MLN Matters® Number: MM6670 Revised
Related Change Request (CR) #: 6670
Related CR Release Date: January 29, 2010
Effective Date: April 1, 2010
Related CR Transmittal #: R1903CP
Implementation Date: April 5, 2010
Note: This article was revised on February 1, 2010 to reflect a revised CR 6670 that was issued on January 29, 2010. Within this article, the CR release date, transmittal number, and the Web address for accessing CR 6670 were revised. All other information remains the same.
Provider Types Affected
This article is for physicians and other providers submitting claims to Medicare contractors (carriers and/or A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
This article is based on Change Request (CR) 6670 which provides your Medicare Contractor with instructions for processing claims for diagnostic services that are subject to the ‘anti-markup payment limitation' and that are billed with missing or incomplete information in Item 20 of the form CMS-1500 or its electronic equivalent.
CAUTION – What You Need to Know
Prior to the implementation of the anti-markup payment limitation, contractors were instructed to assume none of the services presented on a claim were purchased if Item 20 was either not completed or was missing information. CR 6670 gives specific criteria for processing claims with partial information completed in Item 20.
GO – What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.
Background
The Medicare Claims Processing Manual (Chapter 1, Section 80.3.2.1.2 ) establishes guidelines for processing of claims for diagnostic services when:
- There is no entry for the “Yes/No” indicator in Item 20 of the CMS-1500 claim form, or
- The ANSI X12 837P electronic claim is missing a claim or line level PS1 segment to indicate whether the diagnostic services were purchased.
Your Medicare Contractor is instructed to assume that a diagnostic service was not purchased when there is no “Yes/No” indicator marked in Item 20 of the paper claim form or its electronic equivalent. Additionally, the instructions referred to anti-markup as it was formerly known as “purchased diagnostic tests” and applied only to the technical component (TC) of a diagnostic test. (See CR 6122 (Transmittal 1589, Sep. 8, 2008) at http://www.cms.hhs.gov/transmittals/downloads/R1589CP.pdf on the Centers for Medicare & Medicaid Services (CMS) website. An MLN Matters article related to that transmittal is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6122.pdf on the CMS website.)
CR 6670 provides instructions for processing claims for diagnostic services that are subject to what is now known as the ‘anti-markup payment limitation’ and that are billed with missing or incomplete information in Item 20 of the CMS-1500 or its electronic equivalent.
Medicare Contractors will use the following guidelines for determining whether a claim contains a diagnostic service that is subject to the ‘anti-markup payment limitation’: (Note: These guidelines apply to both the CMS-1500 and its electronic equivalent).
- If a “Yes” or “No” is not indicated in Item 20 and the associated dollar amount is missing, contractors shall assume the service is not subject to the anti-markup payment limitation and shall process the claim accordingly;
- If a “Yes” or “No” is not indicated in Item 20 and the associated dollar amount is present, contractors shall return the claim to you as unprocessable;
- If the “Yes” box is marked in Item 20 and the associated dollar amount is missing, contractors shall return the claim as unprocessable;
- If the “No” box is marked in Item 20 and the associated dollar amount is present, contractors shall return the claim as unprocessable.
Note: In accordance with the requirements of the ‘anti-markup payment limitation’, Medicare Contractors will apply the above logic to both the TC and PC (professional component) of diagnostic tests.
Additional Information
If you have any questions, please contact the Palmetto GBA Provider Contact Center at their toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.