Ordering/Referring ServicesIf you bill laboratory services to Medicare, you must obtain the treating physician’s signed order (or progress note to support intent to order) and documentation to support medical necessity for the ordered service(s). These records may be housed at another location (for example, a nursing facility, hospital, or referring physician office). While a physician order is not required to be signed, the physician must clearly document in the medical record his or her intent that the test be performed.
Providers who order diagnostic services for Medicare patients must also maintain documentation of the order/intent to order and medical necessity of the service(s) in the patient’s medical record. Keep this information available and submit it, along with the test results, upon request for a Medicare claim review. For information on “access to documentation,” refer to MLN Matters® Article MM9112 Clarification of Ordering and Certifying Documentation Maintenance Requirements.
Cooperation among ordering/referring providers and facilities that perform diagnostic tests is crucial to reducing errors and avoiding claim denials
Laboratory Billing – Referring Provider
The ordering or referring provider’s name should be included on all CMS-1500 claims submitted with laboratory services in boxes 17, 17a, 17b or its electronic equivalent.
How Should I Report Ordering/Referring Physicians or Non-Physicians on Claims?
For Medicare Part B and DMEPOS providers, the ordering/referring information should be reported on the line, “Name of Referring Provider or Other Source,” along with the referring provider’s NPI (lines 17 and 17b of Form CMS-1500). For Medicare Part A HHAs, the ordering/referring information should be reported on the line, “Attending,” along with the attending provider’s NPI (line 76 of Form CMS-1450). The ordering/referring provider’s name must match the name found in the provider’s PECOS enrollment record.
Why Do I Currently Receive Informational Messages when I Submit a Claim for Ordering/Referring?
Laboratories, imaging centers, DMEPOS suppliers, and HHAs receive this message if the ordering/referring or attending physician/non-physician practitioner reported on the claim does not meet the three basic requirements for ordering/referring. In the future, Medicare Contractors (Part A/B Medicare Administrative Contractors [MACs], Durable Medical Equipment [DME] MACs, and Part A Regional Home Health Intermediaries [RHHIs]) will activate automatic edits to deny claims that do not meet the three basic requirements for ordering/referring providers. CMS will give providers at least 60 days notice before the ordering/referring provider claim edit is applied. Physicians and others who are eligible to order/refer items or services need to be enrolled in Medicare and must be of a specialty that is eligible to order and refer. If the billed service requires an ordering/referring provider and the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, but is not enrolled in Medicare, the claim will not be paid. In addition, if the ordering/referring provider is on the claim, but is not of a specialty that is eligible to order/refer, the claim will not be paid. CMS encourages laboratories, imaging centers, DMEPOS suppliers, and HHAs to work with their ordering/referring providers to ensure they are prepared for this change.
1. What are the ordering and referring edits?
The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B clinical laboratory and imaging, DME, and Part A HHA claims) (1) has a current Medicare enrollment record and contains a valid NPI (the name and NPI must match), and (2) is of a provider type that is eligible to order or refer for Medicare beneficiaries (see list above).
2. Why did Medicare implement these edits?
These edits help protect Medicare beneficiaries and the integrity of the Medicare program.
3. How and when will these edits be implemented*
These edits were implemented in two phases:
Phase 1 -Informational messaging: Began October 5, 2009, to alert the billing provider that the identification of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication. The informational messages used are identified below:
For Part B providers and suppliers who submit claims to carriers:
N264 Missing/incomplete/invalid ordering provider name
N265 Missing/incomplete/invalid ordering provider primary identifier
For adjusted claims, the Claims Adjustment Reason Code (CARC) code 16 (Claim/service lacks information which is needed for adjudication.) is used.
DME suppliers who submit claims to carriers (applicable to 5010 edits):
N544
Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future For Part A HHA providers who order and refer, the claims system initially processed the claim and added the following remark message:
N272 Missing/incomplete/invalid other payer attending provider identifier
For adjusted claims the CARC code 16 and/or the RARC code N272 was used.
