(Medicare Claims Processing Manual)

Providers and suppliers should annotate claims using a new ZIP Code with a remark to that effect.  Providers and suppliers should maintain documentation of the new ZIP Code and provide it to their contractor upon request.   If the provider or supplier believes that a new ZIP Code that the contractor has designated as urban should be designated as rural (under the standard established by the Medicare FS regulation), it may request an adjustment from the A/B MAC (A) or appeal the determination with the A/B/MAC (B), as applicable, in accordance with standard procedures.   When processing a claim with a POP ZIP Code that is not on the Medicare ZIP Code file, contractors must search the USPS Web site at http://www.usps.com/ , other governmental Web sites, and commercial Web sites, to validate the new ZIP Code.  (The Census Bureau Web site located at http://www.census.gov/  contains a list of valid ZIP Codes.)  If the ZIP Code cannot be validated using the USPS Web site or other authoritative source such as the Census Bureau Web site, reject the claim as unprocessable.   C.  Inaccurate ZIP Codes   If providers and suppliers knowingly and willfully report a surrogate ZIP Code because they do not know the proper ZIP Code, they may be engaging in abusive and/or potentially fraudulent billing.  Furthermore, a provider or supplier that specifies a surrogate rural ZIP Code on a claim when not appropriate to do so for the purpose of receiving a higher payment than would have been paid otherwise, may be committing abuse and/or potential fraud.   D.  Claims Outside of the U.S.  The following policy applies to claims outside of the U.S.:    Ground transports with pickup and drop off points within Canada or Mexico will be paid at the fee associated with the U.S. ZIP Code that is closest to the POP;    For water transport from the territorial waters of the U.S., the fee associated with the U.S. port of entry ZIP Code will be paid;    Ground transports with pickup within Canada or Mexico to the U.S. will be paid at the fee associated with the U.S. ZIP Code at the point of entry; and    Fees associated with the U.S. border port of entry ZIP Codes will be paid for air transport from areas outside the U.S. to the U.S. for covered claims.  As discussed more fully below, CMS will provide contractors with a file of ZIP Codes that will map to the appropriate geographic location and, where appropriate, with a rural designation identified with the letter R or B.  Urban ZIP Codes are identified with a blank in this position.   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, wit hin an MSA or Core Based Statistical Area (CBSA).   AB 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 t o 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 p er 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, approximate ly 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 ZI P 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 M ainframe 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 a vailable 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     20.1.6 - Contractor Determination of Fee Schedule Amounts  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  The FS amount is determined by the FS locality, based on the POP of the ZIP Code.  Use the ZIP Code of the POP to electronically crosswalk to the appropriate FS amount.  All ZIP Codes on the ZIP Code file are urban unless identified as rural by the letter R or the letter B.  Contractors determine the FS amount as follows:    If an urban ZIP Code is reported with a ground or air HCPCS code, the contractors determine the amount for the service by using the FS amount for the urban base rate.  To determine the amount for mileage, multiply the number of reported miles by the urban mileage rate.    If a rural ZIP Code is reported with a ground HCPCS code, the contractor determines the amount for the service by using the FS amount for the rural base rate.  To determine the amount for mileage, contractors must use the following formula:   o For services furnished on or after July 1, 2004, for rural miles 1- 17, the rate equals 1.5 times the rural ground mileage rate per mile. Therefore, multiply 1.5 times the rural mileage rate amount on the FS to derive the appropriate FS rate per mile;  o For services furnished during the period July 1, 2004 through December 31, 2008, for all ground miles greater than 50 (i.e., miles 51+), the FS rate equals 1.25 times the applicable mileage rate (urban or rural). Therefore, multiply 1.25 times the urban or rural, as appropriate, mileage rate amount on the FS  to derive the appropriate FS rate per mile.    If a rural ZIP Code is reported with an air HCPCS code, the contractor determines the FS amount for the service by using the FS amount for rural air base rate.  To determine the amount allowable for the mileage, multiply the number of loaded miles by the r ural air mileage rate.   20.2 - Payment for Mileage Charges  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) B3-5116.3, PM AB -00-131