A/B MAC (B) Record Layout for Clinical Laboratory Fee Schedule

40.2 - A/B MAC (B) Record Layout for Clinical Laboratory Fee Schedule (Rev. 1, 10-01-03) PM AB-01-162, AB-02-163 The instructions for each annual update contain the actual data set name for that year. The Data Set Name is included with each annual update instructions. Data Element Name Picture Location Comment HCPCS Code X(05) 1-5 A/B MAC (B) Number X(05) 6-10 Locality X(02) 11-12 00 = Denotes Single A/B MAC (B) State 01 = North Dakota 02 = South Dakota 20 = Puerto Rico 40 = New Hampshire 50 = Vermont 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 waive test. Filler X(03) 58 - 60