Radiology Coding Alert

Ensure provider has current Medicare enrollment record and valid NPI.

Effective Jan. 6, 2014, CMS will turn on the Phase 2 edits for claims with ordering/referring providers. If the provider does not pass the edits, your claim will be denied. Your practice may be handling referrals for radiological services. You may be concerned that your billing provider must not lose payment for items or services furnished based on the order or referral.

Here are answers to five important questions that can help your claim pass the ordering/referring provider edits.

1. Who is a referring provider? You will come across the term ‘ordering/referring provider’ on Part B claims. This refers to the person (physician or a non-physician provider) who ordered or referred an item or service reported in that claim. Physician assistants, clinical nurse specialists, nurse practitioners, clinical psychologists, and fellows may order or refer. Interns and residents can also order or refer. You need to check with laws in your state. If your state provides provisional licenses or permits the interns and residents to order or refer, CMS will accept the same and allow the interns and residents to enroll and order.

2. How do the edits affect the professional and technical components? The phase 2 edits apply to the technical component of imaging services. The professional component will be excluded from the edits. However, if you are billing globally, both components will be impacted by the edits. This implies that the entire claim will be denied if it doesn’t meet the ordering and referring requirements. You can ensure that you bill for the providers and suppliers separately to prevent a denial for the professional component.

3. Does the Advance Beneficiary Notice apply? Your claim will be rejected if it fails the referring edit. This happens when you identify an ordering/referring provider on the claim and the required matching NPI is missing. This does not expose a Medicare beneficiary to liability.

This is in consensus with the Affordable Care Act requirement according to which ‘physicians and eligible professionals enroll in Medicare to order and certify certain Medicare covered items and services, including home health, DMEPOS, imaging and clinical laboratory.’

4. What you need to do? Since your radiologist will order services for Medicare beneficiaries, make sure your provider has a Medicare enrollment record. If not, you need to request the provider to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O). For more, check with CMS, http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html.

According to section 6405 of The Affordable Care Act, “Physicians Who Order Items or Services are required to be Medicare Enrolled Physicians or Eligible Professionals.” If your physician is not already enrolled, you will need to submit an enrollment application. This will need verification. Make sure you do not delay this application or the application may not be processed prior to the implementation date of the ordering/referring Phase 2 provider edits.

There are two important things you need to ensure for your physician to be eligible to order or refer for Medicare beneficiaries:

1. Your physician should have a valid NPI
2. Your physician should establish a Medicare enrollment record

Note: when listing the NPI, you should enter the NPI for the physician or non-physician practitioner and not for the organization or group practice that employs the physician or non-physician practitioner who generated the order or referral.

Remember: When submitting the CMS-1500 or the CMS-1450, you only include the first and last name as it appears on the ordering and referring file. Do not list any middle names, initials, suffixes, or credentials in the ordering/referring fields. You can access the ordering file on http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html.

5. How does this affect the claims for capped rental items? When Phase 2 denial edits are implemented, claims for capped rental items will continue to be paid for up to 13 months from the implementation date, i.e. Jan. 6, 2014. This will allow coverage for the duration of the capped rental period.