Referring and Ordering Physician - CMS-1500 Box 17

by  Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
January 29th, 2018

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in Item 17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each. Enter the physician's first name and last name only. An exact match with PECOS is required. If you cannot fit the entire name in the field, use the first initial of the first name and the entire last name. Do not use a credential (e.g., "Dr." or "M.D") in the field.

Additional instructions for form version 02/12: Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician practitioner) is performing:

Enter the qualifier to the left of the dotted vertical line on Item 17.
NOTE: Under certain circumstances, Medicare permits a non-physician practitioner to perform these roles. Refer to CMS IOM Publication 100-02, Medicare Benefits Policy Manual, Chapter 15 for non-physician practitioner rules. Enter non-physician practitioner information according to the rules above for physicians.

The term "physician" when used within the meaning of §1861(r) of the Act and used in connection with performing any function or action refers to:


Referring physician - is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.


Ordering physician - is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician's or non-physician practitioner's service.

Do not extend the name beyond the confines of this box. Only enter what will fit into item 17. Do not run name into item 17a or 17b.

Note: Box 17a is not required by Medicare. Be sure to verify requirements with other payers.

NPI of the Referring/Ordering Physician - Enter the NPI of the referring, ordering, supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data in 17b.

References:

Referring and Ordering Physician - CMS-1500 Box 17. (2018, January 29). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/referring-and-ordering-physician-cms-1500-box-17-32804.html

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