Reporting of Pricing Localities for Clinical Laboratory Services

50.4 - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 3875, Issued: 10-06-17, Effective: 01-08-18, Implementation: 01-08-18) PM-B-97-12 A/B MACs (B) shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the A/B MAC (B) record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90 modifier. If the laboratory test billed is not a reference laboratory service, the A/B MAC (B) Locality (location 11-12) on the Clinical Diagnostic Laboratory fee schedule should be forwarded to the CWF. For dates of service on or after April 1, 2004, CWF will not edit clinical laboratory pricing locality. The A/B MAC (A) and (B) record layouts, plus the State pricing locations are as follows: A/B MAC (B) RECORD LAYOUT FOR DATA FILE CLINICAL LABORATORY FEE SCHEDULE Data Element Name Picture Location Comment HCPCS Code X(05) 1-5 Data Element Name Picture Location Comment A/B MAC (B) Number X(05) 6-10 A/B MAC (B) LoX(02) 11-12 00--Single State A/B MAC (B) 01--North Dakota 02--South Dakota 02--South Dakota 20--Puerto Rico 60% Local Fee 9(05)V99 13-19 62% Local Fee 9(05)V99 20-26 60% Natl Limit Amt 9(05)V99 27-33 62% Natl Limit Amt 9(05)V99 34-40 60% Pricing Amt 9(05)V99 41-47 62% Pricing Amt 9(05)V99 48-54 Gap-Fill Indicator X(01) 55-55 0 No Gap-fill Required 1-- A/B MAC (B) Gap-fill 2--Special Instructions Apply Modifier X(02) 56-57 Where modifier is shown, QW denotes a CLIA waiver test State Locality X(02) 58-59 See attached FILLER X(01) 60 A/B MAC (A) RECORD LAYOUT FOR DATA FILE CLINICAL LABORATORY FEE SCHEDULE Data Element Name Picture Location Comment HCPCS X(05) 1-5 Filler X(04) 6-9 60% Pricing Amt 9(05)V99 10-16 62% Pricing Amt 9(05)V99 17-23 Filler X(07) 24-30 A/B MAC (B) Number X(05) 31-35 Data Element Name Picture Location Comment A/B MAC (B) Locality X(02) 36-37 00--Single State A/B MAC (B) 01--North Dakota 02--South Dakota 20 Puerto Rico State Locality X(02) 38-39 See Attached FILLER X(21) 40-60 On or after January 1, 2018, the record layouts of the CLFS are as follows: Data Element Name Picture Location Comment Year PIC X(04) 1-4 Calendar year (YYYY) associated with the Clinical Lab Fee Schedule. Filler PIC X(01) 5 Value ' ' HCPCS Code PIC X(05) 6-10 All current year active CPT and alpha- numeric codes subject to CLFS. Filler PIC X(01) 11 Value ' ' Modifier PIC X(02) 12-13 Where modifier is shown, QW denotes a CLIA waiver test. Filler PIC X(01) 14 Value ' ' Effective Date PIC X(08) 15-22 Date the Clinical Lab Fee Schedule became effective (YYYYMMDD). Filler PIC X(01) 23 Value ' ' Indicator PIC X(01) 24 National (N) or Local (L) payment indicator. Filler PIC X(01) 25 Value ' ' Payment Rate PIC Z9(05)V99 26-32 The payment amount associated with each test on the Clinical Lab Fee Schedule. Filler PIC X(01) 33 Value ' ' Description PIC X(40) 34-73 Short description of the applicable HCPCS code. CarrierLocality/StateLocality Map Carrier/Loc 1010200 =State Loc 01 (ALABAMA) Carrier/Loc 0210201 =State Loc 02 (ALASKA) Carrier/Loc 0310200 =State Loc 04 (ARIZONA) Carrier/Loc 0710213 =State Loc 05 (ARKANSAS) Carrier/Loc 0118218 =State Loc 06 (CALIFORNIA) Carrier/Loc 0118226 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111252 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111207 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111205 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111206 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111209 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111251 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111253 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111254 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111255 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111256 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111257 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111258 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111259 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111260 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111261 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111262 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111263 