Payment pricing limitation - When Anti-Markup Applies

Anti-Markup Pricing Limitation

Anti-markup applies when a diagnostic service payable under the Medicare Physician Fee Schedule is performed by one physician/supplier and billed by another physician/suppler. The conditions that must exist to establish whether the anti-markup applies are outlined below.

When Anti-Markup Applies

The anti-markup payment limitation will apply (i.e., must mark “yes” in Item 20 of the claim form and provide the acquisition price) in cases where performing physician does not share a practice with the ordering/billing physician/supplier, either under the “substantially all services” or “site of service” test defined below.

Under the anti-markup payment limitation, payment to the billing physician or other supplier for the TC or PC of the diagnostic test may not exceed the lowest of the following amounts:

* The performing supplier’s net charge to the billing physician/supplier.
* The billing physician’s/supplier’s actual charge.
* The fee schedule amount for the test that would be allowed if the performing provider billed directly.