(ii) Payment may be made under this part for only 1 screening mammography performed on a woman over 34 years of age, but under 40 years of age. (iii) In the case of a woman over 39 years of age, payment may not be made under this part for screening mammography performed within 11 months following the month in which a previous screening mammography was performed. 199 (B) REVISION OF FREQUENCY. (i) REVIEW.-The Secretary, in consultation with the Director of the National Cancer Institute, shall review periodically the appropriate frequency for performing screening mammography, based on age and such other factors as the Secretary believes to be pertinent. (ii) REVISION OF FREQUENCY.-The Secretary, taking into consideration the review made under clause (i), may revise from time to time the frequency with which screening mammography may be paid for under this subsection, but no such revision shall apply to screening mammography performed before January 1, 1992. (3) LIMIT. (A) $55, INDEXED.-Except as provided by the Secretary under subparagraph (B), the limit established under this paragraph (i) for screening mammography performed in 1991, is $55, and (ii) for screening mammography performed in a subsequent year is the limit established under this paragraph for the preceding year increased by the percentage increase in the MEI for that subsequent year. (B) REDUCTION OF LIMIT.-The Secretary shall review from time to time the appropriateness of the amount of the limit established under this paragraph. The Secretary may, with respect to screening mammography performed in a year after 1992, reduce the amount of such limit as it applies nationally or in any area to the amount that the Secretary estimates is required to assure that screening mammography of an appropriate quality is readily and conveniently available during the year. (C) APPLICATION OF LIMIT IN HOSPITAL OUTPATIENT SETTING.-The Secretary shall provide for an appropriate allocation of the limit established under this paragraph between professional and technical components in the case of hospital outpatient screening mammography (and comparable situations) where there is a claim for professional services separate from the claim for the radiologic procedure. (4) LIMITING CHARGES OF NONPARTICIPATING PHYSICIANS. (A) IN GENERAL.-In the case of mammography screening performed on or after January 1, 1991, for which pay 199 P.L. 105-33, §4101(a)(1), amended clause (iii) in its entirety, applicable to items and services furnished on or after January 1, 1998. For clause (iii) as it formerly read, see Vol. II, Superseded Provisions, P.L. 105-33. P.L. 105-33, 4101(a)(2), struck out clauses (iv) and (v), applicable to items and services furnished on or after January 1, 1998. For clauses (iv) and (v) and they formerly read, see Vol. II, Superseded Provisions, P.L. 105-33. ment is made under this subsection, if a nonparticipating physician or supplier provides the screening to an individual entitled to benefits under this part, the physician or supplier may not charge the individual more than the limiting charge (as defined in subparagraph (B), or if less, as defined in subsection (b)(5)(B) or as defined in section 1848(g)(2)). (B) LIMITING CHARGE DEFINED.-In subparagraph (A), the term "limiting charge" means, with respect to screening mammography performed (i) in 1991, 125 percent of the limit established under paragraph (4), (ii) in 1992, 120 percent of the limit established under paragraph (4), or (iii) after 1992, 115 percent of the limit established under paragraph (4). (C) ENFORCEMENT.-If a physician or supplier knowing 200 and willfully imposes a charge in violation of subparagraph (A), the Secretary may apply sanctions against such physician or supplier in accordance with section 1842(j)(2). (d) FREQUENCY LIMITS AND PAYMENT FOR COLORECTAL CANCER SCREENING TESTS.— (1) SCREENING FECAL OCCULT BLOOD TESTS.— (A) PAYMENT AMOUNT.-The payment amount for colorectal cancer screening tests consisting of screening fecal-occult blood tests is equal to the payment amount established for diagnostic fecal-occult blood tests under section 1833(h). (B) FREQUENCY LIMIT.-No payment may be made under this part for a colorectal cancer screening test consisting of a screening fecal-occult blood test (i) if the individual is under 50 years of age; or (ii) if the test is performed within the 11 months after a previous screening fecal-occult blood test. (2) SCREENING FLEXIBLE SIGMOIDOSCOPIES.— (A) FEE SCHEDULE.-With respect to colorectal cancer screening tests consisting of screening flexible sigmoidoscopies, payment under section 1848 shall be consistent with payment under such section for similar or related services. (B) PAYMENT LIMIT.-In the case of screening flexible sigmoidoscopy services, payment under this part shall not exceed such amount as the Secretary specifies, based upon the rates recognized for diagnostic flexible sigmoidoscopy services. (C) FACILITY PAYMENT LIMIT.— (i) IN subsections (i)(2)(A) and (t) of section 1833, in the case of screening flexible sigmoidoscopy services furnished on or after January 1, 1999, that (I) in accordance with regulations, may be performed in an ambulatory surgical center and GENERAL.—Notwithstanding 200 As in original; possibly should be "knowingly". for which the Secretary permits ambulatory (II) are performed in an ambulatory surgical (I) in computing the amount of the amount of any applicable deductible or copayment, the computation of such deductible or coinsurance shall be based upon the fee schedule under which payment is made for the services, and (II) the amount of such coinsurance is equal to 25 percent of the payment amount under the fee schedule described in subclause (I). (D) SPECIAL RULE FOR DETECTED LESIONS.-If during the course of such screening flexible sigmoidoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening flexible sigmoidoscopy but shall be made for the procedure classified as a flexible sigmoidoscopy with such biopsy or removal. (E) FREQUENCY LIMIT.