8806 R3103CP

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CMS Manual System

Department of Health &
Human Services (DHHS)

Pub 100-04 Medicare Claims Processing

Centers for Medicare &
Medicaid Services (CMS)

Transmittal 3103

November 3, 2014

Change Request 8806
Transmittal 3098, dated October 21, 2014, is being rescinded and replaced by Transmittal 3103,
dated November 3, 2014 to correct the effective and implementation date. A business
requirement has been added for the A/B MACs. All other information remains the same.
SUBJECT: Reporting the Service Location National Provider Identifier (NPI) on Anti-Markup and
Reference Laboratory Claims
SUMMARY OF CHANGES: This Change Request (CR) provides guidance for physicians and suppliers
billing anti-markup and reference laboratory claims. Physicians and other suppliers will no longer be
permitted to submit their own NPI in Item 32a (or its electronic equivalent) when the performing physician
or supplier is located in another jurisdiction. The changes that will be implemented in PECOS will allow
contractors the ability to verify all physician and supplier NPIs, regardless of the jurisdiction in which they
are enrolled.
EFFECTIVE DATE: Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: January 5, 2015
April 6, 2015 – For MAC testing of PECOS changes
Disclaimer for manual changes only: The revision date and transmittal number apply only to red
italicized material. Any other material was previously published and remains unchanged. However, if this
revision contains a table of contents, you will receive the new/revised information only, and not the entire
table of contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D

CHAPTER / SECTION / SUBSECTION / TITLE

R

1/10.1.1.2 /Payment Jurisdiction for Services Subject to the Anti-Markup Payment
Limitation

R

1/ 30.2.9 /Payment to Physician or Other Supplier for Diagnostic Tests Subject to
the Anti-Markup Payment Limitation - Claims Submitted to A/B MACs (B)

R

1/30.3.7/Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory
Tests) Subject to the Anti-Markup Payment Limitation/Claims Submitted to A/B
MACs (B)

R

1/80.3.2.1.2/ Conditional Data Element Requirements for A/B MACs (B) and
DMEMACs

R

1/ 80.3.2.1.3 /Carrier Specific Requirements for Certain Specialties/Services

R

16/40.1.1.1 / Paper Claim Submission To Carriers/B MACs (B)

R

16/40.1.1.2 /Electronic Claim Submission to Carriers/B MACs B)

R

26/10.4 / Items 14-33 - Provider of Service or Supplier Information

R

35/ 30 / Diagnostic Tests Subject to the Anti-Markup Payment Limitation

III. FUNDING:
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is
not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.
IV. ATTACHMENTS:
Business Requirements
Manual Instruction

Attachment - Business Requirements
Pub. 100-04

Transmittal: 3103

Date: November 3, 2014

Change Request: 8806

Transmittal 3098, dated October 21, 2014, is being rescinded and replaced by Transmittal 3103,
dated November 3, 2014 to correct the effective and implementation date. A business
requirement has been added for the A/B MACs. All other information remains the same.

SUBJECT: Reporting the Service Location National Provider Identifier (NPI) on Anti-Markup and
Reference Laboratory Claims
EFFECTIVE DATE: Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: January 5, 2015
April 6, 2015 – For MAC testing of PECOS changes only
I.

GENERAL INFORMATION

A. Background: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires
that all covered health care entities follow the same standard for submitting and processing electronic claims
transactions. According to the instructions for use of the American National Standards Institute (ANSI) X12
837 professional electronic claim transaction, suppliers must submit the NPI that matches the name and
address of the servicing provider/supplier identified on the claim.
On anti-markup and reference laboratory claims, physicians and other suppliers are required to identify the
supplier's name, address, and ZIP code in Item 32 of the CMS-1500 claim, or the corresponding loop and
segment of the (ANSI) X12 837 professional electronic claim format. The NPI of the physician or supplier
who actually performed the service is required in Item 32a of the CMS-1500 claim form or the
corresponding loop and segment of the (ANSI X12 837 professional electronic claim transaction.
However, prior to the implementation of the Provider Enrollment Chain of Ownership System (PECOS),
contractors used enrollment systems that were specific to each Medicare contractor and did not allow
Medicare contractors from one State to view provider enrollment information from another State. This
systems limitation prevented contractors from being able to share information about existing
providers/suppliers, and increased the potential for fraud.
As a result, physicians and suppliers that were enrolled in another contractor’s jurisdiction could not validate
the NPI in Item 32a of the CMS-1500 claim form or on the ANSI X12 837 professional electronic claim
format, because the function was not available in PECOS.
Since the NPI of the physician/supplier that actually performed the test may not be available to the billing
physician or supplier, the claims processing Internet Only Manual at Publication 100-04 currently instructs
physicians and suppliers to submit their own NPI with the name and address of the actual performing
physician or supplier in Item 32a (and its electronic equivalent) when billing for reference laboratory
services, or services subject anti-markup, when the performing physician or supplier is enrolled in another
contractor’s jurisdiction. Effective April 1, 2015, changes will be implemented in PECOS to allow
contractors the ability to verify all physician and supplier NPIs, regardless of the jurisdiction in which they
are enrolled. Therefore, beginning April 1, 2015, physicians and suppliers billing anti-markup and reference
laboratory claims must report the NPI of the physician or supplier who actually performed the service in

Item 32a of the CMS-1500 claim form or the corresponding loop and segment of the American National
Standards Institute (ANSI) X12 837 professional electronic claim format. This new requirement applies to
all claims, including claims for services where the performing physician/supplier is out of the processing
contractor’s jurisdiction.
B. Policy: Effective for anti-markup and reference laboratory claims submitted with a receipt date on or
after April 1, 2015, billing physicians and suppliers are required to report the name, address, ZIP code, and
NPI of the performing physician or supplier when the performing physician or supplier is enrolled in a
different contractor’s jurisdiction. Physicians and other suppliers will no longer be permitted to submit their
own NPI in Item 32a (or its electronic equivalent) when the performing physician or supplier is located in
another jurisdiction. Contractors shall validate the entity identified in Item 32 (or its electronic equivalent)
on all claims for reference lab and anti-markup services performed both in and out of jurisdiction.
Contractors shall return as unprocessable any inbound CMS-1500 claim form, or ANSI X12 837
professional electronic claim transaction with an NPI in Item 32a (or its electronic equivalent) that belongs
to the billing physician/supplier or that cannot be verified as a valid, Medicare-enrolled entity.
II.

