Business Briefs: Physicians and NPPs: Maintain Medicare Referring, Ordering, & Supervising Capabilities

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   A well-known adage claims “the most expensive medical implement is the physician’s pen.” In actuality, if physicians and non-physician practitioners (NPPs) do not write a referral and/or an order, medical care cannot be provided to Medicare beneficiaries. Only physicians and certain types of NPPs are eligible to order or refer items or services for Medicare beneficiaries. Those qualified healthcare professionals who typically order or refer for chronic wound care services are:     • physicians (doctor of medicine or osteopathy, doctor of podiatric medicine)     • physician assistants     • clinical nurse specialists     • nurse practitioners     • interns, residents, and fellows.

Ordering and Referring History

  As of Jan. 1, 1992, physicians or suppliers who bill Medicare for a service or item must show the name and unique identifier of the attending physician on the claim if the service or item was the result of an order or referral. Effective May 23, 2008, the unique identifier was selected as the National Provider Identifier (NPI). Beginning in October 2009, the Centers for Medicare & Medicaid Services (CMS) began to alert providers who submitted Medicare claims that the identification of the ordering/referring provider was missing, incomplete, or invalid, or that the ordering/referring provider was not eligible to order or refer. The alerts on the claims were different for various providers. The informational messages that Part B providers and suppliers found on their adjusted claims were:     N264: Missing/incomplete/invalid ordering provider name.     N265: Missing/incomplete/invalid ordering provider primary identifier.   The informational message that durable medical equipment (DME) suppliers found on their adjusted claims was:     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.   The informational message that Part A home health agencies found on their adjusted claims was:     N272: Missing/incomplete/invalid other payer attending provider identifier.   In December 2009, CMS added NPIs to more than 200,000 Provider Enrollment, Chain, and Ownership System (PECOS) enrollment records of physicians and NPPs who were eligible to order and refer, but who had not updated their PECOS enrollment records with their NPIs. On Jan. 28, 2010, CMS made “ordering referring reports” available to the public that contain the NPIs and the names of physicians and NPPs who have current enrollment records in PECOS and who are of a type/specialty that is eligible to order and refer. Providers can now verify if a physician/NPP who orders an item or service or who submits a referral has a PECOS enrollment record (www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html).   Enrolled physicians/NPPs are listed in alphabetical order by last name. The ordering referring report is replaced each week to ensure accuracy. NOTE: Providers could receive an order or a referral from a physician or an NPP who just completed his/her Medicare enrollment and who is not listed in the current week’s report. Check the following week’s report to verify if he/she is listed. Section 6405 (Physicians Who Order Items or Services are Required to be Medicare Enrolled Physicians or Eligible Professionals) of the March 2010 Affordable Care Act requires physicians or other eligible professionals who order or refer items or services for Medicare beneficiaries to have a Medicare enrollment record. They can accomplish this very important task by using the PECOS online or by completing the paper enrollment application (CMS -8550). NOTE: Those physicians or NPPs who don’t have a current Medicare enrollment record should enroll now.

May 1: Ordering and Referring Edits

  To help protect Medicare beneficiaries and the integrity of the Medicare program, effective May 1, CMS will activate ordering/referring claim edits. These edits will determine whether or not the ordering/referring provider:     1. Has a current Medicare enrollment record that contains a valid NPI [name and NPI must match] and     2. Is of a provider type that is eligible to order or refer for Medicare beneficiaries.   These edits will deny Part B, DME supplier, and Part A home health agency claims as non-covered services. When Part B providers’ and suppliers’ claims are denied due to the ordering/referring edits, the following denial messages will be on the claims:     254D: Referring/Ordering Provider         Not Allowed to Refer.     255D: Referring/Ordering         Provider Mismatch.     289D: Referring/Ordering Provider         NPI Required.   When Part A home health agency claims are denied due to ordering/referring edits, the agency will receive one of two possible edits: 37236 or 37237. The message on both edits will be the same:   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 PECOS or the specialty code is not a valid eligible code.

