Meeting Specific Medicare Requirements in Outsourced Radiology Billing

The truth is that the financial stability of your radiology practice completely depends on your radiology billing mechanism. Any mistake in your billing mechanism can lead you to experience hampered cash flow and revenue loss at the end of the financial. It is really important for you to focus on making your billing system robust without compromising the clinical care.

You might think that managing outsourced radiology billing services is simple, but it’s actually trickier than regular onsite billing. You have to know the rules for each payer, especially Medicare and other government programs. Radiology practices really need to keep up with all these requirements to stay in line!

First, you should know about the regulations set by the federal body like Medicare so that you can efficiently meet them.

Regulations set by Medicare:

Did you know Medicare set its Place of Service (POS) rules way back on April 1, 2013? Yes, those rules have been around for over ten years now! If you are in radiology, you probably know them pretty well by now. But here’s a quick recap just in case:

Location of the service facility:

You must use the location of your global radiology billing based on the professional and technical component services and also, do not forget to use the relationship between the parties

You need to know that when you bill for the professional and technical parts separately, the Service Facility Location has to show where the service actually happened. For a radiologist, that means the place where they did the interpretation!

Did you know that the payment amount depends on where the service happened? Yes! The fee schedule is based on the location’s zip code. So, the fee for the professional part might be different from the one for the technical part.

Coding for place of action:

You should know that the location used for billing is usually where the patient’s exam happened, even if you looked at the results from a different location through teleradiology.

Know the difference between global and split radiology billing services:

You need to know that global billing is used when the doctor reading the images works directly with the radiology center, either as an employee or under contract, and when they are in the same payment area. In this case, you only use the radio center’s address, no matter where the doctor is and when they read the images. But if the doctor is in a different payment area, you have to split the billing with a special code (-26) and list each location separately. And if the doctor is reading from somewhere unusual, like a hotel, you don’t put that on the form—you use the doctor’s usual practice address instead!

You should know that when different places handle the Professional Component (PC) and the Technical Component (TC)—like with hospital patients—you have to bill the PC separately using a special code, modifier -26. You also need to list the location (address and zip code) where the doctor did the PC work!

Location of physician services:

You have to enter the exact address, including the zip code, in Box 32 of the CMS-1500 claim form—that’s where they did the interpretation. This address decides the fee schedule based on the zip code’s payment area. If your practice is near the border of two payment areas, you should know the payment rates for each one. That way, you won’t accidentally get paid less, and you might even use teleradiology smartly to get a higher rate!

You know, lots of radiologists read images from home, and if they are billing the PC separately, they have to report their home address if it’s in a different payment area from the radiology site. But if they’re reading from somewhere unusual, like a hotel or vacation spot, you don’t put that on the form—you use the address of their regular work location instead!

Assignment of place of service code:

You should make sure that the Place of Service (POS) code reflects where the patient had their face-to-face interaction, no matter where the reading took place. For example, you should always use POS code 22 instead of 11 when you have read an outpatient hospital case.

It is always important for you to check the list of procedures where the insurance company requires you to have prior authorization approvals for going ahead with the radiology services. Always remember that there are several radiology procedures where you must obtain PA approvals from insurance companies before you administer those specific radiology services to your patients. Missing prior authorization would cause you to claim denials and out-of-pocket payments for your patients.

By now, you might already have realized the fact that radiology billing is not an easy affair as it comes with a lot of complex regulations and a single mistake in using caution can jeopardize your whole radiology billing process. Fortunately, just like the majority of mid and small-scaled radiology billing services, you can also go for radiology billing outsourcing to avoid all the nuances of handling your administrative part.

If you want to make your radiology billing super easy and focus 100% on patient care, hiring a great radiology billing company like Sunknowledge is a smart move for you. When you outsource to Sunknowledge, they handle the billing, making it faster, more accurate, and compliant with all the rules. This helps you cut down on mistakes, speed up claims, and even reduce costs by up to 80%! Plus, we at, Sunknowledge is the only RCM Company that works with both payers and providers in the healthcare domain, so you get the best of both worlds while you focus on what matters most— your patients.

If you want to know more about our end-to-end radiology billing services, schedule a non-obligatory call with us and we would love to assist you in the best possible manner.