Specific Instructions for Filing Claims Subject to Anti-Markup Limitation
Providers may not submit a global billing or total component code on paper or electronic claims when one component of the service is subject to the anti-markup limitation. To determine the correct payment jurisdiction and price services correctly, the technical and professional components of the service must be submitted on separate detail lines or on separate claims, depending on how the claim is filed (paper or electronic).
Paper Claims: The technical component and the professional component must be submitted on separate claim forms. The physical address of the location where the specific test component was rendered should be entered in Item 32, along with the NPI of the performing physician. If the performing physician is enrolled with a different B/MAC, the NPI of the billing entity must be reported in item 32.
Electronic Claims: The services may be submitted on the same claim, but on separate detail lines. The corresponding service facility location and physical address must be entered for each service at the line level.
* The Medicare Physician Fee Schedule National Abstract File for Diagnostic Tests/Interpretations subject to the anti-markup limitation will be used to price all claims for these diagnostic services based on the ZIP code of the location where the service was rendered, including those submitted by physicians for diagnostic services subject to the anti-markup limitation performed outside the local carrier’s jurisdiction.
* Physicians and suppliers must report the rendering physician’s/supplier’s information and the location where the service was rendered on all claims subject to the anti-markup limitation, including those performed outside the local carrier’s jurisdiction.
* Physicians/suppliers are not to report the National Provider Identifier (NPI) of the out-of-jurisdiction performing physician/supplier when submitting a claim for a diagnostic service subject to the anti-markup limitation and acquired outside of their local carrier’s/Medicare Administration Contractor’s (MAC’s) jurisdiction. In the case of the performing physician/supplier being in another B/MAC jurisdiction, the billing physician/supplier must submit its own NPI in Item 32.
* Physicians and suppliers may only submit claims for tests/interpretations when these services are performed within the United States. (In this context, the term “United States” means the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa.)