Wound Care Ordering/Referring Tactics

  Wound care physicians/NPPs who order/refer items or services should ensure:     1. They have a current Medicare enrollment record by:       a.Checking the ordering/referring report to be sure they are on the report and that it contains their NPI.       b. Contacting their designated Medicare enrollment contractor and asking if he/she has an enrollment record in Medicare and it if contains their NPI.       c. Using the online PECOS to look for their Medicare enrollment record.     2. They submit an application for Medicare enrollment if they are not currently enrolled.     3. They submitted an opt-out affidavit to a Medicare contractor within their specific jurisdiction, if they are physicians who have opted out of Medicare but wish to order items or services for Medicare beneficiaries.     4. They are a type/specialty that can order or refer items of service for Medicare beneficiaries.   Wound care physicians, hospital-based outpatient wound care departments (HOPD), DME suppliers, and Part A home health agencies that bill Medicare for items and services that were ordered or referred should ensure:     1. The physicians and NPPs from whom they accept orders and referrals have current Medicare enrollment records and are of the type/specialty eligible to order or refer in the Medicare program.     2. They are correctly spelling the ordering/referring provider’s name.     3. Their claims are properly completed:       a. Do not use “nicknames” on the claim.       b. Do not enter a credential or title (eg, “Dr.”) in a name field.       c. On paper CMS 1500 claims, in item 17, enter the ordering/referring provider’s first name first, and last name second.       d. Do not enter the name and NPI of an organization, such as a group practice that employs the physician or NPP. Ensure the name and NPI belong to the specific physician or NPP who ordered/referred.       e. Make sure the qualifier in the electronic claim is a person, not an organization.

Coverage of Outpatient Therapeutic Services Incident to a Physician’s Service

  Hospital outpatient therapeutic services and supplies must be furnished under the order of a physician or other practitioner practicing within the extent of the Social Security Act, the Code of Federal Regulations, and state law. They must be furnished by hospital personnel under the appropriate supervision of a physician or an NPP. This does not mean that each occasion of service by an NPP must also be the occasion of the actual rendition of a personal professional service by the physician responsible for care of the patient. However, during any course of treatment rendered by auxiliary personnel, the physician must personally see the patient periodically and sufficiently often to assess the course of treatment and the patient’s progress and, when necessary, to change the treatment regimen. A hospital service or supply would not be considered incident to a physician’s service if the attending physician merely wrote an order for the services or supplies and referred the patient to the hospital without being involved in the management of that course of treatment. CMS requires direct supervision by an appropriate physician or NPP in the provision of all therapeutic services to hospital outpatients and critical-access hospital (CAH) outpatients. CMS expects that hospitals already have the credentialing procedures, bylaws, and other policies in place to ensure that hospital outpatient services furnished to Medicare beneficiaries are being provided only by qualified practitioners in accordance with all applicable laws and regulations.   Direct supervision means the physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure. The physician or NPP does not have to be present in the room when the procedure is performed or within any other physical boundary as long as he or she is immediately available. Immediate availability requires the immediate physical presence of the supervisory physician or NPP. The supervisory physician or NPP cannot be performing another procedure or service that he or she could not interrupt, may not be so physically distant from the location where the therapeutic services are being furnished that he or she could not intervene right away, etc. The hospital or supervisory practitioner must judge the supervisory practitioner’s relative location to ensure that he or she is immediately available. The supervisory physician or NPP must have, within his or her state’s scope of practice and hospital-granted privileges, knowledge, skills, ability, and privileges to perform the service or procedure. The supervisory responsibility is more than the capacity to respond to an emergency. It includes the ability to take over performance of a procedure or provide additional orders. CMS would not expect that the supervisory physician or NPP would make all decisions unilaterally without informing or consulting the patient’s treating physician or NPP.

Summary

  Physicians and NPPs who work in organized wound care programs receive referrals and refer patients for many other services and products that are separately billable to the Medicare program. Likewise, these same physicians and NPPs must write the orders for all services, procedures, and products that are provided/supplied to patients with chronic wounds. Therefore, these physicians and NPPs must ensure they are in the Medicare enrollment system. They must also verify that referring physicians have an NPI number and are listed in the Medicare enrollment system. This will ensure that Medicare claims will not be denied during the ordering/referring edits. Physicians and NPPs who are scheduled to provide direct supervision in HOPDs should have an NPI number and should be listed in the Medicare enrollment system. They must also be immediately available to assess new problems, to perform procedures, and to write orders before a care plan is changed and before a new/different service, procedure, or item is provided to the patient. Kathleen Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She can be reached for questions and consultations at 561-964-2470 and kathleendschaum@bellsouth.net.