(Medicare Claims Processing Manual)

The CMS provides a schedule for activities related to furnishing these pricing files in advance each year.  The CMS will provide the completed physician fee schedule, the Durable Medical Equipment and Prosthetics and Orthotics and Supplies (DMEPOS) fee schedules and clinical lab data to United Mine Workers and Indian Health Services.  A/B MACs (A), (B), (HHH), and DME MACs are informed where to access the files for FTP (File Transfer Protocol) download.  30.3.1 - RESERVED  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  30.3.2 - A/B MAC (A), (B), or (HHH) Furnishing Physician Fee Schedule Data for National Codes  (Rev. 4131, Issued: 09- 14-18, Effective: 12 -17-18, Implementation: 12 -17-18)  A/B MACs (A), (B), and (HHH) are responsible for furnishing fee schedules to related providers, suppliers, physicians, and practitioners with billing relationships.  A/B MACs (A), (B), and (HHH) may also receive requests for this information from the State Agencies.  The data is available on the CMS website.  The MACs shall direct State Agencies to the appropriate pages on the website to download the data directly.  The CMS will provide the Medicare physician, ambulance, DMEPOS, and clinical laboratory fee schedules and the zip code file to the A/B MACs (A) and (HHH) , Palmetto GBA (the Specialty MAC or S MAC for Railroad Retirement Board), the Indian Health Services, and the United Mine Workers.  MACs  DO NOT NEED TO SEND FILES TO THOSE ENTITIES.   Fee schedules also are available for the public on the CMS Web site.   30.3.3 - Furnishing Other Fee Schedule, Prevailing Charge, and Conversion Factor Data  (Rev. 1, 10- 01-03) B3-4620.3  A/B MACs (B)  use the file format in 30.3.5 to furnish fee schedule (Excluding Physician Fee Schedule), prevailing charge, and conversion factor information to Palmetto GBA (S MAC for RRB), A/B MACs (A) or (HHH) , State Agencies, Indian Health Services, and United Mine Workers.   A/B MACs (B)  furnish statewide (or A/B MAC (B) -wide for areas less than an entire State) pricing data for certified registered nurse anesthetist conversion factors.  Furnish all fee schedules and conversion factors on tape unless the receiving entity agrees that a paper listing is acceptable.   Clinical Lab pricing files subject to national limitation amounts and DMEPOS pricing files subject to national floor and ceiling limitation amounts will be furnished by CMS to all entities except the State Medicaid Agencies.  The Center for Medicaid and St ate Operations will provide those pricing files to the State Medicaid Agencies.   In addition to the above pricing files, A/B MACs (B)  furnish Palmetto GBA (the S MAC for RRB) with a tape file of locality prevailing charges for ambulance services and inflation indexed prevailing charges for non- physician services subject to the IIC.   Send pricing files for the RRB S MAC to:   Medicare Systems RRB -  AG- 430 Palmetto GBA  Building One  2300 Springdale Drive  Camden, SC 29020  For Indian Health Services, send pricing files to:   IHS Contract Health Services  12800 Indian School Road North East  Albuquerque, NM 87112   For releasing nonphysician pricing files to State Agencies, contact the RO to obtain the name and mailing address of the individual to whom the file should be addressed.  For the United Mine Workers, send the pricing files to:   Government Programs Manager  UMWA Health and Retirement Funds  2121 K Street, NW  Washington, DC 20037, or  MedPricing@umwafunds.org  You may negotiate agreements with the receiving entity to use an alternate medium (e.g., paper, diskette) or a tape file format other than that specified in 30.3.5.  However, such agreements must be in writing and signed by the affected entities (e.g., A/B MAC (A), (B), (HHH), or DME MAC , RRB S MAC, UMWA, etc.).  Furnish your RO with a copy of written agreements for using mediums other than tape or tape file formats other than that in 30.3.5.  30.3.4 - Responsibility to Obtain and Implement Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedules  (Rev. 1, 10- 01-03) B3-4622  The A/B MACs (A), (B), (HHH), and DME MACs must download and implement the DMEPOS fee schedules for the items and services within their jurisdiction.  DME MACs must also forward the DMEPOS fee schedule to Medicaid State Agencies.  The CMS releases new fee schedules on an annual basis, with updates being issued quarterly, if needed.  The CMS issues separate instructions for downloading and implementing fee schedule updates as appropriate.  Central office (CO) will issue annual updates describing the maintenance process for each year.  These instructions provide A/B MACs (A), (B), (HHH), and DME MACs the due dates.  The instructions will also list the date th e release will be made available and an implementation date for each release.   30.3.5 - File Specifications  (Rev. 1, 10- 01-03) B3-4621  The following guidelines are used to create the pricing files.  1. Recommended Physical File Specifications -Magnetic Tape - Tape characteristics -9 track, 8 2 to 10 2 reels with silver mylar reflector (standard reels) with write ring removed.   Parity  Odd   Recording Density -  6250 bytes per inch   Recording Code -  Extended Binary Coded Decimal   File Label - IBM standard label.  The tape must have an end of file mark.  The first data record on the file identifies the submitter and the receiver and serves the function of a file label.   Physical Record Length -  60 characters   Blocking Factor -  100 records per block   The external label on the reel must appear as:   From   To  Reel number HCPCS (see footnote (a) below for entry) number (the unique number by which the tape is identified in your library).   