July 20th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014) The jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is governed by the payment locality where the service is furnished and will be based on the ZIP code. Though a number of additional services appear on the MPFS database, these payment jurisdiction rules apply only to those services actually paid under the MPFS and to anesthesia services. (For example, it does not apply to clinical lab, ambulance or drug claims.)
Effective for claims received on or after April 1, 2004, A/B MACs (B) must use the ZIP code of the location where the service was rendered to determine A/B MACs (B) jurisdiction over the claim and the correct payment locality. Effective for dates of service on or after October 1, 2007, except for services provided in POS “Home,” if they are not already doing so, A/B MACs (B) shall use the CMS ZIP code file along with the ZIP code submitted on the claim with the address that represents where the service was performed to determine the correct payment locality. (See section 10.1.1B for instructions on processing services rendered in POS Home -12 and section 10.1.1.1 for instructions on when a 9-digit ZIP code is required.)
When a physician, practitioner, or supplier furnishes physician fee schedule or anesthesia services in payment localities that span more than one A/B MAC (B)’s service area (e.g., provider has separate offices in multiple localities and/or multiple A/B MACs (B)), separate claims must be submitted to the appropriate area A/B MACs (B) for processing. For example, when a physician with an office in Illinois furnishes services outside the office setting (e.g., home, hospital, SNF visits) and that out-of-office service location is in another A/B MAC (B)’s service area (e.g., Indiana), the A/B MAC (B) which processes claims for the payment locality where the out of office service was furnished has jurisdiction for that service. It is the A/B MAC (B) with the correct physician fee schedule pricing data for the location where the service was furnished. In the majority of cases, the physician fee schedule or anesthesia services provided by physicians are within the same A/B MAC (B) jurisdiction that the physicians’ office(s) is/are located.
Although pricing rules for services paid under the MPFS remain in effect, effective for claims with dates of service on or after January 25, 2005, suppliers (including laboratories, physicians, and independent diagnostic testing facilities [IDTFs]) must bill their A/B MAC (B) for the technical component (TC) and professional component (PC) of diagnostic tests that are subject to the anti-markup payment limitation, regardless of the location where the service was furnished. Beginning in 2005, and in each subsequent calendar year (CY) thereafter, CMS will provide A/B MACs (B) with a national abstract file containing Healthcare Common Procedural Coding System (HCPCS) codes that are payable under the MPFS as anti-markup tests for the year. In addition, CMS will make quarterly updates to the abstract file to add and/or delete codes, as needed, in conjunction with the MPFSDB quarterly updates. As with all other services payable under the MPFS, the ZIP code of the locality in which the service was furnished determines the payment amount. Refer to §30.2.9 of this chapter for information on the anti-markup payment limitation as it applies to supplier billing requirements.
A. Multiple Offices In states with multiple physician fee schedule pricing localities or where a provider has multiple offices located in two or more states, or there is more than one A/B MAC (B) servicing a particular state, physicians, suppliers and group practices with multiple offices in such areas must identify the specific location where office-based services were performed. This is to insure correct claim processing jurisdiction and/or correct pricing of MPFS and anesthesia services. The A/B MAC (B) must ensure that multiple office situations are cross-referenced within its system. If a physician/group with offices in more than one MPFS pricing locality or a multi-contractor state fails to specify the location where an office-based service was furnished, the A/B MAC (B) will return/reject the claim as unprocessable.
Physicians, suppliers, and group practices that furnish physician fee schedule services at more than one office/practice location may submit their claims through one office to the A/B MAC (B) for processing. However, the specific location where the services were furnished must be entered on the claim so the A/B MAC (B) has the ZIP code, can determine the correct claims processing jurisdiction, and can apply the correct physician fee schedule amount.
B. Service Provided at a Place of Service Other than Home-12 or Office-11 For claims submitted prior to April 1, 2004, in order to determine claims jurisdiction, Medicare approved charges, Medicare payment amounts, Medicare limiting charges and beneficiary liability, Part B fee-for-service claims for services furnished in other than in an office setting or a beneficiary’s home must include information specifying where the service was provided.
Effective for claims received on or after April 1, 2004, claims for services furnished in all places of service other than a beneficiary’s home must include information specifying where the service was provided. A/B MACs (B) must use the address on the beneficiary files when place of service (POS) is home - 12, or any other mechanism currently in place to determine pricing locality when POS is home – 12. A/B MACs (B) shall take this same action for any other POS codes they currently treat as POS home.
Effective for claims processed on or after October 5, 2009, for services rendered in POS home -12, or for any other POS the contractor currently treats as POS home, when alerted by the shared system that a 9-digit ZIP code is required according to the CMS ZIP Code file, and a 9-digit ZIP code is not available on the beneficiary file, the contractor shall determine that ZIP code by using the United States Postal Service Web site. They shall use that ZIP code to determine the correct payment locality for the claim for pricing purposes.
A/B MACs (B) processing these claims shall take necessary steps to ensure that the claims for services rendered in the physical location for which they are the MAC are priced and processed correctly applying appropriate edits as necessary.
Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of the ASC X12 837 professional claim format, submission of the complete address of where the service was performed is required regardless of where the service was performed. This information should be entered on the claim per the Implementation Guide for the current version. Contractors shall use that ZIP code to determine correct payment locality.
Effective January 1, 2011 for claims processed on or after January 1, 2011 on paper claims submitted on the CMS-1500 form, submission of the ZIP code of where the service was provided will also be required for all POS code and contractors shall use that ZIP code to determine correct payment locality.
Contractors shall make no changes for claims submitted on the 4010A1 format as they pertain to POS Home and determining pricing locality. Contractors shall require the submission of the 9-digit ZIP code when required per the CMS ZIP Code file.
C. Outside A/B MAC (B) Jurisdiction If A/B MACs (B) receive claims outside of their jurisdiction, they must follow resolution procedures in accordance with the instructions in 10.1.9. If they receive a significant volume or experiences repeated incidences of misdirected Medicare Physician Fee Schedule or anesthesia services from a particular provider, an educational contact may be warranted.
D. HMO Claims For services that HMOs are not required to furnish, A/B MACs (B) process claims for items or services provided to an HMO member over which they have jurisdiction in the same manner as they process other Part B claims for items or services provided by physicians or suppliers. Generally, the physician/supplier who provides in-plan services to its HMO members submits a bill directly to the HMO for payment and normally does not get involved in processing the claim. However, in some cases, claims for services to HMO members are also submitted to A/B MACs (B), e.g., where claims are received from physicians for dialysis and related services provided through a related dialysis facility.