Oncology & Hematology Coding Alert

Don’t get in trouble asking for ABNs.

CMS has announced that “Effective May 1, 2013, CMS will turn on the edits to deny Part B, DME, and Part A HHA claims that fail the ordering/referring provider edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record and must be of a specialty that is eligible to order and refer” (MLN Matters article SE1305 www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf).

For providers who perform ordered services, Medicare recommends the following steps to prevent denials:

·         Ensure the providers who order services “have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program.” Review the MLN Matters article to see which providers are eligible to order services.

·         Check to see whether the ordering provider is listed in the Medicare Ordering and Referring File (updated weekly) at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html. You’ll need the provider’s NPI to confirm he or she is on the list. “Most of the clients I work with try to stay on top of this,” says Rick Ingber with VantaHealth Consulting in Plymouth Meeting, Pa. But the years have worn on with no edit implementation, so some providers may have let physician enrollment checks fall to the bottom of their to-do lists.

·         Verify that the name and NPI listed for the ordering provider on the claim for the ordered service belong to a person and not an organization.

·         Spell the ordering provider’s name correctly on the claim for the ordered service. Don’t use nicknames, and don’t include credentials (e.g., MD). If you still use paper claims, item 17 should list the provider’s first name and then the last name. Medicare offers the example “John Smith.”

Caution: An Advance Beneficiary Notice (ABN) would not be appropriate in cases where the claim will fail because of an ordering/referring provider edit. Such claims “would not expose the Medicare beneficiary to liability,” MLN Matters SE1305 states.