Submitting Clinical Laboratory tests – Billing Steps
A. General
A physician or other supplier may bill and receive payment for the technical component (TC) or professional component (PC) of a diagnostic test (other than clinical diagnostic laboratory test) that is performed by a physician or other supplier with whom the billing physician or other supplier does not share a practice. Reimbursement for that service is subject to the anti-markup payment limitation. If a physician or other supplier’s bill or a request for payment includes a charge for a diagnostic test (other than a clinical diagnostic laboratory test) which the physician or other supplier did not personally perform or supervise, then payment for the test may not exceed the lesser of:
• The performing physician’s net charge to the billing physician or other supplier (net any discounts);
• The billing physician’s actual charge; or
• The fee schedule amount that would be allowed for the test if the performing physician or other supplier billed directly.
For payment to be made, the physician who acquires the TC or PC of a diagnostic test from an outside source must identify the performing physician or other supplier on the claim. (The billing physician or other supplier should maintain a record of the performing physician or other supplier’s NPI in the clinical record for auditing purposes.)
The billing physician or other supplier must also indicate on the claim that the test is subject to the anti-markup payment limitation.
See the guidelines at http://www.wpc-edi.com/ for how to show this on electronic claims.
If using the CMS-1500 paper claim form:
• In item 20 check “yes” to indicate the test is subject to the anti-markup payment limitation and enter the amount the performing physician or other supplier charged.
• In item 32 enter the name, address, and NPI of the performing physician or supplier. If the performing physician provides the service outside the A/B MAC (B) jurisdiction where the billing physician is located, the billing physician must submit its own NPI with the name, address, and ZIP code of the performing physician or other supplier.
No payment may be made to the physician without this information unless the statement “No anti-markup tests are included” is annotated on the claim.
NOTE: If the billing physician performs only the TC or the PC and wants to bill for both components of the diagnostic test, the TC and PC must be reported as separate line items if billing electronically or on separate claims if billing on paper (CMS-1500). Global billing is not allowed unless the billing physician or other supplier performs both components.
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 performing physician or supplier in Item 32a of the CMS-1500 claim form (or its electronic equivalent) on anti-markup claims, even if the performing physician or supplier is enrolled in a different A/B MAC (B) jurisdiction. (See §10.1.1.2 for more information regarding claims filing jurisdiction.)
B. Unassigned Claims with Required Documentation
A physician or other supplier may not bill an individual an amount in excess of Medicare’s payment, except for any deductible and coinsurance, for the TC or PC of a diagnostic test that is subject to the anti-markup payment limitation. A/B MACs (B) must notify physicians and other suppliers that they must indicate when a diagnostic test was acquired, identify the performing physician or other supplier, and show the amount the performing physician or other supplier charged. The notification must inform physicians and other suppliers that they are prohibited by §1842(n)(3) of the Act from billing or collecting an amount in excess of Medicare’s payment, except for the deductible and coinsurance. Excess amounts collected from the beneficiary must be repaid.
C. Unassigned Claims without Required Documentation
A physician may not bill a beneficiary:
• If the bill does not indicate who performed the test; and
• If the bill indicates that a separate physician or other supplier performed the test, it does not identify the performing physician or other supplier or does not include the amount the performing physician or other supplier charged.
The A/B MACs (B) notify the physician when a non-assigned claim for the TC or PC of a diagnostic test subject to the anti-markup payment limitation is received from either the physician or a beneficiary except when the physician submits an assigned claim and the beneficiary submits an unassigned duplicate claim. They use the following sample letter.
Dear Doctor:
We have received an unassigned claim for diagnostic tests furnished to the patient (Beneficiary Name), on (Date of Service). You are prohibited by §1842(n)(3) of the Social Security Act from billing or collecting any amount unless you indicate that “No anti-markup tests are included” or, if the diagnostic test was acquired, you indicate who performed the test and what the physician or other supplier charged you. Some or all of the required information is missing from your patient’s claim. If you have collected any amount from your patient, it must be refunded. This claim may be resubmitted if the required information is included.
D. Beneficiary Information Regarding Unassigned Claims
The A/B MACs (B) must notify the beneficiary that the physician is prohibited from:
• Billing the beneficiary when the necessary documentation is not supplied; and
• Billing or collecting an amount in excess of Medicare’s payment, except for the deductible and coinsurance, when the required documentation is submitted.