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111264 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111265 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111266 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111267 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111268 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111269 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111270 =State Loc 06 (CALIFORNIA) Carrier/Loc 0118271 =State Loc 06 (CALIFORNIA) Carrier/Loc 0118272 =State Loc 06 (CALIFORNIA) Carrier/Loc 0118273 =State Loc 06 (CALIFORNIA) Carrier/Loc 0118274 =State Loc 06 (CALIFORNIA) Carrier/Loc 0118217 =State Loc 06 (CALIFORNIA) Carrier/Loc 0111275 =State Loc 06 (CALIFORNIA) Carrier/Loc 0411201 =State Loc 08 (COLORADO) Carrier/Loc 1310200 =State Loc 09 (CONNECTICUT) Carrier/Loc 1210201 =State Loc 10 (DELAWARE) Carrier/Loc 1220201 =State Loc 11 (DISTRICT OF COLUMBIA) Carrier/Loc 0910203 =State Loc 12 (FLORIDA) Carrier/Loc 0910204 =State Loc 12 (FLORIDA) Carrier/Loc 0910299 =State Loc 12 (FLORIDA) Carrier/Loc 1020201 =State Loc 13 (GEORGIA) Carrier/Loc 1020299 =State Loc 13 (GEORGIA) Carrier/Loc 0121201 =State Loc 15 (HAWAII/GUAM) Carrier/Loc 0220200 =State Loc 16 (IDAHO) Carrier/Loc 0610216 =State Loc 17 (ILLINOIS) Carrier/Loc 0610212 =State Loc 17 (ILLINOIS) Carrier/Loc 0610215 =State Loc 17 (ILLINOIS) Carrier/Loc 0610299 =State Loc 17 (ILLINOIS) Carrier/Loc 0810200 =State Loc 18 (INDIANA) Carrier/Loc 0510200 =State Loc 19 (IOWA) Carrier/Loc 0520200 =State Loc 20 (KANSAS) Carrier/Loc 1510200 =State Loc 21 (KENTUCKY) Carrier/Loc 0720201 =State Loc 22 (LOUISIANA) Carrier/Loc 0720299 =State Loc 22 (LOUISIANA) Carrier/Loc 1411203 =State Loc 23 (MAINE) Carrier/Loc 1411299 =State Loc 23 (MAINE) Carrier/Loc 1230201 =State Loc 24 (MARYLAND) Carrier/Loc 1230299 =State Loc 24 (MARYLAND) Carrier/Loc 1421201 =State Loc 25 (MASSACHUSETTS) Carrier/Loc 1421299 =State Loc 25 (MASSACHUSETTS) Carrier/Loc 0820201 =State Loc 26 (MICHIGAN) Carrier/Loc 0820299 =State Loc 26 (MICHIGAN) Carrier/Loc 0620200 =State Loc 27 (MINNESOTA) Carrier/Loc 0730200 =State Loc 28 (MISSISSIPPI) Carrier/Loc 0530202 =State Loc 29 (MISSOURI) Carrier/Loc 0530201 =State Loc 29 (MISSOURI) Carrier/Loc 0530299 =State Loc 29 (MISSOURI) Carrier/Loc 0320201 =State Loc 30 (MONTANA) Carrier/Loc 0540200 =State Loc 31 (NEBRASKA) Carrier/Loc 0131200 =State Loc 32 (NEVADA) Carrier/Loc 1431240 =State Loc 33 (NEW HAMPSHIRE) Carrier/Loc 1240201 =State Loc 34 (NEW JERSEY) Carrier/Loc 1240299 =State Loc 34 (NEW JERSEY) Carrier/Loc 0421205 =State Loc 35 (NEW MEXICO) Carrier/Loc 1320201 =State Loc 36 (NEW YORK) Carrier/Loc 1320202 =State Loc 36 (NEW YORK) Carrier/Loc 1320203 =State Loc 36 (NEW YORK) Carrier/Loc 1329204 =State Loc 36 (NEW YORK) Carrier/Loc 1328299 =State Loc 36 (NEW YORK) Carrier/Loc 1150200 =State Loc 37 (NORTH CAROLINA) Carrier/Loc 0330201 =State Loc 38 (NORTH DAKOTA) Carrier/Loc 1520200 =State Loc 39 (OHIO) Carrier/Loc 0431200 =State Loc 40 (OKLAHOMA) Carrier/Loc 0230201 =State Loc 41 (OREGON) Carrier/Loc 0230299 =State Loc 41 (OREGON) Carrier/Loc 1250201 =State Loc 42 (PENNSYLVANIA) Carrier/Loc 1250299 =State Loc 42 (PENNSYLVANIA) Carrier/Loc 0920220 =State Loc 72 (PUERTO RICO) Carrier/Loc 1441201 =State Loc 44 (RHODE ISLAND) Carrier/Loc 1120201 =State Loc 45 (SOUTH CAROLINA) Carrier/Loc 0340202 =State Loc 46 (SOUTH DAKOTA) Carrier/Loc 1030235 =State Loc 47 (TENNESSEE) Carrier/Loc 0441231 =State Loc 48 (TEXAS) Carrier/Loc 0441220 =State Loc 48 (TEXAS) Carrier/Loc 0441209 =State Loc 48 (TEXAS) Carrier/Loc 0441211 =State Loc 48 (TEXAS) Carrier/Loc 0441228 =State Loc 48 (TEXAS) Carrier/Loc 0441215 =State Loc 48 (TEXAS) Carrier/Loc 0441218 =State Loc 48 (TEXAS) Carrier/Loc 0441299 =State Loc 48 (TEXAS) Carrier/Loc 0350209 =State Loc 49 (UTAH) Carrier/Loc 1451250 =State Loc 50 (VERMONT) Carrier/Loc 0920250 =State Loc 78 (VIRGIN ISLANDS) Carrier/Loc 1130200 =State Loc 51 (VIRGINIA) Carrier/Loc 0240202 =State Loc 53 (WASHINGTON) Carrier/Loc 0240299 =State Loc 53 (WASHINGTON) Carrier/Loc 1140216 =State Loc 54 (WEST VIRGINIA) Carrier/Loc 0630200 =State Loc 55 (WISCONSIN) Carrier/Loc 0360221 =State Loc 56 (WYOMING)