(Medicare Claims Processing Manual)

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 a nti-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 techni cal 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 MACs (Part B) jurisdiction, for services furnished anywhere in the United States.  For s ervices 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 suppliers 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 ye ar.  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 entitys actual charg e, 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 perfor ming 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.   30.1 - National Provider Identification (NPI) Reported on Claims (Rev. 2994; Issued: 07- 25-14; Effective: 01- 01-12; Implementation: 08 -25-14)  Effective for dates of service May 23, 2008 and later, IDTFs must submit the NPI assigned to the ordering physician using the ASC X12 837 professional claim format or, for paper claims, on the Form CMS -1500.  40 - Interpretations Performed Off the Premise s of the IDTF  (Rev. 1987, Issued: 06- 11-10, Effective: 08- 12-10, Implementation: 08- 12-10)  If an IDTF wants to bill for an interpretation performed by an independent practitioner off the premises of the IDTF, the IDTF must meet the conditions shown in IOM  Pub. 100-04, Chapter 1, 30.2.9.  50 - Therapeutic Procedures  (Rev. 1506; Issued:  05- 16-08; Effective/Implementation Date:  06 -16-08)  An IDTF shall not be allowed to bill for any CPT or HCPCS codes that are solely  therapeutic.  Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#   12/06/2019  Update to Medicare Claims Processing Manual, Chapters 1, 23 and 35  03/09/2020  10882  R3255CP  05/08/2015  Correction to the Multi -Carrier System (MCS) Editing on the Service Location National Provider Identifier (NPI) Reported for Anti -Markup and Reference Laboratory Claims  10/05/2015  9150  R3103CP  11/03/2014  Reporting the Service Location National Provider Identifier (NPI) on Anti -Markup and Reference Laboratory Claims  04/06/2015  8806  R3098CP  10/21/2014  Reporting the Service Location National Provider Identifier (NPI) on Anti -Markup and Reference Laboratory Claims  Rescinded and replaced by Transmittal 3103  04/05/2014  8806  R3047CP  08/22/2014  Reporting the Service Location National Provider Identifier (NPI) on Anti -Markup and Reference Laboratory Claims   Rescinded and replaced by Transmittal 3098  01/05/2014  8806  R2994CP  07/25/2014  Update to Pub. 100 -04, Chapter 35 to Provide Language -Only Changes for Updating ASC X12 08/25/2014  8769  R1987CP  06/11/2010  Correction to the Claims Processing Internet Only Manual (IOM) t o Reinstate Previous Instructions Regarding Payment Jurisdiction for Reassigned Services  08/12/2010  6923  R1931CP  03/12/2010  Revision of the Internet Only Manual (IOM) to Remove References to Purchased Diagnostic Test and Replace With Language Consistent With the Anti -Markup Rule  06/14/2010  6627  R1504CP  05/15/2008  New Chapter for Independent Diagnostic Testing Facilities (IDTF)  06/16/2008  5815  Back to top of chapter