BUSINESS REQUIREMENTS TABLE

"Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.
Number

Requirement

Responsibility
A/B
D
SharedMAC
M
System
E Maintainers
A B H
F M V C
M
H
I C M W
H A S S S F
C S
X
X

8806.1

Contractors shall apply the requirements in this
change request to anti-markup and reference
laboratory claims only.

8806.1.1

Contractors shall identify anti-markup claims by the
presence of the ‘Yes’ indicator in Item 20 of the CMS1500 or its electronic equivalent (loop 2400 PS102 of
the 837 professional claim).

X

8806.1.2

Contractors shall identify reference laboratory claims
by the presence of modifier 90 on any service line.

X

8806.2

Contractors shall return as unprocessable a claim for a
reference laboratory or anti-markup service when
physicians and suppliers submit their own NPI, rather
than the NPI of the performing physician/supplier in
Item 32a of the CMS-1500 claim form, or on the
ANSI X12 837 professional electronic claim format
(loops 2310C NM109 claim level and 2420C NM109
line level).

X

X

8806.3

Contractors shall verify that the NPI in Item 32a (or
its electronic equivalent) matches the NPI of a valid
entity via the new table located in MCS’ internal
claims processing system.

X

X

8806.3.1

PECOS shall provide a format of the file to MCS. The

Other

PECOS

Number

Requirement

Responsibility
A/B
D
SharedMAC
M
System
E Maintainers
A B H
F M V C
M
H
I C M W
H A S S S F
C S

Other

file will consist of the following data elements:
1. NPI,
2. Physician/supplier name,
3. Legal business name,
4. DBA name,
5. CMS specialty code and description,
6. PIN effective and termination date, and
7. Filler
8806.3.2

MCS shall accept an extract file from the PECOS
system on a daily basis.

X

8806.4

Contractors shall return as unprocessable a claim for a
reference laboratory or anti- markup service when the
NPI in Item 32A (or its electronic equivalent) does not
match a valid servicing physician/supplier identified
on the existing table in PECOS located via the MCS
internal claims processing system.

X

8806.5

Contractors shall use the following codes for claims
returned as unprocessable:

X

X

Claim Adjustment Reason Code (CARC) 16 Claim/service lacks information which is needed for
adjudication.
For reference lab claims, use Remittance Advice
Remark Code (RARC) N270 - Missing / incomplete /
invalid other provider primary identifier.
For anti-markup claims, use RARC N283 - Missing /
incomplete / invalid purchased service provder
identifier.
Group Code: Contractual Obligation (CO)
8806.6

MCS shall maintain the ability for contractors to
manually key the facility NPI for claims submitted on
the CMS-1500.

X

PECOS

Number

8806.7

III.

Requirement

MACs shall ensure the related edits are not turned on
in production until April 6, 2015

Responsibility
A/B
D
SharedMAC
M
System
E Maintainers
A B H
F M V C
M
H
I C M W
H A S S S F
C S
X

Other

PROVIDER EDUCATION TABLE

Number

Requirement

Responsibility
A/B
MAC

8806.8

IV.

MLN Article : A provider education article related to this instruction will be
available at http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/ shortly after the CR is released. You will
receive notification of the article release via the established "MLN Matters"
listserv. Contractors shall post this article, or a direct link to this article, on their
Web sites and include information about it in a listserv message within one week
of the availability of the provider education article. In addition, the provider
education article shall be included in the contractor’s next regularly scheduled
bulletin. Contractors are free to supplement MLN Matters articles with localized
information that would benefit their provider community in billing and
administering the Medicare program correctly.

D C
M E
E D
I
A B H
M
H
H A
C
X

SUPPORTING INFORMATION

Section A: Recommendations and supporting information associated with listed requirements:
"Should" denotes a recommendation.
X-Ref
Requirement
Number
8806.3.1

Recommendations or other supporting information:

PECOS file is included.

Section B: All other recommendations and supporting information: N/A
V. CONTACTS
Pre-Implementation Contact(s): Teira Canty, Teira.Canty@cms.hhs.gov
Post-Implementation Contact(s): Contact your regional Coordinator.
VI. FUNDING

Section A: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is
not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.
ATTACHMENTS: 1

Medicare Claims Processing Manual
Chapter 1 - General Billing Requirements
10.1.1.2 - Payment Jurisdiction for Services Subject to the Anti-Markup Payment
Limitation
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are subject to the same
payment rules as all other services paid on the MPFS. Additional explanation is provided here due to general
confusion concerning these services when they are performed or supervised by a physician or other supplier
who does not meet the criteria for “sharing a practice” with the billing physician or other supplier, rather
than rendered and billed by the billing entity. (See §30.2.9 for additional information on “sharing a
practice.”) Physicians and other suppliers must meet the current enrollment criteria stated in chapter 10, of
the Program Integrity Manual, in order to be able to bill for anti-markup tests. That these services are billed
by an entity that does not share a practice with the performing physician or other supplier does not negate
the need for the performing physician or other supplier to follow appropriate enrollment procedures with the
B/MAC that has jurisdiction over the geographic area where the services were rendered.
The B/MACs must accept and process claims for services subject to the anti-markup payment limitation
when billed by physicians or other suppliers enrolled in the B/MAC’s jurisdiction, regardless of the location
where the services were furnished.
Effective for claims processed on or after April 1, 2004, in order to allow the B/MAC to determine
jurisdiction and apply the anti-markup payment limitation correctly, global billing will not be accepted on
electronic or paper claims when billing anti-markup tests. Claims received with global billings in this
situation will be treated as unprocessable per §80.3.
Effective for claims submitted with a receipt date on and after April 1, 2015, billing physicians and suppliers
must report the name, address, and NPI of the performing physician or supplier on all anti-markup and
reference laboratory claims, even if the performing physician or supplier is enrolled in a different
contractor’s jurisdiction. Contractors shall return as unprocessable any anti-markup or reference
laboratory claim with an NPI in Item 32a (or its electronic equivalent) that belongs to the billing
physician/supplier, or that cannot be verified as a valid, Medicare enrolled entity.
A. Payment Jurisdiction for Suppliers of Diagnostic Tests and Interpretations Performed by Other
Suppliers under Contract
Effective for claims with dates of service on or after January 25, 2005, laboratories, physicians, and IDTFs
must submit all claims for anti-markup tests to their local B/MAC. B/MACs must accept and process claims
for services subject to the anti-markup payment limitation when billed by suppliers enrolled in the B/MAC’s
jurisdiction, regardless of the location where the services were furnished. B/MACs should allow claims
submitted by an IDTF for anti-markup tests if the IDTF has previously enrolled to bill for anti-markup test
components they perform.
Effective April 1, 2005, B/MACs must price anti-markup tests billed by laboratories and IDTF’s based on
the ZIP code of the location where the diagnostic test was rendered.

