Diagnostic Tests Subject to the Anti-Markup Payment Limitation

30 - Diagnostic Tests Subject to the Anti-Markup Payment Limitation (Rev. 4473, Issued: 12-6-19; Effective: 3-9-20; Implementation: 3-9-20) In most instances, physicians working for an IDTF do not order diagnostic tests because such tests are generally ordered by the patient’s treating physician. If a physician working for an IDTF does not order a diagnostic test, the test is not subject to the anti- markup payment limitation. However, if a physician working for an IDTF (or a physician financially related to the IDTF through common ownership or control) orders a diagnostic test payable under the Medicare Physician Fee Schedule (MPFS), the anti- markup payment limitation may apply (depending on whether the performing physician or other supplier meets the “sharing a practice” requirements). For additional information, see Pub. 100-04, chapter 1, §30.2.9. If a physician working for an IDTF (or a physician financially related to the IDTF through common ownership or control) orders and the IDTF bills for a diagnostic test that is performed by another physician or supplier, the performing physician or other supplier must be enrolled in the Medicare program. No formal reassignment is necessary; however, reassigned diagnostic testing services may also be subject to the anti-markup payment limitation. The billing entity must report using the ASC X12 837 professional claim format or on the Form CMS-1500 the name, NPI, and address of the performing physician or other supplier. The acquisition price of the either the technical component or professional component of the diagnostic test must also be reported on the claim. Effective for claims with dates of service on or after January 25, 2005, A/B MACs (Part B) must accept and process claims for diagnostic tests subject to the anti-markup payment limitation billed by suppliers (including laboratories, physicians, and independent diagnostic testing facilities [IDTFs]) enrolled in the A/B MAC’s (Part B) jurisdiction, for services furnished anywhere in the United States. For services furnished outside the A/B MAC (Part B) jurisdiction in which the billing entity is enrolled, the billing entity must submit its own NPI with the name, address, and ZIP code of the performing physician or other supplier in the appropriate data field. (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.) Effective April 1, 2005, A/B MACs (Part B) must price claims for diagnostic tests that are subject to the anti-markup payment limitation based on the ZIP Code of the location where the service was rendered, using a CMS- supplied abstract file containing the HCPCS codes that are payable under the MPFS as an anti-markup test for the calendar year. From April 1, 2005, through December 31, 2013, this was done using a CMS-supplied abstract file containing the HCPCS codes that are payable under the MPFS as an anti-markup test for the calendar year. Beginning January 1, 2014, A/B MACs (Part B) began using the Purchased Diagnostic Test Indicator for the HCPCS codes that are payable under the MPFS as an anti-markup test for the calendar year. A/B MACs (Part B) must pay the lesser of: (a) the net acquisition price, (b) the billing entity’s actual charge, or (c) the fee schedule amount as if the test was billed by the performing supplier. 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 on anti-markup and reference laboratory claims, even if the performing physician or supplier is enrolled in a different A/B MAC (Part B) jurisdiction. See Pub. 100-04, Chapter 1, §10.1.1 for more information regarding claims filing jurisdiction. NOTE: As with all services payable under the MPFS, the ZIP Code is used to determine the appropriate payment locality and corresponding fee that is used to price the service that is subject to the anti-markup payment limitation. When a ZIP Code crosses county lines, CMS uses the dominant locality to determine the corresponding fee.