(Medicare Claims Processing Manual)

* The net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the performing supplier by or through the billing physician or other supplier.  Exception to the Anti -markup Payment Limitation  If the performing physician is deemed to share a practice with the billing physician or other supplier (who ordered the test), the anti-markup payment limitation does not apply.  A performing physician is considered to share a practice with the billing physician or other supplier if the performing physician furnishes substantially all (at least 75 percent) of his or her professional services through the billing physician or other supplier.  The substantially all services requirement will be satisfied, if, at the time the billing physician or other supplier submits a claim for a service furnished by the performing physician, the billing physician or other supplier has a reasonable belief that:  (1) for the 12 months prior to and including the month in which the service was performed, the performing physician furnished substantially all of his or her professional services through the billing physician or other supplier; or (2) the performing physician will furnish substantially all of his or her professional services through the billing physician or other supplier for the next 12 months (including the month in which the service is performed).   If the performing physician does not meet the substantially all services test, the performing physician may be deemed to share a practice with the billing physician or other supplier if the arrangement complies with a site of service/same building te st.  This alternative approach requires the performing physician to be an owner, employer, or independent contractor of the billing physician or other supplier and requires that the technical component or professional component be performed in the office of the billing physician or other supplier.  The office of the billing physician or other supplier is any medical office space, regardless of the number of locations, in which the ordering physician or other supplier regularly furnishes patient care, and includes space where the billing physician or other supplier furnishes diagnostic testing services, if the space is located in the same building (as defined in 42 CFR 411.351 of the physician self-referral rules) in which the ordering physician or other ordering supplier regularly furnishes patient care.  With respect to a billing physician or other supplier that is a physician organization (as defined in 42 CFR 411.351 of the physician self- referral rules), the office of the billing physician or other supplier is space in which the ordering physician provides substantially the full range of patient care services the ordering physician provides generally.  The performance of the technical component includes, both, the conducting of the technical component as well as the supervision of the technical component.   The billing physician or other supplier must keep on file the name, the National Provider Identifier, and address of the performing physician.  The physician or other supplier furnishing the technical component or professional component of the diagnostic t est must be enrolled in the Medicare program.  No formal reassignment is necessary .  NOTE:   When billing for the technical component or professional component of a diagnostic test (other than a clinical diagnostic laboratory test) that is performed by another physician, the billing entity must indicate the name, address and NPI of the performin g physician or other supplier in Item32 of the Form CMS-1500 claim form.  Effective for claims submitted with a receipt date on and after October 1, 2015, for reference laboratory and anti-markup claims, the billing physician or supplier must report the name, address, and NPI of the performing physician or supplier in Item 32a of the CMS -1500 claim form (or its electronic equivalent), even if the performing physician or supplier is enrolled in a different A/B MAC (Part B) jurisdiction.  See 10.1.1.2 for more information regarding claims filing jurisdiction.   If the billing physician or other supplier performs only the technical component or the professional component and wants to bill for both components of the diagnostic test, the TC modifier and 26 modifier must be reported as separate line items if billing electronically (ASC X12 837 professional claim) or on separate claims if billing on paper (Form CMS -1500).  Global billing is not allowed unless the billing physician or other supplier performs both components.  Effective for claims received on or after April 1, 2004:   In order to have appropriate service facility location ZIP code and the acquired price of each test on the claim, when billing for anti -markup tests on the Form CMS -1500 paper claim form each test must be submitted on a separate claim form. Treat paper claims submitted with more than one anti -markup test as unprocessable per 80.3.2.  More than one anti -markup test may be billed on the ASC X12 837 professional claim format. When more than one test is billed, the total acquired amount must be submitted for each service. Treat claims received with multiple anti -markup tests without line l evel total acquired amount information as unprocessable per 80.3.2.   Treat paper claims submitted for anti -markup tests with both the technical component and the professional component on one claim as unprocessable per 80.3.2 unless the services are submitted with the same date of service and same place of service codes. When a claim is received that includes both services, and the date of service and place of service codes match, assume that the one address in Item 32 applies to both services. Effective for claims with dates of service on or after April 1, 2005, each component of the test must be submitted on a separate claim form. Treat paper claims with dates of service after March 31, 2005 submitted with more than one anti -markup test as unprocessable per 80.3.2.  ASC X12 837 professional electronic claims submitted for anti -markup tests with both the technical component and professional component on the same claim must be accepted. Assume that the claim level service facility location information applies to both services if line level information is not provided.  In order to price claims correctly and apply anti -markup payment limitations, global billing is not acceptable for claims received on the Form CMS -1500 or on the ASC X12 837 professional claim format. Each component must be billed as a separate line item ( or on a separate claim per the limitations described above). Treat the claim as unprocessable per 80.3.2 when a global billing is received and there is information on the claim that indicates the test was acquired.   