Date (MMDDYYYY)   2. Record Specifications.  The logical HCPCS record is made up of a series of 60 character physical records.   3. Blocking factor of 100 (100 records per data block).   4. Header Type Specifications   Field No. Field Name  Size Picture  Specification  Field Remarks  1 Label  3 X(3)  L See Footnote (b)  2 Filler  7 X(7)  L  3 A/B MAC (B) #  5 9(5) L  4 Filler  1 X(1)    5 Interm.  #  5 9(5) L  6 Filler  1 X(1)  L  7 Date Fee Updated  8 X(8)  L MMDDYYYY  8 Filler  22 X(22)    9 Date File Created  8 X(8)  L MMDDYYYY   5. Detail Record   Field No. Field Name  Size Picture  Specification  Field Remarks  1 HCPCS  5 X(5)  L  2 Filler  2 XX L  3 Filler  2 XX L  4 Fee/CF/Prev.  7 9(5)V99  R See Footnote (c) for applicable category  5 Fee 7 9(5)V99  R See Footnote (d)  6 Fee 7 9(5)V99  R See Footnote (e)  7 A/B MAC (B) #  5 X(5)  L  8 Locality  2 99 L  9 Filler  23 X(23)     (a) Identify the type of information furnished:   DME fee schedule (includes supplies, inexpensive/routinely purchased, frequency service, and capped rental);   Surgical Dressings;   Prevailing charges applicable to hospice physician services;   Lab fee schedule;   Other diagnostic service prevailing charges;   Oxygen fee schedule;   Prosthetic/orthotic fee schedule (includes ostomy, tracheostomy, and urologicals);   Radiology conversion factors;   Portable radiology fee schedule; or   Certified registered nurse anesthetist conversion factors. (b) Show the label for category as:   DME -  durable medical equipment;   S/D -  surgical dressings;   HPH -  prevailing charges for pricing hospice physician services;   LAB -  laboratory;   ODX -  other diagnostic services;   OXY -  oxygen;   P/O -  prosthetic/orthotic;  RAD -  radiology;   PRF -  portable radiology; or   CNA -  certified nurse anesthetist.  (c, d, e)  DME  (c) purchase new  (d) purchase used  (e) monthly rental  NOTE:  When a HCPCS code has multiple fees, list all the fees.  A/B MACs (HHH) are not able to accept procedure codes with modifiers. HPH (c) locality prevailing charge for physician services  LAB  (c) fee schedule amount -  60%  (d) fee schedule amount -  62%  ODX  (c) locality prevailing charge amounts  OXY  (c) purchase new/purchased oxygen contents  (d) purchase used  (e) monthly rental  P/O (c) purchase new  RAD (c) conversion factors  NOTE:   HCPCS codes are not necessary for radiology. PRF (c) fee schedule amount  CNA (c) conversion factor -  medically directed CRNA services  (d) conversion factor -  non-medically directed CRNA services   30.5 - Payment Amounts for Portable X- Ray Transportation Services  (Rev. 1, 10- 01-03) B-02-075  Transportation for portable x- ray services (HCPCS code R0070) is paid under the Medicare physician fee schedule.  There are no national values for this service.  The CMS has not established national relative values for this service because there are no national data for these services and because there are significant differences in the delivery of this service in different geographic areas.  Instead, each A/B MAC (B) is required to determine the payment amounts for its geographic areas.   The CMS has not established specific criteria that A/B MACs (B) should use in determining the payment amounts they establish for A/B MAC (B) priced services.  The CMS has not established a specific annual update factor to be applied to these services.  Mid-year adjustments are possible if the A/B MAC (B) believes such adjustments are appropriate.  Such an appropriation provides A/B MACs (B) with the flexibility to take into account local factors affecting the level of resources required to perform this se rvice.   A/B MACs (B) should periodically review (at least every five years, or more frequently if local conditions warrant) their locally determined payment amounts to determine whether the payment amounts reflect the relative resources (e.g., staff, equipment, supplies and general expenses) required to perform A/B MAC (B) -priced services.  Such periodic reviews for A/B MAC (B) priced services would be consistent with statutory requirements.  If portable x -ray transportation suppliers request such a review, A/B MACs (B) should work with the local suppliers to review the payment amounts for R0070, taking into account local factors and any data available regarding the resources required to provide these services.   40 - Clinical Diagnostic Laboratory Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  The Medicare Claims Processing Manual, Chapter 16, Laboratory Services From Independent Labs, Physicians, and Providers, provides background and additional information for payment of laboratory services.   Clinical diagnostic laboratory tests -  whether performed in a physicians office, by an independent laboratory, or by a hospital laboratory for its outpatients -  are paid based on fee schedules.  This section sets out rules for use of these schedules.   The fee schedule amounts are adjusted annually to reflect changes in the Consumer Price Index (CPI) for all Urban Consumers (U.S. city average), or as otherwise specified by legislation.  Adjustments are applied and amounts are determined by CMS and publis hed for A/B MAC (A), (B), and (HHH) use and also on CMS Web site.  A/B MACs (A), (B), and (HHH) are notified when and where updates are published.   For a cervical or vaginal smear test (pap smear), payment is the lesser of the local fee or the national limitation amount, but not less than the national minimum payment amount.  However, in no case may payment for these tests exceed actual charges.  The Part B deductible and coinsurance do not apply.