Medicare Compliance & Reimbursement

May 23, 2008. The National Provider Identifier (NPI) deadline is just around the corner. Are you sure your practice is ready? Or will you see a slew of rejected claims come May 24? Find out fast with these expert tips on NPI preparedness.

Focus on revenue: The May date is the official end of the NPI contingency CMS allowed practices to invoke. So as of May 23, your Medicare carriers will no longer accept Medicare legacy identifiers in any primary or secondary provider fields. They will only accept NPIs for all primary and secondary provider fields on HIPAA electronic transactions, paper claims, and SPR remittance advice.

What it means: "The threat of enforcement is so negligible that compliance with the deadline isn't the major issue, however," says Martin Jensen, COO and chief analyst for the Healthcare IT Transition Group in Tulsa, OK, and editor of the HIT Transition Web log (http://blog.hittransition.com). "In other words, it's not the code of regulations you need to worry about. It's the code of edits that Medicare and other payers are bringing to bear on your claims. That one hard-date deadline isn't the thing to worry about, but rather what are specific payers doing to solve the NPI problem."

Bottom line: "This is not about compliance. It's about revenue," Jensen says. "The time to line up your ducks is between now and May 23, but don't expect them to all be perfectly aligned on the 23rd."

Check your NPPES info: You need to make sure your NPI is set up properly and you've updated any necessary information in the National Plan and Provider Enumeration System (NPPES) database, says Rebecca Marthaller, CMRS, owner of Lower Columbia Medical Billing in Longview, WA. You can find the NPI database online at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.

"Make sure your NPI is crosswalked to the correct Medicare ID number, especially if you are a group, corp- oration or LLC," Marthaller says. "Groups, corporations and LLCs need to have multiple NPIs for Medicare -- one for the group and one for each medical provider."

Tip: The NPI information should use the physician's legal business name as it appears on Medicare enrollment information, or the claims process will be delayed. You should look at the 855 form and exactly match the NPI database information to what is on that form, including hyphens, spaces and even misspellings.

"In a nutshell, every single thing that might have been passed over or not found in the past is being unearthed," says Leslie Johnson, CCS-P, CPC, manager/consultant of coding and compliance for DR Management in Fort Wayne, IN. "This includes physicians who change their addresses but failed to notify CMS, who work for larger corporations without a tax ID of their own, mistakes that humans would recognize and let go (such as a misspelled name or an initial we used today but dropped in later correspondence) and more."

Good practice: Make sure that your other provider identifiers, especially Medicare ones, appear in the optional other provider ID fields. You can list several other numbers, Jensen says. "Take advantage of that."

Tackle individual payers: Medicare and other payers put NPI edits into place that you need to adapt to, or you risk lost revenue. When a payer cannot identify your provider because the claim doesn't fit the NPI edits, you won't get paid.

Important: The longer you wait to address problems with your NPI processing, the more revenue you'll lose in the long run, experts say.

"Try not to be one of those providers whose claims get caught up systematically. There are practices and facilities that have gone without Medicare payments for months because their claims are failing the NPI cross-walks," Jensen says. He advises practices to look at CMS guidance to overcome the "fixable" problems so that they are not losing revenue because of NPI rejections.

"As more payers go to NPI processing, there may be those same kinds of system hang-ups with other payers as well," Jensen adds. "You should look at NPI as a payer-specific issue and work closely with the payer you're having claims problems with to solve those specific problems."