Jurisdictional Pricing Rules

CR 5543 replaces the temporary physician billing instructions specified in CR 3630 (issued on December 23, 2004) with new billing procedures that (effective October 1, 2007) allow all physicians and suppliers to receive the correct payment amount for all purchased diagnostic services, including those performed outside of their local carrierÕs/Medicare Administrative Contractor’s (MAC) jurisdiction.

• Effective for claims with dates of service on or after October 1, 2007, carriers/MACS will use the MPFS national abstract file for purchased diagnostic tests/interpretations to price all claims for purchased diagnostic services based on the ZIP code of the location where the service was rendered, including those submitted by physicians for purchased diagnostic services performed outside of the local carrier’s jurisdiction, in accordance with the carrier jurisdictional pricing rules specified in Chapter 1, Section 10.1.1 of the Medicare Claims Processing Manual.
• Physicians and suppliers must begin reporting the rendering physician’s/supplier’s information and the location where the service was rendered on all claims for purchased tests / interpretations with dates of services on or after October 1, 2007, including those for tests / interpretations performed outside of the local carrierÕs jurisdiction, following the instructions for submitting a purchased diagnostic service claim in Chapter 1, Sections 10.1.1.2 and 30.2.9 of the Medicare Claims Processing Manual.
• Physicians and suppliers are reminded they may only submit claims for purchased tests / interpretations when these services are performed within the United States. (In this context, the term “United States” means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. See Chapter 1, Section 10.1.4 of the Medicare Claims Processing Manual for additional information.)