Effective for claims with dates of service on or after January 25, 2005, A/B MAC (Part B) must accept and process claims for diagnostic tests subject to the anti- markup payment limitation when billed by suppliers (including laboratories, physicians, and independent diagnostic testing facilities [IDTFs]) enrolled in the A/B MAC (Part B) jurisdiction, regardless of the location where the service was furnished. Effective Apr il 1, 2005, A/B MAC (Part B) must price anti -markup test claims based on the ZIP code of the location where the service was rendered when billed by a laboratory or an IDTF, using a CMS -supplied national abstract file of the MPFS containing the HCPCS codes that are payable under the MPFS as either a technical component or professional component of a diagnostic test subject to the anti- markup payment limitation for the calendar year. Effective for claims with dates of service on or after October 1, 2007 throu gh 2013, A/B MAC (Part B) must use the national abstract file to price all claims for diagnostic tests subject to an anti -markup payment limitation, for all supplier specialty types (including physicians), based on the ZIP code of the location where the se rvice was rendered, in accordance with the A/B MAC (Part B) jurisdictional pricing rules specified in 10.1.1.  Beginning in 2014, A/B MAC (Part B) must refer to an Anti -markup Test Indicator linked to the HCPCS code on the MPFS to price all claims for dia gnostic tests subject to an anti -markup payment limitation, for all supplier specialty types (including physicians), based on the ZIP code of the location where the service was rendered, in accordance with the A/B MAC (Part B) jurisdictional pricing rules specified in 10.1.1.   NOTE: As with all services payable under the MPFS, the ZIP code is used to determine the appropriate payment locality and corresponding fee for the anti -markup test.  When a ZIP code crosses locality lines, CMS uses the dominant locality to determine the corresp onding fee.  lines, CMS uses the dominant locality to determine the corresponding fee.   30.2.10 - Payment Under Reciprocal Billing Arrangements - Claims Submitted to A/B MACS Part B   (Rev.  3774, 05- 12-17, Effective: 06- 13-17, Implementation: 06- 13-17)  A. General requirements applicable to all Reciprocal Billing Arrangements   Under section 16006 of the 21st Century Cures Act, a Medicare- enrolled physical therapist may use a substitute physical therapist to furnish outpatient physical therapy services in a HPSA, a MUA, or a rural area under a reciprocal billing arrangement on or after June 13, 2017.   The patients regular physician or physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services which the regular physician or physical therapist arranges to be provided by a substitute physician or physical therapist on an occasional reciprocal basis, if:    The regular physician or physical therapist is unavailable to provide the services;      The Medicare patient has arranged or seeks to receive the services from the regular physician or physical therapist;    The substitute physician or physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days subject to the following exception: A physician or physical therapist called to active duty in the Armed Forces may bill for services furnished under a reciprocal billing arrangement for longer than the 60- day limit; and    The regular physician or physical therapist indicates that the services were provided by a substitute physician or physical therapist under a reciprocal billing arrangement meeting the requirements of this section by entering in item 24d of Form CMS -1500 H CPCS code Q5 modifier (service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area) after the procedure code.  The regular physician or physical therapist must keep on file a record of each service provided by the substitute physician or physical therapist along with the substitute physician or physical therapists NPI, and make this record available to the A/B MAC Part B upon request.  If the only services a physician performs in connection with an operation are post-operative services furnished during the period covered by the global fee, these services need not be identified on the claim as services furnished by a substitute physician.  A physician or physical therapist may have reciprocal billing  arrangements with more than one physician or physical therapist.  The arrangements need not be in writing.   With respect to physicians, the term  covered visit service includes not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as incident to the physicians services.   With respect to physical therapists, the term  covered visit service  means outpatient physical therapy services furnished in a HPSA, a MUA, or a rural area.  HPSAs and MUAs are designated by the Health Resources & Services Administration (HRSA).  To determine if an area is a HPSA or an MUA, visit HRSAs website at https://www.hrsa.gov.  A rural area is any area that is outside of a Metropolitan Statistical Area or a Metropolitan Division (in the case where a Metropolitan Statistical Area is divided into Metropolitan Divisions), as defined by the Executive Office of Management and Budget, or the following New England counties: Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island.  To determine if an area is rural, consult the Crosswalk of Counties to Core- Based Statistical Areas in the most current Inpatient Prospective Payment system final rule.  Any area that is not designated as urban in the crosswalk is rural.   A continuous period of covered visit services begins with the first day on which the substitute physician or physical therapist provides covered visit services to Medicare Part B patients of the regular physician or physical therapist, and ends with the last day the substitute physician or physical therapist provides services to such patients before the regular physician or physical therapist returns to work.  This period continu es without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or physical therapist or are furnished by some other substitute physician or physical therapist on behalf of the regular physicia n or physical therapist.    A new period of covered visit services can begin after the regular physician or physical therapist has returned to work.