Effective for claims with dates of service on or after October 1, 2007, B/MACs must use the national
abstract file to price all claims for anti-markup tests for all supplier specialty types (including physicians),
based on the ZIP code of the location where the service was rendered.

30.2.9 - Payment to Physician or Other Supplier for Diagnostic Tests Subject to the
Anti-Markup Payment Limitation - Claims Submitted to A/B MACs(B)
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)
A physician or other supplier may bill for the technical component (TC) and/or professional component
(PC) of a diagnostic test that was ordered by the physician or other supplier (or ordered by a party related to
the billing physician or other supplier through common ownership or control), subject to an anti-markup
payment limitation, if the diagnostic test is performed by a physician who does not “share a practice” with
the billing physician or other supplier. (This claim and payment limitation does not apply to clinical
diagnostic laboratory tests, which are paid under the Clinical Laboratory Fee Schedule.) Under the antimarkup payment limitation, payment to the billing physician or other supplier (less the deductibles and
coinsurance paid by the beneficiary or on behalf of the beneficiary) for the TC or PC of the diagnostic test
may not exceed the lowest of the following amounts:
(1) The performing physician/supplier’s net charge to the billing physician or other supplier.* (With respect
to the TC, the performing supplier is the physician who supervised the test, and with respect to the PC, the
performing supplier is the physician who performed the PC.);
(2) The billing physician or other supplier’s actual charge; and
(3) The fee schedule amount for the test that would be allowed if the performing physician/supplier billed
directly. (See section 10.1.1.2 for information on payment jurisdiction for services subject to the antimarkup payment limitation.)
* 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” test. 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
TC or PC 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 TC includes, both, the conducting of the TC as well as the supervision of the TC.
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 TC or PC of the
diagnostic test must be enrolled in the Medicare program. No formal reassignment is necessary.
NOTE: When billing for the TC or PC 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
performing physician or supplier in Items 32 and 32a of the Form CMS-1500 claim form.
Effective for claims submitted with a receipt date on and after April 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 B/MAC jurisdiction. See § 10.1.1.2 for
more information regarding claims filing jurisdiction.
If the billing physician or other supplier 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 (ANSI X12 837) 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 ANSI X12N 837 electronic 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 level total acquired amount information as unprocessable per
§80.3.2.
Treat paper claims submitted for anti-markup tests with both the technical component (TC) and the
professional component (PC) 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.
ANSI X12N 837 electronic claims submitted for anti-markup tests with both the TC and the PC 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 ANSI X12N 837 electronic 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 MACs 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’s
jurisdiction, regardless of the location where the service was furnished. Effective April 1, 2005, carriers
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 TC or PC 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, A/B MACs 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 service was rendered, in accordance with the A/B MAC jurisdictional
pricing rules specified in §10.1.1. (See IOM Publication 100-04, Chapter 23, §30.6, and Addendum for
record layouts and instructions for downloading the Abstract File for Diagnostic Tests Subject to the AntiMarkup Payment Limitation.)
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 corresponding fee.

30.3.7 - Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests)
Subject to the Anti-Markup Payment Limitation - Claims Submitted to A/B MACs(B)
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)
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.

(See §30.2.9 of this chapter for additional information.)
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 in Item 32 of the CMS-1500 claim form (or
electronic equivalent) by supplying their name, address, and NPI. The billing physician or other supplier
must also indicate in Item 20 of the CMS-1500 (or corresponding loop and segment on the ANSI X12N
837) that the test is subject to the anti-markup payment limitation by checking “Yes” and entering the
amount the performing physician or other supplier charged. 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 (ANSI X12

837) 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 April 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 B/MAC 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. B/MACs 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 physician 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 B/MACs 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 B/MACs 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.
(See chapter 21, for MSN messages.)

80.3.2.1.2 - Conditional Data Element Requirements for A/B MACs (B) and
DMEMACs
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)
A - Universal Requirements
The following instruction describes “conditional” data element requirements, which are applicable to certain
assigned A/B MAC (B) claims. This instruction is minimal and does not include all “conditional” data
element requirements, which are universal for processing claims. The CMS has specified which remark
code(s) should be used when a claim fails a particular “return as unprocessable” edit and a remittance advice
is used to return the claim. In addition to the specified remark code(s), A/B MACs (B) must include Remark
Code MA130 on returned claim(s). Reason code(s) must also be reported on every remittance advice used
to return a claim or part of a claim as unprocessable.
Items from the Form CMS-1500 claim form have been provided. These items are referred to as fields in the
instruction.
A/B MACs (B) processing claims on the Form CMS-1500 must return a claim as unprocessable to the
supplier/provider of service in the following circumstances:
a. If a service was ordered or referred by a physician, physician assistant, nurse practitioner, or clinical
nurse specialist (other than those services specified in Claim Specific Requirements) and his/her name
and/or NPI is not present in item 17 or 17a or if the NPI is not entered in item 17b of the Form CMS1500 (8/05). (Remark code N285 or N286 is used)
b. If a physician extender or other limited licensed practitioner refers a patient for consultative services, but
the name and/or NPI is required of the supervising physician is not entered in items 17 or 17a or if the
NPI is not entered in item 17b of the Form CMS-1500 (8/05). (Remark code N269 or N270 is used.)
NOTE: For item 80.3.2.1.2 (a) above, effective for claims with dates of service (DOS) on or after the
implementation date of the Phase 2 ordering and referring denial edits, if the Part B clinical lab and imaging
technical or global component claim or Durable Medical Equipment, Prosthetics, and Orthotics Suppliers
(DMEPOS) claim is denied due to the ordering/referring provider not allowed to order/refer, contractors
shall use Group Code CO, Claim Adjustment Reason Code (CARC) 183 and Remittance Advice Remark
Codes (RARCs) N574 and MA13 when denying such claims. If the claim is denied due to the
ordering/referring provider’s name not matching (i.e., the first four letters of the last name provided on the
claim don’t match what’s listed in the provider’s record), contractors shall use Group Code CO, CARC 16,
RARCs N264 and N575 and MA13.
If the claim is submitted that lists an ordering/referring provider and the required matching NPI is not
reported, then the claim shall be rejected using Group Code CO, CARC 16, RARCs N265 and MA13. This
is the only instance when a rejection is allowed.
c. For the technical component (TC) and professional component (PC) of diagnostic tests subject to the
anti-markup payment limitation:
1. If a “YES” or “NO” is not indicated in item 20 and no acquisition price is entered under the word
“$CHARGES.” A/B MACs (B) shall assume the service is not subject to the anti-markup
payment limitation. This claim shall not be returned as unprocessable for this reason only.
2. If a “Yes” or “No” is not indicated in item 20 and an acquisition price is entered under the word
“$CHARGES.” (Remark Code MA110 is used.)

3. If the “YES” box is checked in item 20 and a required acquisition price is not entered under the
word “$CHARGES.” (Remark code MA111 is used.)
4. If the “NO” box is checked in item 20 and an acquisition price is entered under the word
“$CHARGES.” (Remark code MA110 is used.)
5. If the “YES” box is checked in item 20 and the acquisition price is entered under “$CHARGES",
but the performing physician or other supplier’s name, address, ZIP Code, and NPI is not entered
into item 32a of the Form CMS-1500 (8/05) when billing for diagnostic services subject to the
anti-markup payment limitation. (Remark code N294 is used.)
Entries 4 – 8 are effective for claims received on or after April 1, 2004:
4. On the Form CMS-1500, if the “YES” box is checked in Item 20, and more than one test is billed
on the claim;
5. On the Form CMS-1500, if both the TC and PC are billed on the same claim and the dates of
service and places of service do not match;
6. On the Form CMS-1500, if the “YES” box is checked in Item 20, both the TC and PC are
submitted and the date of service and place of service codes do not match.
7. On the ASC X12 837 professional claim format, if there is an indication on the claim that a test is
subject to the anti-markup payment limitation, more than one test is billed on the claim, and line
level information for each total acquisition amount is not submitted for each test.
8. On the Form CMS-1500 if the “YES” box is checked in Item 20 and on the ASC X12 837
professional claim format if there is an indication on the claim that a test is subject to the antimarkup payment limitation, and the service is billed using a global code rather than having each
component billed as a separate line item.
9. If there is an indication on the claim that the test is subject to anti-markup and the NPI of the
performing entity (in Item 32a of the CMS-1500 or its ANSI X12N 837 equivalent) belongs to the
billing provider OR the performing entity is not a valid, Medicare enrolled entity.
d. If a provider of service or supplier is required to submit a diagnosis in item 21 and either the diagnosis
code is missing, incorrect or truncated; or a narrative diagnosis was not provided on an attachment.
(Remark code M81 or M76 are used.)
e. For claims received on or after April 1, 2013, if a provider of service or supplier is required to submit a
diagnosis in Item 21 of the Form CMS- 1500 (08-05) and an ICD-9-CM “E” code (external causes of
injury and poisoning) is reported in the first field of Item 21. And, effective for dates of service on or
after the effective date for ICD-10-CM codes, if an ICD-10-CM diagnosis code within the code range of
V00 through Y99 is reported in the first field of Item 21. (Remark Code MA63 is used.)
f. If a rendering physician, physician assistant, nurse practitioner, clinical nurse specialist, supplier/or other
practitioner who is a sole practitioner or is a member of a group practice does not enter his/her NPI into
item 24J of Form CMS-1500 (08-05) except for influenza virus and pneumococcal vaccine claims
submitted on roster bills that do not require a rendering provider NPI. (Remark code N290 is used.)
g. If a primary insurer to Medicare is indicated in item 11, but items 4, 6, and 7 are incomplete. (Remark
code(s) MA64, MA88, MA89, or MA92 as appropriate for the missing piece(s) of data are used.)
h. If there is insurance primary to Medicare that is indicated in item 11 by either an insured/group policy
number or the Federal Employee Compensation Act number, but a Payer or Plan identification number

(use HPID when effective) is not entered in field 11C, or the primary payer’s program or plan name
when a Payer or Plan ID (use HPID when effective) does not exist. (Remark code MA92 or N245 is
used.)
i. If a HCPCS code modifier must be associated with a HCPCS procedure code or if the HCPCS code
modifier is invalid or obsolete. (Remark code M20 if there is a modifier but no HCPCS.)
j. If a date of service extends more than 1 day and a valid “to” date is not present in item 24A. (Remark
code M59 is used.)
k. If an “unlisted procedure code” or a “not otherwise classified” (NOC) code is indicated in item 24D, but
an accompanying narrative is not present in item 19 or on an attachment. (Remark code M51 is used.)
l. If the name, address, and ZIP Code of the facility where the service was furnished in a hospital, clinic,
laboratory, or facility other than the patient’s home or physician’s office is not entered in item 32
(Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name,
address, and ZIP Code of the service location for all services other than those furnished in place of
service home – 12 must be entered. (Remark code MA114 is used.)
Effective for claims with dates of service on or after October 1, 2007, the name, address, and 9-digit ZIP
Code of the service location for services paid under the Medicare Physician Fee Schedule and anesthesia
services, other than those furnished in place of service home – 12, and any other places of service A/B
MACs treat as home, must be entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1.
(Remark code MA114 is used.)
Effective for claims with dates of service on or after October 1, 2007, for claims received that require a
9-digit ZIP Code with a 4 digit extension, a 4-digit extension that matches one of the ZIP9 file or a 4digit extension that can be verified according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1
must be entered on the claim. (Remark code MA114 is used.)
Effective January 1, 2011 for claims processed on or after January 1, 2011 on the Form CMS-1500, the
name, address, and 5 or 9-digit ZIP code, as appropriate, of the location where the service was
performed for services paid under the Medicare Physician Fee Schedule and anesthesia services, shall be
entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1 for services provided in all
places of service. (Remark code MA114 is used.)
Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of
the ASC X12 837 professional electronic claim format for services payable under the MPFS and
anesthesia services when rendered in POS home (or any POS they consider home) if submitted without
the service facility location. (Remark code MA114 is used.)
m. Effective for claims received on or after April 1, 2004, if more than one name, address, and ZIP Code is
entered on the Form CMS-1500 (08-05) in item 32.
n. If any of the modifiers PA, PB, or PC are incorrectly associated with a service which is other than a
wrong surgery on a patient, surgery on the wrong body part, surgery on the wrong patient or a service
related to one of these surgical errors. (Claim Adjustment Reason Code 4 is used.)

