CMS Poised to Implement Ordering Referring Physician Policy.

Changes in Final Rule are Beneficial to Practicing Physicians

 

As reported previously, the Centers for Medicare and Medicaid Services (CMS) was planning to implement a policy that any physician who ordered tests and services or referred patients for tests and services would have been required to set up a record in the on-line enrollment system used by Medicare known as PECOS (Provider Enrollment Chain Ownership System).

 

This was an adjunct to the long standing policy that all claims for Medicare covered services and items that are the result of a physician’s order or referral shall include the ordering/referring physician’s name and National Provider Identifier (NPI) on the CMS-1500 claim form

 

Once operational, and if applicable, a practice would need to put the name and NPI of any Ordering or Referring Physician in Box 17 and 17a on their claim form. If that physician did not have a record in PECOS, the claims would be denied.

 

This mandate/requirement was postponed on a number of occasions and was thought to have taken a “back seat” to the many other mandates and initiatives proposed and implemented by the federal government.

 

However, and as of the latest communication from CMS, the Ordering Referring Physician policy is back and will be implemented shortly but with significant changes that are beneficial to practicing physicians. A Final Rule just released by CMS now states that:

 

·        Physicians who order or certify imaging or clinical laboratory services, DMEPOS, or home health services who are enrolled in PECOS OR the legacy Medicare system through a paper 855 enrollment form will satisfy the enrollment requirement.

·        Referrals to physician specialists have been excluded from the final rule.

·        If a state allows a medical resident who has a provisional license, or is otherwise permitted by state law to practice or order and certify services, CMS will permit the resident to enroll in Medicare to order and certify, at the discretion of their institution.

 

CMS will provide a 60 day notice to physicians prior to turning on the edits to deny claims due to lack of an enrollment record and we will keep you apprised of these developments.

 

What Your Practice Needs to Know and Do

 

Physicians who order or certify imaging or clinical laboratory services, DMEPOS, or home health services for Medicare beneficiaries need to:

 

• Enroll or verify enrollment in Medicare now to avoid claim denials. While CMS will give 60 days’ advance notice to the physician community prior to turning on the edits that will deny a claim, the AMA understands that this date will be announced in the near future. Physicians who seek to enroll for ordering or certifying only may do so via PECOS or by submitting the CMS 855-0, a paper enrollment application. Note that this requirement does not extend to physicians who have validly opted-out of Medicare.

• Retain records related to orders or certifications for 7 years. There is no requirement regarding the manner of record retention (i.e. electronic or paper).

 

Important Note:

When this directive goes live, physicians should use their Type I individual NPI in Box 17a when certifying or ordering, even if they are billing and being reimbursed under a Type II or Organizational NPI.

 

For example, if Dr. Smith orders home health services and uses his Type II NPI for John Smith, MD LLC instead of his personal, Type I NPI, the claim may be denied (even if Dr. Smith has reassigned Medicare reimbursement to John Smith, MD LLC).

 

For guidance on this issue, contact us through the Third Party Insurance Help Program.

 

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James A. McNally, CPC

Health Care Consultant Services