Reporting Zip Code of Service Facility Location

on Wednesday, 11 March 2009. All News Items

On February 13, 2009, CMS released Transmittal 1681 (CR 6300) which allows Medicare contractors to pay for certain services provided at an off-campus facility based on that facility’s zip code.  This applies to services paid under the Medicare Physician Fee Schedule (MPFS) such as physical, occupational and speech language therapy services. 

Effective January 1, 2007, CMS Change Request (CR) 5243 instructed Medicare outpatient service providers to report the nine-digit zip code of the actual service facility location in the 2310E loop of the 837 Institutional claim transaction.  However, Medicare has not been able to use this information to process payment due to limitations in their claims processing system (FISS).  The new transmittal (CR 6300) requires changes in FISS to allow capture of the zip code of the service facility location for proper payment when it differs from the main provider address.

If your hospital operates off-site outpatient facilities, be sure to report the nine-digit zip code of the actual service location in the 2310E loop of the 837 claim transactions to ensure proper payment.  Medicare contractors will pay MPFS services based on this zip code for electronically submitted claims.  Direct Data Entry (DDE) and paper claims will continue to be paid based on the master address. If you notify your MAC or FI of timely claims that were paid inaccurately due to lack of the zip code, they will adjust the claims based on the zip code you specify. 

Note that the effective date of the transmittal is October 1, 2007 so claims from this date forward may be subject to payment adjustment if requested.  The implementation date of the transmittal is July 6, 2009 so claims may not process correctly based on the service location zip code until this date.  If you have concerns about proper payment for off-campus facility claims (zip code different than main provider), contact your MAC or FI about the implementation date and claim adjustments.

Link to CMS MLN Matters articles:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6300.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5243.pdf

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