Who Is the Referring Physician and Ordering Physician in Box 17?
In the CMS-1500 claim form, Box 17 is where you report the referring and ordering physician (or non-physician practitioner) for the services you’re billing. Properly filling out this box is important because it helps Medicare and other insurers verify who is responsible for ordering or referring the service, ensuring correct billing and reducing the risk of claim rejections.
1. What Information Goes in Box 17?
Box 17 is divided into two parts:
- Item 17a: This field is no longer used as of May 23, 2008. Leave it blank.
- Item 17b: This field must contain the NPI (National Provider Identifier) of the referring or ordering provider.
Important: Be sure to report the provider’s full name and NPI in Item 17b for every service ordered or referred.
2. Who Is a Referring Physician or Ordering Physician?
A referring physician is one who requests a service for a patient. An ordering physician is someone who requests a test or other service on behalf of the patient, such as ordering laboratory work or prescribing equipment.
Under Medicare rules, any physician or eligible non-physician practitioner who orders or refers a service must be identified in Box 17. This includes:
- Doctors of Medicine (M.D.)
- Doctors of Osteopathy (D.O.)
- Dentists (D.D.S., D.M.D.)
- Podiatrists (D.P.M.)
- Optometrists (within their scope of practice)
- Chiropractors (within their scope of practice)
Non-physician practitioners like physician assistants (PAs) and clinical nurse specialists (CNSs) may also be listed if they’re involved in ordering or referring services, depending on the type of service.
3. Reporting Multiple Providers
If a claim involves multiple referring, ordering, or supervising providers, each provider must be listed on a separate CMS-1500 form. Ensure each provider’s name and NPI are correctly entered, or the claim could be denied.
4. Qualifiers (DN, DK, DQ)
As of February 12, 2012, you must also include a qualifier code to specify the role of the provider in Box 17. Use these qualifiers:
- DN: Referring Provider
- DK: Ordering Provider
- DQ: Supervising Provider
This qualifier is important for ensuring the correct processing of claims and avoiding denials for missing or incorrect information.
5. Therapy Services and Certification
For therapy services (e.g., physical therapy, occupational therapy), the certifying provider’s name and NPI must also be reported in Box 17. Since October 1, 2012, this requirement has been mandatory for all claims involving these services, even if they are provided “incident to” a physician’s services.
6. When is Box 17 Required?
You must report a referring or ordering provider in Box 17 whenever the service is ordered or referred. This includes, but is not limited to:
- Durable Medical Equipment (DME)
- Diagnostic Radiology Services
- Laboratory Tests
- Parenteral Nutrition
- Immunosuppressive Drugs
- Consultative Services
For therapy services, Box 17 is also required to include the certifying provider’s information.
7. Common Pitfalls and Issues
- Item 17a: Do not enter any information in this field. As of May 23, 2008, this field is deprecated and should remain blank.
- NPI Mismatch: Ensure that the NPI provided in Item 17b matches the name listed with the NPI registry. A mismatch can lead to claim rejection.
- Invalid Qualifiers: Make sure you use the correct DN, DK, or DQ qualifier. Claims with missing or incorrect qualifiers may be rejected.
- Physician vs. Non-Physician: If you’re reporting a non-physician practitioner (e.g., PA, CNS), make sure they are eligible to order or refer for the service. Non-physician providers are sometimes limited in what they can order or refer.
8. Enforcement of Referring and Ordering Physician Information
Starting January 6, 2014, claims without the correct referring/ordering information (Box 17) are denied under Phase II edits. Initially, these claims were only flagged with informational messages, but now they are rejected, so be sure to include the necessary information to avoid delays.
Conclusion
Accurately completing Box 17 on the CMS-1500 form is essential to ensuring that your claims are processed smoothly. Reporting the correct referring and ordering physician or non-physician practitioner helps avoid delays and denials. By following these updated guidelines, you can be confident that your claims are compliant and ready for submission.
Internal Links for Further Reading
To learn more about the CMS-1500 claim form, check out our other articles:
Resources
CMS-1500 Official Manual by CMS (Centers for Medicare & Medicaid Services)
The official guidelines from CMS are the most authoritative source for anything related to the CMS-1500 form.
National Provider Identifier (NPI) Registry
This link provides access to the NPI registry to help users verify a provider’s NPI.
CMS Claims Processing Manual
For a deeper dive into claims processing rules, you can link to the CMS Claims Processing Manual.
Coding and Billing Guidelines for Medicare
This resource from CMS helps providers navigate the complexities of Medicare billing, including referring and ordering physician rules.
HIPAA Compliance for NPI Use
This page explains HIPAA’s role in using NPIs for claim forms and how to ensure compliance.