A. General
A physician or other supplier may bill and receive payment for the technical component (TC) or professional component (PC) of a diagnostic test (other than clinical diagnostic laboratory test) that is performed by a physician or other supplier with whom the billing physician or other supplier does not share a practice. Reimbursement for that service is subject to the anti-markup payment limitation. If a physician or other supplier’s bill or a request for payment includes a charge for a diagnostic test (other than a clinical diagnostic laboratory test) which the physician or other supplier did not personally perform or supervise, then payment for the test may not exceed the lesser of:
• The performing physician’s net charge to the billing physician or other supplier (net any discounts);
• The billing physician’s actual charge; or
• The fee schedule amount that would be allowed for the test if the performing physician or other supplier billed directly.
For payment to be made, the physician who acquires the TC or PC of a diagnostic test from an outside source must identify the performing physician or other supplier on the claim. (The billing physician or other supplier should maintain a record of the performing physician or other supplier’s NPI in the clinical record for auditing purposes.)
The billing physician or other supplier must also indicate on the claim that the test is subject to the anti-markup payment limitation.
See the guidelines at http://www.wpc-edi.com/ for how to show this on electronic claims.
If using the CMS-1500 paper claim form:
• In item 20 check “yes” to indicate the test is subject to the anti-markup payment limitation and enter the amount the performing physician or other supplier charged.
• In item 32 enter the name, address, and NPI of the performing physician or supplier. If the performing physician provides the service outside the A/B MAC (B) jurisdiction where the billing physician is located, the billing physician must submit its own NPI with the name, address, and ZIP code of the performing physician or other supplier.
No payment may be made to the physician without this information unless the statement “No anti-markup tests are included” is annotated on the claim.
NOTE: If the billing physician performs only the TC or the PC and wants to bill for both components of the diagnostic test, the TC and PC must be reported as separate line items if billing electronically or on separate claims if billing on paper (CMS-1500). Global billing is not allowed unless the billing physician or other supplier performs both components.
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 performing physician or supplier in Item 32a of the CMS-1500 claim form (or its electronic equivalent) on anti-markup claims, even if the performing physician or supplier is enrolled in a different A/B MAC (B) jurisdiction. (See §10.1.1.2 for more information regarding claims filing jurisdiction.)
B. Unassigned Claims with Required Documentation
A physician or other supplier may not bill an individual an amount in excess of Medicare’s payment, except for any deductible and coinsurance, for the TC or PC of a diagnostic test that is subject to the anti-markup payment limitation. A/B MACs (B) must notify physicians and other suppliers that they must indicate when a diagnostic test was acquired, identify the performing physician or other supplier, and show the amount the performing physician or other supplier charged. The notification must inform physicians and other suppliers that they are prohibited by §1842(n)(3) of the Act from billing or collecting an amount in excess of Medicare’s payment, except for the deductible and coinsurance. Excess amounts collected from the beneficiary must be repaid.
C. Unassigned Claims without Required Documentation
A physician may not bill a beneficiary:
• If the bill does not indicate who performed the test; and
• If the bill indicates that a separate physician or other supplier performed the test, it does not identify the performing physician or other supplier or does not include the amount the performing physician or other supplier charged.
The A/B MACs (B) notify the physician when a non-assigned claim for the TC or PC of a diagnostic test subject to the anti-markup payment limitation is received from either the physician or a beneficiary except when the physician submits an assigned claim and the beneficiary submits an unassigned duplicate claim. They use the following sample letter.
Dear Doctor:
We have received an unassigned claim for diagnostic tests furnished to the patient (Beneficiary Name), on (Date of Service). You are prohibited by §1842(n)(3) of the Social Security Act from billing or collecting any amount unless you indicate that “No anti-markup tests are included” or, if the diagnostic test was acquired, you indicate who performed the test and what the physician or other supplier charged you. Some or all of the required information is missing from your patient’s claim. If you have collected any amount from your patient, it must be refunded. This claim may be resubmitted if the required information is included.
D. Beneficiary Information Regarding Unassigned Claims
The A/B MACs (B) must notify the beneficiary that the physician is prohibited from:
• Billing the beneficiary when the necessary documentation is not supplied; and
• Billing or collecting an amount in excess of Medicare’s payment, except for the deductible and coinsurance, when the required documentation is submitted.