CMS Pub. 100-04, ch. 1, § 10.1.1.2

Payment Limitation

(Rev. 4473, Issued: 12-6-19; Effective: 3-9-20; Implementation: 3-9-20)

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 15, 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 A/B MAC (Part B) that has jurisdiction over the geographic area where the services

were rendered.

The A/B MAC (Part B) must accept and process claims for services subject to the anti-markup payment limitation when billed by physicians or other suppliers enrolled in the

A/B MAC (Part B)’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 A/B MAC

(Part B) 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 October 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 A/B

MAC (Part B). A/B MAC (Part B) must accept and process claims for services subject to

the anti-markup payment limitation when billed by suppliers enrolled in the A/B MAC

(Part B) jurisdiction, regardless of the location where the services were furnished. A/B

MAC (Part B) should allow claims submitted by an IDTF for anti-markup tests if the

IDTF has previously enrolled to bill for anti-markup test components they perform.

Effective April 1, 2005, A/B MAC (Part B) 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 through 2013, A/B

MAC (Part B) 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. Beginning in 2014, A/B MAC (Part B) must

refer to an Anti-markup Test Indicator, to identify HCPCS codes payable under the

MPFS as anti-markup tests for the year.