Physicians and other eligible professionals (EPs) who order or refer items or services for Medicare beneficiaries must be enrolled in the Medicare Program, according to Section 6405 of the Affordable Care Act. Effective May 1, the Centers for Medicare & Medicaid Services (CMS) will turn on the Phase 2 denial edits – thus denying claims for services or supplies that require an ordering/referring physician or other qualified health care professional but are missing ordering/referring information.
The ordering/referring physician or other health care professional and national provider identifier (NPI) must be identified on the claim, be verified in Medicare’s enrollment records and be of a specialty type that may order/refer the service/item being billed. Ordering and referring physicians and other health care professionals must maintain current information on the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS). To obtain and/or verify a physician or other professional’s NPI, visit the National Plan and Provider Enumeration System (NPPES) website.
The Phase 2 denial edit will affect Medicare Part B claims, including Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider and Part A Home Health Agency (HHA) claims that require an attending physician provider.
More information is available in MLN Matters Article #SE1305, “Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856).”
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