80.3.2.1.3 – A/B MAC (B) Specific Requirements for Certain Specialties/Services
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)
A/B MACs (B) must return the following claim as unprocessable to the provider of service/supplier:

a. For chiropractor claims:
1. If the x-ray date is not entered in item 19 for claims with dates of service prior to January 1, 2000.
Entry of an x-ray date is not required for claims with dates of service on or after January 1, 2000.
2. If the initial date “actual” treatment occurred is not entered in item 14. (Remark code MA122 is
used.)
b. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or
AA is employed by a group (such as a hospital, physician, or ASC) and the group’s name, address, ZIP
Code, and PIN number, until the NPI is required, is not entered in item 33 or if the NPI is not entered in item
33a.of the Form CMS-1500 (8/05) when the NPI is required or, until the NPI is required, if their personal
PIN is not entered in item 24K of the Form CMS-1500 (12-90) or if the NPI is not entered into item 24J of
the Form CMS-1500 (8/05) when the NPI is required. (Remark code MA112 is used.)
c. For durable medical, orthotic, and prosthetic claims, if the name, address, and ZIP Code of the location
where the order was accepted were not entered in item 32. (Remark code MA 114 is used.)
d. For physicians who maintain dialysis patients and receive a monthly capitation payment:
1. If the physician is a member of a professional corporation, similar group, or clinic, and, until the NPI
is required, the attending physician’s PIN is not entered in item 24K of the Form CMS-1500 (12-90) or
if the NPI is not entered into item 24J of the Form CMS-1500 (8/05) when the NPI is required).
(Remark code N290 is used.)
2. If the name, address, and ZIP Code of the facility other than the patient’s home or physician’s office
involved with the patient’s maintenance of care and training is not entered in item 32. (Remark code
MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP
Code of the service location for all services other than those furnished in place of service home – 12
must be entered.
e. For routine foot care claims, if the date the patient was last seen and the attending physician’s PIN (or
NPI when required) is not present in item 19. (Remark code N324 or N253 is used.)
f. For immunosuppressive drug claims, if a referring/ordering physician, physician’s assistant, nurse
practitioner, clinical nurse specialist was used and their name is not present in items 17 or 17a., or if the NPI
is not entered in item 17b. of the Form CMS-1500 (8/05). (Remark code N264 or N286 is used.)
g. For all laboratory services, if the services of a referring/ordering physician, physician’s assistant, nurse
practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a. or if
the NPI is not entered in item 17b. of the Form CMS-1500 (8/05). (Remark code N264 or N286 is used.)
h. For laboratory services performed by a participating hospital-leased laboratory or independent laboratory
in a hospital, clinic, laboratory, or facility other the patient’s home or physician’s office (including services
to a patient in an institution), if the name, address, and ZIP Code of the location where services were
performed is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or
after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those
furnished in place of service home – 12 must be entered.
i. For independent laboratory claims:
1. Involving EKG tracing and the procurement of specimen(s) from a patient at home or in an
institution, if the claim does not contain a validation from the prescribing physician that any laboratory

service(s) performed were conducted at home or in an institution by entering the appropriate annotation
in item 19 (i.e., “Homebound”). (Remark code MA116 is used.)
2. If the name, address, and ZIP Code where the test was performed is not entered in item 32, if the
services were performed in a location other than the patient’s home or physician’s office. (Remark code
MA 114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP
Code of the service location for all services other than those furnished in place of service home – 12
must be entered.
3. When a diagnostic service is billed as an anti-markup service and the service is purchased from
another billing jurisdiction, the billing physician or supplier must submit the name, address, and ZIP
Code in Item 32, and the NPI of the performing physician or supplier in Item 32a. If Item 32 and 32a
are not entered, remark code MA114 is used.
j. For mammography “diagnostic” and “screening” claims, if a qualified screening center does not
accurately enter their 6-digit, FDA-approved certification number in item 32 when billing the technical or
global component. (Remark code MA128 is used.)
k. For parenteral and enteral nutrition claims, if the services of an ordering/referring physician, physician
assistant, nurse practitioner, clinical nurse specialist are used and their name is not present in item 17 or if
the NPI is not entered in item 17b. of the Form CMS-1500 (8/05). (Remark code N264 or N286 is used.)
l. For portable x-ray services claims, if the ordering physician, physician assistant, nurse practitioner,
clinical nurse specialist’s name, and/or NPI is not entered in items 17 or if the NPI is not entered in item
17b. of the Form CMS-1500 (8/05). (Remark code N264 or N286 is used.)
m. For radiology and pathology claims for hospital inpatients, if the referring/ordering physician, physician
assistant, nurse practitioner, or clinical nurse specialist’s name, if appropriate, is not entered in item 17, the
NPI is not entered in item 17a., or if the NPI is not entered in item 17b. of the Form CMS-1500 (8/05).
(Remark code N264 or N286 is used.)
n. For outpatient physical or occupational therapy services provided by a qualified, independent physical,
or occupational therapist, Medicare policy does not require the date last seen by a physician, or NPI, of such
physician. Medicare policy does not require identification of the ordering, referring or certifying physician
on outpatient therapy claims, including speech-language pathology service claims. However, physicians and
suppliers are required to comply with applicable HIPAA ASC X12 837 claim completion requirements. (See
Pub. 100-04, chapter 5, §20 and Pub. 100-02, chapter 15, §§220 and 230 for therapy service policies.)
Deletion of this claim requirement for outpatient therapy services does not apply to the requirements for the
date last seen and the NPI of the ordering and supervising physician/nonphysician practitioner for therapy
services provided incident to the services of a physician, because the incident to policies continue to require
them.
1. If the UPIN (or NPI when required) of the attending physician is not present in item 19. (Remark
code N253 is used.)
2. If the 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) date patient was last seen by the
attending physician is not present in item 19. (Remark code N324 is used.)
o. For all laboratory work performed outside a physician’s office, if the claim does not contain a name,
address, and ZIP Code for where the laboratory services were performed in item 32 or if the NPI is not
entered into item 32a of the Form CMS-1500 when the NPI is required, if the services were performed at a
location other than the place of service home – 12. (Use Remark code MA114)

