July 20th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; Implementation January 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are subject to the same payment rules as all other services paid on the MPFS. Additional explanation is provided here due to general confusion concerning these services when they are performed or supervised by a physician or other supplier who does not meet the criteria for “sharing a practice” with the billing physician or other supplier, rather than rendered and billed by the billing entity. (See §30.2.9 for additional information on “sharing a practice.”) Physicians and other suppliers must meet the current enrollment criteria stated in chapter 10, of the Program Integrity Manual, in order to be able to bill for anti-markup tests. That these services are billed by an entity that does not share a practice with the performing physician or other supplier does not negate the need for the performing physician or other supplier to follow appropriate enrollment procedures with the B/MAC that has jurisdiction over the geographic area where the services were rendered.
The B/MACs must accept and process claims for services subject to the anti-markup payment limitation when billed by physicians or other suppliers enrolled in the B/MAC’s jurisdiction, regardless of the location where the services were furnished.
Effective for claims processed on or after April 1, 2004, in order to allow the B/MAC to determine jurisdiction and apply the anti-markup payment limitation correctly, global billing will not be accepted on electronic or paper claims when billing anti-markup tests. Claims received with global billings in this situation will be treated as unprocessable per §80.3.
Effective for claims submitted with a receipt date on and after April 1, 2015, billing physicians and suppliers must report the name, address, and NPI of the performing physician or supplier on all anti-markup and reference laboratory claims, even if the performing physician or supplier is enrolled in a different contractor’s jurisdiction. Contractors shall return as unprocessable any anti-markup or reference laboratory claim with an NPI in Item 32a (or its electronic equivalent) that belongs to the billing physician/supplier, or that cannot be verified as a valid, Medicare enrolled entity.
A. Payment Jurisdiction for Suppliers of Diagnostic Tests and Interpretations Performed by Other Suppliers under Contract
Effective for claims with dates of service on or after January 25, 2005, laboratories, physicians, and IDTFs must submit all claims for anti-markup tests to their local B/MAC. B/MACs must accept and process claims for services subject to the anti-markup payment limitation when billed by suppliers enrolled in the B/MAC’s jurisdiction, regardless of the location where the services were furnished. B/MACs should allow claims submitted by an IDTF for anti-markup tests if the IDTF has previously enrolled to bill for antimarkup test components they perform.
Effective April 1, 2005, B/MACs must price anti-markup tests billed by laboratories and IDTF’s based on the ZIP code of the location where the diagnostic test was rendered.
Effective for claims with dates of service on or after October 1, 2007, B/MACs must use the national abstract file to price all claims for anti-markup tests for all supplier specialty types (including physicians), based on the ZIP code of the location where the service was rendered.