CMS Supplied National ZIP Code File and National Ambulance Fee

20.1.5.1 - CMS Supplied National ZIP Code File and National Ambulance Fee Schedule File (Rev. 2703, Issued: 05-10-13, Effective: 10-01-13, Implementation: 10-07-13) CMS will provide each contractor with two files: a national ZIP Code file and a national Ambulance FS file. A. The national ZIP5 Code file is a file of 5-digit USPS ZIP Codes that will map each ZIP Code to the appropriate FS locality. Every 2 months, CMS obtains an updated listing of ZIP Codes from the USPS. On the basis of the updated USPS file, CMS updates the Medicare ZIP Code file and makes it available to contractors. The following is a record layout of the ZIP5 file effective January 1, 2009 ZIP5 CODE to LOCALITY RECORD LAYOUT Field Name Position Format COBOL Description State 1-2 X(02) Alpha State Code ZIP Code 3-7 X(05) Postal ZIP Code A/B MAC (B) 8-12 X(05) A/B MAC (B) Number Pricing Locality 13-14 X(02) Pricing Locality Rural Indicator 15 X(01) Effective 1/1/07 Blank = urban, R=rural, B=super rural Field Name Position Format COBOL Description Beneficiary Lab CB Locality 16-17 X(02) Lab competitive bid locality; Z1= CBA1 Z2= CBA2 Z9= Not a demonstration locality Rural Indicator 2 18 X(01) What was effective 12/1/06 Blank=urban, R=rural, B=super rural Filler 19-20 X(02) Plus Four Flag 21 X(01) 0 = no +4 extension 1 = +4 extension Filler 22-75 X(54) Year/Quarter 76-80 X(05) YYYYQ NOTE: Effective October 1, 2007, claims for ambulance services will continue to be submitted and priced using 5-digit ZIP Codes. Contractors will not need to make use of the ZIP9 file for ambulance claims. Beginning in 2009, contractors shall maintain separate ZIP Code files for each year which will be updated on a quarterly basis. Claims shall be processed using the correct ZIP Code file based on the date of service submitted on the claim. A ZIP Code located in a rural area will be identified with either a letter “R” or a letter “B.” Some ZIP Codes will be designated as rural due to the Rural Urban Commuting Area (RUCA) Score even though the ZIP Code may be located, in whole or in part, within an MSA or Core Based Statistical Area (CBSA). A“B” designation indicates that the ZIP Code is in a rural county (or RUCA area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density. Effective for claims with dates of service between July 1, 2004 and December 31, 2010, contractors must apply a bonus amount to be determined by CMS to the base rate portion of the payment under the FS for ground ambulance services with a POP “B” ZIP Code. This amount is in addition to the rural bonus amount applied to ground mileage for ground transports originating in a rural POP ZIP Code. Each calendar quarter beginning October 2007, CMS will upload updated ZIP5 and ZIP9 ZIP Code files to the Direct Connect (formerly the Network Data Mover). Contractors shall make use of the ZIP5 file for ambulance claims and the ZIP9 file as appropriate per IOM Pub. 100-04, Medicare Claims Processing Manual, chapter 1 -General Billing Requirements , section 10.1.1 - Payment Jurisdiction Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services and the additional information found in Transmittal 1193, Change Request 5208, issued March 9, 2007. The updated files will be available for downloading on approximately November 15th for the January 1 release, approximately February 15th for the April 1 release, approximately May 15th for the July 1 release, and approximately August 15th for the October 1 release. Contractors are responsible for retrieving the ZIP Code files upon notification and must implement the following procedure for retrieving the files: 1. Upon quarterly Change Requests communicating the availability of updated ZIP Code files, go to the Direct Connect and search for the files. Confirm that the release number (last 5 digits) corresponds to the upcoming calendar quarter. If the release number (last 5 digits) does not correspond to the upcoming calendar quarter, notify CMS. 2. After confirming that the ZIP Code files on the Direct Connect corresponds to the next calendar quarter, download the files and incorporate the files into your testing regime for the upcoming model release. The names of the files will be in the following format: MU00.AAA2390.ZIP5.LOCALITY.Vyyyyr and MU00.AAA2390.ZIP9.LOCALITY.Vyyyyr where “yyyy” equals the calendar year and “r” equals the release number with January =1, April =2, July =3, and October =4. So, for example, the names of the file updates for October 2007 are MU00.AAA2390.ZIP5.LOCALITY.V20074 and MU00.AAA2390.ZIP9.LOCALITY.V20074. The release number for this file is 20074, release 4 for the year 2007. When the updated files are loaded to the Direct Connect, they will overlay the previous ZIP Code files. NOTE: Even the most recently updated ZIP Code files will not contain ZIP Codes established by the USPS after CMS compiles the files. Therefore, for ZIP Codes reported on claims that are not on the most recent ZIP Code files, follow the instructions for new ZIP Codes in §20.1.5(B). B. CMS will also provide contractors with a national Ambulance FS file that will contain payment amounts for the applicable HCPCS codes. The file will include FS payment amounts by locality for all FS localities. The FS file will be available via the CMS Mainframe Telecommunications System. Contractors are responsible for retrieving this file when it becomes available. The full FS amount will be included in this file. CMS will notify contractors of updates to the FS and when the updated files will be available for retrieval. CMS will send a full-replacement file for annual updates and for any other updates that may occur. The following is a record layout of the Ambulance Fee Schedule file: AMBULANCE FEE SCHEDULE FILE RECORD DESCRIPTION Field Name Position Format Description HCPCS 1-5 X(5) Level 2 HCPCs code number for the service. A/B MAC (B) Number 6-10 X(5) Contractor Number Locality Code 11-12 X(2) Identification of Pricing Locality RVU 13-18 9(4)V2 Relative Value Units set a numeric value for ambulance services relative to the value of a base level ambulance service. GPCI (PE) 19-22 9V3 The GPCI for the practice expense portion of the Medicare physician fee schedule is used to adjust payment to account for regional differences. Base Rate 23-29 9(5)V2 A nationally uniform “base” amount used to calculate each HCPCS’ payment amount. Urban Rate 30-36 9(5)V2 Urban Ground/Air mileage rate. Rural Rate 37-43 9(5)V2 Rural Ground/Air mileage rate. Current Year 44-47 x(4) 4 digit current effective year. Current Quarter 48-48 x(1) 1 digit current effective quarter: 1=January, 2=April, 3=July, 4 =October. Current Date 49-56 x(8) Current Effective Start Date. Filler 57-80 X(26) Future use