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Medicare Clarifies CMS-1500 Form Rules

Published on Mon May 24, 2004

Mixing up ordering and supervising physicians could lead to violations

If a urologist orders an incident-to service, such as a diagnostic study, but another physician supervises it, don't use the ordering physician's billing number in box 33 or 24K on your CMS-1500 forms. That's the rule that CMS hopes to clarify with a revision to Medicare's Claims Processing Manual, effective May 24. CMS issued the revision and an instruction in Transmittal 148 to "clarify and standardize the method of indicating the ordering and supervising professionals on the CMS-1500."

Ordering and Supervising: Not the Same

The instruction takes a cue from the preamble of the proposed rule for the Medicare Physician Fee Schedule on Nov. 1, 2001, which states, "The billing number of the ordering physician (or other practitioner) should not be used if that person did not directly supervise the auxiliary personnel." As of May 24, this rule is incorporated into the CMS Claims Processing Manual.

The update also further clarifies where to enter the  physicians' Provider Information Numbers and names on the CMS-1500 when both an ordering provider and a supervising provider are involved in a service.

The changes affect Chapter 26, Section 10.4 in the claims processing manual, and cover Items 14-33 ("Provider of Service or Supplier Information") on the CMS-1500. Under the instructions for Item 17 (the name of the referring or ordering physician), the revised manual provides these definitions:

  •  Referring physician -- a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
  •  Ordering physician -- a physician or, when appropriate, a nonphysician practitioner who orders nonphysician services for the patient. ... Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident-to that physician's or nonphysician practitioner's service.

    Key: CMS has revised the definition of "ordering physician" to emphasize that an NPP can be the ordering provider for incident-to services, just as an MD can.

    Reporting Incident-To Services

    When a nonphysician practitioner (NPP) is billing a medical service incident-to a physician in the same group, but that physician is out of the office when the NPP sees the patient, a second physician in the same group may provide the necessary supervision to allow and meet the requirements for an incident-to visit. However, this may confuse a coder. Whose names should you use, and where should you place the names on the CMS-1500?

    The change request also adds this paragraph: "When a service is incident-to the service of a physician or non-physician practitioner, the name and assigned UPIN ... of the physician or nonphysician practitioner who performs the initial service and orders the nonphysician service must appear in items 17 and 17a."

    The other major change is to the instructions for Item 31 (signature of provider or supplier), in which this paragraph now appears: "In the case of a service that is provided incident-to the services of a physician or non-physician practitioner, when the ordering physician or nonphysician practitioner is directly supervising the service ... the signature of the ordering physician or non-physician practitioner shall be entered in item 31."

    Apply the New Rules

    "When the ordering physician or nonphysician practitioner is not supervising the service," the new text continues, "then enter the signature of the physician or nonphysician practitioner providing the direct supervision in item 31."

    Translation: If the urologist or NPP who ordered the service isn't supervising it, get the signature of whoever is supervising the service for item 31, says India L. Murdaugh, CPC, business manager for McIver Urological Clinic in Jacksonville, Fla. The same rule holds for item 24K -- enter the supervising physician or NPP's UPIN or NPI.

    Real-World Example: In a five-urologist practice, Dr. A sees a patient who has tried pelvic muscle exercises to treat incontinence, with no success. Dr. A orders biofeedback. A nurse performs the treatment (90901, Biofeedback training by any modality) while Dr. A is on vacation; Dr. B. supervises the procedure. Since Dr. A is the ordering physician, enter her name in Item 17 and her UPIN or NPI in Item 17a. Enter Dr. B's UPIN or NPI in Item 24K and have him sign in Item 31.

    Lesson learned: Keep the ordering and supervising physicians straight -- or face denied claims and compliance violations. For more details, visit the Medicare Web site     www.cms.hhs.gov/medlearn/matters.

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