Medicare Referring and Ordering Guidelines

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
September 25th, 2015

If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O). Review the background and additional information below and make sure that your billing staff is aware of these updates.

If when submitting a claim be sure the billing provider identification of the ordering /referring provider is not missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. If it is missing the informational message on an adjustment claim that did not pass the edits will indicate the claim/service lacked information that was needed for adjudication.

Effective January 6, 2014, CMS will turn on the edits to deny Part B clinical laboratory and imaging, DME, and Part A HHA claims that fail the ordering/referring provider edits.

Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record and must be of a specialty that is eligible to order and refer. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record with a valid NPI and must be of a specialty that is eligible to order and refer. If the ordering/referring provider is listed on the claim, the edits will verify that the provider is enrolled in Medicare. The edits will compare the first four letters of the last name. When submitting the CMS-1500 or the CMS-1450, please only include the first and last name as it appears on the ordering and referring file found on http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html on the CMS website.

 Middle names (initials) and suffixes (such as MD, RPNA etc.) should not be listed in the ordering/referring fields.

CMS emphasizes that generally Medicare will only reimburse for specific items or services when those items or services are ordered or referred by providers or suppliers authorized by Medicare statute and regulation to do so. Claims that a billing provider or supplier submits in which the ordering/referring provider or supplier is not authorized by statute and regulation will be denied as a non-covered service. The denial will be based on the fact that neither statute nor regulation allows coverage of certain services when ordered or referred by the identified supplier or provider specialty.

 CMS would like to highlight the following limitations:

     beneficiaries. All services ordered or referred by a chiropractor will be denied.

 

     Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or Doctor of Podiatric

     Medicine (DPM). Claims for HHA services ordered by any other practitioner

     specialty will be denied.

Medicare Enrollment Guidelines for Ordering/Referring Providers

 

References:

Medicare Referring and Ordering Guidelines. (2015, September 25). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/medicare-referring-27286.html

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