CMS has taken actions to reduce the number of informational messages. In December 2009, CMS added the NPIs to more than 200,000 PECOS enrollment records of physicians and non-physician practitioners who are eligible to order and refer but who had not updated their PECOS enrollment records with their NPIs.1 On January 28, 2010, CMS made available to the public, via the Downloads section of the “Ordering Referring Report” page on the Medicare provider/supplier enrollment website, a file containing the NPIs and the names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer. The file, called the Ordering Referring Report, lists, in alphabetical order based on last name, the NPI and the name (last name, first name) of the physician or non-physician practitioner. To keep the available information up to date, CMS will replace the Report twice a week. At any given time, only one Report (the most current) will be available for downloading. To learn more about the Report and to download it, go to https://data.cms.gov on the CMS website.
Phase 2: Effective January 6, 2014, CMS will turn on the Phase 2 edits. In Phase 2, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.
Below are the denial edits for Part B providers and suppliers who submit claims to Part A/B MACs, including DME MACs:
254D or 001L
Referring/Ordering Provider Not Allowed To Refer/Order
255D or 002L
Referring/Ordering Provider Mismatch
CARC code 16 or 183 and/or the RARC code N264, N574, N575 and MA13 shall be used for denied or adjusted claims.
Claims submitted identifying an ordering/referring provider and the required matching NPI is missing (edit 289D) will continue to be rejected. CARC code 16 and/or the RARC code N265, N276 and MA13 shall be used for rejected claims due to the missing required matching NPI.
Below are the denial edits for Part A HHA providers who submit claims: 37236 This reason code will assign when:
* The statement “From” date on the claim is on or after the date the phase 2 edits are turned on
* The type of bill is ’32’ or ’33’
* Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from EPCOS or the specialty code is not a valid eligible code
37237 This reason code will assign when:
* The statement “From” date on the claim is on or after the date the phase 2 edits are turned on
* The type of bill is ’32’ or ’33’
* The type of bill frequency code is ‘7’ or ‘F-P’
* Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code
Effect of Edits on Providers
I order and refer. How will I know if I need to take any sort of action with respect to these two edits*
In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by Medicare for furnishing the item or service that you ordered or referred, you, the ordering/referring provider, need to ensure that:
a . You have a current Medicare enrollment record.
* If you are not sure you are enrolled in Medicare, you may:
i. Check the Ordering Referring Report and if you are on that report, you have a current enrollment record in Medicare and it contains your NPI;
ii. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in Medicare and it contains the NPI; or
iii . Use Internet-based PECOS to look for your Medicare enrollment record (if no record is displayed, you do not have an enrollment record in Medicare).
iv . If you choose iii, please read the information on the Medicare provider/supplier enrollment web page about Internet-based PECOS before you begin.
b . If you do not have an enrollment record in Medicare.
* You need to submit either an electronic application through the use of internet-based PECOS or a paper enrollment application to Medicare.
i. For paper applications – fill it out, sign and date it, and mail it, along with any required supporting paper documentation, to your designated Medicare enrollment contractor.
ii. For electronic applications – complete the online submittal process and either e-sign or mail a printed, signed, and dated Certification Statement and digitally submit any required supporting paper documentation to your designated Medicare enrollment contractor.
iii . In either case, the designated enrollment contractor cannot begin working on your application until it has received the signed and dated Certification Statement.
iv . If you will be using Internet-based PECOS, please visit the Medicare provider/supplier enrollment web page to learn more about the web-based system before you attempt to use it. Go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html, click on “Internet-based PECOS” on the left-hand side, and read the information that has been posted there. Download and read the documents in the Downloads Section on that page that relate to physicians and non-physician practitioners. A link to Internet-based PECOS is included on that web page.
v. If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using Internet-based PECOS or by completing the paper enrollment application (CMS-855O). Enrollment applications are available via internet-based PECOS or .pdf for downloading from the CMS forms page (http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/index.html).
