CMS 1500 Claim Form: A Deep Dive into Field 17 – Referring and Ordering Physician Definitions

Field 17 on the CMS 1500 claim form is crucial for identifying the referring or ordering physician for services or items provided to a Medicare beneficiary. Accurate completion of Field 17, including the referring physician’s National Provider Identifier (NPI), is a fundamental CMS 1500 field 17 requirement for proper claim processing. All physicians who order services or refer Medicare beneficiaries must meticulously report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 must be used for each.

Understanding Field 17: Referring vs. Ordering Physician

Referring Physician Definition Medicare

A referring physician is a physician who formally requests an item or service for the beneficiary for which payment may be made under the Medicare program. This typically involves cases where a primary care physician sends a patient to a specialist or for specific diagnostic tests.

Ordering Physician NPI CMS 1500: Who Can Order Services?

An ordering physician is a physician, or when appropriate, a non-physician practitioner, who orders non-physician services for the patient. Examples of services that might be ordered include diagnostic laboratory tests (e.g., blood work, X-rays), clinical laboratory tests, pharmaceutical services, durable medical equipment (DME), and services incident to that physician’s or non-physician practitioner’s service.

Clarifying the ‘non-physician practitioner rules’ is vital for accurate Medicare billing. Authorized non-physician practitioners (NPPs) who can order services for Medicare beneficiaries on the CMS 1500 form include Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Certified Nurse-Midwives (CNMs), and Clinical Social Workers (CSWs), among others. Detailed rules regarding their scope of practice and ordering authority can be found in the Pub 100-02, Medicare Benefit Policy Manual, chapter 15.

Defining “Physician” for CMS 1500 Field 17: Key Requirements

Understanding the specific types of physicians recognized under §1861(r) of the Social Security Act is essential for correct completion of Field 17. The term “physician” in this context refers to individuals legally authorized to perform specific functions or actions within their state’s scope of practice. Here are the recognized practitioner types and examples of services they might order or refer:

• Doctor of Medicine or Osteopathy (MD/DO)

  A physician legally authorized to practice medicine and surgery by the State in which they perform such functions or actions. MDs and DOs typically order or refer a wide range of services, including advanced diagnostic imaging (MRI, CT scans), specialist consultations (e.g., cardiology, oncology), hospital admissions, prescription medications, and various therapeutic interventions.

• Doctor of Dental Surgery or Dental Medicine (DDS/DMD)

  A doctor legally authorized to practice dentistry by the State in which they perform such functions and who is acting within the scope of their license. Dental professionals may order diagnostic X-rays for oral health, specific laboratory tests related to dental conditions (e.g., biopsy of oral lesions), or refer patients for specialized oral surgery or orthodontic treatment.

• Doctor of Podiatric Medicine (DPM)

  A doctor of podiatric medicine for purposes of §§(k), (m), (p)(1), and (s) and §§1814(a), 1832(a)(2)(F)(ii), and 1835 of the Act, but only with respect to functions which they are legally authorized to perform as such by the State in which they perform them. DPMs commonly order X-rays or MRIs of the foot and ankle, physical therapy for lower extremity conditions, custom orthotics, or referrals to orthopedic surgeons for complex foot surgeries.

• Doctor of Optometry (OD)

  A doctor of optometry, but only with respect to the provision of items or services described in §1861(s) of the Act which they are legally authorized to perform as a doctor of optometry by the State in which they perform them. ODs may order prescription eyeglasses or contact lenses, diagnostic imaging of the eye (e.g., optical coherence tomography), specific ophthalmic laboratory tests, or referrals to ophthalmologists for medical or surgical eye conditions.

• Chiropractor (DC)

  A chiropractor who is licensed as such by a State (or in a State which does not license chiropractors as such), and is legally authorized to perform the services of a chiropractor in the jurisdiction in which they perform such services, and who meets uniform minimum standards specified by the Secretary. This applies only for purposes of §§1861(s)(1) and 1861(s)(2)(A) of the Act, and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation). For the purposes of §1862(a)(4) of the Act and subject to the limitations and conditions provided above, chiropractor includes a doctor of one of the arts specified in the statute and legally authorized to practice such art in the country in which the inpatient hospital services (referred to in §1862(a)(4) of the Act) are furnished. DCs typically order X-rays of the spine to assess subluxations or refer patients for physical therapy or other rehabilitative services related to musculoskeletal conditions.

The Critical Importance of Accurate Field 17 Completion on the CMS 1500

The precise and accurate completion of Field 17, including the referring or ordering physician’s NPI and other required details, cannot be overstated. Errors in this field can lead to significant repercussions for healthcare providers and billing departments. Potential impacts of incorrect or incomplete information include:

• Claim Denials: Medicare claims lacking correct Field 17 information are frequently denied, leading to payment delays and increased administrative burden.
• Processing Delays: Even if not outright denied, claims with Field 17 discrepancies often require manual review, slowing down reimbursement cycles.
• Compliance Issues: Inaccurate reporting can result in compliance violations, potentially leading to audits, penalties, or even accusations of fraud.
• Disruption of Patient Care: Delays in claim processing can indirectly impact patient care if services are held up due to billing issues.

Ensuring that the referring or ordering physician meets Medicare’s definitions and that their information (including their NPI) is correctly entered on the CMS 1500 form is essential for smooth operations and adherence to Medicare guidelines.

Conclusion: Ensuring Compliance with CMS 1500 Field 17 Requirements

Field 17 of the CMS 1500 form plays a critical role in Medicare billing, serving as a gateway for identifying the responsible referring or ordering physician. Adhering to the detailed definitions and requirements for both physician types and the broader definition of a “physician” under Medicare regulations is paramount for preventing claim denials and ensuring timely reimbursement.

Given the dynamic nature of billing regulations, it is always recommended to consult the latest official CMS manuals and guidance for comprehensive and up-to-date information. Staying informed helps healthcare professionals navigate the complexities of the CMS 1500 claim process and maintain compliance.