BE AWARE: You must be giving us the actual address of where the services are performed.

Revised Claims Processing Instructions for Payment Jurisdiction for Claims Received on or After April 1, 2004

The Centers for Medicare & Medicaid Services (CMS) Change Request (CR) 2912 required that changes be made to the National Standard Format (NSF) in order to implement jurisdictional pricing for services paid under the Medicare Physician Fee Schedule and anesthesia services. It has been determined that requiring changes to the NSF format would cause too great an impact on providers, carriers, and standard systems to justify making the changes, as the format will no longer be valid in the near future. Therefore these requirements have been removed.

A. ANSI X12N 837 Electronic Claims
Please note that the following instructions do not apply to services rendered at place of service (POS) home 12. For services rendered at POS home 12, Empire Medicare Services (EMS) will use the address on our beneficiary file to determine pricing locality.

Per the ANSI X12N 837 version 4010/4010A1 implementation guide, it is acceptable for claims to contain the code for POS home and any number of additional POS codes. If different POS codes are used for services on the claim, a corresponding service facility location and address must be entered for each service at the line level, if that location is different from the billing provider, pay-to provider, or claim level service facility location. EMS will pay the service based on the ZIP code of the service facility location, billing provider address, or pay-to provider address, depending upon which information is provided.

Refer to the current ANSI X12N 837 implementation guide to determine how information concerning where a service was rendered, the service facility location, must be entered on a claim. Per the documentation, though an address may not appear in the loop named “service facility address,” the information may still be available on the claim in a related loop. For example:

• Per the 837 version 4010/4010A electronic claim format, the Billing Provider loop 2010AA is required and therefore must always be entered. If the Pay-To Provider Name and Address loop 2010AB is the same as the Billing Provider, only the Billing Provider will be entered. If no Pay-To Provider Name and Address is entered in loop 2010AB, and the Service Facility Location loop 2310D (claim level) or 2420C (line level) is the same as the Billing Provider, then only the Billing Provider will be entered. In this case, EMS will price the service based on the Billing Provider ZIP code.
• If the Pay-To Provider Name and Address loop 2010AB is not the same as the Billing Provider, both will be entered. If the Service Facility Location loop 2310D is not the same as the Billing Provider or the Pay-To Provider, the Service Facility Location loop 2310D (claim level) will be entered. EMS will price the service based on the ZIP code in Service Facility Location loop 2310D, unless the 2420C (line level) is also entered. In that case, EMS will price the service based on the ZIP code in the Service Facility Location loop 2420C (line level) for that line.

Per the 837 version 4010/4010A electronic claims format, if the place where the service was rendered cannot be identified from the claim, all services on the claim will be priced based on the ZIP code in the Billing Provider loop.

If the Pay-To Provider Name and Address loop 2010AB is not the same as the Billing Provider, both will be entered. If the Service Facility Location loop 2310D (claim level) or 2420C (line level) is the same as the Billing Provider or the Pay-To Provider, no entry is required per version 4010/4010A1 for Service Facility Location loop 2310D (claim level) or 2420C (line level).

When the same POS code and same service location address is applicable to each service line on the claim, the service facility location name and address must be entered at the claim level loop 2310D.

In general, when the service facility location name and address is entered only at the claim level, use the ZIP code of that address to determine pricing locality for each of the services on the claim. When entered at the line level, the ZIP code for each line must be used.

If the POS code is the same for all services, but the services were provided at different addresses, each service must be submitted with line level information. This will provide a ZIP code to price each service on the claim.

B - Paper Claims Submitted on the Form CMS-1500
Note that the following instructions do not apply to services rendered at POS home 12. It is acceptable for claims to contain POS home and an additional POS code. No service address for POS home needs to be entered for the service rendered at POS home in this situation as the address will be drawn from the beneficiary file and the information on the claim will apply to the other POS.

A separate claim must be submitted for each POS. The specific location where the services were furnished must be entered on the claim. The ZIP code of the address entered in Item 32 will be used to price the claim. If multiple POS codes are submitted on the same claim, assigned claims will be rejected as unprocessable.

Payment to Physician for Purchased Diagnostic Tests - Claims Submitted to Carriers
A physician or a medical group may submit the claim and (if assignment is accepted) receive the Part B payment, for the technical component of diagnostic tests which the physician or group purchases from an independent physician, medical group, or other supplier. (This claim and payment procedure does not extend to clinical diagnostic laboratory tests.) The purchasing physician or group may be the same physician or group as ordered the tests or may be a different physician or group. An example of the latter situation is when the attending physician orders radiology tests from a radiologist and the radiologist purchases the tests from an imaging center. The purchasing physician or group may not mark up the charge for a test from the purchase price and must accept the lowest of the fee schedule amount if the supplier had billed directly; the physician’s actual charge; or the supplier’s net charge to the purchasing physician or group, as full payment for the test even if assignment is not accepted.

In order to purchase a diagnostic test, the purchaser must perform the interpretation. The physician or other supplier that furnished the technical component must be enrolled in the Medicare program. No formal reassignment is necessary.

Effective for claims received on or after April 1, 2004:

• In order to have appropriate service facility location ZIP code and the purchase price of each test on the claim, when billing for purchased tests on the Form CMS-1500 paper claim form, each test must be submitted on a separate claim form. Paper claims submitted with more than one purchased test will be considered unprocessable.
• More than one purchased test may be billed on the ANSI X12N 837 electronic format. When more than one test is billed, the total purchased service amount must be submitted for each service. Claims received with multiple purchased tests without line level total purchased service amount information will be considered unprocessable.
• Paper claims submitted for purchased services with both the interpretation and the purchased test on one claim will be considered unprocessable, 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, it will be assumed that the one address in Item 32 applies to both services.

ANSI X12N 837 electronic claims submitted for purchased services with both the interpretation and purchased test on the same claim will be accepted. It will be assumed that the claim level service facility location information applies to both services if line level information is not provided.

• When a global billing is received and there is information on the claim that indicates the test was purchased these claims will be considered as unprocessable. In order for EMS to price these claims correctly and apply purchase price 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).
• No changes will be required in either submission or processing for claims for services paid under the Medicare physician fee schedule and anesthesia services subject to jurisdictional pricing submitted on the National Standard Format.

Reference: Pub 100-04, Change Request 3039, Transmittal 67

Posted: 04/26/2004