c. You are an opt-out physician and would like to order and refer services. What should you do*
If you are a physician who has opted out of Medicare, you may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to a Medicare contractor within your specific jurisdiction. Your opt-out information must be current (an affidavit must be completed every 2 years, and the NPI is required on the affidavit). Note, however, that prior to enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician/practitioner opt-out affidavits were only effective for 2 years. As a result of changes made by MACRA, valid opt-out affidavits signed on or after June 16, 2015, will automatically renew every 2 years. If physicians and practitioners that file affidavits effective on or after June 16, 2015, do not want their opt-out to automatically renew at the end of a two year opt-out period, they may cancel the renewal by notifying all Medicare Administrative Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.
d. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries. When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty (Chiropractors are excluded) and only the non-physician practitioner specialties listed above in this article are eligible to order or refer in the Medicare program.
e . I bill Medicare for items and services that were ordered or referred. How can I be sure that my claims for these items and services will pass the Ordering/Referring Provider edits?
* You need to ensure that the physicians and non-physician practitioners from whom you accept orders and referrals have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program.
If you are not sure that the physician or non-physician practitioner who is ordering or referring items or services meets those criteria, it is recommended that you check the Ordering Referring Report described earlier in this article.
* Ensure you are correctly spelling the Ordering/Referring Provider’s name.
* If you furnished items or services from an order or referral from someone on the Ordering Referring Report, your claim should pass the Ordering/Referring Provider edits.
* The Ordering Referring Report will be replaced twice a week to ensure it is current. It is possible that you may receive an order or a referral from a physician or non-physician practitioner who is not listed in the Ordering Referring Report but who may be listed on the next Report.
f. Make sure your claims are properly completed.
* On paper claims (CMS-1500), in item 17, only include the first and last name as it appears on the Ordering and Referring file found on CMS.gov.
* On paper claims (CMS-1450), you would capture the attending physician’s last name, first name and NPI on that form in the applicable sections. On the most recent form it would be fields in FL 76.
* On paper claims (CMS-1500 and CMS-1450), do not enter “nicknames”, credentials (e.g., “Dr.”, “MD”, “RPNA”, etc.) or middle names (initials) in the Ordering/Referring name field, as their use could cause the claim to fail the edits.
* Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral.
* Make sure that the qualifier in the electronic claim (X12N 837P 4010A1) 2310A NM102 loop is a 1 (person). Organizations (qualifier 2) cannot order and refer.
If there are additional questions about the informational messages, Billing Providers should contact their local A/B MAC, or DME MAC.
Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. This is consistent with the preamble to the final rule which implements the Affordable Care Act requirement that 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.
g. What if my claim is denied inappropriately?
If your claim did not initially pass the Ordering/Referring provider edits, you may file an appeal through the standard claims appeals process or work through your A/B MAC or DME MAC.
h. How will the technical vs. professional components of imaging services be affected by the edits* Consistent with the Affordable Care Act and 42 CFR 424.507, suppliers submitting claims for imaging services must identify the ordering or referring physician or practitioner. Imaging suppliers covered by this requirement include the following: IDTFs, mammography centers, portable x-ray facilities and radiation therapy centers. The rule applies to the technical component of imaging services, and the professional component will be excluded from the edits. However, if billing globally, both components will be impacted by the edits and the entire claim will deny if it doesn’t meet the ordering and referring requirements. It is recommended that providers and suppliers bill the global claims separately to prevent a denial for the professional component.
i. Are the Phase 2 edits based on date of service or date of claim receipt* The Phase 2 edits are effective for claims with dates of service on or after January 6, 2014.
j. A Medicare beneficiary was ordered a 13-month DME capped rental item. Medicare has paid claims for rental months 1 and 2. The equipment is in the 3rd rental month at the time the Phase 2 denial edits are implemented. The provider who ordered the item has been deactivated. How will the remaining claims be handled*
Claims for capped rental items will continue to be paid for up to 13 months from the physician’s date of deactivation to allow coverage for the duration of the capped rental period.
Ordering/Referring Physician Checklist for Home Health AgenciesTo receive Medicare reimbursement for home health services, the physician that ordered/ referred the patient for home health care must be enrolled in the Medicare program, and have an enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS). Fiscal Intermediary Standard System (FISS) edits are in place to ensure that the attending and certifying physician information reported on a home health claim meets this requirement. To avoid claim denials, follow the steps below.