-No payment may be made under this part for a colorectal cancer screening test consisting of a screening flexible sigmoidoscopy (i) if the individual is under 50 years of age; or (ii) if the procedure is performed within the 47 months after a previous screening flexible sigmoidoscopy. (3) SCREENING COLONOSCOPY FOR INDIVIDUALS AT HIGH RISK FOR COLORECTAL CANCER. (A) FEE SCHEDULE.-With respect to colorectal cancer screening test consisting of a screening colonoscopy for individuals at high risk for colorectal cancer (as defined in section 1861(pp)(2)), payment under section 1848 shall be consistent with payment amounts under such section for similar or related services. (B) PAYMENT LIMIT.-In the case of screening colonoscopy services, payment under this part shall not exceed such amount as the Secretary specifies, based upon the rates recognized for diagnostic colonoscopy services. (C) FACILITY PAYMENT LIMIT. (i) IN GENERAL.-Notwithstanding subsections (i)(2)(A) and (t) of section 1833, in the case of screening colonoscopy services furnished on or after January 1, 1999, that are performed in an ambulatory surgical center or a hospital outpatient department, payment under this part shall be based on the lesser of the amount under the fee schedule that would apply to such services if they were performed in a hospital outpatient department in an area or the amount under the fee schedule that would apply to such services if they were performed in an ambulatory surgical center in the same area. (ii) LIMITATION ON DEDUCTIBLE AND COINSURANCE.— Notwithstanding any other provision of this title, in the case of a beneficiary who receives the services described in clause (i) (I) in computing the amount of any applicable deductible or coinsurance, the computation of such deductible or coinsurance shall be based upon the fee schedule under which payment is made for the services, and (II) the amount of such coinsurance is equal to 25 percent of the payment amount under the fee schedule described in subclause (I). (D) SPECIAL RULE FOR DETECTED LESIONS.—If during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal. (E) FREQUENCY LIMIT.-No payment may be made under this part for a colorectal cancer screening test consisting of a screening colonoscopy for individuals at high risk for colorectal cancer if the procedure is performed within the 23 months after a previous screening colonoscopy, 201 [(e) Repealed. 202] (f) REDUCTION IN PAYMENTS FOR PHYSICIAN PATHOLOGY SERVICES DURING 1991.— (1) IN GENERAL.-For physician pathology services furnished under this part during 1991, the prevailing charges used in a locality under this part shall be 7 percent below the prevailing charges used in the locality under this part in 1990 after March 31. (2) LIMITATION.-The prevailing charge for the technical and professional components of an 203 physician pathology service furnished by a physician through an independent laboratory shall not be reduced pursuant to paragraph (1) to the extent that such reduction would reduce such prevailing charge below 115 percent of the prevailing charge for the professional component of such service when furnished by a hospital-based physician in the same locality. For purposes of the preceding sentence, an independent laboratory is a laboratory that is independent of a hospital and separate from the attending or consulting physicians' office. (g) PAYMENT FOR OUTPATIENT CRITICAL ACCESS HOSPITAL SERVICES.—The amount of payment under this part for outpatient criti 201 P.L. 105-33, §4104(b)(1), added subsection (d), applicable to items and services furnished on or after January 1, 1998. 202 P.L. 101-234, §201(a)(1); 103 Stat. 1981. 203 As in original; possibly should be "a". cal access hospital services is the reasonable costs of the critical access hospital in providing such services. 204 (h) PAYMENT FOR PROSTHETIC DEVICES AND ORTHOTICS AND PROSTHETICS. (1) GENERAL RULE FOR PAYMENT.— (A) IN GENERAL.-Payment under this subsection for prosthetic devices and orthotics and prosthetics shall be made in a lump-sum amount for the purchase of the item in an amount equal to 80 percent of the payment basis described in subparagraph (B). (B) PAYMENT BASIS.-Except as provided in subparagraphs (C) and (E), the payment basis described in this subparagraph is the lesser of— (i) the actual charge for the item; or (ii) the amount recognized under paragraph (2) as the purchase price for the item. (C) EXCEPTION FOR CERTAIN PUBLIC HOME HEALTH AGENCIES. Subparagraph (B)(i) shall not apply to an item furnished by a public home health agency (or by another home health agency which demonstrates to the satisfaction of the Secretary that a significant portion of its patients are low income) free of charge or at nominal charges to the public. (D) EXCLUSIVE PAYMENT RULE. This subsection shall constitute the exclusive provision of this title for payment for prosthetic devices, orthotics, and prosthetics under this part or under part A to a home health agency. (E) EXCEPTION FOR CERTAIN ITEMS.-Payment for ostomy supplies, tracheostomy supplies, and urologicals shall be made in accordance with subparagraphs (B) and (C) of section 1834(a)(2). (2) PURCHASE PRICE RECOGNIZED.-For purposes of paragraph (1), the amount that is recognized under this paragraph as the purchase price for prosthetic devices, orthotics, and prosthetics is the amount described in subparagraph (C) of this paragraph, determined as follows: (A) COMPUTATION OF LOCAL PURCHASE PRICE.-Each carrier under section 1842 shall compute a base local purchase price for the item as follows: (i) The carrier shall compute a base local purchase price for each item equal to the average reasonable charge in the locality for the purchase of the item for the 12-month period ending with June 1987. (ii) The carrier shall compute a local purchase price, with respect to the furnishing of each particular item (I) in 1989 and 1990, equal to the base local purchase price computed under clause (i) increased by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 6-month period ending with December 1987, or 204 P.L. 105-33, §4201(c)(5), amended subsection (g) in its entirety, applicable to services furnished on or after October 1, 1997. For subsection (g) as it formerly read, see Vol. II, Superseded Provisions, P.L. 105-33. |