CMS Pub. 100-04, ch. 1, § 30.3.7

Laboratory Tests) Subject to the Anti-Markup Payment Limitation -

Claims Submitted to A/B/MACs

(Rev. 10236, Issued: 07-31-2020, Effective: 08-31-2020, Implementation: 08-31-2020)

A. General

A physician or other supplier may bill and receive payment for the technical component

(TC) or professional component (PC) of a diagnostic test (other than clinical diagnostic

laboratory test) that is performed by a physician or other supplier with whom the billing

physician or other supplier does not share a practice. Reimbursement for that service is

subject to the anti-markup payment limitation. If a physician or other supplier’s bill or a

request for payment includes a charge for a diagnostic test (other than a clinical

diagnostic laboratory test) which the physician or other supplier did not personally

perform or supervise, then payment for the test may not exceed the lesser of:

• The performing physician’s net charge to the billing physician or other supplier

(net any discounts);

• The billing physician’s actual charge; or

• The fee schedule amount that would be allowed for the test if the performing

physician or other supplier billed directly.

(See §30.2.9 of this chapter for additional information.)

For payment to be made, the physician who acquires the TC or PC of a diagnostic test

from an outside source must identify the performing physician or other supplier on the

claim. (The billing physician or other supplier should maintain a record of the

performing physician or other supplier’s NPI in the clinical record for auditing purposes.)

The billing physician or other supplier must also indicate on the claim that the test is

subject to the anti-markup payment limitation.

See the guidelines at the official Washington Publishing Company website for how to

show this on electronic claims.

If using the CMS-1500 paper claim form:

• In item 20 check "yes" to indicate the test is subject to the anti-markup payment

limitation and enter the amount the performing physician or other supplier

charged.

• In item 32 enter the name, address, and NPI of the performing physician or

supplier. If the performing physician provides the service outside the A/B MAC

(B) jurisdiction where the billing physician is located, the billing physician must

submit its own NPI with the name, address, and ZIP code of the performing

physician or other supplier.

No payment may be made to the physician without this information unless the statement

“No anti-markup tests are included” is annotated on the claim.

NOTE: If the billing physician performs only the TC or the PC and wants to bill for both

components of the diagnostic test, the TC and PC must be reported as separate line items

if billing electronically or on separate claims if billing on paper (CMS-1500). Global

billing is not allowed unless the billing physician or other supplier performs both

components.

Effective for claims submitted with a receipt date on and after October 1, 2015, the

billing physician or supplier must report the name, address, and NPI of the performing

physician or supplier in Item 32a of the CMS-1500 claim form (or its electronic

equivalent) on anti-markup claims, even if the performing physician or supplier is

enrolled in a different A/B MAC (B) jurisdiction. (See §10.1.1.2 for more information

regarding claims filing jurisdiction.)

B. Unassigned Claims with Required Documentation

A physician or other supplier may not bill an individual an amount in excess of

Medicare’s payment, except for any deductible and coinsurance, for the TC or PC of a

diagnostic test that is subject to the anti-markup payment limitation. A/B MACs (B)

must notify physicians and other suppliers that they must indicate when a diagnostic test

was acquired, identify the performing physician or other supplier, and show the amount

the performing physician or other supplier charged. The notification must inform

physicians and other suppliers that they are prohibited by §1842(n)(3) of the Act from

billing or collecting an amount in excess of Medicare’s payment, except for the

deductible and coinsurance. Excess amounts collected from the beneficiary must be

repaid.

C. Unassigned Claims without Required Documentation

A physician may not bill a beneficiary:

• If the bill does not indicate who performed the test; and

• If the bill indicates that a separate physician or other supplier performed the test,

it does not identify the performing physician or other supplier or does not include the

amount the performing physician or other supplier charged.

The A/B MACs (B) notify the physician when a non-assigned claim for the TC or PC of

a diagnostic test subject to the anti-markup payment limitation is received from either the

physician or a beneficiary except when the physician submits an assigned claim and the

beneficiary submits an unassigned duplicate claim. They use the following sample letter.

Dear Doctor:

We have received an unassigned claim for diagnostic tests furnished to the

patient (Beneficiary Name), on (Date of Service). You are prohibited by

§1842(n)(3) of the Social Security Act from billing or collecting any

amount unless you indicate that “No anti-markup tests are included” or, if

the diagnostic test was acquired, you indicate who performed the test and

what the physician or other supplier charged you. Some or all of the

required information is missing from your patient’s claim. If you have

collected any amount from your patient, it must be refunded. This claim

may be resubmitted if the required information is included.

D. Beneficiary Information Regarding Unassigned Claims

The A/B MACs (B) must notify the beneficiary that the physician is prohibited from:

• Billing the beneficiary when the necessary documentation is not supplied; and

• Billing or collecting an amount in excess of Medicare’s payment, except

for the deductible and coinsurance, when the required documentation is

submitted.

(See chapter 21 of this manual, for MSN messages.)