Step 1: Verify the physician’s NPI, last name, and first name using the “Medicare Ordering and Referring File” available at https://data.cms.gov/
NOTE: This file is updated by CMS twice a week, so it is important to verify the physician information prior to submitting each billing transaction.
Step 2: Home health services must be ordered or referred by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). To verify the credentials of the ordering/referring physician, search the physician’s NPI using the NPPES website, https://npiregistry.cms.hhs.gov/. Refer to Page 3 of this tool for a list of valid home health ordering/referring specialty codes.
Step 3: Prior to submitting the Request for Anticipated Payment (RAP) and claim, verify the following information matches the Ordering/Referring File exactly.
• The NPI of the physician.
• The first four letters of the physician’s last name
• The first letter of the physician’s first name
COMPLYING WITH DOCUMENTATION REQUIREMENTS FOR LABORATORY SERVICES
The majority of improper payments for laboratory services identified by the Comprehensive Error Rate Testing (CERT) Program were due to insufficient documentation. Insufficient documentation means that something was missing from the medical records. For example, the medical record was missing:
** Documentation to support intent to order, such as a signed progress note, signed office visit note, or signed physician order
** Documentation to support the medical necessity of ordered services The Medicare Learning Network® (MLN) and the CERT Part A and Part B (A/B) Medicare Administrative Contractor (MAC) Outreach & Education Task Force developed this publication. The CERT Program estimates improper payments in the Medicare FFS Program. The CERT Program reviews a random sample of all Medicare FFS claims to determine if they met Medicare coverage, coding, and billing rules. Once the CERT Program identifies a claim as part of the sample, it requests the associated medical records and other pertinent documentation from the provider or supplier who submitted the claim. Medical review professionals review the submitted documentation to see if the claim was paid or denied appropriately.
Document Requirements
For more information about signature requirements and attestation statements, refer to Complying with Medicare Signature Requirements.
** The physician who is treating the beneficiary must order all diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests. The physician who treats the beneficiary is the physician who furnishes a consultation, treats a beneficiary for a specific medical problem, and uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician are not reasonable and necessary.
** When completing progress notes, the physician should clearly indicate all tests to be performed (for example, “run labs” or “check blood” by itself does not support intent to order).
** Documentation in the patient’s medical record must support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). Submit these medical records in response to a request for medical records.
** Keep these records available upon request: Progress notes or office notes
Physician order/intent to order Laboratory results
Attestation/signature log for illegible signature(s) Signature Requirements
** Unsigned physician orders or unsigned requisitions alone do not support physician intent to order.
** Physicians should sign all orders for diagnostic services to avoid potential denials.
** If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response. For an example of a signature attestation statement, visit the CERT Provider website. If the signature is illegible, an attestation statement or signature log is acceptable.
** Attestation statements are not acceptable for unsigned physician orders/requisitions.
Medicare Enrollment Guidelines for Ordering/Referring Providers
Ordering/Referring Terms
Medicare Part B claims use the term “ordering/referring provider” to identify the person who ordered, referred, or certified an item or service reported in that claim.
The following are technically correct terms:
1. A provider “orders” non-physician items or services for the beneficiary, such as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); clinical laboratory services; or imaging services.
2. A provider “certifies” home health services for a beneficiary. The health care industry uses the terms “ordered,” “referred,” and “certified” interchangeably. To view comments about this terminology, read the Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements Final Rule.
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Who Are Ordering/Referring Providers?
Any Medicare-enrolled Part B provider, DMEPOS supplier, or Part A Home Health Agency (HHA) provider may submit claims with ordering/referring information.
The ordering/referring provider must meet these three basic requirements:
1. Have an individual National Provider Identifier (NPI)
NOTE Organizational NPIs do not qualify and cannot order/refer.
