Medicare postpones enforcement of new ordering/referring rule

April 26, 2013

Medicare Part B claims from laboratories, imaging centers and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) suppliers will not be rejected May 1, as planned, if they were not ordered by a physician enrolled in Medicare. The U.S. Centers for Medicare & Medicaid Services (CMS) previously announced May 1 as the date when warnings would be replaced by rejections, but now reports technical difficulties making that change to its claims processing systems.

However, practitioners should still make a point of providing complete ordering/referring practitioner information on CMS 1500 line 17, the CMS warned. Agency officials still plan to begin rejecting claims lacking complete ordering/referring information “in the near future,” according to an email advisory.

Practitioners and their billing staff should also watch Medicare remittance advice for codes indicating claims lacked necessary ordering/referring information, according to the CMS. The agency, over the coming weeks, plans to issue a new deadline after which such claims will be rejected.

A new federal regulation requires the CMS to deny claims for any DMEPOS or services that require the ordering provider to be identified, if that provider is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer the service/item being billed.

Practitioners should put their own names on line 17 (“Name of referring provider or other source”) of the CMS 1500 form even if they are both ordering and providing the eyewear, or ordering performing the test(s), on the claim, according to the CMS. A National Provider Identifier (NPI) should also be provided.

Although a recent Medicare Learning Network Matters article, using terminology common in Medicare documents, indicated the new identification requirement applies to “ordering/referring” providers, the regulation actually applies to any provider who “orders” non-physician items or services for the beneficiary (such as DMEPOS, clinical laboratory services, or imaging services) or ”certifies” patients for home health services, according to the AOA Advocacy Group.

The regulation does not apply to providers who are “referring” patients for physician services, AOA Advocacy Group staff noted.

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