the program pays 80 percent of the reasonable charges after the application of any unmet deductible, whether the particular claim is submitted on an assigned or unassigned basis.

The amendment is effective for services furnished after June 30, 1981. Radiological or pathological services furnished prior to July 1, 1981, to inpatients of qualified hospitals by physicians in the field of radiology or pathology will be reimbursed at the 100 percent rate in all cases even though the claim is filed after that date.

Under the amendment, the definitions of such terms as “qualified hospital,” “inpatient,” “radiological services,” “pathological services,” “field of radiology,” and “field of pathology” remain the same as in existing instructions.

B. Field of radiology or pathology

A physician in the “field of radiology or pathology” includes not only a specialist in one of those fields, but also a physician who normally performs or supervises the radiological or pathological services for patients of a particular hospital. The reading of an X-ray film as part of his usual services for his own patients by an attending physician or a surgeon would normally be covered only as a regular physicians' services i.e., the basis for reimbursement would be 80 percent of the reasonable charge, subject to the Part B deductible.

C. Status of independent laboratory

An independent laboratory is not considered “a physician in the field of radiology and pathology” even if it is physician-directed and provides tests requiring performance by a physician. An independent laboratory is by definition independent of a physician's office or a hospital. When it provides “diagnostic laboratory tests” to hospital inpatients and bills the patients directly, the services are subject to the Part B deductible and coinsurance provisions.

To Link to this section - Use this URL:
HI 00610.070 - Radiological and Pathological Services to Hospital Inpatients - 09/15/1989
Batch run: 05/09/2014