Part B Insider (Multispecialty) Coding Alert

Even Incident to Claims Will Require Ordering/Referring Doc's NPI, Medicare Says

It's time now to prepare for the claims processing edits that will start in January, Medicare reps want to remind you. That's the word from a Nov. 9 NGS Medicare webinar on ordered and referred services.

In today's Medicare environment, you certainly can't afford to have payments denied or rejected, so be ready for the ordering and referring edits so you can continue to collect your reimbursement. If your physician performs a service as the result of an order or referral, your claim must include the ordering or referring practitioner's NPI, and that number must be in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) or the payer's computer system.

Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician's information is not in the MAC's claims system or in PECOS, your practice will get an informational message letting you know that the practitioner's information is missing from the system. But CMS will start denying claims as of Jan. 3, 2011.

Part B reminder: In Part B, MACs will take two steps before denying your claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected starting this January.

The following tips, offered by NGS's Andrea Freibauer during the call, can help you stave off rejections this January:

1. Know Who Is Affected: An "Ordering physician" refers to a physician or non-physician practitioner who orders services for a beneficiary, including diagnostic or clinical lab tests, durable medical equipment, prosthetics, orthotics, and supplies, Freibauer said. A "referring physician" is the physician who requests the item or service, she noted.

Consider this: You'll have to submit the ordering/referring provider's NPI for all Medicare-covered services and items resulting from a physician's order or referral.

2. Include Incident To, X-Ray Orders in Rule: Although some practices consider the ordering/referring edits to be only applicable to those practices that deal with DME, they are grossly misinformed.

Claims for parenteral and enteral nutrition, portable x-ray services, diagnostic radiology and laboratory services, immunosupporessive drug claims, services performed incident to the services of a physician or non-physician provider, and other visits require ordering/referring providers' NPIs, Freibauer explained. She reminded practices, however, that the inclusion of the referring doctor's NPI does not guarantee payment--you'll also have to meet the other requirements of each specific service based on Medicare guidelines.

Plus: You'll also have to add the ordering/referring physician's NPI to claims even when the ordering physician is also the performing physician, Freibauer noted.

3. Know Where to Place the NPI: When you fill out a paper CMS-1500 form, you'll put the name of the ordering/referring physician in Item 17, and you'll add that provider's NPI to Item 17b on the claim. Leave Item 17a blank.

4. Don't Add Credentials: "I want to stress that when entering the name of the ordering or referring physician or NPP on your paper or your electronic claim, do not include titles such as 'doctor' or 'MD,' as these will cause problems with your claim," Freibauer said. In addition, you don't want to include name suffixes (such as "Jr.").

5. Avoid Nicknames: If you report the ordering/referring doctor's name as "Bob" but the PECOS system has him listed as "Robert," the claim will fail the edit.

6. Remove apostrophes, Periods, and Commas: If the doctor's last name is O'Connell, "Remove the apostrophe and don't leave a blank space between the O and the C," Freibauer said. The same goes for periods or commas that you would normally add to a physician's name.

7. Keep that 'caps lock' key pressed: Be sure to use all uppercase letters when reporting the ordering/referring provider's name on electronic claims. "I verified with our EDI department and our claims processing department that claims that are not in all uppercase letters will result in claim denials," Freibauer said.

8. Don't Look to ABNs As Safety Net: If you can't get the referring/ordering physician's NPI, you should not simply ask the patient to sign an advance beneficiary notice (ABN) and expect the patient to pay for the service. "Using an ABN to shift responsibility to the beneficiary is not an appropriate practice and it's not an acceptable practice," Freibauer said.

9. Make Sure You Are in PECOS: Some practices have spent so much time researching whether their referring/ordering providers are in PECOS that they haven't yet confirmed that they are in there themselves. If you can't find your PECOS record in the CMS file (see #10 below for information on how to find it), contact your provider contact center for help.

10. Prepare now: Get ready for the edits before the calendar turns to 2011 by ensuring that physicians and NPPs from whom you accept orders and referrals are of the type and specialty eligible to order and refer under Medicare, and have current enrollment records in PECOS. If you are unsure of whether your information is in the PECOS system, you can check the file, which contains approximately 800,000 practitioner records, on the CMS Web site (http://www.cms.hhs.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp).