Coverage and Reimbursement for Fluoroscopy

Coverage and Reimbursement for Fluoroscopy

Coverage

Currently, Medicare does not have a national coverage policy that addresses fluoroscopy for pain
management procedures. Coverage of these procedures is at the discretion of local Medicare
contractors who process claims on behalf of the Medicare program. Providers should ascertain
coverage for the pain management procedure in addition to coverage for fluoroscopy itself.

Reimbursement

Medicare reimbursement for fluoroscopic guidance is comprised of a professional component,
the amount paid for the physician’s service, and a technical component, the amount paid for all
other services (including staffing and equipment costs). When these components are combined and paid to the same individual or entity, this is often referred to as the total or global
reimbursement.
Currently, Medicare reimburses fluoroscopic guidance differently depending on the site of care.
The technical component of the procedure performed in a physician’s office or IDTF is
reimbursed under the Medicare physician fee schedule. In a hospital outpatient department,
the technical component of a procedure is reimbursed under an Ambulatory Payment
Classification (APC) under Medicare’s hospital outpatient department prospective payment
system (HOPPS). In a hospital inpatient site of care, the technical (facility) payment is
subsumed within the payment to the hospital that is determined based on the Diagnosis Related
Group (DRG) to which the patient is assigned. The professional component is reimbursed under
the Medicare physician fee schedule regardless of setting.
In the case of a Medicare certified ambulatory surgical center (ASC), please note that the
technical component of fluoroscopy is not separately payable. However, when an ASC and
IDTF share space (but do not operate at the same time in that space), CMS and its local carriers
generally allow the IDTF to bill and be paid for by the program for the technical component of
fluoroscopy if it is reasonable and necessary, directly related to the performance of a surgical
procedure and furnished in conjunction with a surgical procedure during the ASC’s designated
hours.10 However, the ASC should consult with the local Medicare carriers regarding this issue
before submitting an IDTF enrollment application.

Table 3 provides information concerning Medicare national payment rates for fluoroscopy
imaging guidance performed in the hospital inpatient, hospital outpatient, IDTF and physician
office sites of service. It is important to note that, in the hospital outpatient site of care, the
fluoroscopy procedures are not reimbursed separately, but rather are “packaged” or included in
the APC payment to the hospital. For more information about reimbursement of these
procedures in your area, consult your local Medicare contractor.