p. For all physician office laboratory claims, if a 10-digit CLIA laboratory identification number is not
present in item 23. This requirement applies to claims for services performed on or after January 1, 1998.
(Remark code MA120 is used.)
q. For investigational devices billed in an FDA-approved clinical trial if an Investigational Device
Exemption (IDE) number is not present in item 23, for dates of service through March 31, 2008. (Remark
code MA50 is used.) With the use of new modifier Q0, effective for dates of service on and after April 1,
2008, contractors will no longer be able to distinguish an IDE claim from other investigational clinical
services. Therefore this edit will no longer apply.
r. For physicians performing care plan oversight services if the 6-digit Medicare provider number of the
home health agency (HHA) or hospice is not present in item 23. (Remark code MA49 is used.)
s. For Competitive Acquisition Program drug and biological claims, in accordance with the instructions
found in the Medicare Claims Processing Manual, chapter 17, section 100.2.1 – section 100.9.
t. For claims for artificial hearts covered by Medicare under an approved clinical trial, if procedure code
0051T is entered in Item 24D, and an 8-digit clinical trial number that matches an approved clinical trial
listed at: http://www.cms.hhs.gov/MedicareApprovedFacilitie/06_artificialhearts.asp#TopOfPage is not
entered in Item 19; and the HCPCS modifier Q0 is not entered on the same line as the procedure code in
Item 24D, and the diagnosis code V70.7 (if ICD-9-CM is applicable) or Z00.6 (if ICD-10-CM is applicable)
is not entered in Item 21 and linked to the same procedure code. (As appropriate, use remark code MA97 –
Missing/ incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial
registry number; M64 – Missing/incomplete/invalid other diagnosis; or claim adjustment reason code 4 The procedure code is inconsistent with the modifier used or a required modifier is missing.)
u. For clinical trial claims processed after September 28, 2009, with dates of service on or after January 1,
2008, claims submitted with either the modifier QV or the modifier Q1, if the diagnosis code V70.7 (if ICD9-CM is applicable) or Z00.6 (if ICD-10-CM is applicable) is not submitted with the claim.
v. For ambulance claims, claims submitted without the ZIP Code of the loaded ambulance trip’s point-ofpickup in Item 23 of the CMS-1500 Form.

Medicare Claims Processing Manual
Chapter 16 - Laboratory Services
40.1.1.1 - Paper Claim Submission To A/B MACs (B)
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)
An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred
laboratory service (as it would any laboratory service). The line item services must be submitted with a
modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e.,
self-performed) and referred services on the same CMS 1500 claim form. When the referring laboratory
bills for both non-referred and referred tests, it shall submit two separate claims, one claim for non-referred
tests, the other for referred tests. If billing for services that have been referred to more than one laboratory,
the referring laboratory shall submit a separate claim for each laboratory to which services were referred
(unless one or more of the reference laboratories are separately billing Medicare). A paper claim that
contains both non-referred and referred tests is returned as unprocessable. When the referring laboratory is
the billing laboratory, the reference laboratory’s name, address, and ZIP Code shall be reported in item 32
on the CMS-1500 claim form to show where the service (test) was actually performed. The NPI shall be
reported in item 32a. Also, the CLIA number of the reference laboratory shall be reported in item 23 on the
CMS-1500 claim form. A paper claim that does not have the name, address, and ZIP Code of the reference
laboratory in item 32 and NPI in 32a or the CLIA number of the reference laboratory in item 23 is returned
as unprocessable.
EXAMPLE: A physician has ordered the ABC Laboratory to perform carcinoembryonic antigen (CEA)
and hemoglobin testing for a patient. Since the ABC Laboratory is approved to perform tests only within
the hematology LC level (which includes the hemoglobin test), it refers the CEA testing (which is a routine
chemistry LC) to the XYZ laboratory.
Result: The ABC laboratory submits a claim for the hemoglobin test and reports its CLIA number in item
23 on the CMS-1500 form. Since the ABC laboratory referred the CEA test to the XYZ laboratory to
perform, the ABC laboratory (billing laboratory) submits a second claim for the CEA testing, reporting
XYZ’s CLIA number in item 23 on the CMS-1500 form. The XYZ laboratory’s name, address, and ZIP
Code are also reported in item 32 and the NPI is reported in item 32a on Form CMS-1500 to show where the
service (test) was actually rendered.
NOTE: Effective for claims submitted with a receipt date on and after April 1, 2015, the billing physician
or supplier must report the name, address, and NPI of the performing 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 B/MAC jurisdiction. See Pub. 100-04, Chapter 1, § 10.1.1 for more information regarding claims
filing jurisdiction.

40.1.1.2 - Electronic Claim Submission to A/B MACs (B)
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)

Electronic Claim Submission
SC X12 837 professional claim format (HIPAA compliant version):
CLIA number:
An electronic claim for laboratory testing will require the presence of the performing (and billing)
laboratory’s CLIA number; if tests are referred to another laboratory, the CLIA number of the laboratory
where the testing is rendered must also be on the claim. An electronic claim for laboratory testing must be
submitted using the following rules:
ANSI Electronic claim: the billing laboratory performs all laboratory testing.
The independent laboratory submits a single claim for CLIA-covered laboratory tests and reports the billing
laboratory’s number in:
X12N 837 (HIPAA version) loop 2300, REF02. REF01 = X4
ANSI Electronic claim: billing laboratory performs some laboratory testing; some testing is referred to
another laboratory.
The ANSI electronic claim will not be split; CLIA numbers from both the billing and reference laboratories
must be submitted on the same claim. The presence of the ‘90’ modifier at the line item service identifies
the referral tests. Referral laboratory claims are only permitted for independently billing clinical
laboratories, specialty code 69.
The billing laboratory submits, on the same claim, tests referred to another (referral/rendered) laboratory,
with modifier 90 reported on the line item and reports the referral laboratory’s CLIA number in:
X12N 837 (HIPAA version) loop 2400, REF02. REF01 = F4
EXAMPLE: A physician has ordered the DEF independent laboratory to perform glucose testing and tissue
typing for a patient. Since the DEF Laboratory is approved to perform only at the routine chemistry LC
level (which includes glucose testing), it refers the tissue-typing test to the GHI laboratory.
The DEF laboratory submits a single claim for the glucose and tissue typing tests; the line item service for
the glucose test is submitted without a ‘90’ modifier since the DEF laboratory performed this test. The
CLIA number for the DEF laboratory is entered in the electronic claim in:
X12N 837 (HIPAA version) loop 2300, REF02. REF01 = X4
On the same claim, the line item service for the tissue typing test is submitted with a ‘90’ modifier and the
referral/rendering GHI laboratory’s CLIA number is entered on the electronic claim in:
X12N 837 (HIPAA version) loop 2400, REF02. REF01 = F4
Reference Laboratory’s Address:
An electronic claim for laboratory testing requires the presence of the performing and billing laboratory’s,
name and address. The performing laboratory for a service with a line item CPT 90 modifier requires
provider information for the appropriate 837 loop.
NOTE: Effective for claims submitted with a receipt date on and after April 1, 2015, the billing physician
or supplier must report the name, address, and NPI of the performing physician or supplier on the claim on

reference laboratory claims, even if the performing physician or supplier is enrolled in a different B/MAC
jurisdiction. See Pub. 100-04, Chapter 1, § 10.1.1 for more information regarding claims filing jurisdiction.

Medicare Claims Processing Manual
Chapter 26 - Completing and Processing
Form CMS-1500 Data Set
Item 19 - Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date patient was last seen
and the NPI of his/her attending physician when a physician providing routine foot care submits claims.
NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of
an NPI.
Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) x-ray date for chiropractor services
(if an x-ray, rather than a physical examination was the method used to demonstrate the subluxation). By
entering an x-ray date and the initiation date for course of chiropractic treatment in item 14, the chiropractor
is certifying that all the relevant information requirements (including level of subluxation) of Pub. 100-02,
Medicare Benefit Policy Manual, chapter 15, is on file, along with the appropriate x-ray and all are available
for carrier review.
Enter the drug's name and dosage when submitting a claim for Not Otherwise Classified (NOC) drugs.
Enter a concise description of an "unlisted procedure code" or an NOC code if one can be given within the
confines of this box. Otherwise an attachment shall be submitted with the claim.
Enter all applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d. If modifier -99
is entered on multiple line items of a single claim form, all applicable modifiers for each line item
containing a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item
and "mod" represents all modifiers applicable to the referenced line item.
Enter the statement "Homebound" when an independent laboratory renders an EKG tracing or obtains a
specimen from a homebound or institutionalized patient. (See Pub. 100-02, Medicare Benefit Policy
Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04, Medicare Claims
Processing Manual, Chapter 16, "Laboratory Services From Independent Labs, Physicians and Providers,"
and Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5,
"Definitions," respectively for the definition of "homebound" and a more complete definition of a medically
necessary laboratory service to a homebound or an institutional patient.)
Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses to assign
benefits to a non-participating physician/supplier who accepts assignment on a claim. In this case, payment
can only be made directly to the beneficiary.

Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearing aid(s)
is used to obtain intentional denials when other payers are involved.
When dental examinations are billed, enter the specific surgery for which the exam is being performed.
Enter the specific name and dosage amount when low osmolar contrast material is billed, but only if HCPCS
codes do not cover them.
Enter a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or relinquished date for a
global surgery claim when providers share post-operative care.
Enter demonstration ID number "30" for all national emphysema treatment trial claims.

Enter demonstration ID number “56” for all national Laboratory Affordable Care Act Section 113
Demonstration Claims.
Enter the NPI of the physician who is performing the technical or professional component of a diagnostic
test that is subject to the anti-markup payment limitation. (See Pub. 100-04, chapter 1, section 30.2.9 for
additional information.)
NOTE: Effective May 23, 2008, all identifiers submitted on the Form CMS-1500 MUST be in the form of
an NPI.
Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRD
beneficiaries on dialysis. (See Pub. 100-04, chapter 8, section 60.7.2.)
Individuals and entities who bill carriers or A/B MACs for administrations of ESAs or Part B anti-anemia
drugs not self-administered (other than ESAs) in the treatment of cancer must enter the most current
hemoglobin or hematocrit test results. The test results shall be entered as follows: TR= test results
(backslash), R1=hemoglobin, or R2=hematocrit (backslash), and the most current numeric test result figure
up to 3 numerics and a decimal point [xx.x]). Example for hemoglobin tests: TR/R1/9.0, Example for
Hematocrit tests: TR/R2/27.0.

Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998)
the form was signed.
In the case of a service that is provided incident to the service of a physician or non-physician practitioner,
when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR
410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31.
When the ordering physician or non-physician practitioner is not supervising the service, then enter the
signature of the physician or non-physician practitioner providing the direct supervision in item 31.
NOTE: This is a required field, however the claim can be processed if the following is true. If a physician,
supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is
attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature.
Item 32 – For services payable under the physician fee schedule and anesthesia services, enter the name and
address, and ZIP code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility
other than the patient's home or physician's office. Effective for claims received on or after April 1, 2004,
enter the name, address, and ZIP code of the service location for all services other than those furnished in
place of service home – 12. Effective for claims received on or after April 1, 2004, on the Form CMS-1500,
only one name, address and ZIP code may be entered in the block. If additional entries are needed, separate
claim forms shall be submitted. Effective January 1, 2011, for claims processed on or after January 1, 2011,
submission of the location where the service was rendered will be required for all POS codes.
Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP code when
billing for anti-markup tests. When more than one supplier is used, a separate Form CMS-1500 shall be
used to bill for each supplier. (See Pub. 100-04, chapter 1, §10.1.1.2 for more information on payment
jurisdiction for claims subject to the anti-markup limitation.)
For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States.
These claims will not include a valid ZIP code. When a claim is received for these services on a beneficiary
submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a
foreign claim. If it is a foreign claim, follow instructions in chapter 1 for disposition of the claim. The

carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is
not returned as unprocessable due to the lack of a ZIP code.
For durable medical, orthotic, and prosthetic claims, the name and address of the location where the order
was accepted must be entered (DME MAC only). This field is required. When more than one supplier is
used, a separate Form CMS-1500 shall be used to bill for each supplier. This item is completed whether the
supplier's personnel performs the work at the physician's office or at another location.
If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification
number.
Complete this item for all laboratory work performed outside a physician's office. If an independent
laboratory is billing, enter the place where the test was performed.
Item 32a - If required by Medicare claims processing policy, enter the NPI of the service facility.
Effective for claims submitted with a receipt date on and after April 1, 2015, the billing physician or
supplier must report the NPI of the performing physician or supplier in Item 32a on all anti-markup and
reference laboratory claims, even if the performing physician or supplier is enrolled in a different
jurisdiction.
Item 32b - Effective May 23, 2008, Item 32b is not to be reported.
Item 33 - Enter the provider of service/supplier's billing name, address, ZIP code, and telephone number.
This is a required field.
Item 33a - Enter the NPI of the billing provider or group. This is a required field.
Item 33b - Effective May 23, 2008, Item 33b is not to be reported.

Medicare Claims Processing Manual
Chapter 35 – Independent Diagnostic Testing
Facility (IDTF)
30 - Diagnostic Tests Subject to the Anti-Markup Payment Limitation
(Rev.3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming
April 1, 2015 - For Testing and Implementation; Implementation- January 5, 2015, April 6, 2015 – For
MAC testing of PECOS changes only)
In most instances, physicians working for an IDTF do not order diagnostic tests because such tests are
generally ordered by the patient’s treating physician. If a physician working for an IDTF does not order a
diagnostic test, the test is not subject to the anti-markup payment limitation. However, if a physician
working for an IDTF (or a physician financially related to the IDTF through common ownership or control)
orders a diagnostic test payable under the Medicare Physician Fee Schedule (MPFS), the anti-markup
payment limitation may apply (depending on whether the performing physician or other supplier meets the
“sharing a practice” requirements). For additional information, see Pub. 100-04, chapter 1, §30.2.9.
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
anti-markup payment limitation.
The billing entity must report on the CMS 1500 claim form (or corresponding loop and segment of the ANSI
X12N 837) the name, NPI, and address of the performing physician or other supplier. The acquisition price
of either the TC or PC of the diagnostic test must also be reported on the claim.
Effective for claims with dates of service on or after January 25, 2005, carriers 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 carrier’s
jurisdiction, for services furnished anywhere in the United States.
Effective for claims submitted with a receipt date on and after April 1, 2015, the billing physician or
supplier must report the name, address, and NPI of the performing 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 B/MAC jurisdiction. See Pub. 100-04, Chapter 1, § 10.1.1 for more information regarding claims
filing jurisdiction.
Effective April 1, 2005, carriers 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 CMSsupplied abstract file containing the HCPCS codes that are payable under the MPFS as an anti-markup test
for the calendar year. (See Pub. 100-04, chapter 23, §30.6 and Addendum for record layouts and
instructions for downloading the Abstract File for Purchased Diagnostic Tests/Interpretations.) Carriers

must pay the lesser of: (a) the net acquisition price, (b) the billing entity’s actual charge, or (c) the fee
schedule amount as if the test was billed by the performing supplier.
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.

SAMPLE PECOS FILE LAYOUT FOR CR 8806
Descript

Field

Leng

Defa

Start

PECOS Table

ion

Name

th

ult

Positi

(Enrollment)

Valu

on

PECOS Field

PECOS Table

PECOS Field

(Affidavit)

NPI

NPI

10

e
N/A

1

PEC_NPI

NPI

PEC_NPI

NPI

First
Name

FNAME

25

N/A

11

PEC_IND_NAME

FIRST_NAME

PEC_INDVDL_NAME

FIRST_NAME

Middle
Name

MNAME

25

N/A

36

PEC_IND_NAME

MDL_NAME

PEC_INDVDL_NAME

MDL_NAME

Last
Name

LNAME

35

N/A

61

PEC_IND_NAME

LAST_NAME

PEC_INDVDL_NAME

LAST_NAME

Legal
Business
Name

BASELBANAME

70

N/A

96

PEC_ORG_BUSNS
_NAME

ORG_NAME

PEC_ORG_BUSNS_NA
ME

ORG_NAME

DBA
Name

BASEDBANAME

70

N/A

166

PEC_ORG_DBA_N
AME

ORG_NAME

PEC_ORG_DBA_NAM
E

ORG_NAME

Specialty
Code

SPCLTY_C
D

2

N/A

236

PEC_ENRT_NPHY
_SPC,
PEC_ENRT_PHY_S
PC

PHYSN_SPCLTY
_CD

PEC_AFDVT_NPHYSN
_SPCLTY,

NPHYSN_SPCLT
Y_CD,

PEC_AFDVT_PHYSN_S
PCLTY

PHYSN_SPCLTY
_CD

Specialty
Descripti
on

SPCLTY_D
ESC

150

N/A

238

PEC_NPHY_SPC_R
EF,
PEC_PHY_SPC_RE
F

PHYSN_SPCLTY
_DESC

PEC_NPHY_SPC_REF,
PEC_PHY_SPC_REF

PHYSN_SPCLTY
_DESC

PIN
Effective
Date

EFF_DT

8

N/A

388

PEC_MDCR_NUM

EFCTV_DT

PEC_AFDVT_MDCR/
PEC_AFDVT_ORDR_R
FRG

EFCTV_DT

PIN
Termina
tion
Date

TRM_DT

8

N/A

396

PEC_MDCR_NUM

END_DT

PEC_AFDVT_MDCR/
PEC_AFDVT_ORDR_R
FRG/ PEC_AFDVT

END_DT

Filler

FILLER

37

N/A

404

N/A

N/A

N/A

N/A

Total
Length

441



---

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