2. Be enrolled in Medicare in either an “approved” or an “opt-out” status
3. Be of a specialty type that is eligible to order/refer Denial of Ordering/Referring Claims
MACs deny the following claims if they lack a valid individual NPI:
• Claims from clinical laboratories for ordered tests
• Claims from imaging centers for ordered imaging procedures
• Claims from suppliers of DMEPOS for ordered DMEPOS
• Claims from Part A HHAs
If a billed service requires an ordering/referring provider and one is not present on the claim, the MAC will deny the claim. In addition to a valid individual NPI, the claim must contain the ordering/referring provider’s name as it appears in the Provider Enrollment, Chain, and Ownership System (PECOS).
How Do I Enroll in Medicare as an Ordering/Referring Provider?
CMS allows certain physicians and other eligible NPPs to enroll in Medicare for the sole purpose of ordering/referring specific items or services for Medicare beneficiaries. Those who enroll as ordering/referring providers only may not seek or receive reimbursement from Medicare for services they furnish. They do not have billing privileges for submitting claims to Medicare directly for services provided to Medicare beneficiaries.
Medicare Ordering/Referring Provider Requirements
The Affordable Care Act, Section 6405, requires physicians and other eligible Non-Physician Practitioners (NPPs) to enroll in the Medicare Program to order/refer items or services for Medicare beneficiaries, including those physicians and other eligible NPPs who do not and will not send claims to a Medicare Contractor for the services they furnish.
Effective May 1, 2013, Medicare will deny claims for all covered Medicare Part B, durable medical equipment, orthotics, and supplies (DMEPOS), and Part A home health agency (HHA) services when the ordering/referring provider is not enrolled in Medicare and the claim does not list the national provider identification (NPI) number for the ordering or referring provider.
Providers eligible to order/refer services:
* Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry and optometrists)
* Physician Assistants
* Clinical Nurse Specialists
* Nurse Practitioners
* Clinical Psychologists
* Interns, Residents and Fellows
* Certified Nurse Midwives
* Clinical Social Workers
This includes interns, residents, fellows, and those who are employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD), or the Public Health Service (PHS) who order or refer items or services for Medicare beneficiaries. State-licensed residents may enroll to order or refer and may be listed on claims. Claims from unlicensed interns and residents may still specify the name and NPI of the teaching physician. If States provide provisional licenses or otherwise permit residents to practice or order and refer services, interns and residents are allowed to enroll to order and refer consistent with State law.
Limitations:
* Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.
* Optometrists may only order and refer DMEPOS products/services, and laboratory and X-Ray services payable under Medicare Part B. Providers eligible to order/refer for Medicare Part A Home Health Agency (HHA) services:
* Doctors of Medicine or Osteopathy
* Doctors of Podiatric Medicine
Claims for HHA services ordered by any other practitioner specialty will be denied.
Informational Messages
Providers billing services that require the reporting of an ordering/referring physician or NPP, including laboratories, imaging centers, DMEPOS suppliers, and HHAs get an informational message if the ordering/referring or attending physician/NPP reported on the claim does not meet the three basic requirements for ordering/referring. Currently, informational messages alert the billing provider that the identification of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjusted claim that did not pass the edits indicates the claim/service lacked information that was needed for adjudication. The informational messages used are identified below:
For Part B providers who submit claims:
N264 Missing/incomplete/invalid ordering provider name
N265 Missing/incomplete/invalid ordering provider primary identifier
For DME suppliers who submit claims:
N544 Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future
For Part A HHA providers who submit claims:
N272 Missing/incomplete/invalid other payer attending provider identifier If you have received these messages on your remittance advice, the physician/non-physician practitioner that ordered/referred the services may not:
* Be enrolled in Medicare, either in an approved or an opt-out status
* Have an Individual National Provider Identifier (NPI)
* Be of a specialty type that is eligible to order and refer On and after May 1, 2013 your claims will be denied if the physician/NPP thatordered/referred the services you billed does not meet the above requirements
Denial Messages
Effective May 1, 2013, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.
For Part B providers and DME suppliers who submit claims:
254D Referring/Ordering Provider Not Allowed To Refer
255D Referring/Ordering Provider Mismatch
289D Referring/Ordering Provider NPI Required
CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted claims.
http://www.cms1500claimbilling.com/2010/06/who-is-referring-physician-and-ordering.html
