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.